Every finding on record at Alamo Cove Rehab and Nursing Center

Based on observation, interview, and record review, the facility failed to ensure adequate nurse staffing to promote the physical, mental and psychosocial well-being in 3 residents (Resident #3, Resident #74, Resident #5) of 19 residents reviewed for staffing and 9 of 11 residents as reported during a confidential resident council interview, resulting in unmet care needs and the potential for physical and psychosocial harm for all residents in the facility.Findings include: Resident #3 (R3) Review of the admission Record and Minimum Data Set (MDS) dated [DATE] revealed R3 admitted to the facility on [DATE] with pertinent diagnoses including multiple sclerosis (autoimmune disease where immune system damages the area around the nerves in the brain and spinal cord), anxiety, and depression. Brief Interview for Mental Status (BIMS) reflected a score of 15 out of 15 which indicated R3 was cognitively intact. During an interview on 4/29/2026 at 7:49 AM, R3 was lying on her bed. R3 stated that the facility only had 2 CNAs for 24 residents down on her unit and it was hard for the staff to meet all the residents' needs. R3 said that the shower aide got pulled a lot and then the CNAs found it hard to get showers done that day. R3 said she wanted to get up at 10 AM every day but they didn't get her up until 11 AM many days and she was usually the last one up. R3 also stated at night it was hard to get help and she had to wait for a long time to get help, which could end up being an hour. R3 reported that agency staff didn't know the routine of the residents. R3 said Staffing needs to be fixed. Management should help but it won't happen. They need more staff and I don't care how they fix it. During another interview on 4/30/2026 at 7:42 AM, R3 stated that she didn't get up until 11:25 AM the day before. R3 stated that usually it wasn't until 11:30 AM that she got up. R3 said this was a daily occurrence and filing a grievance didn't help. Review of R3's Grievance dated 1/4/2026 revealed . Date of report:1/4/2026. Describe Grievance: On 1/4/2025 (sic) the agency aid on p1st shift got me up and only did pericare (washing genital area). I asked her about how she washed up the residents and she said she only does pericare. I pointed out that the face, back and under breast should be washed too. The aide said she didn't need to do that because there isn't enough time to do all the tasks. Staff unacceptable. Review of R3's Grievance dated 2/21/2026 revealed . Time: lunchtime. Received by Social Service Aide (SSA) RR Grievance Description: Resident reported she had to go to room [ROOM NUMBER] to get 2 residents for lunch because the staff did not remind them to get up for lunch and the dining room staff did not go get them either since they could not leave the dining room to get them. Review of R3's Grievance dated 3/31/2026 revealed . Date Administrator received: 3/31/2026. Administrator assigned to: RNM PP. Investigation: Spoke with CNA (name omitted) and she has not been able to get her up at desired time the last two days. It is planned for tomorrow to have her up at 10 AM to attend an activity. This is arranged between the resident and CNA. Resolution: If we know don't have shower aid we'll make plans for what time resident wants to be up. Statement written by Regional Nurse Consultant (RNC) VV dated 3/31/2026 revealed RNC went and met with resident (R3)-states she regularly gets her shower which is scheduled on second shift. She states that there is still a delay in getting up for the day which she attributes to staffing. She has the desire to get up at 10 AM and some days she hasn't gotten up until 12 but, I get it because there isn't enough staff. RNC thanked her for communicating her concerns and assured her that we will address her concerns with possibility leadership. Resident #74 (R74) Review of the admission Record and Minimum Data Set (MDS) dated [DATE] revealed R74 admitted to the facility on [DATE] with pertinent diagnoses including legal blindness and depression. Brief Interview for Mental Status (BIMS) reflected a score of 12 out of 15 which indicated R74's cognition was moderately impaired. During an interview on 4/28/2026 at 11:06 AM, R74 reported he had to wait for a while for help the day before for staff to help him. R74 said he Pooped and sat in poop for a while. R74 stated What's the point in having a call light button when you need help and they don't come to help for a while? R74 said he can't see good so he relied on staff to help him. R74 asked this surveyor Have you needed help and then had to sit in your poop until someone helped you? It's a terrible feeling. During another interview on 4/30/2026 at 3:09 PM, R74 stated he didn't like sitting in urine but it is better than sitting in poop. R74 said not receiving the help he needed occurred on different shifts and multiple occasions. Review of an email correspondence dated 2/10/2026 between R74's daughter and Social Service Aide (SSA) RR revealed . I have concerns regarding my father. He says he has trouble with his call button because nobody comes. I was visiting him Friday and pushed the button a couple times in half an hour and nobody came. This is frustrating, my father knows what is going on and understands that everyone is working but he is a resident and has needs. I understand it's only been a few weeks but a lot has happened. When my dad said he peed his pants 3 times today because nobody helped him to the bathroom? I don't understand. Review of R74's grievance dated 4/28/2026 revealed Received by Minimum Data Set nurse (MDS) LLL Grievance Description: Met with resident regarding care concerns. Resident stated it happened around 3 to 4x (times) since he's been here. He puts his call light on because he really needs to go to the bathroom and has to go right when he puts it on. Resident stated that the longest he's waited on 2 responses was around 30 minutes. During an interview on 4/30/2026 at 2:46 PM, MDS LLL stated that R74 didn't say anything to her about waiting for a long time for help until he spoke to the State Surveyor the other day. MDS LLL said he used his call light and asked for help verbally. During an interview 04/30/2026 2:43 PM, Social Service Director (SSD) SS stated that she was unaware of R74 waiting for a while for help until he mentioned something to the State Surveyor. SSD SS stated that SSA RR checked on him and works with him more often. SSD SS reported that concerns are brought up daily at their interdisciplinary meetings. During an interview on 4/28/2026 at 10:11 AM, Certified Nursing Assistant (CNA) P stated that staffing was bad at times because staff doesn't show up and then they had no one to help cover the halls. CNA P said that North Hall (100 Hall) was the hardest hall and CNAs struggle a lot when they worked that hall since 2 CNAs weren't enough to take care of the residents. During an interview on 4/28/2026 at 10:33 AM, Licensed Practical Nurse (LPN) HH stated that staffing was hard when call ins occurred and they pulled the shower aide often to help fill openings. During an interview on 4/28/2026 at 11:40 AM, CNA R stated that the shower aide was pulled quite often to fill openings and then they had to give showers on top of taking care of the residents. CNA R said it was hard only having 2 CNAs down the hall and having to take care of all 24 residents' needs, showers, and make sure they got meals/assistance with meals. CNA R stated that a float CNA would be helpful otherwise they had trouble meeting resident needs. During an interview on 4/28/2026 at 12:46 PM, CNA W and CNA M stated that staffing was really bad especially when they only had 2 CNAs to take care of 28 residents and the shower aide was pulled. CNA W and CNA M stated that they had to give 8 showers on top of trying to meet resident's needs when the shower aide was pulled. CNA W said mealtimes were especially hard since 1 CNA had to oversee 3 halls since the other CNAs were in the dining room helping feed residents. CNA W and CNA M stated they had quite a few residents that were a 2 person assist down their hall. Review of the facility list of residents that require 2 person assist with transfers dated 4/29/2026 revealed 38 residents that required a 2 person assist with transfers with a census of 91 residents upon entrance. During an interview on 4/29/2026 at 2:36 PM, Business Office/Scheduler (BO/S) G stated that the shower aide was pulled when there was an opening for a CNA or a call in. BO/S G stated she was aware of the staffing concerns from the CNAs working the halls and the heavy workload and that management was aware as well. When discussing specifically North Hall staffing challenges and the fact that they didn't have enough staff to meet resident needs, she stated management and her were both aware of that. BO/S G stated that they didn't mandate staff to stay over when they were short staffed and would call agency to come in. BO/S G reported that residents complain about not getting the help they need during rounds and she heard staff talking about the staffing challenges in the hallway. During an interview on 4/29/2026 at 2:04 PM, Registered Nurse Manager (RNM) PP stated that R3 filed a grievance a few weeks ago because she likes to get up by 10 AM every day and she didn't get up that day until much later because the shower aide was pulled. RNM PP said staffing was bad that morning and they CNAs did get her up the next day and she didn't hear that she hadn't been up by 10 AM since then. When discussing R74, RNM PP stated that he yelled if he needed something but she didn't hear about him having any concerns with CNAs not responding to his needs or changing him when soiled. During an interview on 4/29/2026 at 11:43 AM, this surveyor discussed a resident oxygen tubing laying on the ground with shoes on top of it on 4/28/2026 from 9am to 5pm with LPN EE shrugged her shoulders and said What can you do? You would think that someone went and checked on her and her roommate during the day but who knows if they did. During an interview on 4/29/2026 at 4:11 PM, this surveyor discussed the staffing concerns that were found during the survey with Director of Nursing (DON) B, Regional Nurse Consultant (RNC) VV and Regional Director of Operations (RDO) AA. RDO AA and RNC VV reported that they thought staffing was good in the building. DON B said she was unaware of R3 and R74's concerns until this week. Review of the Call Light Policy dated 7/11/2018 revealed Policy: It is the policy of this facility to provide the resident a means of communication with nursing staff. Procedure:1. All facility personnel must be aware of call lights at all times. 2. Facility shall answer call lights in a timely manner. Resident #5 Review of an admission Record revealed Resident #5 was originally admitted to the facility on [DATE] with pertinent diagnoses which included: diabetes mellitus (chronic metabolic condition characterized by high blood sugar caused by insulin deficiency) and adjustment disorder with depression (a short-term, stress-related condition occurring when an individual struggles to cope with a specific life change or event). Review of a Minimum Data Set (MDS) assessment for Resident #5 with a reference date of 2/27/26, revealed a Brief Interview for Mental Status (BIMS) assessment score of 13/15, which indicated the resident was cognitively intact. Section D of the MDS revealed Resident #5 expressed feeling down, depressed, or hopeless during 2-6 days of the 14-day assessment period. Section GG revealed Resident #5 required substantial/maximal (helper does more than half the effort) to transfer from the bed to a wheelchair and to/from the toilet. Review of a Care Plan for Resident #5 with a reference date of 2/23/26 revealed the following focuses/goals/interventions: 1. Focus: The resident has hypoglycemia (low blood sugar) r/t (related to) diabetes.Goal: The resident will have no complications related to hypoglycemia.Interventions.Monitor.s/sx (signs and symptoms) of hypoglycemia.2. Resident at risk for falls.Goal: Resident will remain free from fall related injury.Interventions.provide assistance as needed for mobility tasks.anticipate and meet resident's needs. Review of a Fall Risk Assessment for Resident #5 with a reference date of 3/30/26 revealed a score of 40, moderate risk for falling. In an interview on 4/28/26 at 12:54pm, Resident #5 reported she often experienced long call light wait times, and although she knew she was not safe to do so, she took herself to the bathroom because she could not wait any longer and did not want to have an episode of incontinence (involuntary loss of urine or stool). Resident #5 confirmed she was frustrated and anxious when she felt she had no choice but to risk injuring herself by going to the bathroom without the help she needed. When queried, Resident #5 reported she regularly waited more than 30 minutes for staff to assist her to the bathroom and on one occasion, waited 3 hours. Resident #5 reported the staff did the best they could, but she felt the current level of staffing was not enough to ensure her needs were met. Resident #5 stated I know they're busy but there should be enough staff to help me when I need something. In an interview on 4/30/26 at 11:48am, Family Member (FM) EEE reported she visited Resident #5 regularly and witnessed call light response times of greater than 30 minutes. FM EEE reported Resident #5 also called her once and reported she (Resident #5) was concerned for her own well-being because she felt her blood sugar level was dropping and had been waiting for her call light to be answered for more than 30 minutes. Review of a Grievance and Satisfaction Form for Resident #5, filed by FM EEE, with a reference date of 4/17/26 revealed Grievance/Satisfaction Description: 1. Slow response to call light. Investigation: Initial internal call light response audit. Resolution: Facility completed call light audit to identify additional concerns and provided (sic) education to staff. Notifications:4/29/26 Satisfied: No, Resident expressed call light getting better but not completely improved. In a confidential meeting on 4/29/26 at 3:00pm, 9 of 11 residents reported experiencing call light response times greater than 30 minutes on a regular basis. Review of Grievance and Satisfaction Form with a reference date of 1/16/26 revealed Contact Info: Name: Resident Council.Grievance/Satisfaction Description: north, basic, south (halls) long call lights on 1st and 3rd shift.Investigation: Concerns will be addressed at staff meeting. Resolution: Staff meeting held 1/30/26. In an interview on 4/30/26 at 9:58am, Licensed Practical Nurse (LPN) JJJ reported the facility regularly operated with less Certified Nursing Assistants (CNAs) and Nurses than scheduled due to staff call ins. LPN JJJ reported she often provided basic care to residents because there were not enough CNA's to ensure care needs were met. LPN JJJ stated You can only work like that for a few days before you're burned out; that's why staff call in. In an interview on 4/30/26 at 12:25pm, CNA Q reported she regularly cared for 30 residents alone during the overnight shift. CNA Q reported incontinent residents who required the assistance of 2 staff members, were not changed every 2 hours because she had to wait for staff from other halls to be available to assist her. When queried, CNA Q reported her hall had at least 6 residents who required assistance of 2 staff members for changing their incontinence briefs. CNA Q reported other residents on her hall were not supervised while she was caring for residents in their rooms. CNA Q reported the facility was aware of her concerns. In an interview on 4/28/26 at 9:10 AM, Certified Nurse Assistant (CNA) M reported she was the only CNA working on the north unit from 6:00-7:30 AM, when they pulled the assigned shower aide to assist. CNA M reported there were 27 residents on the north hall. CNA M reported the usual staffing for the north hall was 2 CNAs and 1 nurse. On 4/28/26 at 10:46 AM, the north hall had no staff present in the hallway and 3 call lights were on. On 4/28/26 at 10:46 AM, CNA M exited a room on the north hall, acknowledged this surveyor standing across the hall, pointed to the call lights on, and said see, 3 lights on and no one else is around. On 4/28/26 at 12:51 PM, call lights were observed activated on the north hall for 2 rooms. On 4/28/26 at 12:53 PM, the call light to room [ROOM NUMBER] was on, Licensed Practical Nurse (LPN) II entered the room, shut off the light, and as she was exiting the room was heard saying we will be around in a hot minute. LPN II did not meet the resident's needs. Upon LPM II's exit, the call light to room [ROOM NUMBER] was immediately reactivated. LPN II walked from room [ROOM NUMBER] to room [ROOM NUMBER], entered the room and turned off the call light and exited the room. LPN II did not meet the resident's needs. Upon LPN II walked from room [ROOM NUMBER] to room [ROOM NUMBER] and asked from the doorway what the residents needed. LPN II stated, I'll be back in just a minute and did not enter room [ROOM NUMBER] and did not meet the resident's needs. At 12:56 all three call lights were still active, LPN II was present at the medication cart parked outside of room [ROOM NUMBER] where an unknown resident in room [ROOM NUMBER] was heard asking LPN II for pain medications, to which LPN II stated make yourself comfortable, I'll be there in a few minutes. On 4/28/26 at 1:02 PM, call lights in room [ROOM NUMBER], 112, and 113 were still activated. Unknown staff were present on the north hall and beginning to answer call lights. On 4/28/26 at 1:06 PM, the call light in room [ROOM NUMBER] was still activated. On 4/28/26 at 1:21 PM, the call light in room [ROOM NUMBER] was still activated. On 4/28/26 at 1:28 PM, the call light in room [ROOM NUMBER] was answered, after being on for 35 minutes. In an interview on 4/28/26 at 3:30 PM, CNA K and CNA L reported staffing could be better. CNA L reported the north hall had at least 8-10 residents who required a mechanical lift transfer that required 2 staff members to complete. During two person transfers the rest of the hall was unobserved during a two-person transfer. CNA L reported she worked like crazy when she was on the north hall and things did not get done timely. CNA L reported the residents had to wait a long time for their call lights to be answered. CNA K reported the mangers help by calling in extra staff when the state was in the building, but they did not help on the floor much otherwise. In an interview on 4/30/26 at 1:45 PM, Registered Nurse Manager (RNM) QQ reported north hall was assigned two CNAs, a shower aide, and a nurse. RNM QQ reported north hall was a heavy hall and the residents experienced long call light wait times. RNM QQ stated she did not know what to do about the long call light wait times.

Based on interview and record review, the facility failed to update the facility assessment related to current staffing concerns resulting in the potential for unmet care needs for all residents in the facility.Findings include:Review of the Quality Assessment and Assurance Committee and Facility Assessment Sheet dated 8/28/2025 revealed . Input for staffing for Facility assessment. 9/26/2024. Residents: We conduct Resident Council meetings monthly. We have had no concerns pertaining to staffing We will continue to complete the resident survey annually and address any issues individually at any time during the grievance/concern process. Family Members/Responsible Parties: We receive input from families and responsible parties with each care conference. We do not have any concerns pertaining to staffing from the care conference meetings . Staffing Decisions: We review the transfer status and the acuity of the residents to make staffing decisions. We use a guide for staffing numbers based on census but also consider the acuity of each resident and their location in the building. Group discussion. Residents were reviewed for transfer status, special needs, behavioral needs, acuity and number of residents on each hall in the building. Any individual issue with care or staffing are investigated and corrected as they occur.During an interview on 4/29/2026 at 4:11 PM, this surveyor discussed the staffing concerns that were found during the survey with Director of Nursing (DON) B, Regional Nurse Consultant (RNC) VV and Regional Director of Operations (RDO) AA. RDO AA and RNC VV reported that they thought staffing was good in the building. The facility assessment meeting which was held on 8/28/2025 with latest information on staffing from 9/26/2024 was also discussed and RNC VV and RDO AA said they would look for any updated staffing information from that meeting since the current Nursing Home Administrator (NHA) A was not here at the time. During an interview on 4/30/2026 at 12:57 PM, RDO AA stated he couldn't find any updated staffing information on the last facility assessment meeting held on 8/28/2025. During an interview on 4/30/2026 at 1:12 PM, DON B stated she was new to the building when she attended the facility assessment meeting on 8/28/2025 and she couldn't remember what was discussed at the meeting. Review of the Facility Assessment Policy dated 7/11/2018 revealed Policy: It is the policy of this facility to conduct and document a facility-wide assessment to determine what resources are necessary to care for its residents competently during both day-to-day operations and emergencies. 2. Content of the facility assessment: Each facility assessment will address at least the following topics.A. The facility's resident population, including, but not limited to: . ii. The care required by the resident population considering the types of diseases, conditions, physical and cognitive disabilities, overall acuity, and other pertinent facts that are present within that population. Timing of assessments: .1. The facility will review and update the assessment as necessary and at least annually. Use of the facility assessment: The facility will use the facility assessment to assist with the following: 1. Understand the nature of its resident population and the resources (human, physical, contractual and electronic, among others) that it will need to care for those residents competently during day to day emergency operations. This will include how those resources will be managed (e.g. staffing assignments, oversight of third party contracts, etc.).

Based on observation, interview, and record review the facility failed to maintain proper infection control practices for 1). Transmission based (contact isolation) precautions for 1 (Resident #59) of 1 resident, 2). Enhanced barrier precautions for 1 (Resident #88) of 1 resident, 3). Storage of nebulizer (a medical device that converts liquid medication into a fine mist that can be inhaled directly into the lungs) for 1 (Resident #34) of 1 resident, 4). Use of gloves during insulin administration for 1 (Resident #90) of 1 resident, 5). Cleanliness of shared resident equipment, 6). Proper hand hygiene during medication administration, 7). Storage of oxygen tubing for 1 (Resident #43) of 1 resident, and 8). Cleanliness of ice chest used for all residents during water pass resulting in the potential for the spread of infection, cross contamination, and disease transmission for all residents who resident in the facility. Findings include:Resident #59 Review of an admission Record revealed Resident #59 was a female who originally admitted to the facility on [DATE] and had pertinent diagnoses which included: Ileostomy (relocation of the small bowel to the surface of the abdomen creating an opening), ulcerative colitis (chronic inflammation of the bowels), peritoneal abscess (a localized collection of pus that forms within the abdominal cavity) and dehydration. Review of a Minimum Data Set (MDS) assessment for Resident #59, with a reference date of 3/6/26 revealed a Brief Interview for Mental Status (BIMS) score of 15/15 which indicated Resident #59 was cognitively intact. On 4/28/26 at 9:15 AM, signage posted outside of Resident #59's room was blue and indicated contact precautions (the use of personal protective equipment (PPE), gown, gloves, and mask) must don (put on) before entering the room. In an interview on 4/28/26 at 10:46 AM, Certified Nurse Assistant (CNA) M reported the signage outside of Resident #59 room indicated PPE needed to be worn when providing care. CNA M reported no PPE was needed when entering the room to deliver water, a meal, answer the call light, or to have a conversation with the resident. On 4/29/26 at 8:38 AM, signage posted outside of Resident #59's room was yellow and indicated she was in contact precautions and a gown and gloves needed to be donned before entering the room. In an observation and interview on 4/29/26 at 8:38 AM, Agency -Licensed Practical Nurse (LPN) HHH was outside of Resident #59's room. Agency-LPN HHH reported she needed to check on Resident #59's IV. Agency LPN HHH was observed applying a gown by placing her right hand into the sleeve, bringing the gown around her back and placing her left arm into the other sleeve; she did not tie the gown and the front was open, clothing exposed. Agency-LPN HHH was then observed retrieving a pair of gloves from the box on the door and held both gloves in her right hand when she turned to this surveyor and stated I need to go check her PICC (peripherally inserted central catheter) line dressing as she entered Resident #59's room holding the gown together in the front with her left hand and holding the gloves in her right hand. Agency-LPN HHH was observed donning the gloves and coming into physical contact Resident #59 at the same time. Agency- LPN HHH exited the room and did not perform hand hygiene. Review of Order Summary for Resident #59 revealed .Contact Isolation precautions for MRSA (methicillin-resistant staphylococcus aureus; a type of bacteria that causes skin infections and is resistant to many antibiotics) . with a start date of 4/15/2026.Enhanced barrier precautions [ileostomy; biliary drainage tube (a tube inserted through the abdomen into the gallbladder; abscess] every shift for patient monitoring with a start date of 4/9/2026. In an interview on 4/29/26 at 10:46 AM, LPN KK reported Resident #59 was in contact precautions. LPN KK reported CNAs were notified if a resident was in precautions by the signage posted outside of the resident room and the nurses' verbal communication. LPN KK reported everyone should check the door for signage before they enter a resident's room. In an interview on 4/29/26 at 2:00 PM, CNA U reported Resident #59 was in contact precautions and a gown, gloves, and mask needed to be worn during all cares. In an interview on 4/29/26 at 3:30 PM, Director of Nursing (DON) B reported no residents in the building were in transmission-based precautions. In an interview on 4/29/26 at 3:35 PM, Infection Preventionist (IP) PP reported Resident #59 was in transmission-based precautions, contact isolation, related to a MRSA infection, and had been in contact isolation for about two weeks. IP PP reported she had repeatedly educated staff, and it was an ongoing battle that would never be complete. IP PP then exited her office stating, I'm going to go re-educate again. Review of Care Plan for Resident #59 revealed Focus.Resident has sepsis (a systemic blood infection) r/t (related to) bacteria and recent surgery.Interventions. Maintain standard precautions (minimum infection prevention measures) when providing resident care.initiated on 4/9/26.Focus. Resident has an ADL self-care performance.Intervention.Gloves and gown (Enhanced barrier precautions/EBP) required. Documentation of contact isolation and/or transmission based precautions were not noted in Resident #59's care plan. On 4/30/26 at 9:35 AM, Agency LPN BBB was observed in Resident #59's room administering medications to her, wearing a gown and gloves. Agency LPN BBB then removed the PPE she was wearing and placed it into the garbage can next to Resident #59's roommate's bed, while she lay in the bed. Agency-LPN BBB was further observed touching Resident #59's roommate's arm, removing the straw from one cup and replacing it into another cup on the roommates over the bed table before exiting the room. Agency -LPM BBB did not perform hand hygiene. In an interview on 4/30/26 at 9:45 AM, IP PP accompanied this surveyor to Resident #59's room and confirmed that staff was disposing of used PPE into Resident #59's roommates' garbage can and that was a concern for infection control. IP PP reported a larger garbage can should be present either in the room or just outside of the room for disposal of used PPE. In an interview on 4/30/26 at 9:55 AM, IP PP, DON B, and Regional Nurse Consultant (RNC) VV reported there should be sufficient garbage cans available to dispose of used PPE and the garbage cans should not be near a resident. Review of facility policy Transmission Based Precautions Contact Precautions with an updated date of 2/22/2021 revealed .Hand hygiene should be completed prior to donning gloves.Gloves should be worn when entering the room.Gloves should be removed before leaving the resident's room and hand hygiene should be performed immediately.a gown should be donned prior to entering the room or resident's cubicle. Resident #88 Review of an admission Record revealed Resident #88 was a female who was originally admitted to the facility on [DATE] and had pertinent diagnoses which included: dementia, history of falling, and history of/healed fracture. On 04/28/26 at 10:46 AM, signage noted outside of Resident #88's room indicated she was in enhanced barrier precautions, and a gown and gloves were required to be worn by staff during care activities. Review of Order Summary for Resident #88 revealed .Enhanced barrier precautions related to pressure wound on foot. with a start date of 4/6/2026. Review of Care Plan for Resident #88 revealed no noted care plan related to enhanced barrier precautions. On 4/28/26 at 3:30 PM. CNA K and CNA L were present in Resident #88's room and positioning a dependent lift sling under her body. Neither CNA K nor CNA L were wearing a gown or gloves. CNA K retrieved the mechanical lift, and CNA K and CNA L donned gloves while inside Resident #88's room and used the mechanical lift to transfer Resident #88 into her wheelchair. Neither CNA K nor CNA L were wearing a gown. When queried, CNA K and CNA L both denied Resident #88 had any wounds present. Upon exiting the room, when queried, CNA L reported the signage posted outside of Resident #88 room indicated she should wear a gown and gloves when caring for her, and she did not. In an interview on 4/29/26 at 10:46 AM, LPN KK reported Resident #88 was in enhanced barrier precautions. LPN KK reported everyone should check the door for signage before they enter a resident's room. In an interview on 4/29/26 at 2:00 PM, CNA U reported Resident #88 was in enhanced barrier precautions and a gown and gloves needed to be worn during all cares. In an interview on 4/29/26 at 3:35 PM, Infection Preventionist (IP) PP reported Resident #88 was in enhanced barrier precautions related to a wound on her right foot. IP PP reported her expectations were that PPE was worn during high contact care activities, including transfers. Review of facility policy Subject: Enhanced Barrier Precautions with an updated date of 6/28/2025 revealed .to use Enhanced barrier precautions to expand the use of PPE.Residents with wounds.EBP should be used for resident who meet criteria.high contact resident care activities.transferring.Identify residents requiring enhanced barrier precautions. wounds.post clear signage on the door/wall outside the room.personal protective equipment required. Resident #34 Review of an admission Record revealed Resident #34 was a female who originally admitted to the facility on [DATE] and had pertinent diagnoses which included: pneumonia, pulmonary embolism (a blood clot in the lungs), and COPD (chronic obstructive pulmonary disease- a lung disease that makes it difficult to breathe). Review of a Minimum Data Set (MDS) assessment for Resident #34, with a reference date of 3/20/2026 revealed a Brief Interview for Mental Status (BIMS) score of 12/15 which indicated Resident #34 was cognitively intact. On 4/28/26 at 10:34 AM, a nebulizer was observed in the basket of the motorized wheelchair in Resident #34's room. On 4/28/26 at 10:35 AM, Resident #34 reported she was waiting for the nurse to bring her a treatment (a nebulizer treatment). Resident #34 reported she used her nebulizer sometimes and kept it close when she needed it. On 4/29/26 at 9:06 AM and 10:06 AM, a nebulizer was observed under the pillow of Resident #34's bed. Resident #34 was sitting on the side of her bed. In an interview on 4/29/26 at 10:46 AM, LPN KK reported Resident #34 did use her nebulizer treatments occasionally. LPN KK reported it should be stored in plastic bag when not in use. On 4/29/26 at 11:07 AM and 1:07 PM a nebulizer was observed under the pillow of Resident #34's bed. Resident #34 was sitting on the side of her bed. In an interview on 4/29/26 at 1:55 PM, CNA U reported the nurses were responsible for the nebulizers. CNA U reported the nebulizers should be stored in a plastic bag when not in use. In an interview on 4/30/26 at 12:51 PM, DON B reported her expectations were that nebulizers were cleaned after each use, set out to dry, and when dry stored in a plastic bag. Resident #90 Review of an admission Record revealed Resident #90 was a female who originally admitted to the facility on [DATE] and had pertinent diagnosis which included: type 2 diabetes (a chronic conditions including insulin resistance and high blood sugar levels). Review of Order Summary for Resident #90 revealed .Humalog (insulin) injection solution/Lispro inject 15 units subcutaneously before meals.with a start date of 3/26/2026. On 4/29/26 at 11:50 AM, Agency-LPN GGG was observed administering an insulin injection into the right abdominal area of Resident #90. Agency-LPN GGG did not wear gloves during the administration of an insulin injection nor did she perform hand hygiene at any time. In an interview on 4/29/26 at 12:04 PM, Agency-LPN GGG reported infection control practices for medication administration included hand hygiene and wearing gloves. Agency-LPN GGG reported she did not sanitize her hands before or after administering medications to Resident #90 and she confirmed she did not wear gloves. Agency-LPN GGG reported she should have done both when she administered insulin to Resident #90. Agency-LPN GGG stated I don't think about sanitizing hands or wearing gloves because I know the residents are clean; I just give the insulin. In an interview on 4/29/26 at 3:30 PM, DON B reported her expectations were that gloves were worn with insulin administration and hand hygiene was done before and after resident contact. Review of facility policy Injections. with an adopted date of 7/11/2018 revealed .3. Wash hands, apply gloves.15. Insert the needle quickly and firmly.17. Inject the medication slowly.23. Removed gloves, wash hands. On 4/28/26 at 9:43 AM, LPN II was observed using the vital machine in room [ROOM NUMBER], exiting the room, returning to the medication cart, and then entering an unknown resident's room and using the vital machine again. LPN II did not clean the vital machine between resident use. Noted on the basket of the vital machine stand was a plastic container of cleaning wipes. On 4/28/26 at 1:27 PM, CNA K and CNA L were observed using a mechanical lift in room [ROOM NUMBER] to transfer an unknown resident into bed. Upon exit of room [ROOM NUMBER], CNA L and CNA K immediately entered room [ROOM NUMBER] and completed a mechanical lift transfer with the same lift. The lift was not cleaned between the residents. On 4/28/26 at 3:30 PM. CNA K and CNA L were observed performing a mechanical lift transfer in room [ROOM NUMBER]. Upon exit of the room, CNA L positioned the lift in the hallway. The lift was not cleaned. In an interview on 4/28/26 at 3:30 PM, CNA L reported mechanical lifts should be cleaned after every use. CNA L confirmed the lift was not cleaned after it was used. In an interview on 4/29/26 at 10:46 AM, LPN KK reported mechanical lifts, and vital machines should be cleaned after every use. In an interview on 4/29/26 at 2:00 PM, CNA U reported mechanical lifts and vital machines should be cleaned after every use and there should be cleaning wipes in a bag on the lift handles. On 4/29/26 at 2:05 PM the lift in the north hall did not have any cleaning wipes present on it. In an interview on 4/29/26 at 3:30 PM, DON B reported her expectations were that resident shared equipment was cleaned after each use. On 4/29/26 at 11:50 AM, Agency-LPN GGG was observed exiting a resident's room following the administration of medications, returning to the medication cart, preparing and administering medications to another resident and returning to the medication cart to prepare medications for a third resident. At no time during the observation did Agency-LPN GGG perform hand hygiene. On 4/30/26 at 8:19 AM, Agency-LPN BBB was observed preparing and administering medications to a resident, assisting with the straw of the cup for the resident. Then Agency-LPN BBB went to the roommate, gave her a hug, and then returned to the medication cart to prepare and administer medications to another resident. Agency-LPN BBB assisted the third resident with her straw and drink cup [NAME] she took the medications, exited the room and returned to the medication cart. At no time during the observation did Agency-LPN BBB perform hand hygiene. In an interview on 4/29/26 at 3:30 PM, DON B reported her expectations were that hand hygiene was completed before and after resident contact. Resident #43 (R43) Review of the admission Record and Minimum Data Set (MDS) dated [DATE] revealed R43's initial admission to the facility was on 4/13/2023 with pertinent diagnoses including chronic obstructive pulmonary disease (COPD) with acute exacerbation (lung disease with sudden worsening symptoms). Brief Interview for Mental Status (BIMS) reflected a score of 3 out of 15 which indicated R43 was severely cognitively impaired. During observations in R43's room on 4/28/2026 at 9:37 AM, 10:08 AM, 12:28 PM and 4:22 PM R43's oxygen tubing with the nasal cannula were on the ground with her shoes on top of it and the clear bag that it was supposed to be put in was laying on the ground. Review of Physician Orders revealed Oxygen at 2 liters via (through) nasal cannula, ok to titrate up (move up) as needed. If Hypoxia (deficiency in oxygen levels) at 4 liters, call provider as needed for Hypoxia, SOB (shortness of breath) related to COPD with exacerbation. Start date: 4/26/2026. During an interview on 4/29/2026 at 11:43 AM, Licensed Practical Nurse (LPN) EE stated that R43 was started on oxygen for a few days and she didn't need it anymore since her oxygen sats (oxygen saturation) were good and it was just discontinued. LPN EE said she was on it as a prn (as needed) basis. When discussing R43's oxygen tubing laying on the ground with shoes on top of it on 4/28/2026 from 9am to 5pm, LPN EE shrugged her shoulders and said What can you do? You would think that someone went and checked on her and saw that during the day and who knows if they did. LPN EE reported that oxygen tubing and the nasal cannula should be in a bag in resident's room when not in use. During an interview on 4/29/2026 at 12:15 PM, Certified Nursing Assistant (CNA) V stated that oxygen tubing should be in a bag attached to the concentrator when it wasn't in use and should not be on the ground. Review of the Oxygen Use Policy dated 9/24/2018 revealed . Procedure: The following procedure will be observed in oxygen administration.2. The tubing (oxygen) should be kept off the floor. During an observation on 4/28/26 at 3:04pm, an unknown resident walked up to the blue ice cooler that sat on a metal cart in the 200 hall. Without washing her hands, the resident picked up the ice scoop next to the cooler, opened the cooler and scooped ice from the bottom of the cooler. The resident then removed a straw and the top from a cup that sat on her wheeled walker and rested the scoop on the edge of the cup as she poured ice into it. It was noted that the cup appeared to be previously used as it was lightly soiled with a quarter sized spot of dried brown liquid on the side, dried brown residue was present on the lid, and the cup had writing on it. The resident then repeated the task; she scooped ice from the bottom of the cooler, while doing so, the inside of her arm brushed against the interior wall of the cooler. The resident then rested the scoop against the top of the cup as she poured the ice. The resident returned the ice scoop to the top of the cart and walked away using her wheeled walker. In an interview on 4/28/26 at 3:05pm, Certified Nursing Assistant (CNA) O, reported the individual who was observed using the ice scoop was a resident who resided on another hallway; however, CNA O did not know the resident's name. In an interview on 4/29/26 at 11:58am, CNA KKK reported the blue cooler on the cart was used for staff to pass fresh ice water to residents. CNA KKK reported for Infection Control purposes, only staff were supposed to touch the ice scoop/cooler, but it was left unattended in the hallway where residents and visitors could access it without staff knowing. In an interview on 4/30/26 at 11:23am, Infection Preventionist (IP) PP reported residents were allowed to get their own ice/water from the cooler, but they should not use a previously used cup or allow the scoop to touch their personal cups.

Based on observation, interview and record review, the facility failed to maintain general cleanliness and repair of the facility. This resulted in an increased potential for contamination and a possible decrease in satisfaction of living for residents of the facility. Findings Include: On 4/28/26 at 10:05 AM, a window was observed open in Resident #11's room, with no screen was present. Dirt was observed on the over-the-bed table at the foot of the bed, the floor, and on the foot of the bed. Resident #11 was in bed sleeping. In an interview on 4/29/26 at 8:30 AM, Resident #11 reported she was mad and did not understand why she could not have a screen on her window. Resident #11 reported her window was open yesterday when she left the building for an appointment and when she returned, her bed had grass and dirt on it. Resident #11 reported she also preferred not to have bugs come in her room when the window was open. On 4/28/26 at 9:27 AM, room [ROOM NUMBER] had a strong odor of urine. On 4/28/26 at 10:14 AM, a pedestal fan present in room [ROOM NUMBER] was noted to have dust and debris on the wire protective cage and base of the fan. The fan was blowing on low and positioned directly at the pillow at the head of the bed. On 4/28/26 at 10:22 AM, Housekeeper (HSK) CC was observed mopping the floor in room [ROOM NUMBER]. When she finished, she exited the room and did not place any wet floor signage. The floor in room [ROOM NUMBER] was visibly wet. In an interview on 4/28/26 at 10:22 AM, HSK CC reported there was only two housekeepers working that day, and she was to cover north, west, and rehab halls. HSK CC reported the workload was a lot and she did what she could. On 4/28/26 at 10:28 AM, the floor in room [ROOM NUMBER] remained visibly wet with no wet floor sign present. On 4/28/26 at 10:29 AM, HSK BB was standing on the north hall and was heard saying I'm not going to rush through it, all I am going to do is the bare minimum cleaning (sic), I'm not trying to deal with being short again. HSK CC was heard responding to HSK BB saying You can only do what you can do On 4/29/26 at 2:22 PM, a pedestal fan present in room [ROOM NUMBER] was noted to have dust and debris on the wire protective cage and base of the fan. The fan was on low and blowing directly on the resident in bed's face. On 4/29/26 at 2:24 PM, room [ROOM NUMBER] still had a strong odor of urine. In an interview on 4/30/26 at 10:00 AM, HSK CC reported she did not use wet floor signs when she mops floors. HSK CC stated most residents would wait to get up until the floor was dry. HSK CC reported she would ring out the mop, and it would be mostly dry, and she would not need to put up a wet floor sign. HSK CC reported if the floor was wet it wasn't wet for too long. HSK CC reported she did not clean resident's personal items, but she would dust about once a week. When queried, HSK CC replied she did the bases of fans in resident rooms, but not the protective cages. In an interview on 4/30/26 at 3:11 PM, Nursing Home Administrator (NHA) A reported she was currently acting as the director of housekeeping as the position was vacant. NHA A reported she was aware that cleaning needed to be done and she as still learning how the department was supposed to run. NHA A reported her expectations were that wet floor signs were to be used every time. On 04/28/2026 at 10:21AM, observed a mattress laying on the sidewalk at back of building. On 04/28/2026 at 10:22 AM, observed an adjustable bed, that appeared to be broken, sitting in hallway in front of the door leading to the basement. On 04/28/2026 at 10:25AM, observed on the 600 hall, a missing plastic cover for the corner of the handrail, exposing the plastic edge of railing and connection base. On 04/28/2026 at 10:27AM, observed on the 500 hall, a missing plastic cover for the corner of the handrail. On 04/28/2026 at 10:30AM, observed on the 100 hall, a missing corner protector for the handrail. On 04/28/2026 at 10:31AM, observed on the100 hall, a strong odor of urine at the end of the hall in the area of rooms 111, 112, 113, and 114. On 04/28/2026 at 12:14PM, during interview regarding earlier observations with the Maintenance Supervisor (MS) LL, MS LL disclosed the adjustable bed in front of the basement door was broken and was waiting to be moved outside. MS LL was also aware of the missing end caps and broken or loose handrails and has ordered parts to make the repairs. On 04/28/2026 at 12:20PM, when asked about several windows in the facility that are missing screens, MS LL stated some screens have been pulled from the windows by the maintenance department as part of preparing to install the air conditioner window units. On 04/28/2026 at 12:27PM, observed that there were several pieces of equipment (bed frames, furniture) and debris (shingles, old water softeners) that were sitting near or next to the outbuildings and dumpsters. MS LL stated that they are currently working on contracting dumpsters for the removal of trash that does not fit in the current garbage dumpsters and that the storage building is currently full. MS LL also stated that the housekeeping supervisor recently left the facility's employment and at that time brought several pieces of furniture out of the facility and left them by the dumpster. On 04/28/2026 at 12:40PM, during review of pest control practices, MS LL said there had been issues with mice in the facility. On 04/28/2026 at 1:44PM, received an email from MS LL providing proof of purchase for handrail parts email was dated 4/22/2026. On 04/28/2026 at 2:10PM, observed a loose handrail with a missing end cap, next to room [ROOM NUMBER], there was a trash can blocking most of the handrail. On 04/28/2026 at 2:12PM, observed on the 100 hall, a continued strong urine odor at the end of the hall. On 04/28/2026 at 2:13PM, observed a window was open in room [ROOM NUMBER], the window did not have a screen. At time of observation resident was not in the room.

Based on interview, and record review, the facility failed to take prompt efforts to resolve resident grievances in 1(Resident #5) of 19 residents reviewed for concern resolution, and 9 of 11 residents who attended a confidential meeting, resulting in dissatisfaction with call light response, unresolved concerns related to missing items and the potential for additional care concerns to go unaddressed.Findings include: Resident #5Review of an admission Record revealed Resident #5 was originally admitted to the facility on [DATE] with pertinent diagnoses which included: diabetes mellitus (chronic metabolic condition characterized by high blood sugar caused by insulin deficiency) and adjustment disorder with depression (a short-term, stress-related condition occurring when an individual struggles to cope with a specific life change or event).Review of a Minimum Data Set (MDS) assessment for Resident #5 with a reference date of 2/27/26, revealed a Brief Interview for Mental Status (BIMS) assessment score of 13/15, which indicated the resident was cognitively intact. Section D of the MDS revealed Resident #5 expressed feeling down, depressed, or hopeless during 2-6 days of the 14-day assessment period. Section GG revealed Resident #5 required substantial/maximal (helper does more than half the effort) to transfer from the bed to a wheelchair and to/from the toilet.Review of a Care Plan for Resident #5 with a reference date of 2/23/26 revealed the following focuses/goals/interventions: 1. Focus: The resident has hypoglycemia (low blood sugar) r/t (related to) diabetes.Goal: The resident will have no complications related to hypoglycemia.Interventions.Monitor.s/sx (signs and symptoms) of hypoglycemia.2. Resident at risk for falls.Goal: Resident will remain free from fall related injury.Interventions.provide assistance as needed for mobility tasks.anticipate and meet resident's needs.In an interview on 4/28/26 at 12:54pm, Resident #5 reported she often experienced long call light wait times, and although she knew she was not safe to do so, she took herself to the bathroom because she could not wait any longer and did not want to have an episode of incontinence. Resident #5 confirmed she was frustrated and anxious when she felt she had no choice but to risk injuring herself by going to the bathroom without the help she needed. When queried, Resident #5 reported she regularly waited more than 30 minutes for staff to assist her to the bathroom.In an interview on 4/29/26 at 8:10am, Resident #5 reported she had made the facility aware of several missing items, but nothing had been done. Resident #5 reported she was missing a pair of black pants, a black t-shirt, 2 white camisoles, a pair of scissors and 2 pairs of black socks. Resident #5 reported the items had been missing for more than 2 months. Resident #5 reported she was frustrated by the lack of response on the facility's behalf and stated, I shouldn't have to worry about my belongings turning up missing and never being replaced.In an interview on 4/30/26 at 11:48am, Family Member (FM) EEE reported she visited Resident #5 regularly and witnessed call light response times of greater than 30 minutes. FM EEE reported Resident #5 also called her once and reported she (Resident #5) was concerned for her own well-being because she felt her blood sugar level was dropping and had been waiting for her call light to be answered for more than 30 minutes. FM EEE reported she had filed 2 grievance forms prior to 4/29/26 and had no resolution to her concerns regarding long call light wait times and Resident #5's missing items. FM EEE reported the facility contacted her on 4/29/26 and asked her to file a new grievance form regarding Resident #5's missing items.In an interview on 4/30/26 at 11:33am, Nursing Home Administrator (NHA) A reported she was unable to locate the grievance forms FM EEE filed regarding Resident #5's missing items, so the social worker reached out to FM EEE to ask her to file a new grievance. NHA A confirmed that upon beginning her role as Administrator a few weeks ago, it became apparent the facility did not have an effective grievance process. Review of a Grievance and Satisfaction Form for Resident #5, filed by FM EEE, with a reference date of 4/17/26 revealed Grievance/Satisfaction Description: 1. Slow response to call light. Investigation: Initial internal call light response audit. Resolution: Facility completed call light audit to identify additional concerns and provided (sic) education to staff. Notifications: Date person who submitted form was notified of resolution: 4/29/26, Satisfied? No.In a confidential meeting on 4/29/26 at 3:00pm, 9 of 11 residents reported experiencing call light response times greater than 30 minutes on a regular basis. 9 of 11 residents indicated the group had filed a grievance regarding the call light wait times previously and felt the situation had not improved.Review of Grievance and Satisfaction Form with a reference date of 1/16/26 revealed Contact Info: Name: Resident Council.Grievance/Satisfaction Description: north, basic, south (halls) long call lights on 1st and 3rd shift.Investigation: Concerns will be addressed at staff meeting. Resolution: Staff meeting held 1/30/26, Notifications: Date person who submitted form was notified of resolution: blank, Satisfied? Blank.Review of a Nursing Administration Grievance policy with a reference date of 5/2/19 revealed Policy: It is the policy of this facility to investigate all grievances. Administrator or designee.will make contact with the concerned party within 24 hours of being made aware of a grievance.and will keep in frequent contact until a resolution is obtained. The Administrator or designee .shall confer with persons involved.within three to seven days of receiving the grievance, shall provide a written explanation, upon request, of findings and proposed remedies. the facility shall put into place immediate action to prevent potential violation of resident's rights.all written grievance decisions will include .summary of pertinent findings.a statement as to whether the grievance was confirmed.if grievance is confirmed, the facility will take appropriate corrective action.Conclusion: evaluate if the course of action was effective.

Based on interview and record review, the facility failed to sustain a system to ensure corrective measures related to pressure ulcers in 1 of 2 residents (Resident #88) reviewed for pressure ulcers and quality improvement as evidenced by repeated deficiencies on two of the past three surveys and current noncompliance with pressure ulcer concerns, resulting in the potential for continued development or worsening of pressure ulcers for residents with actual skin breakdown or at risk of skin breakdown.Findings include:Resident #88 Review of an admission Record revealed Resident #88 was a female who was originally admitted to the facility on [DATE] and had pertinent diagnoses which included: dementia, history of falling, and history of/healed fracture. Review of a Minimum Data Set (MDS) assessment for Resident #88, with a reference date of 1/30/2026 revealed Mobility, Resident #88 was dependent on staff for mobility, and Skin conditions, Resident #88 was at risk for developing pressure ulcers. In an observation and interview on 4/28/26 at 12:30 PM, Resident #88 was sitting in a broda chair (a high back reclinable wheelchair), and her heel protectors (soft padded material designed to protect the skin of the heels) light green in color, were dislodged from her feet and were noted to be around her legs. Family Member (FM) AAA reported Resident #88's heel boots shift when she moved, and he was concerned Resident #88 continued to get wounds. FM AAA reported Resident #88 always had to wear her boots for her heels to prevent her wound from getting worse or developing others. In an observation and interview on 4/28/26 at 3:30 PM, Certified Nurse Assistant (CNA) K reported Resident #88 should wear the boots (heel protectors) on her feet all the time. Review of Care Plan for Resident #88 revealed Focus.Resident has potential impairment to skin integrity.Intervention: off-loading boot cushions to bilateral (both) lower extremities at all times as tolerated. initiated on 7/10/2025. On 4/30/26 at 8:07 AM, Resident #88 was observed sitting in her broda chair, in the dining room, and she was not wearing any heel protectors. Her heels were observed directly in contact with the foot cradle of the broda chair. On 4/30/26 at 9:35 AM, Resident #88 was observed sitting in her broda chair, in her room, and she was not wearing any heel protectors. Her heels were observed directly in contact with the foot cradle of the broda chair. A light green colored set (2) of heel protectors and 2 sets of dark green colored heel protectors were observed in Resident #88's room. On 4/30/26 at 12:23 PM, Resident #88 was observed sitting in her broda chair, in the dining room, and she was not wearing any heel protectors. Her heels were observed directly in contact with the foot cradle of the broda chair. In an interview on 4/30/26 at 12:24 PM, Director of Nursing (DON) B reported Infection Preventionist (IP) PP, Registered Nurse Manager (RNC) QQ and Assistant Director of Nursing (ADON) F were all responsible for auditing. DON B reported topic that were being monitored were treatment orders, treatment completion, and wound vac (vacuum; a medical device that applies constant pressure to a wound to assist with healing). When queried, who was responsible for monitoring the implementation of pressure ulcer prevention interventions, such as Resident #88's heel protectors, DON B reported the nurses and CNAs were responsible to ensure that heel protectors were in place as ordered. When further queried, DON B stated we are not monitoring (through direct observation) if pressure ulcer prevention interventions are implemented. Review of the facility Plan of Correction with an alleged compliance date of 4/10/26 revealed, By 04/10/2026, all licensed nurses will receive education on skin and wound management standards, with emphasis on: Accurate transcription of physician and wound clinic orders Ensuring necessary treatment supplies are available Completion of treatments as ordered Proper assessment and monitoring of wound vac devices and indwelling catheters to ensure they are functioning correctly The DON/ designee will conduct random audits of 5 residents receiving wound care weekly for 4 weeks, then monthly for 3 months, or until substantial compliance is achieved. These audits will ensure accuracy of order transcription in the medical record, completion of treatments as ordered and proper functioning of wound vac devices. The results will be presented to the QAA committee for review and consideration of further corrective actions. The DON will be responsible for assuring substantial compliance is attained through this plan of correction and for sustained compliance thereafter. In an interview on 4/30/26 at 12:51 PM, Nursing Home Administrator? (NHA) A reported the facility currently had a plan of correction they were working on related to pressure ulcers. NHA A reported the facility had been monitoring MARs (medication administration records) and TARs (treatment administration records) to make sure the wound treatments were done and to make sure the residents had the supplies they needed. NHA A reported they also provided education to the nurse if they were unsure of how to do the wound dressing changes. NHA A reported audits were done weekly and would be done for 3 months to ensure sustained compliance. NHA A reported part of the plan of correction was that if any concerns were identified through the audits, it would be referred to the QAPI (quality assurance performance improvement) committee. NHA A reported the QAPI team met to make the plan of correction for the pressure ulcers. In an interview on 4/20/26 at 1:19 PM, Director of Nursing (DON) B reported wound rounds were completed on a weekly basis and the facility also reviewed the pressure ulcers and complicated wounds at the resident at risk weekly meeting. DON B reported things like pressure reliving boots and air mattresses had a physician's order and were care planned. DON B reported the nurse was responsible for ensuring that the orders were carried out. In a follow-up interview on 4/30/26 at 1:25 PM, DON B reported the nurses answer to the unit managers and the unit managers were the ones responsible for the care provided by staff under the DON's umbrella. In an interview on 4/30/26 at 2:26 PM, NHA A and Regional Director of Operations (RDO) AA reported the facility conducted ambassador rounds every week to check in with residents, ask any questions, and ask if they have any needs, and to check the rooms for any environmental things that need to be done. NHA A and RDO AA reported the clinical team rounded every morning and if there was someone that was identified with a pressure injury or wound, the clinical team would review their documents and any changes the doctors or nurses identify. There was no discussion on how the facility conducts observations to ensure care planned pressure ulcer/skin breakdown prevention interventions were consistently in place for residents.

Based on interview and record review, the facility failed to treat residents with dignity and respect and failed to provide an environment that promoted and enhanced resident quality of life for 3 (Resident #1, #6, and #74) of 4 residents reviewed for dignity, resulting in long call light wait times and the potential for feelings of frustration, depression, and loss of self-worth and an overall deterioration of psychological well-being.Findings include:Resident #1 Review of an admission Record revealed Resident #1 was a male, with pertinent diagnoses which included: weakness, and major depressive disorder. Review of a Minimum Data Set (MDS) assessment for Resident #1, with a reference date of 3/20/26 revealed a Brief Interview for Mental Status (BIMS) score of 12, out of a total possible score of 15, which indicated Resident #1 was cognitively impaired. Section H of the MDS revealed Resident #1 was occasionally incontinent of bladder and always incontinent of bowel. Review of a current Care Plan for Resident #1 revealed the focus of Resident has an ADL (activities of daily living) self-care performance deficit r/t (related to) IRON DEFICIENCY ANEMIA SECONDARY TO BLOOD LOSS with a revision date of 12/15/25 and care planned interventions which included TOILET USE: The resident requires maximum to moderate assistance with toileting with a revision date of 12/16/25. In an interview on 4/29/26 at 9:43 AM, Resident #1 reported he has had to wait a long time for his call light to be answered. Resident #1 reported he has soiled his brief a lot of times while waiting for staff to come and answer his call light. Resident #1 reported he has had to wait longer than an hour for them to answer his call light. Resident #1 reported it makes him feel bad when he soils his brief. In an interview on 4/30/26 at 8:18 AM, Licensed Practical Nurse (LPN) FF confirmed that Resident #1 does use his call light. Resident #6 Review of an admission Record revealed Resident #6 was a male, with pertinent diagnoses which included: adjustment disorder with depression, and anxiety disorder, unspecified. Review of a Minimum Data Set (MDS) assessment for Resident #6, with a reference date of 3/20/26 revealed a Brief Interview for Mental Status (BIMS) score of 10, out of a total possible score of 15, which indicated Resident #6 was cognitively impaired. Section H of the MDS revealed Resident #6 was always incontinent of bladder and always incontinent of bowel. Review of a current Care Plan for Resident #6 revealed a focus of Resident has an ADL self-care performance deficit r/t right sided weakness post CVA (stroke). with a revision date of 4/10/26 and care planned interventions which included TOILET USE: The resident requires max (maximum) assistance by 1 staff for toileting with a revision date on 3/21/25. In an interview on 4/28/26 at 2:19 PM, Resident #6 reported it takes forever for things to get done, specifically to change his pants. Resident #6 reported he has had to wait an hour for them to change his brief before. Resident #6 reported it makes him feel dirty when he has to wait for a brief change. In an interview on 4/29/26 at 11:14 AM, Certified Nurse Aide (CNA) P reported once in a while residents would complain to her about long call light wait times. In an interview on 4/29/26 at 11:18 AM, CNA N reported sometimes residents complain to her about long call light wait times. In an interview on 4/30/26 at 8:21 AM, Activities Director (AD) D reported residents have complained to her about long call light wait times. AD D reported residents have also brought it up in resident council. In an interview on 4/30/26 at 8:25 AM, CNA W reported residents have complained about long call light wait times to her. CNA W reported residents say it has been a long time that they have been waiting for her to answer their call light. Resident #74 (R74) Review of the admission Record and Minimum Data Set (MDS) dated [DATE] revealed R74 admitted to the facility on [DATE] with pertinent diagnoses including legal blindness and depression. Brief Interview for Mental Status (BIMS) reflected a score of 12 out of 15 which indicated R74's cognition was moderately impaired. During an interview on 4/28/2026 at 11:06 AM, R74 reported he had to wait for a while for help the day before for staff to help him. R74 said he Pooped and sat in poop for a while. R74 stated What's the point in having a call light button when you need help and they don't come to help for a while? R74 said he could not see good so he relied on staff to help him. R74 asked this surveyor Have you needed help and then had to sit in your poop until someone helped you? It's a terrible feeling. During another interview on 4/30/2026 at 3:09 PM, R74 stated he didn't like sitting in urine but it is better than sitting in poop. R74 said not receiving the help he needed had occurred on different shifts and multiple occasions. Review of an email correspondence dated 2/10/2026 between R74's daughter and Social Service Aide (SSA) RR revealed . I have concerns regarding my father. He says he has trouble with his call button because nobody comes. I was visiting him Friday and pushed the button a couple times in half an hour and nobody came. This is frustrating, my father knows what is going on and understands that everyone is working but he is a resident and has needs. I understand it's only been a few weeks but a lot has happened. When my dad said he peed his pants 3 times today because nobody helped him to the bathroom? I don't understand. Review of R74's grievance dated 4/28/2026 revealed Received by Minimum Data Set nurse (MDS) LLL Grievance Description: Met with resident regarding care concerns. Resident stated it happened around 3 to 4x (times) since he's been here. He puts his call light on because he really needs to go to the bathroom and has to go right when he puts it on. Resident stated that the longest he's waited on 2 responses was around 30 minutes. During an interview on 4/29/2026 at 2:04 PM, Registered Nurse Manager (RNM) PP stated she was unaware of R74 having to wait for a long time for help and having to sit in his soiled brief. During an interview on 4/29/2026 at 2:04 PM, Registered Nurse Manager (RNM) PP stated that R74 would yell if he needs something but she didn't hear about him having any concerns with CNAs not responding to his needs or changing him when soiled. During an interview on 4/30/2026 at 2:46 PM, MDS LLL stated that R74 didn't say anything to her about waiting for a long time for help until he spoke to the State Surveyor the other day. MDS LLL said he used his call light and asked for help verbally. During an interview on 4/29/2026 at 4:11 PM this surveyor discussed R74's staffing concerns that were found during the survey with Director of Nursing (DON) B and she stated she was unaware of his concerns prior to this week. During an interview 04/30/2026 2:43 PM, Social Service Director (SSD) SS stated that she was unaware of R74 waiting for a while for help until he mentioned something to the State Surveyor. SSD SS stated that SSA RR checked on him and worked with him more often. SSD SS reported that concerns are brought up daily at their interdisciplinary meetings. During an interview on 4/30/2026 at 3:06 PM, Nursing Home Administrator (NHA) A stated that MDS LLL told her about R74's complaint while talking to the State Surveyor so she filled out the grievance form. NHA A stated she was unaware he had complaints about sitting in soiled brief for a while before anyone could help him and thought it was only to use the bathroom. Review of the Dignity and Respect Policy dated 7/11/2018 revealed Policy: It is the policy of this facility that all residents be treated with kindness, dignity and respect. Procedure:1. The staff shall display respect for Resident's.and dignity as human beings. are elicited and respected by the facility. Review of the Call Light Policy dated 7/11/2018 revealed Policy: It is the policy of this facility to provide the resident a means of communication with nursing staff. Procedure:1. All facility personnel must be aware of call lights at all times. 2. Facility shall answer call lights in a timely manner.

Based on observation, interview, and record review the facility failed to ensure residents were assess to be appropriate for self-administration of medications for 2 (Resident #5 and Resident #34) of 10 residents reviewed for medication administration resulting in medications being left unsecured in resident rooms, residents self-administering medications without staff assessment, and the potential for negative outcomes from taking/applying too much or too little medications. Findings include:Resident #5 Review of an admission Record revealed Resident #5 was a female who originally admitted to the facility on [DATE] and had pertinent diagnosis which included: acute diastolic heart failure. Review of a Minimum Data Set (MDS) assessment for Resident #5, with a reference date of 2/27/26 revealed a Brief Interview for Mental Status (BIMS) score of 13/15 which indicated Resident #5 was cognitively intact.In an observation and interview on 4/29/26 at 12:15 PM, a white bottle of ipratropium bromide nasal solution was observed on Resident #5's bedside dresser. Resident #5 stated that is my nose spray. I am not sure if it came from here (the facility) or from home, they know I have it and I do use it every day, 2 or 3 times a day. Resident #5 reported the facility staff did not take it from her. Resident #5 reported the facility has a bottle of nose spray for her, and the bottle was different, it was brown, not white. Resident #5 stated Sometimes I use this bottle (indicating the white one on her bedside stand) and other times I use the one from the facility. Review of Order summary report for Resident #5 revealed . Ipratropium Bromide Nasal solution 0.06% 2 sprays in each nostril three times a day for allergies with an order date of 2/22/26.In an interview on 4/30/26 at 8:55 AM, Licensed Practical Nurse (LPN) FF reported she had a male resident who was assessed to self-administer medications, and he was the only person she was aware of in the building that was allowed to self-administer any medications.In an interview on 4/30/26 at 9:13 AM, Assistant Director of Nursing (ADON) F reported no residents were able to self-administer medications. ADON F reported if a resident was going to self-administer medications, the resident needed to be assessed, the clinical team needed to discuss the resident at risk management, the provider needed to agree to the self-administration, and there had to be a physician order for self-administration.Review of Resident #5's medical record revealed no noted assessment or order for self-administration of medications.In an interview on 4/30/26 at 12:59 PM, Director of Nursing (DON) B reported her expectations were that a resident was assessed, the provider had given an order, and a care plan was in place for self-administration of medications. DON B reported Resident #5 had not been assessed, did not have a care plan in place and did not have an order to self-administer medications.Resident #34 Review of an admission Record revealed Resident #34 was a female who originally admitted to the facility on [DATE] and had pertinent diagnosis which included: chronic obstructive pulmonary disease (COPD). Review of a Minimum Data Set (MDS) assessment for Resident #34, with a reference date of 3/20/26 revealed a Brief Interview for Mental Status (BIMS) score of 12/15 which indicated Resident #34 was cognitively intact.In an observation and interview on 4/28/26 at 10:34 PM, a box with a bottle of nose spray was observed on Resident #34's over the bed table, at the end of her bed. Resident #34 reported the night nurse from the evening before had left it there after she used it. Resident #34 stated she said she was going to come back and grab it and she never did. Resident #34 reported the nurses will give her the nose spray to use and then come back and grab it when she was done.Review of Order Summary Report for Resident #34 revealed .Fluticasone Propionate Nasal Suspension 50 MCG (micrograms) 1 spray in both nostrils every morning and at bedtime. with a start date of 3/27/2026.In an interview on 4/29/26 at 10:54 AM, LPN KK reported a resident had to be assessed and a physician order needed to be in place for a resident to self-administer medications. LPN KK reported she did not have any residents on the north unit that self-administered medications.On 4/30/26 at 8:47 AM, a brown bottle of nasal spray with a label revealing Resident #34's name was observed on the over-the-bed table in Resident #34's room. Resident #34 was sleeping in the bed.Review of Resident #34's medical record revealed no noted assessment or order for self-administration of medications.In an interview on 4/30/26 at 12:59 PM, Director of Nursing (DON) B reported her expectations were that a resident was assessed, the provider had given an order, and a care plan was in place for self-administration of medications. DON B reported Resident #34 had not been assessed, did not have a care plan in place and did not have an order to self-administer medications.

Based on observation, interview, and record review, the facility failed to honor resident choice for getting up in the morning by 10 AM for 1 resident (Resident #3), of 19 residents reviewed for choices, resulting in the potential for this resident to not meet her highest practicable physical, mental, and psychosocial well-being.Findings include: Resident #3 (R3)Review of the admission Record and Minimum Data Set (MDS) dated [DATE] revealed R3 admitted to the facility on [DATE] with pertinent diagnoses including multiple sclerosis (autoimmune disease where immune system damages the area around the nerves in the brain and spinal cord), anxiety, and depression. Brief Interview for Mental Status (BIMS) reflected a score of 15 out of 15 which indicated R3 was cognitively intact. During an interview on 4/29/2026 at 7:49 AM, R3 was lying on her bed. R3 stated that they only had 2 CNAs (Certified Nursing Assistants) for 24 residents down on her unit and it was hard for the staff to meet all the residents' needs. R3 said that the shower aide got pulled a lot and then the CNAs found it hard to get showers done that day. R3 said she wanted to get up at 10 AM every day but they didn't get her up until 11 AM many days and she was usually the last one up. During another interview on 4/30/2026 at 7:42 AM, R3 stated that she didn't get up until 11:25 AM the day before. R3 stated that usually it isn't until 11:30 AM that she gets up. R3 said this was a daily occurrence and filing a grievance didn't help. Review of R3's Grievance dated 3/31/2026 revealed . Date Administrator received: 3/31/2026. Administrator assigned to: RNM PP. Investigation: Spoke with CNA (name omitted) and she has not been able to get her up at desired time the last two days. It is planned for tomorrow to have her up at 10 AM to attend an activity. This is arranged between the resident and CNA. Resolution: If we know don't have shower aid we'll make plans for what time resident wants to be up. Statement written by Regional Nurse Consultant (RNC) VV dated 3/31/2026 revealed RNC went and met with resident (R3)-states she regularly gets her shower which is scheduled on second shift. She states that there is still a delay in getting up for the day which she attributes to staffing. She has the desire to get up at 10 AM and some days she hasn't gotten up until 12 but, I get it because there isn't enough staff. RNC thanked her for communicating her concerns and assured her that we will address her concerns with facility leadership.During an interview on 4/29/2026 at 2:04 PM, Registered Nurse Manager (RNM) PP stated that R3 filed a grievance a few weeks ago because she liked to get up by 10 AM every day and she didn't get up that day until much later because the shower aide was pulled. RNM PP said staffing was bad that morning and the CNAs got her up the next day and she didn't hear that R3 hadn't been up by 10 AM since then. During an interview on 4/29/2026 at 4:11 PM, this surveyor discussed the staffing concerns that were found during the survey with Director of Nursing (DON) B and she said she was unaware of R3 concerns until this week.Review of the Dignity and Respect Policy dated 7/11/2018 revealed Policy: It is the policy of this facility that all residents be treated with kindness, dignity and respect. Procedure: 2. Schedules of daily activities allow maximum flexibility for residents to exercise choices about what they will do and when they will do it. Residents' individual preferences. are elicited and respected by the facility.

Based on interview and record review the facility failed to notify a resident responsible party regarding a change in condition for 1 (R303) of 3 residents reviewed for change in condition resulting in the responsible party not receiving x-ray results and knowing extent of injury.Findings include:According to R303's Minimum Data Set (MDS) dated [DATE], the resident was cognitively impaired as indicated by a score of 8/15 on his BIMS (Brief Interview Mental Status).Review of R303's Progress Note dated 5/26/26 at 12:45 PM revealed, .resident observed on the floor laying on left side with head raised off floor. With left hip and left shoulder resting on footrest.resident stated left shoulder hurt.New order for stat left hip and left shoulder x-ray.Family Member (FM) P arrived at facility.Review of R303's Progress Note dated 5/27/26 at 12:34 PM, revealed, .x-ray results show no fracture or dislocations. It was noted the resident's representative was not documented as being contacted regarding the radiograph results.Review of R303's Radiology Results Report, examination date: 5/26/26 at 8:41 PM, reported date: 5/27/26 6:04 AM, revealed x-rays were taken for R303's left hip and pelvis. Findings included left shoulder to have no recent fracture or dislocation. Left hip had no recent fracture or dislocation.During an interview on 5/27/26 at 1:00 PM, Family Member (FM) P stated, (R303) fell yesterday, 5/26/26, staff were supposed to have x-rays done yesterday and no one has told me the results yet. I waited there for 4 hours and no x-ray was done. The nurse told me it would be later than 5:30 PM and I had an appointment I had to go to. I was told I would be called with the results and go from there to plan for treatment. I never got a call. I still do not know if the x-rays were done or what the x-ray results are. I've been worried about the results. How can the facility take care of my father if they don't know what is wrong with him. How can I make decisions for him if I don't know what is wrong with him? I don't want him to be in pain.During an interview on 5/28/26 at 4:00 PM, Director of Nursing (DON) B reported R303's FM P had been called and an apology was made for not notifying her prior to today of R303's x-ray results taken on 5/26/26.Review of facility policy, Change in Condition-Reporting adopted 7/11/2018, revealed, .To clearly define guidelines for timely notification of a change in resident condition.Licensed nurse will notify, consistent with the resident's authority, the resident's representative of change of condition and what steps have been taken.Resident plan of care will be updated.Review of R303's Care Plan, dated 4/21/26, revealed R303 was at Risk for Falls related to dementia, muscle wasting, Acute kidney failure, Parkinson's disease, physical debility, diabetes mellitus, diabetes mellitus II, cardiomyopathy, history of repeated falls, atrial fibrillation, history of previous head injury (fall on 4/23/20). The goal was R303 to remain free of serious fall related injury through the review date. It was noted; an intervention was not placed in the resident's care plan to provide immediate safety measures for a fall on 5/26/26.

Based on observation, interview, and record review the facility failed to develop a comprehensive resident-specific treatment plan for Enhanced Barrier Precautions (EBP) for 1 resident (Resident #306) of 4 residents reviewed for comprehensive care plans resulting in the potential for unmet care needs and the spread of infection to a vulnerable population.Findings include:Resident #306 (R306)Review of the admission Record and Minimum Data Set (MDS) dated [DATE] revealed R306 admitted to the facility on [DATE] with pertinent diagnoses including benign prostatic hyperplasia with lower urinary tract symptoms (enlargement of prostate gland causing squeezing of the bladder). Brief Interview for Mental Status (BIMS) reflected a score of 15 out of 15 which indicated R306 was cognitively intact.During an observation on 5/27/2026 at 9:13 AM, R306 was observed to be lying on his bed and had a urinary catheter (thin flexible tube inserted into the bladder to drain urine). An Enhanced Barrier Precautions (EBP) sign was observed to be on R306's door indicating Everyone must clean their hands before entering and leaving the room. Providers and Staff must also wear gloves and a gown for the following high contact resident activities. device care or use. urinary catheter. Review of R306's physician order revealed . Enhanced Barrier Precautions every shift for foley urinary catheter placement. Initials indicate precautions maintained throughout shift. Start date 5/17/2026.Review of R306's care plan revealed that there was no care plan for enhanced barrier precautions. During an interview on 5/28/2026 at 11:05 AM, Director of Nursing (DON) B' stated it was the expectation when a resident was under EBP that the EBP sign went up on the door, personal protective equipment was available, an order was put in the chart, and a care plan was developed. DON B said anyone from the floor nurse all the way to DON B could put the care plan in. DON B was aware that R306 did not have a care plan for EBP in his chart. Review of the Care Planning Policy with an updated date of 1/15/2020 revealed . It is the policy of this facility that the interdisciplinary team (IDT) shall develop a comprehensive care plan for each resident. Procedure. 8. The Care Plan will be reviewed and revised by the IDT after each assessment and as the resident's care needs change.

Based on observation, interview and record review, the facility failed to review and revise care plan interventions to accurately reflect resident care needs for 1 (Resident #5) of 19 residents reviewed for revision of care planning, resulting in a potential for staff not knowing how to properly care for the resident.Findings include:Resident #5Review of an admission Record revealed Resident #5 was originally admitted to the facility on [DATE] with pertinent diagnoses which included: congestive heart failure (condition in which blood may back up/fluid may accumulate in the body causing shortness of breath, fatigue, swelling) and peripheral vascular disease (circulation disorder involving narrowing or blocking of vessels which may cause numbness in the lower legs).Review of a Minimum Data Set (MDS) assessment for Resident #5 with a reference date of 2/27/26, revealed a Brief Interview for Mental Status (BIMS) assessment score of 13/15, which indicated the resident was cognitively intact. Section GG revealed Resident #5 required substantial/maximal (helper does more than half the effort) to transfer from the bed to a wheelchair and to/from the toilet.Review of a Care Plan for Resident #5 with a reference date of 1/18/26 revealed the following focus/goal/interventions: Resident has limited physical mobility r/t (related to) CHF (congestive heart failure).Goal: Resident will remain free of complications related to immobility.Interventions:.Ambulation: The resident is able unable (sic) .Transfer: The resident requires maximum assistance (helper provides more than half the effort) with four wheeled walker for sit to stand transfers and surface transfers.During an observation on 4/28/26 at 12:54pm, Resident #5 walked down the hall using a wheeled walker as an unknown therapy staff member walked next to her. The staff member provided no physical assistance as Resident #5 ambulated.In an interview on 04/29/2026 at 2:30pm, Occupational Therapy Assistant (COTA) III reported changes in a resident's mobility were discussed during daily Interdisciplinary Team meetings and care need determinations were made at that time.In an interview on 4/30/26 at 2:11pm, Assistant Director of Nursing (ADON) F reported the care plan for Resident #5 did not accurately reflect the resident's current level of independence/need for assistance with transferring and ambulation.In an interview on 4/29/26 at 2:39pm, Rehabilitation Director (RD) ZZ reported Resident #5 was currently able to transfer herself and ambulate with stand by assistance. RD ZZ confirmed stand by assistance meant the resident needed only light touching or verbal cues for these tasks.Review of a Care Planning policy with a reference date of 1/15/20 revealed Policy: It is the policy of this facility that the interdisciplinary team (IDT) shall develop a comprehensive care plan for each resident .the care plan will be reviewed and revised by the IDT after each assessment and as the resident's care needs change.

Based on observation, interview, and record review the facility failed to ensure interventions were implemented to prevent the development of and/or worsening of pressure ulcers in 1 (Resident #88) of 2 residents reviewed for pressure ulcers resulting in the potential for the development of and/or the worsening of an existing pressure ulcer.Findings include: Resident #88Review of an admission Record revealed Resident #88 was a female who was originally admitted to the facility on [DATE] and had pertinent diagnoses which included: dementia, history of falling, and history of/healed fracture.Review of a Minimum Data Set (MDS) assessment for Resident #88, with a reference date of 1/30/2026 revealed Mobility, Resident #88 was dependent on staff for mobility, and Skin conditions, Resident #88 was at risk for developing pressure ulcers.In an observation and interview on 4/28/26 at 12:30 PM, Resident #88 was sitting in a broda chair (a high back reclinable wheelchair), and her heel protectors (soft padded material designed to protect the skin of the heels) light green in color, were dislodged from her feet and were noted to be around her legs. Family Member (FM) AAA reported Resident #88's heel boots shift when she moved, and he was concerned Resident #88 continued to get wounds. FM AAA reported Resident #88 always had to wear her boots for her heels to prevent her wound from getting worse or developing others.In an interview on 4/28/26 at 3:30 PM, Certified Nurse Assistant (CNA) K reported Resident #88 should wear the boots (heel protectors) on her feet all the time.Review of Care Plan for Resident #88 revealed Focus.Resident has potential impairment to skin integrity.Intervention: off-loading boot cushions to bilateral (both) lower extremities at all times as tolerated. initiated on 7/10/2025.Review of Order Summary for Resident #88 revealed .heel protector boots on at all times every shift with a start date of 8/7/2025.On 4/30/26 at 8:07 AM, Resident #88 was observed sitting in her broda chair, in the dining room, and she was not wearing any heel protectors. Her heels were observed directly in contact with the foot cradle of the broda chair. On 4/30/26 at 9:35 AM, Resident #88 was observed sitting in her broda chair, in her room, and she was not wearing any heel protectors. Her heels were observed directly in contact with the foot cradle of the broda chair. A set (2) of heel protectors light green in color and 2 sets of dark green colored heel protectors were observed in Resident #88's room.On 4/30/26 at 12:23 PM, Resident #88 was observed sitting in her broda chair, in the dining room, and she was not wearing any heel protectors. Her heels were observed directly in contact with the foot cradle of the broda chair.Review of Medication Administration Record (MAR) for Resident #88 for the month of April 2026 revealed .heel protector boots on at all times every shift. was documented as completed by Agency-Licensed Practical Nurse, (LPN) BBB.In an interview on 4/30/26 at 12:24 PM, Director of Nursing (DON) B reported the nurses and CNAs were responsible to ensure that Resident #88's heel protectors were in place as tolerated. DON B stated she was going to go investigate why Resident #88 was not wearing her heel protector boots.On 4/30/26 at 12:36 PM, Registered Nurse Manager (RNM) QQ was observed carrying a light green pair of heel protectors towards the dining room where Resident #88 was eating lunch.

Based on observation, interview and record review, the facility failed to maintain an environment free from hazards for 2 (Resident #5 and #48) of 5 resident reviewed for accidents, resulting in an increased risk for falls. Findings include: Resident #5 Review of an admission Record revealed Resident #5 was originally admitted to the facility on [DATE] with pertinent diagnoses which included: congestive heart failure (condition in which blood may back up/fluid may accumulate in the body causing shortness of breath, fatigue, swelling) and peripheral vascular disease (circulation disorder involving narrowing or blocking of vessels which may cause numbness in the lower legs). Review of a Minimum Data Set (MDS) assessment for Resident #5 with a reference date of 2/27/26, revealed a Brief Interview for Mental Status (BIMS) assessment score of 13/15, which indicated the resident was cognitively intact. Section GG revealed Resident #5 required substantial/maximal (helper does more than half the effort) to transfer from the bed to a wheelchair and to/from the toilet. Review of a Care Plan for Resident #5 with a reference date of 2/23/26 revealed the following focus/goal/interventions: 1. Resident at risk for falls.Goal: Resident will remain free from fall related injury.Interventions.provide assistance as needed for mobility tasks.anticipate and meet resident's needs. Review of a Fall Risk Assessment for Resident #5 with a reference date of 3/30/26 revealed a score of 40, moderate risk for falling. During an observation on 4/28/26 at 12:54pm, Resident #5 walked down the hall using a wheeled walker as an unknown therapy staff member walked next to her. Resident #5 was not wearing a gait belt (safety device typically made of canvas or nylon, placed around a patient's waist to allow caregivers to safely stabilize and support individuals with limited mobility or balance). In an interview on 4/29/26 at 12:11pm Licensed Practical Nurse (LPN) FF reported if a resident was not deemed as Independent with ambulation (walking) they should wear a gait belt when walking with staff. In an interview on 4/29/26 at 2:39pm, Rehabilitation Director (RD) ZZ reported Resident #5 was currently assessed as able to ambulate with stand by assistance. RD ZZ confirmed this meant Resident #5 needed cues or touching as she walked. When further queried, RD ZZ reported she would recommend using a gait belt when staff ambulated with her. In an interview on 4/30/26 at 2:11pm, Assistant Director of Nursing (ADON) F reported Resident #5 was documented as needing assistance of 1 person during ambulation. ADON F confirmed that any resident who was not assessed as Independent for ambulation, should wear a gait belt when ambulating with staff. ADON F confirmed Resident #5 had not been assessed as Independent for ambulation. Review of a Gait belt-Transfer Belt policy with a reference date of 7/11/18 revealed Policy: It is the policy of this facility to: Provide safety for the unsteady and/or confused resident. Prevent injuries to employees and residents (.resident falls or fractures) .Ambulation: 1. Place gait belt around resident's waist.grasp belt at the back.observe for general weakness in body and gait (pattern or manner of walking) . Resident #48 Review of an admission Record revealed Resident #48 was a female who originally admitted to the facility on [DATE] and had pertinent diagnoses which included: hypertension (high blood pressure), cerebral infarction (stroke), and vertigo (dizziness). Review of a Minimum Data Set (MDS) assessment for Resident #48, with a reference date of 1/30/26 revealed a Brief Interview for Mental Status (BIMS) score of 3/15 which indicated Resident #3 was severely cognitively impaired. On 4/28/26 at 10:22 AM, Housekeeper (HSK) CC was observed mopping the floor in Resident #48's room. Resident #48 was observed sitting in the chair in her room with her over the bed table positioned in front of her and her 4 wheeled walker across the room out of reach. When HSK CC finished mopping the floor, she exited the room and did not place any wet floor signage. The floor was visibly wet. Review of Care Plan for Resident #48 revealed Focus.Resident at risk for falls r/t (related to) confusion, decondition, unaware of safety needs.Interventions.provide assistance as needed for mobility tasks and assure utilization of appropriate devices.Ensure that resident is wearing appropriate footwear when ambulating.all initiated on 3/5/2025. Review of Fall Risk Assessment for Resident #48 dated 4/21/26 revealed .High Risk for Falling with a score of 80.0, History of falling.Yes.Ambulatory Aid.Uses crutches, cane or walker.Gait.weak.Mental status.overestimates or forgets limits.Morse Fall Scoring High Risk 45 and higher. On 4/28/26 at 10:25 AM, Resident #48 was observed walking from her room into the hallway, without the use of her 4 wheeled walker. Certified Nurse Assistant (CNA) I was observed walking from the other side of the unit to Resident #48. CNA I said to Resident #48 Where is your walker? We don't want you to fall. Oh look, your floor is wet too. On 4/28/26 at 10:28 AM, the floor in Resident #48's room remained visibly wet with no wet floor sign present. In an interview on 4/30/26 at 10:00 AM, HSK CC reported she did not use wet floor signs when she mops floors. HSK CC stated most residents would wait to get up until the floor was dry. HSK CC reported she would ring out the mop, and it would be mostly dry, and she would not need to put up a wet floor sign. HSK CC reported if the floor was wet it wasn't wet for too long. In an interview on 4/30/26 at 3:11 PM, Nursing Home Administrator (NHA) A reported she was currently acting as the director of housekeeping as the position was vacant and was still learning how the department was supposed to run. NHA A reported her expectations were that wet floor signs were used every time.

Based on interview and record review the facility failed to ensure pre and post dialysis treatment assessment and monitoring communication between themselves (the facility) and the dialysis provider (Name Omitted) was maintained for 1 (Resident #11) of 1 resident reviewed for dialysis services resulting in the potential for unrecognized adverse reactions or resident decline due to adverse reactions of dialysis treatments and disruption in the continuity of care.Findings include: Resident #11Review of an admission Record revealed Resident #11 was a female who originally admitted to the facility on [DATE] and had pertinent diagnoses which included: Type 2 diabetes (a chronic conditions including insulin resistance and high blood sugar levels) and dependence on renal dialysis (a medical treatment that removes waste products, excessive fluids, and toxins from the blood when the kidneys are unable to perform those functions naturally).Review of Care Plan for Resident #11 revealed .Resident on hemodialysis r/t (related to) kidney failure.Interventions.dialysis appointment every Tue, (Tuesday), Thur (Thursday) Sat (Saturday). Have ready by 11:00 at the front door and send meal with patient.Do not take blood pressure or blood specimens from LEFT arm, Monitor AV (arteriovenous a connection between an artery and a vein) shunt site for bruit and thrill as directed. Reprot any changed to dialysis center and/or physician. with an initiation date of 7/29/2025 and 8/19/2025.Review of Order Summary for Resident #11 revealed .Hemodialysis per physician order @ (at) (Name Omitted) on Tuesday, Thursday, and Saturday with a start date of 7/29/2025.Review of Dialysis Communication Forms for Resident #11 from the dates of 3/26/26 through 4/28/26 revealed communication forms were documented 7/15 times.Review of Dialysis Communication Form for Resident #11 dated 4/2/26 was noted to be blank in the area to be completed by the facility.Review of Resident #11's electronic medical record Progress Notes revealed no documentation was noted for pre or post dialysis assessment on 9/15 scheduled dialysis treatment days.In an interview on 4/29/26 at 8:31 AM, Resident #11 reported the nurses at facility did not send the dialysis form as they should, and she brings back whatever was sent with her. Resident #11 reported the nurses do an assessment before she goes for dialysis treatment, but they do not do an assessment when she gets back to the facility.On 4/29/28 at 8:31 AM, review of the dialysis binder in Resident #11's bag on the back of her wheelchair revealed one communication form dated 4/23/26.In an interview on 4/29/26 at 10:43 AM, Licensed Practical Nurse (LPN) KK reported a communication sheet including vital signs, weight, and any medication changes needed to be completed before Resident #11 went to dialysis. LPN KK reported Resident #11 should have her weight and vital signs checked when she comes back from a dialysis treatment. LPN KK reported she documented when Resident #11 left the facility and when she returned from dialysis.In an interview on 4/30/26 at 12:38 PM, Agency- LPN BBB reported Resident #11 was picked up at 11:00 AM and she was not sure what appointment she went to. Agency-LPN BBB reported there was a communication form that needed to be completed for a resident going to dialysis. When queried, Agency-LPN BBB stated I didn't send that (communication form for dialysis), I don't know where she (Resident #11) went, it might be to dialysis.In an interview on 4/30/26 at 12:46 PM, Director of Nursing (DON) B reported weight, and vital signs should be completed and documented on a communication form before a resident went to dialysis treatment. DON B reported when a resident returned from dialysis treatment, the nurse should review the communication form, check the resident, complete an assessment, and visualize the AV site. When queried, DON B reported there was no place to document a dialysis assessment, and the information should be put into a nurses note/progress note. DON B reported she did not expect to have a note related to vital signs and weight before dialysis treatment, that information should be on the communication form and they communication form was to be kept in the resident's record. DON B reported her expectations were that the nurses assessed Resident #11 for a bruit and thrill and that the communication form needed to be completed and scanned into the resident's record.

Based on interview and record review, the facility failed to find a pharmacy recommendation for 1 resident (Resident #86) of 5 residents reviewed for medications resulting in the potential for the resident to experience avoidable medication side effects and/or receive unnecessary medications. Findings include: Resident #86 (R86)Review of the admission Record and Minimum Data Set (MDS) dated [DATE] revealed R86 admitted to the facility on [DATE] with pertinent diagnoses including depression, psychotic disorder with delusions (mental health condition by holding false beliefs), agoraphobia (intense, irrational fear of being in situations where escape might be difficult or unavoidable), anxiety and post-traumatic stress disorder (mental health condition triggered by witnessing terrifying, life threatening or violent events). Brief Interview for Mental Status (BIMS) reflected a score of 15 out of 15 which indicated R86 was cognitively intact.Review of R86's Medication Regimen Review completed by the pharmacist on 11/25/2025 revealed A. Criteria: See report for any noted irregularities. B. Comment: Chart reviewed, recommendations sent to the physician.Review of R86's chart revealed no pharmacy recommendation for 11/25/2025. During an interview on 4/30/2026 at 2:50 PM, Nursing Home Administrator stated that they couldn't find the pharmacy recommendation from 11/25/2025. During an interview on 4/30/2026 at 3:16 PM, Director of Nursing (DON) B stated that the pharmacist reviews resident medications monthly and then emails the recommendations to the facility and then it gets dispersed to the appropriate department head/nurse manager and they follow-up with the doctor who signs the recommendation on whether he agrees or disagrees and then it's uploaded in the chart. DON B said she is getting the pharmacy recommendations consistently now and didn't get it before. DON B reported they couldn't find the pharmacy recommendation for R86 from 11/25/2025.Review of the Medication Regimen Review (MRR) Policy dated 7/11/2018 revealed Policy:It is the policy of this facility that: 1. The drug regimen of each resident must be reviewed at least once a month by a licensed pharmacist and 2. The pharmacist must report any irregularities to the attending physician, facility medical director and the Director of Nursing Services. 3. These reports must be acted upon. 5. Upon conducting the MRR, the pharmacist may identify and report irregularities in one or more of the following categories: The Pharmacist MRR and nursing medication documentation review reports are processed as follows: A. MRR recommendations to physician: The report is provided by the Pharmacist or facility to the responsible physicians and the Director of Nursing Services within seven (7) working days of review. The physician provides a written response to the report to the facility within one (1) month after the report is sent. A copy of the report is kept by the facility until the physician's signed response is returned. The facility maintains copies of signed reports on file in the residents medical record. B. Nursing Documentation Review: The report is provided by the Pharmacist within seven (7) working days of review. Nursing personnel provide a written response to the review within two (2) weeks after the report is received. A copy of the report is kept by the facility until the nurse's response is returned. Nursing staff response to the report is provided to the Pharmacist for review and then filed by the facility. The facility maintains copies of completed reports on file in the resident's medical record.

Based on observation, interview, and record review the facility failed to maintain a medication error rate of less than 5% (total error rate of 10%) in 2 of 8 sampled residents (Resident #48 and Resident #59) reviewed for medication administration, resulting in the potential for reduced medication effectiveness and increased risk of adverse reaction and/or side effects.Findings include: Resident #48Review of an admission Record revealed Resident #48 was a female who originally admitted to the facility on [DATE] and had pertinent diagnoses which included: hypertension (high blood pressure), cerebral infarction (stroke), and vertigo (dizziness).Review of a Minimum Data Set (MDS) assessment for Resident #48, with a reference date of 1/30/26 revealed a Brief Interview for Mental Status (BIMS) score of 3/15 which indicated Resident #3 was severely cognitively impaired.During an observation and interview on 4/30/26 at 8:19 AM, Agency- Licensed Practical Nurse (LPN) BBB dispensed medications for Resident #48. Agency-LPN BBB did not dispense nor administer the ordered Lasix 40 mg (milligrams) by mouth in the morning. When queried, Agency-LPN BBB reported that Resident #48's Lasix was on hold and was not to be given.Review of Order Summary for Resident #48 revealed .Lasix Oral tablet 20 mg (furosemide) give 1 tablet by mouth two times a day for LE (lower extremity) edema, weight gain ordered on 10/17/26 and noted to be on hold.Lasix oral tablet 40 mg (furosemide) Give one tablet by mouth in the morning for fluid retention. with a start date of 4/28/26.Review of Medication Administration Record (MAR) for Resident #48 for April 2026 revealed Agency-LPN BBB documented that she had administered 40 mg of Lasix to Resident #48 as ordered on 4/30/2026 at 9:00AM. Resident #59 Review of an admission Record revealed Resident #59 was a female who originally admitted to the facility on [DATE] and had pertinent diagnoses which included: Ileostomy (relocation of the small bowel to the surface of the abdomen creating an opening), ulcerative colitis (chronic inflammation of the bowels), peritoneal abscess (a localized collection of pus that forms within the abdominal cavity) and dehydration.Review of a Minimum Data Set (MDS) assessment for Resident #59, with a reference date of 3/6/26 revealed a Brief Interview for Mental Status (BIMS) score of 15/15 which indicated Resident #59 was cognitively intact.During an observation and interview on 4/30/26 at 8:56 Am, Agency-LPN BBB spoke to Resident #59 who requested pain medications. Agency-LPN BBB reported that Resident #59 was out of pain medications, and she did not have access to the back up narcotic box to pull medications. Agency-LPN BBB reported Director of Nursing (DON) B would have to pull the narcotic medication from the back up box.During observation and interview on 4/30/26 at 9:35 AM, Agency-LPN BBB did not dispense lactated ringers 125 mL (milliliters) during medication administration.Review of Order Summary for Resident #59 revealed .Lactated Ringers intravenous solution.use 125 cc (ML) intravenously every hour for hydration for high output ileostomy with a start date of 4/29/2026.Oxycodone HCl oral tablet 5 Mg (milligrams) give 2 tablets by mouth every 4 hours as needed for moderate pain.with a start date of 4/7/2026.Review of MAR for Resident #59 for April 2026, printed at 11:04 AM, revealed Agency-LPN BBB documented she had administered Lactated Ringers 125 mL at 0900, and there was no documentation indicating Resident #59 had received her requested as needed pain medications two hours after requesting them.

This citation pertains to intake #2728846Based on interview and record review, the facility failed to provide adequate care to prevent skin breakdown and the worsening of pressure ulcers in 1 of 3 (Resident #101) residents reviewed for pressure ulcers, resulting in the worsening of a pressure ulcer. Findings include:Resident #101Review of an admission Record revealed Resident #101 was originally admitted to the facility on [DATE] with pertinent diagnoses which included need for assistance with personal care and muscle weakness. Review of Resident #101's Care Plan revealed, Resident has potential for impairment to skin integrity r/t (related to) TBI (traumatic brain injury) post MVA (motor vehicle accident. Date Initiated: 06/16/2025. Goal: Resident will maintain intact skin with no skin breaks through the next review date. Interventions: Alternating pressure mattress to bed. Check for comfort and proper inflation with care. Report any concerns. Date initiated: 12/9/25. Elevate heels off bed surface while at rest in bed as tolerated, encourage good nutrition and hydration in order to promote healthier skin, Keep skin clean and dry. Use lotion on dry skin. Do not apply on open injuries, Monitor/document location, size and treatment of skin injury. Report abnormalities, failure to heal, s/sx (signs and symptoms) of infection, maceration etc. to MD (Medical Doctor). Observe skin daily with care activities. Report any changes in coloration, integrity, etc. to nurse. Date initiated: 6/16/25 . Review of Resident #101's Braden Scale for Predicting Pressure Sore Risk assessment dated [DATE] revealed that Resident #101 had a score of 12, indicating that he was High Risk for skin breakdown. Review of Resident #101's Nursing admission Screening dated 6/13/25 revealed, .Skin: Note all skin issues: (there were no skin issues documented) Notes: Skin intact. Review of Resident #101's Nursing admission Screening dated 9/16/25 revealed, .Skin: Note all skin issues: (there were no skin issues documented) Notes: Skin intact with some dryness noted. Review of Resident #101's Hospital Surgery consult dated 10/20/25 revealed, Surgery Consultation . (Resident #101) . presented to the hospital from his SNF (skilled nursing facility) for sepsis (Sepsis is a life-threatening reaction to an infection that causes your immune system to harm healthy tissues and organs) found to have a bilateral pneumonia (infection of the lungs) . Overnight he had a temperature of 100.2 therefore prompting a skin search for other possible sources of infection given his resolving pneumonia. A small sacral wound was found .general surgery was consulted for the sacral wound . From nursing and IM (internal medicine) physician, it drained purulent (pus) fluid earlier in the day with foul smelling odor . Physical Exam: Warm, mepilex (type of dressing) dressing covering sacral area, small 2 cm wound with scab over the top, no drainage or fluctuant area noted. Wound appears to have scabbed over the previous draining area .Plan: Local wound care as needed, Mepilex dressing and offloading area as much as possible. No acute surgical intervention at this time . Review of Resident #101's Nursing Re- admission Screening dated 10/27/25 revealed, . Skin: Note all skin issues: (there were no skin issues documented) Notes: dry skin noted. Noted there were no skin issues related to Resident #101's sacral skin alteration previously noted in the hospital records. Review of Resident #101's Hospital records dated 11/2/25 revealed, .Physical Exam: Skin: Lesion (Grade 1 pressure ulcer which does not appear to be acutely infected to the coccyx) present .Review of Resident #101's Nursing re-admission Screening dated 11/5/25 revealed, . Skin: Note all skin issues: (there were no skin issues related to Resident #101's sacral skin alteration previously noted in the hospital records). Left elbow: open area length 0.5 cm. Width: 0.3 cm. Notes: Dry skin to feet .Review of Resident #101's Skin Issues progress note dated 11/11/25 revealed, Skin issue #001: new skin issue: Location: right gluteus. Laterality/Orientation: Medial. Issue type: abrasion. Progress: new wound. Wound acquired in house. Signs and symptoms of infection: none. Painful: no. Length (cm-centimeters): 0.94. Width: 0.89. Depth: 0. Area: (cm2) 0.59. Undermining (tissue beneath the skin separates from the deeper wound bed, creating a pocket or shelf that extends under the wound edges, often making the wound larger than it appears on the surface.) No. Tunneling (narrow channel or tract extending from the surface into deeper tissue layers) No. Odor after cleaning: none. Surrounding tissue: fragile. Edema: No swelling or edema . #002: new skin issue: location: left gluteus. Laterality/Orientation: Medial. Issue type: abrasion. Progress: new wound. Wound acquired in house. Signs and symptoms of infection: none. Painful: no. Length (cm-centimeters): 6.7. Width: 2.28 Depth: 0. Area: (cm2) 11.58 Undermining (tissue beneath the skin separates from the deeper wound bed, creating a pocket or shelf that extends under the wound edges, often making the wound larger than it appears on the surface.) No. Tunneling (narrow channel or tract extending from the surface into deeper tissue layers) No. Odor after cleaning: none. Surrounding tissue: fragile. Edema: No swelling or edema .Review of Resident #101's Orders revealed, left gluteal abrasion cleanse with NS (normal saline), apply A&D ointment BID (twice a day) and leave OTA (open to air) every morning and at bedtime for wound care. Start date: 11/12/25 .Review of Resident #101's Hospital Wound Consult dated 11/17/25 revealed, . Wound Assessment: Date: 10/15/25 . Primary wound: Pressure. Present on admission: yes. Pressure injury stage: U (unstageable) . wound site assessment: Black; eschar (dead tissue); pink; dark purple. Color percent wound length (cm). 60 black eschar, 10 dark purple, 30 pink . Wound length: 7 cm, Wound width: 5 cm, Wound depth: 0.1 cm. Wound surface area: 27.49 cm^2 (centimeters squared) . Location: Right Heel. Present on admission: yes. Pressure injury stage: DTPI (Deep tissue pressure injury) .Wound site assessment: black. Wound length: 3 cm. Wound width: 5 cm. Wound depth: 0 cm. Wound surface: 11.78 cm^2 Location: Left Heel. Present on admission: yes. Pressure injury stage: cluster of two . Wound site assessment: Dark purple; black. Wound length: 3.5 cm. Wound width: 3 cm. Wound depth: 0 cm. Wound surface: 8.25 cm^2 .Recommendations for discharge: Outpatient wound clinic .Review of Resident #101's Progress note dated 11/21/25 revealed, . Skin assessment completed, no edema, dry, fragile skin noted. Multiple pressure injuries extending to coccyx extending to right and left buttock (unstageable), left heel, right elbow and left elbow Review of Resident #101's Progress note dated 11/21/25 revealed, Resident wound measures: Left heel: 2cm x1.125 cm, Right elbow: 3.5 cm x3cm, L (left) elbow: 5cmx1cm, Coccyx-7.5 cm x 9cm .Review of Resident #101's Progress note dated 11/21/25 revealed, . Okay to initiate treatments to coccyx (right and left buttock), left heel, right elbow, and left elbow .Review of Resident #101's Orders revealed, cleanse coccyx unstageable with wound wash, pat dry, apply nickel thick Santyl (wound treatment cream) to wound bed, cover with dry dressing, change daily and as needed one time a day for pressure injury. Start date: 11/22/25 . cleanse left elbow with wound wash, pat dry, apply dry dressing change daily one time a day for wound care. Start date: 11/22/25 .cleanse right elbow open area with wound wash, pat dry, apply dry dressing change daily one time a dayfor wound care. start date: 11/22/25 . betadine (topical antiseptic) BID (twice daily) to left heel wound #1 two times a day for wound care. Start date: 11/26/25 .betadine to left heel wound #2 BID two times a day for wound care. Start date: 11/26/25 .Review of Resident #101's Progress Note dated 11/25/25 revealed, (Wound Care Nurse Practitioner (WCNP) HH) in to assess resident right and left gluteal abrasions . 1. Coccyx pressure ulcer unstageable mechanically debrided (dead tissue removed) with 40% slough and 60% eschar with moderate amount of serosanguineous (thin, watery, pale pink to light red fluid that commonly drains from wounds) drainage. 8.6x9.x2 UTD. (unable to determine). Peri wound fragile. area declined while in hospital. 2. Left elbow stage 2 pressure injury 1.0x1.0x SF (superficial) 100% superficial with scant amount of serosanguineous drainage . 3. left medial heel DTI (deep tissue injury) 100% (sic) 1.2x0.8xUTD with no drainage .Review of Resident #101's Progress Note dated 12/9/25 revealed, left and right wound abrasion have combined into one coccyx wound .Review of Resident #101's Progress Notes dated 12/17/25 revealed, WCNP HH into (sic) assess resident. Left elbow stage 2 and right elbow area resolved. Coccyx wound unstageable community acquired PI (pressure injury) 7.6 x 7.5xUTD (unable to determine) post debridement (dead tissue removal). 10% granulation (newly formed connective tissue that develops on the surface of a wound during the healing process) tissue, 90 % slough (soft, yellowish or white dead tissue that impedes healing and requires removal for proper recovery) with moderate amount of serosanguineous drainage, positive for odor, peri-wound fragile declined. Left medial heel 1.0 x0.7xUTD DTI (deep tissue injury) 100% (sic) with no drainage. area calloused and stable. Left heel DTI now stage 3 1.0x0.4x0.1 100 % superficial improved . Review of Resident #101's January Treatment Administration Record (TAR) revealed, cleanse coccyx with dakins solution, pack with calcium alginate and cover with largesacral dressing every shift every shift for treatment. Noted that there were 9 treatments with missing documentation (not documented as completed or refused). During an interview at on 2/18/25 at 11:25 AM, Family Member (FM) PP reported Resident #101 did not have any skin issues when he was admitted to facility in June 2025. FM PP reported that Resident #101 required total assistance from staff with all care, and that he was not able to reposition himself. FM PP reported she frequently visited Resident #101 for 3 or more hours at a time, and every time she visited Resident #101, she never witnessed staff assist Resident #101 with repositioning or any other care. FM PP reported that she frequently voiced her concerns that Resident #101 was not receiving adequate care to the nurses, Unit Manager (UM), Director of Nursing (DON), and Social Worker (SW), but she felt that the facility staff did not take her concerns seriously. During an interview on 2/19/25 at 11:13 AM, Licensed Practical Nurse (LPN) N reported she had cared for Resident #101 frequently and confirmed that Resident #101 was dependent on staff for all care. LPN N reported Resident #101 had been in and out of the hospital due to several medical conditions while he was at the facility, and every time he was readmitted , the admitting nurse was responsible for completing an admission assessment which included a total skin assessment to ensure that the facility was aware of any new conditions that may have developed when Resident #101 was in the hospital. LPN N reported Resident #101 was always compliant with treatments, and he did not refuse care. LPN N reported she had provided treatment to Resident #101's coccyx wound before, but she could not recall the date. LPN N recalled that she had noted that Resident #101's coccyx wound was open and draining during a recent treatment that she had completed, but she thought that it was an old wound and she did not notify the provider regarding this. During an interview on 2/19/25 at 12:15 PM, Unit Manager (UM) W reported she was responsible for overseeing the care of Resident #101. UM W reported that Resident #101 had been in and out of the hospital several times, and that the facility had been monitoring his sacral area after they found abrasions on the area in November, and that when Resident #101 returned from the hospital on November 21, 2025, he had an unstageable pressure ulcer. UM W reported that the facility had WCNP P had assessed Resident #101's wounds on 11/12/25 and noted that Resident #101's coccyx wound was a stage 3, and that the facility then initiated treatments. When this writer queried as to why Resident #101's nursing re-admission assessment on 10/27/25 and 11/5/25 did not indicate that Resident #101 had a pressure ulcer on his coccyx, UM W reported that the nurse must have missed documenting this. UM W reported the facility staff were supposed to complete skin checks twice a week during showers, and that nurses were also supposed to complete weekly skin assessments. When this writer queried about Resident #101's missing shower sheets (sheets that aides document skin checks on during bath care) and weekly skin assessments, UM W confirmed that Resident #101 had missing skin assessments and shower sheets. UM W was unable to report how many weekly skin assessments Resident #101 had missed. UM W reported she was responsible for ensuring that the staff had completed skin assessments and shower sheets, and that she had been having ongoing issues with staff completing those tasks timely. UM W reported that she was not aware that Resident #101 had missing wound care treatments in his treatment administration record. UM W confirmed that the facility did not identify and begin treatment on Resident #101's coccyx wound until 11/12/25. UM W was unable to provide any documentation that the facility had assessed Resident #101's coccyx area prior to 11/11/25 when this writer queried for more documentation to verify that staff were assessing and monitoring Resident #101's sacral area for skin breakdown. UM W reported that she felt like the hospital was at fault for Resident #101's pressure ulcer development, and that the facility had just failed to accurately document their assessments and treatments. During an interview on 2/19/25 at 2:07 PM, LPN M reported that she frequently cared for Resident #101. LPN M confirmed that Resident #101 was dependent on staff for all care. LPN M confirmed that nurses were responsible for completing the weekly skin assessments for residents, and that the aides were responsible for completing skin checks during showers and letting the nurse know if they saw any new skin issues for the nurse to assess. LPN M reported that the aides were often not able to complete showers/baths for residents, and so they were not completing shower sheets twice a week as they were supposed to. LPN M reported that she knew that Resident #101 had been missing showers and skin assessments because she had been approached by his family a few times to ask when he had last had a shower and she would look and note that staff had documented not available or refused when he was available and did not refuse care. LPN M reported that it was common for staff at the facility to skip care and treatments at the facility because they were often short staffed and unable to get to it. During an interview on 2/20/26 at 12:05 PM, LPN P reported that she was familiar with Resident #101 and cared for him frequently. LPN P confirmed that Resident #101 was not getting showers or skin checks regularly. LPN P reported that the facility often did not have the staff to provide care and treatments, so it was common for residents to miss them. LPN P reported that Resident #101 was not getting checked on and repositioned every 2 hours as he required because the facility did not have the staff to provide care. LPN P reported that she had voiced her concerns about residents missing treatments and care to facility management, but she did not feel like they had done anything to address the care concerns. During an interview on 2/24/26 at 10:03 AM, Director of Nursing (DON) B reported that she was aware that Resident #101's family had concerns with his care at the facility. DON B reported Unit Managers were expected to review the residents on their units daily to ensure that all treatments and assessments were completed, and if not, they were expected to follow up with the nursing staff. DON B confirmed that Resident #101 was admitted to the facility without any skin conditions. DON B reported that she did not think that Resident #101's wounds developed at the facility, and she reported she would look into that and let me know if she had any further evidence or documentation to provide. DON B did not provide any further documents prior to survey exit. During a follow up interview on 2/24/26 at 2:15 PM, UM W reported that she did not feel that Resident #101 developed a pressure ulcer at the facility. UM W showed this writer the skin assessments which were completed by the facility on 11/12/25. This writer again confirmed that the facility first identified the wounds on Resident #101's coccyx and elbows on 11/12/25. UM W was unaware of the wound care treatment note dated 10/27/25 from the hospital which indicated that Resident #101 had a wound on his coccyx at that time. Review of the facility's Pressure ulcer policy dated 7/11/2018 revealed, Policy: It is the policy of this facility that 1. A resident who enters the facility without a pressure ulcer does not develop pressure ulcers unless the individual's clinical condition or other factors demonstrate that a developed pressure ulcer was unavoidable; and 2. A resident having pressure ulcers receives necessary treatment and services to promote healing, prevent infection, and prevent new, unavoidable sores from developing .

This citation pertains to intake 2748436 and 2728846. Based on interview and record review the facility failed to ensure 2 residents (Resident #112 and Resident #101) were free from significant medication errors when (a) medications were administered outside physician prescribed parameters (b) medications were not administered as ordered without provider notification resulting in Resident #112 being hospitalized for hypoglycemia (low blood sugar) and Resident #101 missing multiple doses of seizure medication, having a seizure and subsequent change in condition resulting in hospitalization. Findings include: Findings include: Resident #112 Review of an admission Record revealed Resident #112 was originally admitted to the facility on [DATE] with pertinent diagnoses which included type 2 diabetes mellitus (condition where the body cannot use insulin properly or doesn't make enough of it leading to high blood sugar). Review of Resident #112's Care Plan revealed, Resident has risk for fluctuations in blood sugar and complications r/t (related to) diagnosis of DM (diabetes mellitus). Date Initiated: 01/18/2026. Goal: Resident will have no complications related to fluctuations in blood sugar through the review date. Date Initiated: 01/18/2026. Interventions: Administer medication(s) as ordered by doctor. Refer to physician orders or eMAR (Medication Administration Record) for current. Monitor/document for side effects and effectiveness. Adjust as directed by physician, diet as ordered. offer substitutes for foods not eaten, dietary consult for nutritional regimen and ongoing monitoring, Discuss mealtimes, portion sizes, dietary restrictions, snacks allowed in daily nutritional plan, compliance with nutritional regimen, Follow facility protocol for acute s/sx (signs and symptoms) of hypoglycemia. Report to Physician and adjust plan of care as directed, Monitor/document/report PRN (as needed) compliance with diet and document any problems, Obtain fingerstick glucose as ordered and prn. Report abnormal or changes in pattern to Physician for review and adjustment of plan of care as directed. Date initiated: 1/18/26 . Review of Resident #112's Progress Note dated 1/31/26 revealed, Resident requires assistance with feeding. Eating only bites of her meals. Review of Resident #112's Progress Note dated 2/5/26 revealed, resident blood sugar before dinner was 399 (typical target blood sugar levels are 80-130 mg/dL before meals and under 180 two hours after eating.) On call provider notified. verbal order to change insulin glargine (long-acting insulin) 5 units BID (Twice daily) to 10 units at bedtime. New sliding scale (a method of adjusting insulin doses based on current blood sugar levels to help manage glucose) added as order to give 7 units (of insulin) with meals . Review of Resident #112's Progress Note dated 2/7/26 and documented by Licensed Practical Nurse (LPN) P revealed, entered resident room to assess evening blood sugar. upon entering room, resident was found to be non-responsive to verbal stimuli/fingerstick blood glucose measured 27 (critically low level) administered glucagon (hormone produced by the pancreas that raises blood sugar) per protocol. Rechecked in 15 minutes: 46. Provided oral gel glucose and orange juice, subsequent blood glucose increased to 76. Resident became awake, alert, and talking. Offered and fed dessert from dinner. resident remained stable with improved responsiveness. Review of Resident #112's Progress Note dated 2/11/26 and documented by LPN L revealed, CNA (Certified Nursing Assistant) reported to this nurse that resident was hot and didn't want any blankets on around 1515 (3:15 PM). At 1525 (3:25 PM) this nurse went in to check on resident. Resident was diaphoretic (sweating) and unresponsive. CBG (current blood glucose) was 29 (critically low). This nurse ran and got two glucagon injections and administered them. 2 other floor nurses and both Unit Managers came into resident room to assist. NP (Nurse Practitioner) also on site. 1540 (3:40 PM) Resident continues to be diaphoretic and unresponsive. 3 more glucagon injections given, and NP gave resident a tube of glucose gel orally. at 1600 (4:00 PM) CBG was 52 and resident began to respond to her name but was still disoriented. resident drank 240cc of orange juice and immediately vomited it up. 1615 (4:15 pm) CBG was 55. At this time, resident was sent to (local hospital) for evaluation . Review of Resident #112's Hospital Records dated 2/11/26 revealed, Chief complaint: Hypoglycemia .comes in with hypoglycemia observed at (facility). Patient was found to be with a glucose of 26, patient received 5 doses of glucagon and unknown amount of oral glucose her blood glucose had improved to 87 by the time EMS (Emergency Medical Services) arrived on scene . Patient takes 10 units long-acting insulin at night with 2 units scheduled with meals, patient had been receiving both doses of insulin during her stay at the nursing home, at this point hypoglycemia could be due to iatrogenic ( illness caused by medical examination or treatment)insulin dosing error or accurate insulin dosing in a patient who is not eating due to decreased appetite. Other potential causes include infection or systemic disease causing a drop in blood glucose . Review of Resident #112's Orders revealed, Insulin Glargine (long acting insulin) . Inject 10 unit subcutaneously at bedtime for Diabetes. Start date: 2/5/26 .Fingerstick Blood Sugar. call MD (Medical Doctor) if less than 70 or greater than 350. before meals for Diabetes . Insulin Lispro (short acting insulin) .Inject 7 unit subcutaneously with meals for diabetes. Start date: 2/5/26 . Insulin Lispro Injection Solution (Insulin Lispro) Inject as per sliding scale: if 150 - 200 = 2; 201 - 250 = 4; 251 - 349 = 6; 350 - 400 = 7; 401 - 450 = 8 Notify MD/PA, subcutaneously before meals for diabetes. Start date: 2/5/26 Noted that Resident #112's insulin orders did not reflect what was documented in Resident #112's hospital records. Review of Resident #112's Medication Administration Record (MAR) revealed, Insulin Lispro Injection Solution (Insulin Lispro) Inject 7 unit subcutaneously with meals for diabetes at 8:00 AM. Noted that LPN L had documented that she had administered 7 units of insulin to Resident #112 at 10:32 AM. It was noted that Resident #112 had a documented blood glucose reading of 140 at 10:32 AM. Review of Resident #112's MAR revealed, Insulin Lispro Injection Solution (Insulin Lispro) Inject 7 unit subcutaneously with meals for diabetes at 12:00 PM .Insulin Lispro Injection Solution (Insulin Lispro) Inject as per sliding scale: if 150 - 200 = 2; 201 - 250 = 4; 251 - 349 = 6; 350 - 400 = 7; 401 - 450 = 8 Notify MD/PA subcutaneously before meals for diabetes at 11:30 AM. Noted that LPN L had documented that she had administered 7 units of insulin to Resident #112 in addition to 2 units per sliding scale for a blood glucose of 177 at 1:05 PM. Review of Resident #112's Eating task revealed that on 2/11/26, facility staff had documented that Resident #112 had eaten her lunch independently, and her meal intake was between 51-70% for breakfast and lunch. Noted that the facility did not document if Resident #112 ate independently for breakfast. During an interview on 2/20/26 at 8:46 AM, LPN N reported that Resident #112 always at in her room, and that she did often need assistance and queuing with eating. LPN N reported that she had noticed that Resident #112 did not eat much when she did not have assistance with eating. During an interview on 2/20/26 at 12:05 PM, LPN P reported that she had cared for Resident #112 on 2/5/26 when Resident #112 had experienced her first episode of hypoglycemia. LPN P reported that she had found Resident #112 in the afternoon in her room and she seemed out of it, so she checked her blood glucose and found that Resident #112's blood glucose was critically low, so she administered glucagon and continued to monitor Resident #112 throughout the remainder of her shift, and Resident #112 remained stable. LPN P reported she thought that she had notified the provider, but she could not recall. LPN P reported that she would have documented if she notified the provider in her progress note if she did. LPN B reported Resident #112 had not been eating well, and the facility had recently increased her insulin orders. Noted that LPN P did not indicate in her progress note if she had notified the provider of Resident #112's hypoglycemic episode. During an interview on 2/20/26 at 10:51 AM, LPN L confirmed that she was the nurse caring for Resident #112 on 2/11/26 when she was sent to the hospital for hypoglycemia. LPN L reported she had been notified by a CNA that Resident #112 was feeling hot, so she went to check on Resident #112 and when she entered her room, she found Resident #112 lying in her bed, and that she was very sweaty and out of it. LPN L reported that when she checked her blood glucose and it was critically low at 29. LPN L reported she ran to grab glucagon and with the assistance of two Unit Managers and Physician Assistant (PA) JJ, the facility was able to administer a total of 5 glucagon injections to help increase Resident #112's blood sugar. LPN L reported that after 45 minutes, Resident #112's blood glucose had increased to 57, and the facility sent Resident #112 to the hospital for evaluation and treatment. LPN L reported she was aware that Resident #112 had a previous episode of hypoglycemia the previous week. During a follow up interview on 2/20/26 at 3:40 PM, LPN L reported that she had been running behind on 2/11/26 and she was late to administer medications that day. LPN L confirmed that she did administer Resident #112's insulin at 10:32 AM, and that it was well after she had breakfast, and that she did not know if Resident #112 had already eaten lunch or not when she administered her afternoon dose of insulin. LPN L confirmed that she had not paid attention to if Resident #112 had ate at all for breakfast or lunch, and that she did not know how much she had eaten. LPN L reported that she had not realized that she had administered Resident #112's morning and afternoon doses of insulin 2.5 hours apart. LPN L was unable to answer if Resident #112's short acting insulin (lispro) should have been administered so close together. LPN L did confirm that she should have checked Resident #112's blood glucose prior to eating, and she should have monitored how much food Resident #112 had eaten. During an interview on 2/20/26 at 11:00 AM, Unit Manager (UM) U confirmed that Resident #112's insulin orders were changed on 2/5/26, and Resident #112's short and long-acting insulin orders were increased. UM U reviewed Resident #112's record with this writer and confirmed that Resident #112's had not been assessed by a provider after her first episode of hypoglycemia on 2/7/6, and that Resident #112's insulin orders had also not been reviewed to determine if they should be adjusted after 2/7/26. UM U confirmed that nursing staff were supposed to notify the provider when a blood glucose is out of parameters, and for any change in condition. During an interview on 2/24/26 at 10:00 AM, Director of Nursing (DON) B reported she was aware of Resident #112's hypoglycemic episode on 2/11/26. DON B reported that she had investigated the situation, but that she was not aware that LPN L had administered Resident #112's short acting insulin 2.5 hours apart. DON B reported that nurses were supposed to administer medications within 1 hour of the scheduled administration time. DON B confirmed that Resident #112 received her morning and lunch dose of insulin late, as it was ordered to be given at 8:00 AM and 11:30 AM. DON B reported that nurses were supposed to assess a resident's blood glucose prior to eating, and that the nurses assess that the Resident is eating appropriately. When this writer queried as to if DON B would be concerned that LPN L administered Resident #112's short acting insulin within 2.5 hours of the first dose without knowing how much the resident had eaten, DON B reported that she would need to look into it more. During an interview on 2/24/26 at 10:54 AM, Medical Director (MD) GG reported that he had not been made aware of Resident #112's hypoglycemic episode on 2/7/26, and that the facility providers had not assessed and reviewed Resident #112's insulin orders. MD GG reported that he was unaware that Resident #112 had received her short acting insulin orders 2.5 hours apart, but that he would be concerned about the insulin being administered so close together as that would increase Resident #112's risk of hypoglycemia. MD GG reported that insulin lispro was supposed to be administered with meals, and monitoring of food intake was needed to ensure that residents receive the correct amount of insulin based on their blood glucose levels, and how much they eat. During an interview on 2/24/26 at 1:30 PM, Physician Assistant (PA) JJ reported she was at the facility when Resident #112 had her second episode of hypoglycemia. PA JJ reported Resident #112 was diaphoretic and disoriented. PA JJ reported that she would be concerned about a resident experiencing an episode of hypoglycemia if they received lispro 2.5 hours apart. PA JJ reported it was important for nurses to know when and how much a resident was eating with insulin administration to ensure that they are receiving an adequate amount of insulin, and that nurses were supposed to follow the physician orders of administering insulin with meals for that reason. During an interview on 2/24/26 at 2:00 PM, Pharmacist KK reported that it was critical for insulin to be administered with meals and per the physician orders. Pharmacist KK confirmed that if a resident received insulin lispro 2.5 hours apart without knowledge of how much a resident had eaten, there would be a potential concern for hypoglycemia. Resident #101 Review of an admission Record revealed Resident #101 was originally admitted to the facility on [DATE] with pertinent diagnoses which included need for assistance with personal care and epilepsy (brain condition that causes recurrent seizures). Review of Resident #101's Care Plan revealed, The resident has a seizure disorder r/t (related to) head injury dx (diagnosis) of epilepsy. Date Initiated: 07/21/2025. Goal: The resident will be free from injury from seizure activity through the review date. Date Initiated: 07/21/2025. Interventions: Give medications as ordered. Monitor/document for effectiveness and side effects. Date Initiated: 07/21/2025. Review of Resident #101's July 2025 MAR revealed, Orders: Keppra (anti-epileptic drug) Oral Tablet 500 MG (Levetiracetam). Give 2 tablet by mouth two times a day for seizures. Noted that on 7/20/25, it was documented that Resident #101 did not receive the 8:00 AM dose. Review of Resident #101's July 2025 MAR revealed, Orders: Keppra Oral Tablet 750 MG (Levetiracetam) Give 1 tablet by mouth two times a day for seizures. Noted that it was documented that Resident #101 did not receive the 8:00 AM dose. Review of Resident #101's July 2025 MAR revealed, Orders: Valproic Acid (anti-epileptic drug) Oral Solution 250 MG/5ML (Valproate Sodium). Give 10 ml by mouth three times [NAME] for seizures. Noted that it was documented that Resident #101 did not receive this medication on 7/19/25 at 8:00 AM, 1:00 PM, and on 7/20/25 and the 8:00 AM and 1:00 PM on 7/20/25 and 1:00 PM on 7/21/25. Review of Resident #101's Progress Note dated 7/19/25 at 11:46 AM, revealed, patient refused morning medications. Nurse reapproached patient at breakfast and sat with him for 20 minutes, but patient still refused medications. Patient's guardian approached nurse asking about morning medications, at this time, nurse was trying to send out another patient out on a medical emergency. The patient's guardian was asking if he received his medications and asked if we could reapproach give the medications (sic). Nurse reapproached the patient and he took 50% of his meds. Patient's guardian seemed pleased with the amount of medication that he took. Review of Resident #101's Progress Note dated 7/19/25 at 3:22 PM revealed, Patient's sister called asking nurse if the patient ate lunch, after he refused his morning medications. The sister noticed that the patient had not been responding normally stating, I visited with him yesterday and we were laughing together. He was acting normal yesterday. But today he struggled to keep his eyes open and was not responding like he usually does. I would be okay with him being sent out today (to the hospital) in case of seizure. Physician notified of patient's current symptoms and vital signs. Physician ordered patient to be sent out due to DPOA's (durable power of attorney) request. EMS called. Review of Resident #101's Progress Note dated 7/20/25 at 6:55 AM revealed, Resident returned from (local hospital) at approximately 5:00 AM this AM .new order received to increase Keppra to 1000 mg po (by mouth) twice daily. Review of Resident #101's Progress Note dated 7/20/25 at 6:21 PM revealed, Resident noted to be lethargic today and refused all meals, refused medications at time as well. Review of Resident #101's Physician Note dated 7/21/25 revealed, . Patient is assessed today for refusing medications and meals. Patient also noted to have a fever of 101 which improved with Tylenol . Review of Resident #101's Progress Note dated 7/21/25 revealed, Resident had seizure activity while getting ready to eat dinner. Resident's eyes rolled back and foaming at the mouth. resident returned to bed, laying on the left side. Provider notified and told to administer Ativan (medication used to treat seizure activity) and continue to monitor . Review of Resident #101's Progress Note dated 7/25/25 at 11:23 AM revealed, CNA notified nurse of resident being unable to swallow foods and medication the past couple of days, resident did not swallow his medication this morning and appeared to have dysphagia (difficulty swallowing), resident was not given his valproic acid for this reason . Review of Resident #101's Progress Note dated 7/25/25 at 2:15 PM revealed, Resident unable to swallow food and liquid the past couple of days. Dr was notified and ordered resident to send out to ED (Emergency Department) . Review of Resident #101's Hospital Notes dated 7/25/25 revealed, Chief Complaint: .male with history of TBI (traumatic brain injury), epilepsy, and nonverbal status who presents emergency department for failure to thrive patient has been dealing with significant dysphagia for quite some time but over the last 24 to 48 hours has been unable to take his medicines or have any significant oral intake due to dysphagia. (Family) is at bedside and states she was told by nursing staff at his rehab facility that when they give him his oral antiepileptic medication today they just drooled out of the side of his mouth and he was unable to swallow them. (Family Member) states the patient is otherwise at his baseline and as far as she is aware the patient has had no fevers, vomiting, difficulty breathing. His last seizure was a few days ago which she believes was also due to inability to take his oral medications .Summary of hospitalization: Patient was found to be in Status epilepticus (dangerous brain condition that happens when a person has seizures that last too long or happen too quickly in sequence) on 7/27 with Acute right parietal, temporal, occipital distribution ischemic infarction (stroke) on 7/27/25 . Attending update: It seems that due to dysphagia he would frequently miss doses of his antiepilepticsand therefore, is not particularly surprising that he has breakthrough seizures . During an interview on 2/18/26 at 11:25 AM, Family Member (FM) PP reported that when she had gone to visit Resident #101 on 7/19/25, she had noticed that Resident #101 had seemed more lethargic and confused and was unable to swallow his coffee. FM PP reported that she had approached Resident #101's nurse LPN Q to report her concern that he was not swallowing his coffee, and she learned that Resident #101 had not taken all of his medications that morning. FM PP reported that she had asked LPN Q to reapproach Resident #101 and try to administer his medications again, because she was very concerned about him missing his seizure medications. FM PP reported that she had called later that day to check on Resident #101 and when she was told that he was still unable to eat or take his medications, she asked that the facility to send Resident #101 to the hospital to be evaluated. FM PP reported feeling frustrated with LPN Q because she did not seem to be concerned that Resident #101 was unable to eat or take his medications appropriately. During an interview on 2/19/26 at 11:01 AM, LPN Q reported that she had cared for Resident #101 on 7/19/25, and she recalled that Resident #101's family member was upset regarding his care and wanted him sent to the hospital. LPN Q reported that FM PP was concerned that Resident #101 may have had a seizure. When this writer queried LPN Q about if she had notified the provider about Resident #101 missing doses of his Keppra and Valproic acid on 7/19/25 and 7/20/25, LPN Q reported that she could not recall any details of that date, and she did not know if she had notified the provider. During an interview on 2/19/25 at 12:15 PM, Unit Manager (UM) W reported that she had been made aware that FM PP had concerns that LPN Q had not responded to her concerns about Resident #101 missing his medications and change in his condition. UM W reported that after FM PP reported her concerns with LPN Q, the facility removed LPN Q from caring for Resident #101 per FM PP request, and she did not look into the concern further. UM W reported that nurses were supposed to notify the provider anytime a resident missed a medication. UM W' reviewed Resident #101's July 2025 MAR with this writer and confirmed that Resident #101 had missed multiple doses of anti-epileptic medication, and she could not verify that nursing staff had notified the provider. UM W confirmed that the facility provider did not assess Resident #101 until 7/21/25 when he had a seizure at the facility. During an interview on 2/19/26 at 2:07 PM, LPN M reported that she had been approached by a CNA E that Resident #101 had been having issues swallowing and taking his medications for days, and that staff were not doing anything about it. LPN M reported that she went to assess Resident #101 and noted that he was unable to swallow medications/liquids, so she notified the provider and Resident #101 was sent to the hospital. LPN M reported that nurses were supposed to notify the provider anytime a resident missed medications. During an interview on 2/24/26 at 10:03 AM, Director of Nursing (DON) B reported that nurses were expected to notify the provider any time a resident missed a medication. DON B reviewed Resident #101's MAR with this writer and confirmed that Resident #101 had missed doses of his keppra and valporic acid, and that she could not find a note indicating that the provider had been notified. DON B reported that she also expected nurses to notify the provider anytime a resident had a change in condition. DON B reported the facility Unit Managers were supposed to review Resident's treatment records and notes every day to ensure that all changes in condition and missed treatments/medications were identified. DON B reported she was unaware that Resident #101 had missed multiple doses of keppra and valporric acid. During an interview on 2/24/26 at 1:30 PM, PA JJ reported that Resident #101 was admitted to the facility with a history of seizures. PA JJ' reported that nurses were supposed to notify the provider anytime a resident missed medications, so that the provider could assess the resident. PA JJ reviewed her notifications and reported that she did not have any notification on 7/19, 7/20, 7/21, 7/22, 7/23 or 7/24 regarding Resident #101 missing his medications due to issues swallowing. PA JJ reported that if nursing staff had notified the facility provider, they should have documented that, and she also did not see documentation from nursing staff noting a notification to the provider. PA JJ confirmed that she would be concerned that Resident #101 could have seizures and complications from seizures if he missed doses of his medication. Review of the facility's Medication Administration policy dated 7/11/18 revealed, Policy: It is the policy of this facility that medications shall be administered as prescribed by the attending physician. Procedures . 2. Medications must be administered in accordance with the written orders of the ordering/prescribing physician. NOTE: If a dose seems excessive considering the resident's age and condition, or a drug order seems to be unrelated to the resident's current diagnosis or condition, the nurse should contact the physician .7. Medications should be administered in accordance to meet the needs of the resident. Facilities that follow standard med pass models, medications may not be set up in advance and must be administered within one (1) hour before or after their prescribed time. NOTE: Before and/or after meal orders must be administered as ordered. Facilities that follow a resident centered med pass model, refer to specific facility administration times . 12. Should a drug be withheld, refused, or given other than the scheduled time, the nurse must enter an explanatory note. NOTE: The Director of Nursing and attending Physician must be notified when two (2) doses of a medication are refused or withheld .Review of the facility's Change in Condition policy dated 7/11/28 revealed, Policy: It is the policy of this facility that all changes in resident condition will be communicated to the physician. Procedure: . Acute Medical Change: 1. Any sudden or serious change in a resident's condition manifested by a marked change in physical or mental behavior will be communicated to the physician with a request for physician visit promptly and/or acute care evaluation. The licensed nurse in charge will notify the physician .3. Licensed nurse will notify, consistent with the resident's authority, the resident's representative of the change of condition and what steps have been taken. 4. All nursing actions will be documented in the licensed progress notes as soon as possible after resident needs have been met .

This citation pertains to intake 2661176, 2728846, 2638850. Based on observation, interview, and record review, the facility failed to provide appropriate Activities of Daily Living (ADL) care for 5 (Resident #101,#103,#110, #113, and #114) of 7 residents reviewed) reviewed for ADL care, resulting in the potential for avoidable negative physical and psychosocial outcomes for resident's who are dependent on staff for assistance. Findings include: Resident #101 Review of an admission Record revealed Resident #101 was originally admitted to the facility on [DATE] with pertinent diagnoses which included need for assistance with personal care and muscle weakness. Review of Resident #101's Care Plan revealed, Resident has an ADL (Activities of daily living) self-care performance deficit .Date Initiated: 06/16/2025. Goal: Resident will improve current level of function in mobility, strength through the review date. Resident will be able to: assist with self-care. Date Initiated: 06/16/2025. Interventions: . BATHING/SHOWERING: The resident is totally dependent on 2 staff to provide bath and or shower 2 times a week and as necessary. Date Initiated: 08/03/2025 . Review of Resident #101's Hospital Records dated 11/2/25 revealed, HPI (History of Present Illness): (Resident #101) is . male past medical history of TBI (traumatic brain injury) in 2023 . and recent admission . for community-acquired and sepsis . Was reportedly soaked in urine, right eye crusted shut, and crusted around the mouth . During an interview on 2/18/26 at 11:25 AM, Family Member (FM) PP reported Resident #101 required total assistance from staff with all care. FM PP reported she frequently visited Resident #101 for 3 or more hours at a time, and every time she visited Resident #101, she never witnessed staff assist Resident #101 with care. FM PP reported Resident #101 was often observed as disheveled during her visits, with peeling skin, soiled briefs, wearing double briefs, and with salvia down his mouth and face. FM PP' reported Resident #101 was supposed to get two showers or bed baths a week, and that he was often missing showers. FM PP reported she felt like Resident #101 was often ignored because he was nonverbal and unable to ask for assistance. FM PP reported she would practically beg the staff to provide basic care to Resident #101 ever time she was at the facility. FM PP reported she frequently voiced her concerns that Resident #101 was not receiving adequate care to the nurses, Unit Manager (UM), Director of Nursing (DON), and Social Worker (SW), but she felt that the facility staff did not take her concerns seriously, and Resident #101's care did not improve. This writer requested Resident #101's Shower Sheets from 12/19/25-2/19/25. The facility provided 7 shower sheets from 12/19/25- 2/19/25. It was noted that Resident #101 should have had 14 showers/bed baths or documented refusals for the requested time frame. During an interview on 2/19/26 at 11:01 AM, Licensed Practical Nurse (LPN) Q reported that the facility's certified nursing assistants (CNA's) were supposed to provide a shower sheet to the nurse every time they completed a bed bath or shower, or let the nurse know that the resident refused, so that the nurse could reapproach the resident. LPN Q confirmed that when the facility was short staffed, they were not able to complete showers for residents. During an interview on 2/19/26 at 11:13 AM, LPN N reported that when the facility was short staffed, the staff struggled to complete all care for residents, and that residents had been missing showers and bed baths. During an interview on 2/19/26 at 2:07 PM, LPN M reported that residents at the facility were often missing showers at the facility. LPN M reported that the facility had a shower aide, but she was often getting pulled from that position to assist on the floor, and when that happened, residents would miss their showers. LPN M reported that she was aware that FM PP had voiced concerns about Resident #101 not getting adequate ADL care. During an interview on 2/20/26 at 10:51 AM, LPN L reported that staffing at the facility had been a struggle, and that residents were often missing showers because the shower aide would get pulled to work the floor. LPN L reported when the shower aide was pulled to work the floor, the aides were supposed to complete resident showers, but that was not always happening. During an interview on 2/20/26 at 11:47 AM, CNA H reported that staffing was hit and miss and that it was very common for the aides to have to skip ADL care such as showers and bed baths because they did not have enough time to complete them. During an interview on 2/20/26 at 12:05 PM, LPN P reported that she cared for Resident #101 often, and she was aware that FM PP had voiced concerns about Resident #101 missing ADL care often. LPN P reported that FM PP concerns about Resident #101 missing ADL care were valid, because she had often observed Resident #101 as disheveled. LPN P reported that the aides were often documenting refused or not available under resident shower tasks because they were not able to get to them. During an interview on 2/19/25 at 12:15 PM, Unit Manger (UM) W reported that she was aware that FM PP had voiced concerns about Resident #101's ADL care. UM W reported that CNA's were supposed to complete a shower sheet and turn it into the nurse to review after every bed bath or shower, or they should document a refusal. UM W reported that she was responsible for reviewing the shower sheets and ensuring that residents were receiving their showers as scheduled. When this writer queried about Resident #101's missing shower sheets, UM W reported that the staff were not great at ensuring that they were completed, and the facility had been working on trying to come up with a better process to ensure showers were being completed. When this writer queried about Resident #101's hospital record dated 11/2/25 which noted that Resident was admitted to the hospital soaked in urine, with his eyes crusted shut, UM W reported that she was aware of that incident, and that it was very embarrassing and upsetting to the facility, but that he could have urinated on himself in the ambulance to the hospital. UM W reported that she had not done any follow-up regarding ADL care for Resident #101 after the incident on 11/2/25. During an interview on 2/24/26 at 10:03 AM, Director of Nursing (DON) B' reported she was not aware that FM PP had concerns about Resident #101 getting ADL care at the facility. DON B reported Unit Managers at the facility were supposed to be reviewing shower sheets and resident care tasks every day and following up on any missed documentation/care. Resident #103: Review of an admission Record revealed Resident #103 was a male with pertinent diagnoses which included repeated falls, multiple sclerosis (a chronic autoimmune disease where the immune system attacks the protective myelin sheath of nerves in the brain and spinal cord causing communication issues, incurable), dementia, anxiety, and weakness. Review of current Care Plan for Resident #103, revised on 4/18/25, revealed the focus, .Resident has an ADL (activities of daily living) self-care performance deficit r/t (related to) weakness, infection (right knee and UTI (urinary tract infection)). with the intervention .BATHING/SHOWERING: The resident requires set up assistance for UB (upper body) and mod (moderate) assistance for LB (lower body) by 1 staff with bathing/showering twice weekly and as necessary. Review of Task-Shower for the last 30 days for Resident #103 revealed, on 1/21/26 (Wed) it was documented a shower was given. Review of Skin Observation Shower Sheet for Resident #103 dated 1/21/26 revealed, Resident #103 had refused a shower. Review of Progress Notes for Resident #103 revealed, no progress note entered which documented Resident #103's 1/21/26 shower refusal. Review of Skin Observation Shower Sheet for Resident #103 dated 2/6/26 (Fri), revealed, Resident #103 had refused his shower. Review of Progress Notes for Resident #103 dated 2/6/26 revealed, no progress note entered which documented Resident #103's 2/6/26 shower refusal. Review of Shower Schedule for Resident #103 revealed he was scheduled to receive his showers on Wednesdays and Sunday evenings. Resident #103 should have received a shower on 1/18/26, 1/25/26, 1/28/26, 2/1/26, 2/4/26, 2/8/26, 2/11/26, 2/15/26, and 2/18/26, which created 9 opportunities for showers to be provided for the last 30 days. Review of Skin Observation Shower Sheet dated 2/26/26, revealed Resident #103 had refused his shower. This writer received the shower sheets for Resident #103 on 2/19/26. Resident #113: Review of an admission Record revealed Resident #113 was a male with pertinent diagnoses which included chronic pain syndrome, depression, muscle weakness, unsteadiness on feet, and wheelchair dependence. Review of Care Plan for Resident #113, revised on 6/30/24, revealed the focus, .Resident has an ADL self-care performance deficit r/t (related to) impaired mobility, chronic pain, and muscle weakness. Dx (diagnosis) includes: dystonia (neurological movement disorder characterized by involuntary often painful sustained muscle contractions causing repetitive twisting movements, or abnormal posture), generalized muscle weakness, h/o (history of) TBI (traumatic brain injury), w/c (wheelchair) dependence.h/o nervous system disorders, arthritis, .adjustment disorder w/ (with) mixed anxiety & depressed mood, major depressive disorder, COPD (chronic obstructive pulmonary disease). with the intervention .Showering/Bathing per schedule or as needed. Prefers to be bathed twice per week. BATHING/SHOWERING: The resident requires Extensive assist with scheduled & PRN (as needed) showers. In an interview on 2/20/25 at 9:21 AM, Resident #113 reported he does not get a shower every week and would at times he would get a shower every other week. Resident #113 reported that when the shower aide takes a day off on his shower day, he doesn't get a shower that day. Resident #113 reported he wanted a shower at least once a week as he had long hair and only wanted it washed in the shower not during a bed bath. Review of Shower Schedule for Resident #113, revealed, he was scheduled to receive his showers on Tuesday and Saturday days. Review of Resident #113's Documentation Survey Report for November 2025, revealed, Resident #113 had his hair washed on 11/18/25, received a shower on 11/4/25, 11/11/25, 11/18/25 and 11/25/25, refused a shower on 11/8/25. Review of Resident #113's Skin Observation Shower Sheet dated 11/11/25 revealed, Resident #113 refused the shower due to not feeling well. Resident #113 should have received a shower on 11/4/25, 11/8/25, 11/11/25, 11/15/25, 11/18/25, 11/22/25, 11/25/25 11/29/25 which created 8 opportunities for a shower. Review of Resident #113's Documentation Survey Report for December 2025, revealed Resident #113 received a bed bath on 12/6/25, 12/13/25, 12/20/25, and 12/30/25. Received one shower on 12/23/25 with his hair washed. Resident #113 should have received a shower on 12/2/25, 12/6/25, 12/9/25, 12/13/25, 12/16/25, 12/20/25, 12/23/25, 12/27/25, 12/30/25 which created 9 opportunities for a shower. Review of Resident #113's Documentation Survey Report for January 2026 revealed, Resident #113 received a shower on 1/13/26, 1/20/26, and 1/27/26 (hair washed this day). Refused on 1/6/26, 1/17/26, and 1/23/26 noted in the report. No noted bed baths during this time. No documentation in the medical record to indicate Resident #113 refused his showers on 1/6/26, 1/17/26, and 1/23/26. Resident #113 should have received a shower on 1/3/26, 1/6/26, 1/10/26, 1/13/26, 1/17/26, 1/20/26, 1/24/26, 1/27/26, 1/31/26, which created 9 opportunities for a shower. Review of Resident #113's Documentation Survey Report for February 2026, revealed, Shower with hair washed on 2/3/26 and 2/10/26. No noted bed baths during this time. No documentation in the medical record to indicate Resident #113 refused his showers. Resident #113 should have received a shower on 2/3/26, 2/7/26, 2/10/26, 2/14/26, 2/17/26 which created 5 opportunities for a shower. Resident #114: Review of an admission Record revealed Resident #114 was a female with pertinent diagnoses which included wedge compression fracture T11-T12 (broken bone collapses and takes on a wedge shape), muscle atrophy, arthritis, and anemia (low red blood count). Review of Kardex dated 2/20/26 for Resident #114, revealed, .BATHING/SHOWERING: The resident requires setup with upper body and moderate to maximum assistance with lower body. Review of Shower Schedule for Resident #114, revealed, she was scheduled to receive his showers on Wednesday and Saturday evenings. Review of Resident #114's Task – Showers dated 2/20/26, revealed, for the previous 30 days Resident #114 received a shower on 2/4/26 and 2/11/26 and 1 refusal noted for 1/31/26. Resident #114 should have received a shower on 1/21/26, 1/24/26, 1/28/26, 1/31/26, 2/4/26, 2/7/26, 2/10/26, 2/14/26, and 2/18/26 which created 9 opportunities for a shower/bath. Review of Resident #114's progress noted revealed no documented refusal. Resident #110: Review of an admission Record revealed Resident #110 was a female with pertinent diagnoses which included diabetes, depression, overactive bladder, and multiple sclerosis (a chronic autoimmune disease of the central nervous system where the immune system attacks the myelin sheath protecting nerves, disrupting brain to body communication). In an interview on 02/19/26 at 1:25 PM, Resident #110 reported she felt the resident to staff ratio affected resident care. Resident #110 reported she had contracture on her left hand, and at times it was hard to get staff to respond to her call for assistance for something simple like the remote especially on third shift when the staffing was less. Resident #110 reported she had concerns with staff getting her and other residents up in the morning and in bed before 10:00 PM. Resident #110 reported that if the shower aide called in, the CNAs (Certified Nursing Assistant) who worked on the floor were not completing showers for the residents whose showers were scheduled that day. Resident #110 reported the shower aide had too many showers scheduled for her during her hours scheduled and she was not able to complete them. Resident #110 had reported she requested to get her showers before dinner so she knows she would be able to receive one. Resident #110 reported some CNAs try to postpone the shower to later, but she insists the shower got done otherwise she would not get one. Resident #110 reported she had been the resident council president prior but now was an attendee and had heard these same concerns from the residents when she attended resident council. Review of Shower Schedule revealed the number of residents scheduled, .Day shift showers: Monday: 17 residents, Tuesday: 13 residents, Wednesday: 5 residents, Thursday: 10 residents, Friday: 17 residents, and Saturday: 6 residents; Evening shift showers: Monday: 8 residents, Tuesday: 10 residents, Wednesday: 6 residents, Thursday: 9 residents, Friday: 10 residents, and Saturday: 6 residents. In an interview on 2/20/26 at 12:10 PM, CNA OO reported if a resident refused a shower or bath, the staff would go back and reapproach to see if the resident would like to continue with a shower/bath. CNA OO reported if the resident continued to refuse the shower/bath the CNA would inform the nurse supervisor of the refusal, the nurse would reapproach and see if the nurse can get the resident to take a shower/bath, if not, it was documented on the shower skin sheet and signed by the nurse. CNA OO reported if the shower aide was not able to complete the resident's showers/baths, the CNA assigned to the resident would provide the resident with their shower/bath. In an interview on 2/20/26 at 1:07 PM, Shower Aide (SA) F reported she started work most mornings at 4:30 AM to get here to start the resident showers. SA F reported she got pulled a lot to work the floor and she got at the facility early as there were residents willing to take a shower early so they would have one on their shower day. SA F reported she was pulled to work the floor at least 3 times per week and that was 3 days residents were not receiving their showers. SA F reported with the shower scheduling it was impossible for her to complete the number of showers scheduled for the day. SA F reported until recently she had 20 showers scheduled to complete on Mondays. SA F reported with the scheduling of showers she was not able to keep up with showers for residents and she couldn't provide every shower scheduled that day. In an interview on 2/20/26 at 1:30 PM, Unit Manager (UM) W reported when the shower aide was pulled from showers to work in assisting residents the CNA assigned to the resident was responsible for completing the shower for the resident that day. UM W reported the Kardex indicated what days a resident was to receive a shower or bed bath. UM W reported if a resident had refused a shower/bed bath, the CNA was to attempt to complete at a different time or have someone else approach, if the resident was still refusing the shower/bed bath, the CNA would notify the nurse and if the resident was still refusing it was documented on the shower sheet the resident refused and the nurse would enter a progress note. UM W reported the nurse would sign the sheet and the sheets would be submitted to the unit manager to follow up on with the resident.

This citation pertains to intake #2595324.Based on observation, interview, and record review the facility failed to provide adequate care to prevent skin breakdown and worsening of pressure ulcers in 1 resident (Resident #108) of 3 residents reviewed for pressure ulcers, resulting in actual skin breakdown and worsening of pressure ulcers due to inadequate treatments, proper repositioning and incontinence care.Findings include:Review of an admission Record revealed Resident #108 was originally admitted to the facility on [DATE], with pertinent diagnoses which included: fall and pressure ulcer of sacrum (tailbone). Review of Resident #108's Kardex (direct care guide) revealed, Gloves and Gowns (enhanced barrier precautions/EBP) (an infection control strategy that uses gloves and gowns during high-contact resident care to reduce the spread of and/or risk of acquiring drug-resistant bacteria) Required for following: dressing, bathing, showering, changing of briefs or toileting, personal hygiene, transferring, changing linens, device and/or wound care.Check resident every two hours and assist with toileting.Elevate heels off bed surface while at rest.Review of Resident #108's Braden Scale for predicting pressure sore risk dated 9/3/25 revealed, High Risk .Ability to change and control body position: Very Limited.Friction & Shear: Problem: Requires moderate to maximum assistance in moving . Frequently slides down in bed or chair, requiring frequent repositioning with maximum assistance.During an observation and interview on 9/16/25 at 3:54 PM Resident #108 was lying in bed flat on her back with her feet and heels pressed on the surface of the bed. A foley catheter bag was noted hanging from the bed rail. Resident #108 reported that she would like to have an aide come and place a pillow under her butt to relieve pain. Resident #108 reported that she had a wound on her butt that was getting worse. Resident #108 reported that staff had been putting cream on the wound but they didn't have it with them when they came in that morning, so her butt was burning. Resident #108 reported that she doesn't move around in bed because of her pain but can help roll when staff provide care. Review of Resident #108's Wound Note dated 9/9/25 revealed, .right gluteal (buttock) Stage 3, 0.3 (centimeters) x 0.6.scant amount of serosanguineous drainage, area fragile and stable.Review of Resident #108's Wound Note dated 9/16/25 revealed, right gluteal (buttock) Stage 3, 6.0 (centimeters) x 2.9 x 0.1.scant amount of serosanguineous (containing blood) drainage, area fragile and declined. It was noted that the wound significantly increased in size between assessments. Review of Resident #108's Physician Orders start date 8/19/25 revealed, every shift for wound care right gluteal stage 3, cleanse with soap and water, apply barrier cream BID (twice daily).Review of Resident #108's Physician Orders start date 8/26/25 revealed, Enhanced barrier precautions r/t (related to) foley (urine catheter) and pressure wounds. In an interview on 9/16/25 at 4:06 PM Certified Nursing Assistant (CNA) S reported that she had started at 2:00 PM that day, was assigned to Resident #108 but had not checked on the resident yet. CNA S reported that Resident #108 did not have any wounds that she was aware of. During an observation and interview on 9/17/25 at 8:24 AM in Resident #108's room, the resident was lying in bed on her back with a catheter bag noted hanging on the bed frame. Resident #108 reported burning pain on her butt from her wound. Resident #108 reported that her wound was not covered with a bandage and the aides had not been in to apply the cream that day. Resident #108 reported that her catheter had leaked and soaked her clothes multiple times over the past few days. During an observation on 9/17/25 at 8:45 AM in Resident #108's room with CNA Y and LPN OO. Resident #108 is reporting that her pants are soaking wet. Observed catheter tubing twisted on Resident #108's leg and tubing full of urine. LPN OO reported that the resident's urine was flowing back to her bladder because the placement of the catheter tubing is not below her bladder and therefore overflowing onto the bed. LPN OO adjusted the catheter and removed the catheter securement device from the resident's leg. Observed Resident #108's buttocks with a large non-blanchable area in the middle and a large open wound on the right buttocks. The wound on the right buttocks had an area of eschar (dead tissue) and a bright red linear (line) open wound approximately 4 inches long that was actively bleeding. CNA Y reported that the red wound was new. CNA Y performed incontinence care, rolled up the wet pad underneath the resident and then pulled it out from under the resident's butt. CNA Y obtained a tube of barrier cream that was sitting on the resident's nightstand and applied the cream over the wounds. CNA Y reported that the day before the barrier cream was missing, but normally the CNA's apply cream to wounds during incontinence care. CNA Y reported that Resident #108 did not use incontinence briefs and was always continent of bowel and bladder. It was observed that CNA Y and LPN OO did not maintain EBP and wear a gown prior to providing direct care. In an interview on 9/17/25 at 9:12 AM, LPN OO reported that she frequently worked Resident #108's hall but had not observed Resident #108's wound on her buttocks. In an interview on 9/17/25 at 10:06 AM, Unit Manager (UM) X reported she had assessed Resident #108's wound on 9/16/25 along with the wound provider; Resident #108's wound on her right buttocks was superficial but had worsened since the previous assessment. UM X reported that the wound is not being covered with a bandage, but that the CNA's have a barrier cream in the room to use as needed. Resident #108's wound was observed at 10:10 AM along with UM X who reported the wound looked much worse than the day before. UM X pointed out a small superficial round wound on the lower right buttock that she was aware of and reported that the area of eschar and the bright red linear wound were new. UM X reported that staff should not pull the linens, pads or briefs out from under the resident due to potential for shearing (skin on the surface is pulled away from underlying tissue when linen is pulled across skin). UM X reported that Resident #108 required EBP due to wounds and catheter, but that it was not posted at the door. In an interview on 9/17/25 at 10:39 PM, Director of Nursing (DON) B reported that Resident #108 was cognitively intact and would be able to verbalize events related to her care. DON B reported that all wound care treatment orders should be administered by nursing staff so that the nurse was observing the wound routinely. In an interview on 9/17/25 at 12:27 PM, CNA DD reported working with Resident #108 the previous night shift. CNA DD reported that Resident #108 had a painful wound on her bottom, CNA DD used a spray wound cleanser, applied barrier cream, and change the resident's brief once that night. CNA DD reported that the wound was red, elongated and had yellow open areas. In an interview on 9/17/25 at 12:31 PM, LPN BB reported that she had not seen Resident #108's wound; that hall is very busy and difficult to get through medication pass. In an interview on 9/17/25 at 1:50 PM, UM X reported that she had spoken to the provider and Resident #108 wound orders have been changed to Medi Honey (a topical medication that promotes a moist wound environment and debridement (removes dead, infected, or damaged tissue from a wound) and will be covered with a bandage. UM X had applied the new wound dressing.Review of Resident #108's Physician Orders start dated 9/18/25 revealed, Right gluteal unstageable (pressure injury where the depth cannot be determined due to slough (dead tissue) or eschar) wound, cleanse with wound cleanser apply Medi Honey and collagen (maintains moist environment) cover with border gauze in the morning for wound care.

This citation pertains to intakes M100146395 and M100146349. Based on interview and record review, the facility failed to follow their policy and appropriately provide pressure ulcer care as ordered for 1 (Resident #2) of 4 residents reviewed for pressure ulcers, resulting in hospitalization . Findings include: A Wound Vacuum-Assisted Closure (or wound VAC) is a method used to decrease air pressure around a wound to assist the healing. It is also referred to as negative pressure wound therapy. During a VAC procedure, a healthcare professional applies a foam bandage over an open wound, and a vacuum pump creates negative pressure around the wound. This means the pressure over the wound is lower than the pressure in the atmosphere. The pressure pulls the edges of the wound together while removing fluids and infections from the wound. https://www.webmd.com/a-to-z-guides/what-is-vacuum-assisted-wound-closure Review of a Face Sheet for R2 revealed she admitted to the facility on [DATE] with pertinent diagnoses of osteomyelitis of vertebral, sacral and sacrococcygeal region and pressure ulcers of right hip and sacral region. In an interview on 8/28/24, Family Member (FM) M reported R2 was sent to the facility for care of her pressure ulcers. There was a malfunction with the wound vac for at least 3 days and R2 did not receive any wound care when it was not working. She is now in the hospital because of it. FM M reported he and R2 did express concerns to staff that wound care was not being done. In an interview on 8/27/24 at 4:00 PM, Confidential Informant (CI) N reported R2 did not have wound care services as ordered. The wound vac was not working because the nursing staff did not know how to use it. One time the wound vac was not working and R2 had a wet to dry dressing in place that was in place for several days. When it was finally changed, the dressing was dry and hard to get out of the wound. Review of Hospital Records dated 8/5/24 for R2 revealed she was sent to the emergency department with a chief complaint of increased confusion. Had wound vac in place for known decubitus ulcer but was removed on 8/1 because the facility 'had no more canisters. Pt (patient) now febrile (fever) and tachycardic (increased heart rate) . Apparently, they ran out of the canisters was for osteomyelitis (bone infection) of the sacral (base of spine in pelvic area) and coccygeal (tailbone) region and they therefore took off the wound VAC. Assessment: 1. MRSA (methicillin-resistant Staphylococcus aureus) Septicemia (blood poisoning) in setting of stage IV decubitus ulcer, 2. Subacute/chronic osteomyelitis with a contiguous focus of infection. CT Abdomen and Pelvis with Contrast: Final Result- 1. Worsened sacral decubitus ulcer with worsened associated osteomyelitis and myositis (muscle inflammation). In an interview on 8/27/24 at 9:15 AM, Wound Care Nurse Practitioner (NP) P reported if the staff had a problem with the wound vac for R2, they are to do a wet to dry dressing in its place. If staff were not able to troubleshoot the wound vac, they are to call the Director of Nursing (DON), the Unit Manager, or their direct supervisor. NP P was aware the facility had a problem with the wound vac for R2. Review of a Nursing Progress note dated 7/9/24 for R2 revealed Wound vac removed due to machine malfunction. Wet to dry dressing placed on open areas. Wound vac reordered, awaiting arrival. Review of the Practitioner Progress note dated 7/9/24 for R2 revealed: The patient has a large sacral wound with wound VAC. The margins of which are increasing, and she has some slight purulent material with discharge on the lateral aspect of the wound. Review of the Practitioner Wound Care Progress Notes dated 7/10/24 for R2 revealed: -Wound 1: Pressure wound sacral stage IV- Plan: Clean with normal saline and wound VAC to be applied and changed on Tuesday, Thursday, and Saturday. Measurement: 10.1 x 9.7 x 1.4. Post debridement: 10.1 x 9.7 x 1.5 cm. -Wound 2: Right trochanter, unstageable pressure-induced tissue damage. Plan: Cleanse with normal saline and apply Santyl and then wound VAC to be applied and changed on Tuesday, Thursday, and Saturday. Measurement: 4.3 x 4.4 cm x undetermined. Post debridement measurements: 4.4 x 4.6 cm x undetermined. -Wound 3: Left heel, stage III pressure wound. Plan: Cleanse with normal saline and apply A&D ointment daily. Measurement: 0.3 x 0.5 cm x scab. Review of the Practitioner Wound Care Progress Notes dated 7/23/24 for R2 revealed: -Wound 1: Pressure wound sacral stage IV- Plan: Cleanse with Dakin's and apply wound Vac to be changed Tuesday, Thursday, and Saturday. -Wound 2: Right trochanter, unstageable pressure-induced tissue damage, which is now reclassified to stage IV pressure wound. - Plan: Cleanse with normal saline and apply Santyl and bridge wound VAC to be changed on Tuesday, Thursday, and Saturday. -Wound 3: Left heel, stage III pressure wound. - Plan: Cleanse with normal saline and apply A&D ointment daily. Review of Wound Care Progress Notes dated 7/30/24 for R2 revealed: -Wound 1: Pressure wound sacral stage IV- Plan: Cleanse with Dakin's and apply wound Vac to be changed Tuesday, Thursday, and Saturday and apply barrier cream to surrounding tissue. Apply Flagyl (antifungal) powder. Measurement: 11.6 x 12.8 x 1.4 cm. No undermining or tunneling was noted. Post-debridement Measurement 11.8 x 12.8 x 1.5 cm. -Wound 2: Right trochanter, unstageable pressure-induced tissue damage, which is now reclassified to stage IV pressure wound. - Plan: Cleanse with normal saline and apply Flagyl powder and then apply wet-to-dry dressing daily and apply barrier cream to surrounding to tissue. Measurement: 3.7 x 3.9 x 1.2 cm with undermining of 1.7 at 5 o'clock. Post-debridement Measurement: 3.8 x 4.0 x 1.4, with undermining of 1.9 cm at 5 o'clock. -Wound 3: Left heel, stage III pressure wound. - Plan: Apply A&D ointment daily. Review of a Physician Progress note dated 8/1/24 for R2 revealed: Have asked the nursing staff to apply Dakins wet to dry for the wound infection of the right hip. Review of the Order Summary and the Treatment Administration Record (TAR) for R2 revealed the following orders: 6/25/24- Apply Triple antibiotic ointment to left heel. Present as small, scabbed area on outer aspect. Monitor for any changes, every day and night shift. Not documented as done on the day shift on 7/23, 7/25, or 7/30. 6/26/24 - Negative pressure wound therapy to Sacrum and right hip @ 125 mmHg continuous: Cleanse areas with NS, pat dry, skin prep wound edges, Apply black sponge, cut to fit wound cavity, cover with plastic drape- bridge areas together and secure vac (Ensure Black foam is not touching any intact skin) every day shift, every Tue, Thu, Sat. use Dakins to cleanse coccyx wound. (sic) -Not documented as done on 7/23/24, 7/27/24, 7/30/24 or 8/1. (The resident received one wound vac dressing change from 7/20 to 8/3 (7/25/24 and 8/3/24 only). 6/26/24 - Santyl Ointment 250 UNIT/GM (Collagenase) Apply to right hip wound topically every day shift every Tue, Thu, Sat for wound care. -Santyl Ointment to the right hip was documented as a see nursing notes (code 9) on 7/9 and 7/11, not documented as done on 7/27, documented as a refusal (code2) on 8/1, and not documented as done on 8/3. 7/19/24-Wound Care for Stage 4 on Sacrum and Stage 3 on right hip: Cleanse with Normal saline; Apply wet to dry dressing. when wound vac is not connected or fail, as needed for wound care change daily if wound vac is not in use. -Not documented as done 7/20 to 7/23 then it was discontinued. 7/23/24- Wound Care for Stage 4 on Sacrum and Stage 3 on right hip: Cleanse with Dakins solution; Apply wet to dry dressing. when wound vac is not connected or fail, as needed for wound care change daily if wound vac is not in use. -Not documented as done on the TAR 7/24 to 7/31 when it was discontinued. 7/23/24- H-Chlor 12 External Solution (Sodium Hypochlorite) Apply to coccyx topically every day shift every 3 day(s) for stage 3 wound too be used with dressing change. -Not documented as done on 7/24, 7/27, or 7/30 and was discontinued on 7/31/24. 7/31/24- Right trochanter wound- cleanse with dakins and soak for 5 minutes apply flagyl 250 mg crushed tablet to wound bed and apply wet to dry drsg daily every day shift. (sic) - not documented as done on 7/31 or 8/1. 7/31/24- Sacral wound- cleanse with dakins solution 0.125% and let soak for 5 minutes. Apply flagyl 250 mg crushed tablet to wound bed and apply wound vac every tues, thurs, sat. use wet to dry drsg (dressing) if wound vac is not working properly daily as needed for daily wet to dry drsg change. (sic) -Not documented as done on 7/31 and discontinued 8/1. 7/31/24- Sacral wound- cleanse with dakins solution 0.125% and let soak for 5 minutes. Apply flagyl 250 mg crushed tablet to wound bed and apply wound vac every tues, thurs, sat. use wet to dry drsg if wound vac is not working properly daily every day shift every Tue, Thu, Sat. (sic) -Not documented as done on 8/1. In an interview on 11/28/24 at 11:20 AM, the Assistant Director of Nursing (ADON) L reported it had been a very long time since the facility took care of a resident who had a wound vac before R2. She confirmed the staff did not have any training for the wound vac R2 needed for her wounds. When asked if staff knew how to care for a resident with a wound vac, she reported she was not told specifically that staff didn't know how to use a wound vac but knew they were not comfortable doing it. ADON L reported she was not aware of any concerns that R2 was not receiving her pressure ulcer dressing changes. In an interview on 8/28/24 at 12:30 PM, the Director of Nursing (DON) reported she has been here since April and is not aware of nursing staff having any training on wound Vacs. When asked about the wound Vac not working for R2 and wound care not being done for several days in July and August, the DON reported she did not know about it. The DON expected her staff to report to her if there were any complications with the wound vac and notify the physician. The staff are to do a wet to dry dressing when the wound vac is not working and confirmed that it was not done. The DON does expect to see documentation regarding the missed treatments and notify the physician. Review of a Skin Monitoring and Management - Pressure Ulcer adopted 7/11/18 revealed: It is the policy of this facility that: A resident having pressure ulcers receives necessary treatment and services to promote healing, prevent infection, and prevent new, unavoidable sores from developing.

This citation pertains to intakes: MI00146486 and 146502 Based on interview and record review the facility failed to provide supervision and assistance in 1 of 4 residents (R1) reviewed for falls/safety, resulting in falls and injuries. Findings included: Review of R1's face sheet dated 8/26/24 revealed he was a [AGE] year-old male admitted to the facility on [DATE] and had diagnoses that included: personal history of traumatic brain injury, mild neurocognitive disorder, severe protein-calorie malnutrition, post-traumatic stress disorder and repeated falls. R1 was not his own responsible party. Review of R1's fall care plan dated 4/26/24 revealed, resident at risk for falls r/t (related to) weakness, repeated falls encephalopathy and debility. HX (history) of TBI (traumatic brain injury) with cognitive deficit, removing socks and shoes, impulsive with transfer. Actual fall on 4/26/24 review of interventions revealed no interventions for supervision. Review of R1's incident and accident reports from 4/24/24 to 5/15/24 revealed R1 had 9 unwitnessed (unsupervised) falls. Review of the incident/accident reports and the post fall evaluations for these falls revealed the facility did not add any supervision interventions to R1's care plan. Review of R1's incident and accident report dated 4/26/24 at 21:45 (9:45 PM) revealed he was found in bed with blood coming from above his right eyebrow and his right elbow. He reported he fell and got into bed. He required medical treatment to stop the bleeding. The report documented he was noncompliant and forgetful to call for assistance. There was no indication of any supervision being added to his plan of care. Review of the Progress Noted dated 5/6/24 at 1:00PM revealed the Nurse Practitioner had seen R1 due to having multiple falls and need for medication changes. There was no mention of an injury of any type (including right elbow) for R1 due to falls but that an xray of the ribs had been completed with no negative results. Review of R1's incident and accident report dated 5/14/24 at 1:37 AM revealed R1 had an unwitnessed fall. R1 said he made it to the toilet but did not know exactly where he fell , he did not know what happened. R1 was educated to use the call light. No new intervention for supervision or assistance was located. Under injury, skin tear to the right elbow was listed. Review of R1's fall report dated 5/14/24 at 1:37 AM and locked on 5/23/24 revealed, pt (patient) has a large skin tear on right elbow. Cleaned and bandaged. Review of the Progress Noted dated 5/15/24 at 1:00PM revealed the Nurse Practitioner had seen R1 due to having multiple falls and an xray of his elbow was ordered due to swelling and limited mobility in the right elbow that had begun after R1's fall on 5/14/24. Review of the Progress Noted dated 5/17/24 at 1:00PM revealed the Nurse Practitioner (NP) had seen R1 as a follow up to the xray of his right elbow. Xray showed no acute fracute, but did show olecranon bursitis. R1 had redness and swelling and warmth in his right elbow indicative of cellulitis. The NP wrote that R1's frequent falls and injury to his elbow could have caused the cellulitis due to the skin tear which would have allowed bacteria in. The practitioner wrote there was a concern for a septic elbow and ordered labs for a C-reactive protein and uric acid levels. Review of R1's Emergency Department History and Physical Note dated 5/19/24 revealed he had been treated at the nursing home for 2 weeks for cellulitis of his right arm and a urinary tract infection. Orthopedic surgery was consulted for irrigation and debridement of the right olecranon septic bursitis with bursectomy as well as irrigation and debridement of the right foream abscess that was deep and multiloculated. Review of R1's hospital discharge summary dated 5/31/24 revealed he had surgical treatment for a septic olecranon bursitis (elbow injury resulting in infection), he was treated for urinary tract infection, he had a feeding tube placed on 5/26/24. Outpatient follow up issues included: 1:1 feeding, ortho follow up for suture removal. Keep are wound open to air, ongoing wound care, and complete IV (intravenous) antibiotics. During an interview with the Assistant Director of Nursing (ADON) V on 8/27/24 at 11:10 AM she recalled caring for R1 during his stay at the facility. ADON V recalled R1 having multiple falls and did not recall any time the treatment team recommended activities or any way to supervise R1 when he was awake. During an interview with the Director of Nursing (DON) on 8/27/24 at 12:30 PM R1's 9 falls and post fall evaluations were reviewed. The DON confirmed that R1 was not his own responsible party, he was impulsive and unsafe. The DON could not locate any documentation that the facility implemented any care plan to supervise R1 when he was awake. The DON could not find any summary of an interdisciplinary review post fall or any investigation into R1's status prior to each fall.

This citation pertains to intake MI00146486. Based on interview and record review, the facility failed to ensure adequate care for a resident who required tube feeding in 1 of 1 resident (R1) reviewed for tube feeding, resulting in an acute change of condition immediate need for ambulance transport to the hospital. Findings include: Review of R1's face sheet dated 8/26/24 revealed he was a [AGE] year-old male admitted to the facility on [DATE] and had diagnoses that included: personal history of traumatic brain injury, mild neurocognitive disorder, severe protein-calorie malnutrition, post-traumatic stress disorder and repeated falls. R1 was not his own responsible party. Review of R1's hospital discharge summary dated 5/31/24 revealed he had surgical treatment for a septic olecranon bursitis (elbow injury resulting in infection), he was treated for urinary tract infection, he had a feeding tube placed on 5/26/24. Review of R1's Emergency department history and physical note dated 6/3/24 revealed, Patient was residing at nursing home facility, was on tube feeds and per daughter was supposed to have his head elevated at 30 degrees. However, when she arrived, he was not responsive, irregular breathing while lying flat. In transit to the hospital, pulses were lost, and family had elected to allow natural death. Patient pronounced upon arrival to the emergency department. Review of R1's progress noted dated 6/4/24 at 00:38 (12:38 AM) revealed, when I arrived for my shift (10:00PM), I was alerted that the patient needs to be assessed. Pt (patient) was grayish in color, gurgling, and short of breath, sweating profusely. T (temperature) 97.4, HR (heart rate) 27 then 115, unable to get O2 reading, reading as low. Put on 4 L (liters) NC (nasal canula) and sat patient up completely from his 45-degree angle that increased to 63 %. Unable to obtain BP. Patient left with (name of ambulance company and his sister at 10:58 PM. Name of hospital ER (emergency room ) called at 12:34 AM and informed us that patient passed away en route. Signed electronically by, Licensed Practical Nurse (LPN) T During a telephone interview with LPN T on 8/27/24 at 8:33 AM, LPN T said she started her shift on 6/3/24 at approximately 10:00 PM. She could not recall which certified nurse told her R1 was distress and recalled the nurse in charge at the time was an agency nurse but could not recall her name. LPN T recalled R1 was lying flat in bed when she arrived with his tube feeding running. LPN T said R1 was known to scoot down and slide down in bed with his tube feeding running. During a telephone interview with LPN B on 8/28/24 LPN B confirmed she was the nurse on R1's unit 6/3/24. Record review showed LPN B gave R1 medications at 6:00 PM that night. LPN B could not recall what R1 was like between 6:00 PM and 10:00 PM when he was found flat and unresponsive in bed. LPN B did not recall why she did not document on R1 condition in the medical record. LPN B did not recall why other nurses did the transfer notes and did the assessment on R1. LPN B was aware R1 slid down in bed when his tube feeding was running. LPN B said she tried to do frequent checks due to his unsafe behaviors but had no recall of the last time she saw him on 6/3/24. During a telephone interview with LPN U on 8/28/24 at 9:42 AM, LPN U recalled doing the hospital transfer sheet for R1 on 6/3/24. LPN U had no recall of seeing R1 at any time on 6/3/24. During an interview with the Assistant Director of Nursing (ADON) V on 8/27/24 at 11:10 AM she recalled caring for R1 during his stay at the facility. ADON V said she did not know R1 was scooting down or sliding down in his bed when his tube feeding was running. During an interview on 8/27/24 at 12:30 PM, Director of Nursing (DON) denied any knowledge of R1 sliding or scooting down in bed when his tube feeding was running. The DON did not have any investigation or documentation of any care provided for R1 from 6:00 PM to 10:00 PM on 6/3/24 when he was found lying flat in bed, tube feeding running and in respiratory distress.

This citation pertains to intake # MI00141109 Based on interview and record review, the facility failed to maintain an environment free from abuse for 2 (Resident #105 and Resident #108) of 8 residents reviewed for abuse, resulting in physical injury, feelings of frustration, mental anguish, and a potential for psychosocial harm. Findings include: Resident #105 Review of an Admission Record revealed Resident #105 was admitted to the facility on [DATE] with the following pertinent diagnoses: unspecified dementia without behavioral, psychotic, or mood disturbance (condition characterized by progressive loss of intellectual functioning), and hemiplegia (loss of movement on one side of the body). Review of a Minimum Data Set (MDS) assessment for Resident #105 dated 11/10/23 revealed was usually able to make self understood, usually understood others. Resident #105 scored 11/15 on a Brief Inventory for Mental Status (BIMS) assessment which suggested he had a moderate cognitive impairment. Section E of the MDS revealed Resident #105 displayed no physical or verbal behavioral symptoms directed toward others during the 14-day assessment period. Section GG of the MDS revealed Resident #105 required dependent assistance for transferring from a lying to sitting position, transferring to and from a wheelchair, bathing, lower body dressing, and toileting. Review of a care plan dated 11/15/23 revealed the following pertinent problems: I present as alert and oriented but have memory problems. I prefer to be in my room watching TV. I have a dx (diagnosis) of dementia and have a potential to display signs and symptoms of .memory deficits. Pertinent approaches within the care plan included: Anticipate and meet the resident's needs. Monitor me for changes in mood . Review of a facility policy titled Abuse Program Policy and Procedure last revised on 8/5/16 revealed a definition: Abuse means the willful infliction of injury .intimidation .with resulting physical harm or pain, mental anguish . Under the heading of Policy was a statement: It is the policy of (name of the facility) that Residents will not be subjected to abuse by .facility staff, other residents . Review of a progress note for Resident #106 dated 7/25/23 revealed: Quickly went to room as resident was yelling at his roommate (Resident #105) to get out and swore at him. Review of a progress note for Resident #106 dated 9/7/23 revealed: Resident being aggressive towards (sic) roommate (Resident #105). Saying nasty things and swinging his arm to hit his roommate's feet. Review of a progress note for Resident #106 dated 9/18/23 revealed: Resident heard taunting roommate (Resident #105) from hallway. Resident calling roommate names, and harassing roommate. Review of a progress note for Resident #105 dated 9/18/23 revealed: Resident notably agitated this AM (sic) in correlation with roommate calling resident names, taunting, and harrassing. Resident asked this nurse if resident can not be in the same room with roommate. This nurse told resident this nurse will inform assigned SW (social worker). Review of a progress note for Resident #106 dated 10/13/23 revealed: Resident could be heard from assigned unit hallway, verbally accosting roommate (Resident #105). Using foul language, calling roommate insulting names. In an interview on 12/18/23 at 10:42am, Resident #105 reported he recently moved to a new room and that he liked it much better. Resident #105 described his previous roommate (Resident #106) as an a**hole that yelled at him repeatedly and eventually hit him in the mouth with his fist. When asked if staff were aware of the issues he had, Resident #105 stated the staff knew, and they didn't do anything about it. Resident #105 reported the situation was emotionally upsetting and caused him to feel frustrated frequently prior to moving to a new room. In an interview on 12/18/23 at 12:02pm, Social Worker (SW) N reported Resident #105 and Resident #106 had been roommates for several months during which time they had ongoing verbal altercations involving swearing at each other, yelling, and name calling. SW N reported she was aware of an initial physical altercation in which Resident #106 grabbed Resident #105's feet, as well as the physical altercation during which Resident #106 punched Resident #105 in the face. When queried about the facility's efforts to curtail the verbal and physical abuse, SW N reported the facility had not attempted to move one of the residents to another room until Resident #105 was physical injured. SW N reported she considered offering Resident #105 the opportunity to move to another room due to the abusive nature of the interactions he was enduring, but to do so, other residents would have needed to be moved. SW N reported at times during the ongoing issues between Resident #105 and Resident #106, the facility had open rooms in the rehab area of the facility, but she did not ask the NHA for permission to move Resident #105. SW N reported she would have needed authorization from management to offer Resident #105 a room in the rehab area. In an interview on 12/19/23 at 11:47am, Nursing Home Administrator (NHA) A reported the facility had not offered Resident #105 the opportunity to change rooms despite ongoing verbal altercations with his roommate. When asked about the possibility of Resident #105 being moved to a room in the rehab area of the building, where the facility had open beds at times, NHA A stated we don't like to do that. NHA A reported Resident #105 was assisted with moving after he was physically assaulted, and a room was available on his unit. NHA A reported Resident #106 remained in a double occupancy room but would not have a roommate because it's not safe to have another resident in there. In an interview on 12/14/23 at 2:44pm, Certified Nursing Assistant (CNA) TT reported they witnessed Resident #106 displaying ongoing verbally aggressive behaviors toward Resident #105 in the months leading up to the physical altercation that took place on 11/8/23. CNA TT reported the verbal aggression directed toward Resident #105 included almost daily swearing, yelling, and name calling. CNA TT reported on 11/8/23 the residents were seated near each other in their room while CNA TT assisted them with grooming. CNA TT reported Resident #106 unloaded on (Resident #105) and punched him three times in the face. CNA TT reported he and another staff member separated the residents and noted Resident #105 had a cut and swelling on his lower lip. CNA TT reported after the residents were separated, the privacy curtain was pulled between them to reduce their interactions. CNA TT reported he did not know if either resident had previously been given the opportunity to move to another room, but ultimately Resident #105 was moved within days, after the physical altercation. In an interview on 12/18/23 at 12:50pm, Licensed Practical Nurse (LPN) D reported she witnessed Resident #105 being verbally accosted nearly every day by Resident #106 and documented the incidents in the 24-hour report reviewed by management. LPN D reported she never witnessed Resident #105 initiate any verbal or physical aggression toward Resident #106. LPN D reported Resident #105 asked her on 9/18/23 if he could move to a different room and his request was shared with social services. In an interview on 12/18/23 at 4:00pm, Family Member (FM) R, reported he was the Durable Power of Attorney (DPOA) for Resident #105 and visited him regularly. FM R reported he witnessed Resident #106 yelling and swearing at Resident #105 during his visits. FM R reported Resident #105 expressed to him that he (Resident #105) did not like sharing a room with Resident #106. FM R reported Resident #105 appeared stressed and frustrated by the interactions he experienced with Resident #106. Applying the reasonable person concept, though Resident #105 had decreased ability to verbalize his thoughts and recall events due to his medical diagnosis, he was clearly frustrated and emotionally upset about the verbal and physical altercations he experienced with another resident. This frustration and emotional upset have the potential to continue well past the date of the incidents based on the reasonable person concept. Resident #108 Review of an Admission Record for Resident #108 dated 1/23/19 revealed the resident was admitted to the facility with the following pertinent diagnoses: major depressive disorder (persistent feeling of sadness and loss of interest). Review of a Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #108 scored 15/15 on a Brief Interview for Mental Status (BIMS) assessment which indicated she was cognitively intact. Section E of the MDS revealed Resident #108 had no delusions (misconceptions held contrary to reality) and no behaviors directed toward others. Review of a care plan for Resident #108 dated 11/21/23 revealed relevant problem/goal/approaches as follows: Problem: I have a dx (diagnosis) of depression. Goal: My goal is to participate with monitoring of my moods and communicate my emotions to staff social worker .Approaches: staff will provide me with positive reinforcement for positive coping skills . In an interview on 12/14/23 at 12:47pm, Resident #108 reported she felt she experienced verbal abuse during an interaction with Director of Nursing (DON) B on 12/7/23 at approximately 10:00am. Resident #108 reported DON B stood over her and yelled at her in angry tone, stated You had your sister-in-law call me and yell at me regarding an issue related to a dental appointment. Resident #108 described DON B facial expression as angry and frustrated during the interaction and that DON B blamed the resident for having a dental emergency because she cancelled two other appointments. Resident #108 reported she felt embarrassed and disrespected by the interaction. In an interview on 12/14/23 at 12:55pm, Confidential Informant (CI) L reported she overheard the interaction between DON B and Resident #108 on 12/7/23 and was appalled by the tone of voice that DON B used toward Resident #108. CI L described the tone of voice and wording used by DON B as disrespectful, emotionally charged, and blaming. CI L reported clearly hearing DON B's comments from more than 30 feet away because he was yelling. In an interview on 12/14/23 at 1:14pm, NHA A reported she was aware that Resident #108 felt as though DON B had yelled at her but had not followed up with an investigation. NHA A reported DON B talked with Resident #108 afterward and entered a progress note. NHA A reported an investigation of abuse would be initiated. Review of a progress note entered by DON B on 12/11/23 at 11:39am revealed a statement: (Resident's name) came to this writer's office and asked why I yelled at her last Thursday .I explained I did not yell .I was sorry but .I was upset because I got a phone call from her sister .but not once did you (Resident #108) approach me about .having increased pain . In an interview on 12/14/23 at 3:32pm, Resident #108 approached the surveyor and reported NHA A asked her to come down and voice that she (Resident #108) was not damaged from the interaction with DON B on 12/7/23. Resident #108 confirmed that during the interaction DON B acted unprofessional, appeared angry, and confrontational. Resident #108 reported she felt disrespected and frustrated at the time of the interaction. Review of an investigation summary documented on 12/15/23 revealed Resident #108 continued to express that DON B yelled at her, and was unprofessional, and his behavior was uncalled for on 12/7/23, causing her to feel emotionally upset, disrespected, and unheard. Resident #108 felt she was yelled at for advocating for herself. The investigation summary revealed that DON B confirmed his emotions got the best of him during that interaction. Review of Fast Facts: Preventing Elder Abuse dated 6/2/21, https://www.cdc.gov/violenceprevention/elderabuse/fastfact.html, revealed a definition: Emotional Abuse: refers to verbal or nonverbal behaviors that inflict anguish, mental pain, fear, or distress on an older adult. Examples include humiliation or disrespect, verbal and non-verbal threats, harassment, and geographic or interpersonal isolation.

Based on interview and record review the facility failed to provide a safety intervention to 1 of 16 residents (Resident #43) reviewed for falls resulting in a fall with fracture (broken bone) for Resident #43 Findings include: Review of the Face Sheet revealed Resident #43 was a [AGE] year old female admitted to the facility on [DATE] and diagnosed with Alzheimer's disease. Review of the Minimum Data Set (MDS) dated [DATE] revealed Resident #43 had a brief interview for mental status (BIMS) score of 0 out of 15 which indicated she had severely impaired cognition. Review of the Fall Report dated 9/4/21 at 02:35 AM, revealed Resident #43 was confused, drowsy, had weakness and had impaired memory. The Fall report further revealed Resident #43 .fell straight over to left side before staff could provide assistance with initiated interventions of Pressure PAS (personal alarm system) in bed and w/c (wheelchair) with tab PAS. Review of Physician's Orders dated 9/15/21 revealed Resident #43 had an order for Personal Alarm System (PAS)- pressure PAS (personal alarm system) in bed and tab pas in w/c (wheelchair). Monitor every shift for placement and function. Review of the Fall Risk Evaluation dated 9/28/21 at 10:21 AM revealed Resident #43 was at risk for falls. Review of the Progress Notes dated 10/10/2021 at 09:40 PM revealed, Resident (Resident #43) repeatedly attempting to self transfer during this shift. Resident (Resident #43) is very unsteady. This resident (Resident #43) has also been trying to deactivate her (Resident #43) alarm for her chair and for her bed. Resident (Resident #43) has been educated several times during this shift, that the alarms are there for her safety. Review of the Kardex dated 12/2021 revealed Resident #43 was to have staff MONITOR-safety check .check PAS alarms in place. Review of the Fall Report dated 10/23/21 at 04:45 PM revealed Licensed Practical Nurse (LPN) QQ had found Resident #43 .on the floor on her right side and Resident #43 .was sent to the ER (emergency room ). Review of the Nurses Notes dated 10/23/2021 at 04:45 PM, This nurse (Licensed Practical Nurse (LPN) QQ heard a body falling, and someone saying aww. Resident observed lying on the floor on her right side. Resident was crying out that her right side, RLE (right lower extremity) was having a lot of pain. Resident is also clinching that area. Resident also presents with a contusion on the back of her head. Niece notified of incident. Order obtained to transfer resident to .ER (emergency room ) for further eval(uation). Review of the Progress Note dated 10/23/2021 at 05:30 PM revealed an Incident Note .EMS (emergency medical service) in to transfer resident (Resident #43) to ER for further evaluation. Review of the Progress Note dated 10/23/2021 at 05:44 PM revealed an Incident Note late entry: Resident (Resident #43) unhooked PAS, alarm was not sounding when resident fell . Resident has been restless throughout shift, and was triggering alarm constantly. Review of the Progress Note dated 10/23/2021 at 07:56 PM revealed a Health Status note that Resident #43 was .being admitted to .hospital with a positive fracture to right hip. During an interview on 12/09/21 at 02:17 PM, Certified Nurse Aide (CNA) XX stated Resident #43 has had falls and that's why she (Resident #43) has the alarms (PAS) on now. CNA XX stated, no she (Resident #43) does not like the alarms because she (Resident #43) will try to hide it (alarm/PAS) or take it (alarm/PAS) off. CNA XX further stated, sometimes (Resident #43) wants it to be quiet so she can do what she wants to do. CNA XX stated, on 10/23/21, I was here that day and Resident #43 was like a yo yo, up down up down; she wasn't happy. During an interview on 12/09/21 01:28 PM, LPN QQ stated, on 10/23/21, Resident #43 .turned off her alarm (PAS) and started to walk. LPN QQ stated staff had Resident #43 sitting in the common area and went to get her roommate and heard someone falling. LPN QQ stated Resident #43's alarm (PAS) wasn't working, she unhooked it. LPN QQ stated Resident #43 turns it (PAS/alarm) off all the time and Resident #43 was always confused. During an interview on 12/09/21 at 03:03 PM, Nursing Home Administrator (NHA) A stated Resident #43 had fallen multiple times and Resident #43 doesn't understand and the alarm/PAS use angers Resident #43. NHA A stated, no Resident #43 doesn't like the alarm. NHA A stated, yes Resident #43's alarm/PAS was to be on and assume it's (alarm/PAS) functioning all the time. Review of the Orthopedic (bone specialist) Trauma Surgery Consult Note dated 10/23/21 at 08:14 PM revealed Resident #43 .was reportedly trying to leave her nursing home facility when she fell and .has been having frequent falls and therefore is supposed to be using a wheelchair for mobility. The Consult Note further revealed Resident #43 had a work-up in the emergency department revealed a right .hip fracture with plan for ORIC (open reduction internal fixation (surgical repair) for right hip fracture.

This citation has 2 Deficiency Practice Statements (DPS), A and B. DPS A Based on observation, interview, and record review, the facility failed to prevent and contain the spread of COVID-19 for 16 of 18 sampled residents (#117, #106, #107, #113, #114, #115, #116, #102, #103, #104, #105, #109, #110, #111, #112, and #101) reviewed for infection control practice, resulting in an immediate jeopardy when: 1) on [DATE], staff with COVID-19 symptoms continued to work and the first resident tested positive COVID-19 on [DATE], 2.) screening of staff prior to work and follow up on staff illness symtpms did not occur, and 3) process and outcome surveillance were inadequately conducted to ensure staff were adhering to appropriate infection control practices including personal protection equipment (PPE) use throughout the facility between known COVID-19 positive residents and COVID-19 negative residents. This deficient practice resulted in serious harm for 74 residents and 14 resident deaths. On [DATE] at 2:53 P.M., the Nursing Home Administrator and Director of Nursing were verbally notified and received written notification of the Immediate Jeopardy that began on [DATE] and was identified on [DATE] due to the facility's failure to prevent and contain the spread of COVID-19. A written plan for removal for the immediate jeopardy was received on [DATE] and the following was verified on [DATE]: 1. On [DATE], the facility contracted with (name of firm omitted) for Infection Control Consultant to review all aspects of the Infection Control Plan to review, revise, and implement a program that is effective in preventing the spread of a communicable disease. The consultant began working with the facility on [DATE]. 2. On [DATE], 4 negative residents were assessed and continue to be in a private room. A large sign posted outside of room showing they are negative status with instructions to remove and apply clean PPE (Personal Protection Equipment) when entering the negative resident's room. 3. On [DATE], negative residents will continue to be tested on a weekly basis. 4. On [DATE], a new policy on staff call-ins and staff return to work criteria was formulated based on CDC (Centers for Disease Control) guidelines. On [DATE], 38 employees received 1:1 education on policy, 12 employees were educated prior to their shift on new policy on [DATE] & will continue to educate staff [DATE] prior to each shift. A copy of the new policy has also been posted at the time clock. 5. On [DATE], the ICP (Infection Control and Preventionist) or Human Resources began to review all call-in slips daily and call those staff members to obtain specific symptoms and appropriateness for return to work-based on CDC guidance for Return to Work. 6. On [DATE], staff who have tested positive will be off work for 10-days since symptoms first appear and at least 24 hours since last fever without medications and if symptoms have improved. 7. Per the conference call on [DATE] with (county health department name omitted, and state agency name omitted), COVID positive staff who are stable may assist with staffing only during a staffing crisis situation but may not work with those residents or staff who have tested negative. Schedules are prepared with knowledge of staff testing results and staff notified of need not to change assignments. A designated area has been provided for breaks for employees who are negative. Staffing crisis situation has improved with those employees past their 10-day quarantine returning to work and anticipate end of staffing crisis being [DATE]. 8. On [DATE], the facility contracted with 2 agencies to assist with staffing. They do not totally fill open spots on schedule therefore continuing the need for contingency staffing. 9. Beginning [DATE], per new contract, the ICP, Director of Nurses, Emergency Preparedness Coordinator and Administrator with assistance of (consultant name omitted) will review the Infection Control Program to ensure that it includes the surveillance of staff and implement an effective system for tracking, monitoring, and report of staff symptoms to prevent ill staff from working. 10. On [DATE], 38 employees and on [DATE] 12 employees were educated 1:1 by Emergency Preparedness Coordinator and designated staff on PPE usage and the rest of staff will be educated prior to start of next scheduled shift. After surveyor review on [DATE] of infection control breeches of staff use of PPE, re-education of staff began. No staff will be allowed to work without the re-education. 11. Beginning on [DATE], ICP, Director of Nurses, Emergency Preparedness Coordinator, Administrator, or designated staff on a daily basis will monitor/audit random staff from all department on all shifts to ensure all staff is adhering to proper PPE use between COVID positive and COVID negative residents throughout the facility with immediate education and corrective measures as needed. Audits will be documented and include any of those corrective measures that were needed. Although the Immediate Jeopardy was removed on [DATE], the facility remained out of compliance at a scope of widespread and severity of actual harm due the fact that not all facility staff have received education, the Infection Control Consultant had not yet began working with the facility, and sustained compliance has not been verified by the State Agency. Findings include: Review of Centers for Disease Control (CDC) Criteria for Return to Work for Healthcare Personnel with [DIAGNOSES REDACTED]-CoV-2 Infection (Interim Guidance) Updated Aug. 10, 2020 revealed, HCP with symptoms of COVID-19 should be prioritized for [MEDICAL CONDITION] testing with approved nucleic acid or [MEDICATION NAME] detection assays. When a clinician decides that testing a person for [DIAGNOSES REDACTED]-CoV-2 is indicated, negative results from least one FDA Emergency Use Authorized COVID-19 molecular [MEDICAL CONDITION] assay for detection of [DIAGNOSES REDACTED]-CoV-2 RNA indicates that the person most likely does not have an active [DIAGNOSES REDACTED]-CoV-2 infection at the time the sample was collected. A second test for [DIAGNOSES REDACTED]-CoV-2 RNA may be performed at the discretion of the evaluating healthcare provider, particularly when a higher level of clinical suspicion for [DIAGNOSES REDACTED]-CoV-2 infection exists .Symptom-based strategy for determining when HCP can return to work. HCP with mild to moderate illness who are not severely immunocompromised: At least 10 days have passed since symptoms first appeared - and At least 24 hours have passed since last fever without the use of fever-reducing medications and Symptoms (e.g., cough, shortness of breath) have improved .HCP with severe to critical illness or who are severely immunocompromised: At least 10 days and up to 20 days have passed since symptoms first appeared - At least 24 hours have passed since last fever without the use of fever-reducing medications - and Symptoms (e.g., cough, shortness of breath) have improved . In an interview on [DATE] at 1:15 P.M., Licensed Practical Nurse (LPN) JJ indicated had tested negative for COVID-19 on [DATE] (date was notified of results) and positive for COVID-19 on [DATE] (date was notified of results). LPN JJ reported had symptoms which included upper chest tightness, shortness of breath, and severe lethargy when tested for COVID-19 on [DATE] and that symptoms persisted though [DATE] with positive COVID-19 test. LPN JJ indicated had reported symptoms to Nurse Scheduler (NS) NN and Infection Control and Preventionist (ICP) S the time of the [DATE] COVID-19 test. LPN JJ indicated had worked all over (indicating had worked on multiple resident care units) between [DATE] and [DATE]. LPN JJ reported took breaks in the facility break room and confirmed other staff were often in the break room at the same time, with masks off, and not socially distanced. Review of a facility Punch Source Report (timeclock report detailing when employees clock in and clock out) revealed LPN JJ worked on [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE]. Review of a listing of COVID-19 positive employees provided to this surveyor by ICP S revealed LPN JJ date of positive COVID-19 test was [DATE]. Review of a document Employee Health Screening revealed, Date, Employee Printed Name, Daily Temp (temperature), If you answer yes to the following question, you must see (NHA A), (DON B), (RN H), or (ICP S). Uncontrolled cough, Shortness of Breath, Loss of taste or smell, Muscle Aches, Sore Throat, Severe Headache, Stomach pain, Diarrhea, or Vomiting. Since you last reported to work, have you had any of the above symptoms not explained by a known medical or physical condition? Circle One: Yes / No. In an interview on [DATE] at 9:39 A.M., Housekeeper (Hsk) P reported tested COVID-19 positive on [DATE] and had been off work for 10 days after positive result ([DATE]-[DATE]). Hsk P indicated [DATE] was first day back to work. Hsk P indicated Hsk G was a family member who resided in same household and was also off work between [DATE] - [DATE] (10 days) due to potential exposure to COVID-19 and also returned to work on [DATE]. In an interview on [DATE] at 8:50 A.M., Housekeeper (Hsk) G indicated main job was housekeeping but also helps to feed residents and assist with transferring residents with a hoyer (a lifting device used in the transfer of a resident between two surfaces; for example - from bed to commode). Hsk G indicated worked all over the building Hsk G stated, I was told to walk around and see who needs help. In an interview on [DATE] at 9:45 A.M., Housekeeper (Hsk) G indicated had been off work from [DATE] to [DATE] because family member who resided in same household had tested positive for COVID-19. Hsk G indicated had not yet tested positive for COVID-19 but had a fever of 100.8 on [DATE] and [DATE]. Hsk G stated, right now I have no sense of taste or smell and I have a stuffy nose and body aches. This surveyor asked Hsk G to describe the employee COVID-19 screening policy. Hsk G indicated there was a thermometer and form by the timeclock; staff must take their own temperature, fill out the (Employee Health Screening) form, and answer if they have any new symptoms prior to starting their shift. Hsk G then showed this surveyor the (Employee Health Screening) form and in doing so stated I just realized I didn't fill out the form when began this shift but I took my temperature. Hsk G wrote down temperature previously taken and hesitated when began to answer question about new symptoms. Hsk G stated, I'm not sure if I should answer yes or no to the new symptoms question because I had these symptoms for a while so they are not new. Social Worker (SW) W, who was down the hall, shouted to Hsk G, you need to say yes and then go tell (Infection Control Preventionist - ICP S). This surveyor asked Hsk G if they understood the employee screening process prior to being told by SW W. Hsk G reported knew to take temperature and supposed to fill out Employee Health Screening form prior to shift but had not fully understood how to answer the yes or no question about having new symptoms. In an observation/interview on [DATE] at 11:05 A.M., noted Hsk G wiped down handrails in the hallway of the Rehab Unit (considered a COVID negative unit). Hsk G indicated had been rapid COVID-19 tested by ICP S about a half hour ago. Hsk G reported was told would know results in 20 minutes and since hadn't heard anything, assumed was negative. In an observation/interview on [DATE] beginning at 11:11 A.M., noted Hsk P was cleaning a COVID-19 negative resident's room on the Rehab Unit. Hsk P stated I assume they all have COVID-19 (indicating unaware of COVID-19 negative status of resident whose room (Hsk P) was cleaning). Hsk P reported had not asked anyone, to confirm COVID-19 status of residents on the Rehab Unit where working. During same observation/interview, noted Hsk G entered in a different COVID-19 negative resident's room (Resident #117). In an interview on [DATE] at 9:30 A.M., Infection Control and Preventionist (ICP) S indicated Hsk G's rapid test of [DATE] had resulted as positive for COVID-19. In an interview on [DATE] at 3:08 P.M., Infection Control and Preventionist (ICP) S indicated did not know Hsk G was working on COVID negative hall while waiting for rapid test results. ICP S indicated Hsk G should not have been working on COVID negative hall if had symptoms. ICP S reported did not know Hsk G had symptoms when reported to work. ICP S stated, I can't be everywhere, everyday, monitoring, plus do patient care. Resident #117 Review of a Admission Record revealed Resident #117 was a [AGE] year-old female, originally admitted to the facility on [DATE], with pertinent [DIAGNOSES REDACTED]. Review of Progress Notes dated [DATE] at 7:40 AM, revealed Resident's COVID test returned positive. In an interview on [DATE] at 10:15 AM, Dietary Aide (DA) II reported that on Sunday morning [DATE] he felt sick, super dizzy, bad cough, freezing, sweat all night, the dizziness did not last long, and he felt better on Tuesday. DA II reported that he had called in both days and that he did not have symptoms like he had been having. DA II reported that when he returned to work on Tuesday ([DATE]) he worked 6 AM - 2 PM and was tested for COVID that day along with all the other staff and on Wednesday about 4 PM was told that he was positive. DA II reported that he took breaks in the break room and that we do not wear masks in that room and out of that room [ROOM NUMBER] people came out positive. In an interview on [DATE] at 1:40 PM, Foodservice Director (FD) M reported that DA II was her family member and had picked up [DATE], she stated he left me a note that he did not feel good. He does have allergies [REDACTED]. FD M reported that DA II called in on Monday, again which was his scheduled day because he was still not feeling well, and she spoke with the Nursing Home Administrator (NHA) about what was going on. FD M reported that on Tuesday DA II felt better and was scheduled to work and she had spoken to NHA who had felt it was fine for him to return to work since he had tested negative the week before. Review of the Call-In-Slips dated [DATE], revealed DA II symptoms were cough, stomach ache. No call-in slip was documented for [DATE]. In an interview on [DATE] at 11:18 AM, NHA A reported that DA II had called in on a Sunday and Monday ([DATE] and [DATE]) with allergy symptoms and with mild symptoms, no fever, mild cough, and he felt it was his allergies [REDACTED]. NHA A reported she had DA II come back to work, the staff were wearing cloth mask in the kitchen, had no symptoms, and he was negative the week before on ([DATE]). NHA A reported that he did his routine COVID testing on Tuesday [DATE]. NHA A stated Do not recall if I talked to DA II about his symptoms. NHA A reported that DA II COVID test came back positive on Wednesday and he was off work 14 days. In an interview on [DATE] at 4:35 P.M., Director of Nursing (DON) B reported when staff call off work, the person taking the call (office staff, nurses) is supposed to ask the caller for their symptoms and fills out a Call-In slip which is given to DON B or Infection Control and Preventionist (ICP) S for review. DON B stated, unfortunately, the staff does not always give symptoms - they just say they don't feel good or use the diarrhea or throwing up excuse. DON B indicated when staff report COVID-19-like symptoms but have tested negative, they must still remain off work if they have a fever, cough, or GI issues. Regarding reporting to work at the beginning of a shift, DON B reported staff are supposed to fill out the (Employee Health Screening) form and are supposed to circle (yes or no) if they have had any symptoms since their last shift. DON B stated, (Infection Control and Preventionist (ICP) S) is supposed to be tracking and trending for residents and staff. I can guarantee there is not much documentation for October because we have been on the floor and patient care comes before paperwork. In an interview on [DATE] at 12:50 P.M., regarding return to work policy for staff who called off sick, ICP S indicated facility hadn't been telling people a day that they could come back to work. ICP S reported staff knew they had to be off at least 24 hours without symptoms, but if they had multiple symptoms return to work decision was on a case by case basis (based on symptoms and who they were and what their job was). ICP S stated there is nowhere documented where we told them when they could return to work. In interviews on [DATE] at 9:20 AM, [DATE] at 12:45 PM, [DATE] at 2:40 PM, and [DATE] at 3:45 PM, Licensed Practical Nurse (LPN) / Infection Control & Preventionist (IPC) S revealed that the Director of Nursing (DON) works with the Nurse Practitioner and Physician on rounds and starts the process for collecting the data for infections for the residents. LPN/ICP S reported that she had the data for tracking infection up to [DATE] and then the facility got busy and the data was not moved to the spreadsheets, but was in the residents charts. LPN/ICP S reported that she knows the residents and can track the clusters by looking at a spreadsheet and does not need to map the building I know where the rooms are in the building it is small and I know the residents. LPN/ICP S reported that she checks the call in slips daily, uses a spreadsheet to verify what staff call in and monitor any of the symptoms the residents are having where the staff were working in the building. LPN/ICP S reported that staff generally work in the same area, I have a good understanding of where they work (if I am not sure of where they worked I can check the rosters) because I am out on the floor working. I am aware of who is calling in, I see the call in slips so I am aware of the symptoms. LPN/ICP S reported that she only calls staff back if more information was needed on call in slips. LPN/ICP S reported that the work for October has been done; I just have to go through the charts and put it in the spreadsheet and track and trend it. LPN/ICP S stated, It was very hard to do infection preventionist paperwork as patient care come first. The data is all there in the records it is just not on the spread sheet. I was working the floor because patient care comes first. During an observation/interview on [DATE] at 3:25 PM, Nursing Home Administrator (NHA) A reported all but (4) resident were positive for COVID. The interior double doors were closed to the ,[DATE] halls but there was no signage posted stating that there was COVID positive resident down those halls. During an observation on [DATE] at 3:30 PM, the interior double doors were closed to the 100 hall did not have any signage posted stating that there was COVID positive residents down the hall, and when this surveyor walked to the end of the hall there was an isolation cart outside of room (113) and Certified Nursing Assistant (CNA) L reported that the (2) residents in that room were negative and she had to change her gown, face shield, and gloves, prior to entering that room. The room was not posted with signage to indicate the residents were negative, there was just had a isolation cart sitting outside the room. During an observation/interview on [DATE] at 3:42 PM, the interior double doors leading into the 200 hall from the nursing station did not have any signage posted stating that there was COVID positive residents down the hall, and the double door leading into the Rehab hall did not have any signage posted stating what type of residents were on that hall. CNA BB reported that she was agency and at this time there were 3 positive COVID residents and 5 negative residents (on the Rehab hall). CNA BB reported that the residents that are positive have an isolation cart outside there room, if there was no isolation cart then the resident was negative, but she did point out that (2) of the residents who have rooms next to each other share an isolation cart. There was no signage going into the 300 hall or 200 hall from the Rehab hall that indicated Covid-19 statuses. During an observation on [DATE] at 3:50 PM, the interior double doors leading into the 300 hall from the nursing station did not have any signage posted stating that there was COVID positive residents down the hall, and the double door leading into the Rehab hall did not have any signage posted stating what type of residents were on that hall. Review of a policy Novel ;Coronavirus Prevention and Response implemented and last reviewed/revised [DATE] revealed, Policy: This facility will respond promptly upon suspicion of illness associated with a novel coronavirus in efforts to identify, treat, and prevent the spread of [MEDICAL CONDITION] .Policy Explanation and Compliance Guidelines: 1. The Infection Preventionist will assess facility risk associated with COVID-19 through surveillance activities of emerging diseases in the community and illnesses present in the facility .5. Interventions to prevent the spread of respiratory germs within the facility: a. Keep residents and employees informed by answering questions and explaining what they can do to protect themselves and their fell ow residents .b Monitor residents and employees for fever or respiratory symptoms .iii. Implement heightened surveillance activities . Resident #106 Review of a Face Sheet revealed Resident #106 was a [AGE] year-old female, originally admitted to the facility on [DATE], with pertinent [DIAGNOSES REDACTED]. Review of Resident #106's medical record revealed resident tested positive for COVID-19 on [DATE]. Review of a Health Status Note for Resident #106 dated [DATE] at 9:45 P.M. revealed, .T (Temperature)-97.9, SpO2 (Oxygen Saturation)-89 on 5L (Liters of Oxygen) via nasal canula. HOB (head of bed) and Q2 (every 2 hours) turns. Refused meds this shift, and dinner. No cough, SOB (shortness of breath), N/V/D (nausea/vomiting/diarrhea) noted this shift. Review of a Health Status Note for Resident #106 dated [DATE] at 2:23 A.M. revealed, . T 97.9, SPO2=88 on 5 L via nasal cannula. No cough, SOB, N/V/D noted this shift. Review of a Health Status Note for Resident #106 dated [DATE] at 10:06 A.M. revealed, .0915 (9:15 A.M.) Resident expired . Resident #107 Review of a Face Sheet revealed Resident #107 was a [AGE] year-old male, originally admitted to the facility on [DATE] and readmitted on [DATE], with pertinent [DIAGNOSES REDACTED]. Review of Resident #107's medical record revealed resident tested positive for COVID-19 on [DATE]. Review of a Health Status Note for Resident #107 dated [DATE] at 9:20 A.M. revealed, Late Entry: .0730 (7:30 A.M.) This nurse called to room. Res (resident) lying in bed with no pulse, no BP (blood pressure) .Family notified and DR (doctor) notified . Review of the Death Certificate dated [DATE], revealed Resident #107 died due to or as a consequence of COVID -19. Resident #113 Review of a Face Sheet revealed Resident #113 was a [AGE] year-old female, originally admitted to the facility on [DATE], with pertinent [DIAGNOSES REDACTED]. blood as well as it should), chronic [MEDICAL CONDITIONS] (excess fluid in the lungs), [MEDICAL CONDITION] (a disease in which the kidneys don't filter excess waste and fluid from the blood effectively), and hypoxemia (a low level of oxygen in the blood). Review of Resident #113's medical record revealed resident tested positive for COVID-19 on [DATE]. Review of a Health Status Note for Resident #113 dated [DATE] at 9:20 A.M. revealed, .This nurse went to go check the residents blood sugar and it was at 54, resident was nonresponsive, unable to wake up to sternal rub. Left the room to go get some fast acing carbohydrate to put in the pockets of the residents mouth to elevate the blood sugar. Upon entering back into the residents (sic) the resident was white in color and tongue sticking out, took vitals and no blood pressure noted, check HR (heart rate) and no heart rate noted, listen for heart sounds and no heart sound noted, pronounced death at 0707 (7:07 A.M.) . Resident #114 Review of a Face Sheet revealed Resident #114 was an [AGE] year-old male, originally admitted to the facility on [DATE], with pertinent [DIAGNOSES REDACTED]. Review of Resident #114's medical record revealed resident tested positive for COVID-19 on [DATE]. Review of a Health Status Note for Resident #114 dated [DATE] at 11:38 P.M. revealed, .upon arrival resident was nonresponsive. Mouth breath with a rattle. Resident is on 10 liters of O2 (oxygen) via non (sic) re-breather bask. O2 stat 85%. temp (temperature) is 98.1 . Review of a Health Status Note for Resident #114 dated [DATE] at 12:41 A.M. revealed, .resident continues to mouth breath (sic) with a rattle. Resident is on 10 liters of O2 via none (sic) re-breather mask. O2 stat 67%. temp is 97.5 . Review of a Health Status Note for Resident #114 dated [DATE] at 1:41 A.M. revealed, .aide notified writer that resident had expired. Resident vitals were taken and are not reading. Resident was pronounced expired at 1:20am . Resident #115 Review of a Face Sheet revealed Resident #115 was an [AGE] year-old male, originally admitted to the facility on [DATE], with pertinent [DIAGNOSES REDACTED]. excess waste and fluid from the blood effectively). Review of Resident #115's medical record revealed resident tested positive for COVID-19 on [DATE]. Review of an Infection Note for Resident #115 dated [DATE] at 12:07 P.M. revealed, .T (temperature) 98.1, PO2 (pulse oximetry) ,[DATE]% on 10L (liters of oxygen) via non rebreather mas. Res (resident) has shallow rapid resp (respirations) 36 . Review of a Health Status Note for Resident #115 dated [DATE] at 2:19 P.M. revealed, .This nurse in room with 2 cenas (certified nursing assistants) when res took last breath. No BP (blood pressure), no resp (respirations) noted .NP (nurse practitioner) in and assessed res, no BP, no resp noted .See order to release body to funeral home. Funeral home notified. Resident #116 Review of a Face Sheet revealed Resident #116 was an [AGE] year-old male, originally admitted to the facility on [DATE], with pertinent [DIAGNOSES REDACTED]. causes poor blood flow), [MEDICAL CONDITION] (high levels of fat in the blood), and hypertension (high blood pressure). Review of Resident #116's medical record revealed resident tested positive for COVID-19 on [DATE]. Review of an Infection Note for Resident #116 dated [DATE] at 1:32 P.M. revealed, .T (temperature) 97.9 PO2 (pulse oximetry) 94% RA (room air), P (pulse) 107. Res (resident) is lethargic, poor intake both meals . Review of a Health Status Note for Resident #116 dated [DATE] at 10:05 P.M. revealed, .Transfer resident to (hospital name omitted) due to worsening increased secretion, decreased level of consciousness no respond to verbal (stimuli), fever 100.9 after taking Tylenol 2 away, unable to maintain pox (pulse oximetry) above 84%, called wife and she request for resident to be sent out at hospital . Review of the Death Certificate dated [DATE], revealed Resident #116 died due to or as a consequence of COVID -19. Resident #102 Review of a Admission Record revealed Resident #102 was a [AGE] year-old female, originally admitted to the facility on [DATE], with pertinent [DIAGNOSES REDACTED]. Review of the Progress Notes dated [DATE] at 9:58 AM, revealed positive test results for COVID. Review of the Progress Notes dated [DATE] at 1:45 PM, revealed SPO2 (blood oxygen level) 77% on room air (RA) & 84% on 4 liters of oxygen. Breathing labored and lung sounds course. Difficulty getting O2 stats above 88% .Family request transfer to hospital. Review of record revealed Resident #102 was transfer to the hospital on [DATE], did not return to the facility and that she died on [DATE]. Review of the Death Certificate dated [DATE], revealed Resident #102 died due to or as a consequence of COVID -19 Pneumonia. Resident #103 Review of a Admission Record revealed Resident #103 was a [AGE] year-old male, originally admitted to the facility on [DATE], with pertinent [DIAGNOSES REDACTED]. Review of the Progress Notes dated [DATE] at 1:35 PM, revealed Resident #103 tested positive for COVID. Review of record revealed Resident #103 was transfer to the hospital, did not return to the facility and that he died on [DATE]. Review of the Death Certificate dated [DATE], revealed Resident #103 died due to or as a consequence of COVID -19 Pneumonia. Resident #104 Review of a Admission Record revealed Resident #104 was a [AGE] year-old female, originally admitted to the facility on [DATE], with pertinent [DIAGNOSES REDACTED]. Review of the Progress Notes dated [DATE] at 11:32 PM, revealed Resident #104 tested positive for COVID. Review of record revealed Resident #104 had expired in the facility on [DATE]. Review of the Death Certificate dated [DATE], revealed Resident #104 died due to or as a consequence of COVID -19. Resident #105 Review of a Admission Record revealed Resident #105 was a [AGE] year-old female, originally admitted to (TRUNCATED)

Based on observation, interview, and record review the facility failed to follow Local Health Department (LHD), Center for Disease Control (CDC) and Centers for Medicare and Medicaid Services (CMS) guidance to 1.) place newly admitted /readmitted residents in isolation and transmission based precautions for 4 of 19 (Resident #188, #189, #190 and #191) reviewed for infection control; 2.) assist residents in maintaining social distancing and encourage use of face coverings during dining and activities for 36 of 36 residents (Resident #3, #16, #23, #25, #31, #39, #51, #53, #67, #77, #78, #81, #1, #21, #22, #45, #46, #55, #70, #74, #85, #4, #5, #10, #38, #44, #45, #49, #50, #60, #63, #65, #73, #76 #57, and #188) reviewed for infection control practices, 3.) properly handle and disinfect food carts between meal services for 4 of 19 residents (Resident #188, #189, #190 and #191) reviewed for infection control; resulting in an immediate jeopardy when, beginning on 09/2/20, facility staff did not implement nationally established infection control standard interventions to prevent the likelihood of the spread of Covid-19 in a community with a positivity rate at or near 3% to staff members and residents in the facility. This deficient practice placed all residents at risk for serious harm and/or death. On 09/15/20 at 05:44 PM, the Nursing Home Administrator (NHA) A was verbally notified and received written notification of the immediate jeopardy on 09/16/20 at 10:39 AM, that began on 9/2/2020 due to the facility's failure to implement established infection control interventions and follow CDC guidance. A written plan for removal for the immediate jeopardy was received on 09/22/20 and the following was verified on 09/23/20 and is as follows . Dining Rooms -On 9-16-2020 these residents were assessed #1, #74, #55, #45, #85, #21, #70, #31, #81, #25, #53, #16, #23, #3, #78, for need for feeding assist and supervision to ensure that resident receives nutrition in a safe and timely manner. Each of the above residents were determined to need to remain in assisted dining as they require assistance /supervision and encouragement to complete meals. All residents will be assessed for need for feeding assist. -On 9-16-2020 Each Dining and seating area were assessed, and seating was determined based on need for assist while maintaining social distancing per CDC guidelines. Seating charts were posted at each dining area. -On 9-16-2020 staff was notified of the dining changes and changes posted for all staff to see. -On 9-16-2020 24 staff and 9-17-2020 37 staff and on 9-18-2020 13 staff prior to shift were educated on the dining changes and need to maintain social distances at all times, and will continue to educate until all staff have been educated. On 9-16-2020 24 staff were educated, on 9-17-2020 37 staff were educated, on 9-18-2020 13 staff prior to shift were educated prior to their shift on the new procedures for quarantine, social distancing, and infection control. Will continue to educate until all staff have been educated. No staff will work without education. -On 9-15-2020 at 6 pm dietary was notified that on 9-16-2020 All dining areas where residents do not need assist/supervision/encouragement would be closed effective @ breakfast. Those residents are now eating in their rooms. It was explained to the residents that due to the continued guidelines from the CDC that this practice must and would continue. -On 9-16-2020 The care plans for 16 out of 87 residents (1,74,55,45,85,21,70,30,81,25,53,16,23,3,78) were reviewed along with the tasks in Point Click Care and updated to indicate they will be eating in the appropriate assisted dining room. On 9/17/20 the rest of the 87 residents were assessed for their dining status. -On 9-16-2020 A group e-mail was sent to resident's family/and or responsible person regarding the citation and that changes were being put in place regarding social distancing and infection control. -9-16-2020 It was explained to the residents that due to the continued guidelines from the CDC that this practice must and would continue. -On 9-17-2020 an updated email was sent to resident's family/and or responsible person to identify the concerns and a reminder that we must follow national guidelines for infection control and social distancing -Beginning 9-17-2020 CDC guidelines will continue to be monitor by the Adm, and ICP per e-mail and contacts from CDC, CMS and State Health Department and policies and procedures will be updated as needed to meet the CDC guidelines. Infection Control Preventionist will maintain communication with the local health department to be proactive in meeting expectations for infection control stands -On 9-16-2020 Residents #22, #46, #77, #67, #39, #51 were reassessed and it was determined that they could safely eat in their rooms with regional supervision. On 9-16-2020 residents # 22,46,77,67,39,51 care plans along with the task in Point Click Care were updated to indicate they will be eating in their room with regional supervision. -9-17-2020 Administrator, DON, or designee will begin to audit the assisted dining rooms 4-5 times weekly to ensure compliance of social distancing and infection control. Any breeches of national standards will be immediately corrected with staff/resident education. Adm. DON and all designated staff will monitor daily for any breech of national standards and will immediately correct any breeches and provide education and reminders. Policies and Procedures will be updated as needed per CDC guidelines. INFECTION CONTROL RESIDENTS -On 9-16-2020 Resident #188, #189, #190 was moved to private room and placed in quarantine. PPE was placed outside of room and staff notified of need for use. (N95 masks, face shields and gowns and gloves. With instructions posted in accordance with CDC guidelines. Education will be done on how to put on /remove gloves and PPE. -On 9-16-2020 Dietary was notified of need for the use of disposable dishes for meals and nursing staff notified that hard tray is not to enter the room and disposable dishes are not to return to the kitchen. -On 9-16-2020 Care Plans for residents # 188, #189, #190 were reviewed and updated. -On 9-17-2020 Policies and procedures for infection control were reviewed and updated by ICP to include disposable dishes and current CDC guidelines for quarantine. -Beginning on 9-17-2020 All new and readmissions will be placed in quarantine per CDC guidelines with proper use of PPE. DON and Infection Control Preventionist will monitor each new admission and readmission for compliance. Any breech in national standards will be corrected immediately and education provided. Any resident who leaves the facility for an outside appointment will be given a surgical mask and educated on wearing the mask the entire time they are out of the facility. When they return they will be monitored for signs and symptoms of COVID-19 and will wear a mask if they come out of their room if they will allow, for a period of 14-days. -On 9-16-2020 24 staff were educated, on 9-17-2020 37 staff were educated, on 9-18-2020 13 staff prior to shift were educated prior to their shift on the new procedures for quarantine, social distancing, and infection control. Will continue to educate until all staff have been educated. -On 9-15-2020 Resident #191 completed the 14-day quarantine and remained asymptomatic with repeat negative Covid-19 testing. -On 9-16-2020 Care Plans were reviewed fir resident #191 and updated with quarantine CP resolved. -Housekeeping and maintenance will continue to concentrate on cleanliness of high touch areas such as door knobs, phones ,handrails and light switches in an attempt to decrease the potential for spread of Covid- 19 and other communicable diseases. Logs will be maintained and monitored by ICP and ADM. ACTIVITIES -On 9-15-2020 4 Activity Staff were notified of changes and the need to cease all group activities. On 9-16-2020 24 staff members were notified of changes and the need to cease all group activities. On 9-17-2020 37 staff were notified of changes and the need to cease all group activities -On 9-16-2020 Residents were notified of the national standards and CDC guidelines and need for social distancing and restrictions on group activities. -As of 9-15-2020 all residents are receiving 1:1 activities with activity staff depending on their interest and abilities. -On 9-16-2020 Resident #10 was notified that 1-1 activities would continue per the activity staff and that she could continue to eat and visit with her daughter who is also a resident at facility but that we would continue to remind her of need to social distance in accordance with the CDC guidelines. The Activity Care plan for resident #10 was reviewed and updated on to reflect 1-1 activities only. -On 9-16-2020 Residents 60, 04, 05, 50, 44, 45,49,65,38,63,76 were notified of the national standards and CDC guidelines and need for social distancing and restrictions on group activities. Residents were notified that 1-1 activities would continue per the activity staff. Residents were reminded that we would continue to educate/remind and encourage social distancing. All residents will be educated on the importance of CDC guidelines for social distancing. -On 9/16/2020 staff educated/reminded and encouraged resident to maintain social distance. Also, staff continue to educate all residents at all times on the importance to wear mask depending on their wishes and maintain social distancing and good hand hygiene. -Beginning 9-16-2020 Activities staff will do one-on-one activities in resident's room as tolerated. Staff will work to find solitary activities resident enjoys. -On 9-16-2020 staff will encourage frequent hand washing of resident #73 as she self ambulates through facility. -Resident #73 does not sit down for long periods of time. Residents have dementia and are not able to understand the need for restrictions. -Beginning on 9-16-2020 All staff attempt to monitor where abouts and to redirect and or walk with the resident #73 to maintain distancing from other residents and to assist with hand hygiene. -On 9-17-2020 Policies and procedures regarding Covid-19 quarantine for new /readmission were reviewed by the ICP and updated to include disposable dishes and current CDC guidelines. Although the immediate jeopardy was removed on 9/17/20, the facility remained out of compliance at a scope of widespread and severity of no actual harm with the potential for more than minimal harm that is not immediate jeopardy due the fact that not all facility staff have received education and sustained compliance has not been verified by the State Agency. Review of the Covid-19 Long Term Care Facility Guidance dated 4/2/20 revealed CMS and the Centers for Disease Control (CDC) had issued .new recommendations to State and local governments and long-term care facilities (also known as nursing homes) to help mitigate the spread of the 2019 Novel Coronavirus (COVID-19). Long-term care facilities are a critical component of America's healthcare system. The Guidance further revealed long term care facilities were to .isolate all admitted residents (including readmissions) in their room in the COVID19-positive facility for 14 days if their COVID-19 status is unknown. Review of the faclity Policy Temporary Policy on Admissions during COVID 19 Pandemic dated 04/1/20 revealed, Resident will receive COVID19 swab testing at least 72 hrs prior to arrival to facility, Resident will be placed in isolation for 14 days, Staff will wear necessary PPE (personal protective equipment) included, but not limited to, N95 mask, gown, gloves, and eye protection, Dietary will send resident disposable dishes and utensils for all meals, which will be disposed of in resident room. The plastic tray will not enter resident room and New admissions will be placed in a private room. Review of the Policy Personal Protective Equipment dated 3/5/20 and up-dated 7/24/20 revealed, This facility promotes appropriate use of personal protective equipment to prevent the transmission of pathogens to residents, visitors, and other staff. The Policy further revealed for respiratory protection staff were to Wear a NIOSH (National Institute for Occupational Safety and Health) approved N95 or higher-level respirator to prevent inhalation of pathogens transmitted by the airborne route. Resident #188 Review of the Face Sheet revealed Resident #188 was a [AGE] year old female admitted to the facility on [DATE] and diagnosed with [REDACTED]. The Face Sheet further revealed Resident #188 was admitted from private home. Review of the Clinical Admissions Evaluations dated 09/14/20 revealed Resident #188 was confused, disoriented, had short term memory loss, steady gait and yes wanders at night. During an observation on 09/15/20 at 11:21 AM, Resident #188's room door was open and doorway to room was observed without PPE or isolation precaution signage on doorway. Resident #188 was not observed to be in her room. Review of the Facility resident list revealed Resident #188 had a roommate. During an interview on 09/15/20 at 11:21 AM Certified Nurse Aide (CNA) O stated she .just saw her (Resident #188) go down the hallway .she's walking by herself. CNA O stated, she (Resident #188) just came in new yesterday afternoon to the facility and to my knowledge she (Resident #188) is in isolation. CNA O observed Resident #188's room doorway without any isolation precautions and stated, actually no there isn't any PPE or isolation signaled outside of Resident #188's room. During an interview on 09/15/20 at 11:23 AM , Licensed Practical Nurse (LPN) L stated, she (Resident #188) came in yesterday and she (Resident #188) roams and wanders on her own; we (staff) can't make her stay in her room .or wear a mask. During an observation on 09/15/20 at 11:24 AM, Resident #188 was noted to be ambulating in the hallway with no mask on and holding Social Worker (SW) G's hand. During an observation on 09/15/20 at 11:25 AM, SW G was observed in Resident #188's room wearing only a surgical mask and was observed holding hands with Resident #188. During an observation on 09/15/20 at 11:27 AM, CNA O entered Resident #188's room wearing only a surgical mask to assist Resident #188 to the bathroom. During an observation and interview on 09/15/20 at 11:31 AM, SW G left resident #188's room and entered another resident room. SW G stated she entered the resident's room to grab a brief and was then observed to go back into Resident #188's room. During an interview on 09/15/20 at 11:32 AM, SW G stated, she (Resident #188) is a new admit she got here yesterday afternoon and Resident #188 was pretty confused. SW G stated, she (Resident #188) was steady on her feet and she was trying to get her to walk back to her room when surveyor witnessed her in the hallway with Resident #188. SW G stated, yes she (Resident #188) should be in isolation but she did have a negative Covid test (Covid 19) and she (Resident #188) is supposed to wear a mask but she's been tearing it off. SW O stated there was no PPE outside Resident #188's room and yes she (Resident #188) can leave her room without a mask. During an interview on 09/15/20 at 02:33 PM, Infection Control Preventionist (ICP) D stated, we (facility) would love her (Resident #188) to be quarantined to her room but she's not having any part of that. ICP D stated, ideally she (Resident #188) would be in quarantine/isolation and Resident #188 does have a roommate. Resident #189 Review of the Face Sheet revealed Resident #189 was a [AGE] year old female admitted to the facility on [DATE] and diagnosed with [REDACTED]. Review of the Hospital Discharge report dated 09/7/20 revealed Resident #189 was diagnosed with [REDACTED]. Review of the Clinical Admissions Evaluations dated 09/9/20 revealed Resident #189 was alert and oriented and had steady gate. During an observation on 09/15/20 at 12:32 PM, Resident #189's door was open and Resident #189 was noted to be on her bed not wearing a mask. No PPE was observed outside Resident #189's room and no signage for isolation precautions were noted on Resident #189's doorway. Resident #190 Review of the Face Sheet revealed Resident #190 was a [AGE] year old admitted to the facility on [DATE] and diagnosed with [REDACTED]. Review of the Hospital Discharge report dated 09/6/20 revealed Resident #190 was diagnosed with [REDACTED]. During an observation on 09/15/20 at 12:35 PM, Resident #190's door was open and Resident #190 was noted to be in her room in her wheelchair. No PPE was observed outside Resident #190's room and no signage on doorway for isolation. During an interview on 09/15/20 at 12:40 PM, Resident #190 stated, .as long as I have a face mask on I can leave my room. During an observation on 09/15/20 at 12:46 PM, Licensed Practical Nurse (LPN) L walked into Resident #190's room with cloth mask on face, no gloves, no additional PPE on her person and removed Resident #190's food tray from room. During an observation on 09/15/20 at 12:47 PM, Housekeeper R walked into Resident #190's room with cloth mask on face, no gloves on and no additional PPE. Housekeeper R walked up next to resident within 6 ft when Resident #190 did not have a face mask on. During an interview on 09/15/20 at 1:00 PM, Housekeeper R stated the PPE for Resident #190's room was to wear gloves if I am cleaning in her (Resident #190) room. Housekeeper R stated she did not need to wear a gown or any additional PPE because I don't do care for Resident #190. Resident #191 Review of the Face Sheet revealed Resident #191 was a [AGE] year old male admitted to the facility on [DATE] and diagnosed with [REDACTED].#191 was admitted from a hospital. During an observation on 9/15/20 at 12:40 PM, Resident #191 was noted to be his wheelchair in his room. Resident #191's doorway was open with no PPE outside the doorway and no signage to indicate an isolation room on the doorway. During an interview 09/15/20 at 12:43 PM, LPN Y stated Residents #189, #190 and #191 were .on quarantine for 14 days and if they (Residents #189, #190 and #191) come out the room they have to have a mask on. LPN Y observed the lack of isolation PPE outside of Resident #189, #190 and #191's rooms and stated, yeah I can go in and out without any additional PPE (indicated only cloth face mask). During an interview on 09/15/20 at 02:33 PM, Infection Control Preventionist (ICP) D stated, new admission quarantine/isolation depends on where they're (Resident) coming from . and what is working best in our facility. ICP D stated, .quarantine and isolation are not the same thing; quarantine we are treating as if they could have a communicable disease but are keeping them away from other residents and isolation is when they have something and they fall under contact or droplet precautions. ICP D stated the facility .had a positive employee for Covid last week During an interview on 09/15/20 at 02:49 PM, Local Health Department Clinical Services Supervisor (LHDCCP) BB stated the health department expectations would be for long term facilities to quarantine that individual for 14 days upon admission to the facility and by quarantine keep them (residents) in own room and wear PPE of gown, gloves, N95 mask when entering the room. During an interview on 09/15/20 at 03:00 PM, Local Health Department Older Adult Services Director (LHDASD) AA stated, a Covid negative test would still require a 14 day quarantine which would mean not putting (the newly admitted or readmitted resident) with any other person and PPE used. LHDASD AA stated PPE would not (be) a cloth mask. During an interview on 09/16/20 at 02:10 PM, ICP D stated, no staff were not given N95 masks. ICP D stated staff were using cloth masks for source (control of Covid 19) control. ICP D stated isolation PPE would be for staff to wear surgical mask and no no other PPE was required for staff to enter an isolation/quarantine room. According to the Centers for Disease Control and Prevention (CDC), Preparing for COVID-19 in Nursing Homes . Updated June 25, 2020 . Implement Social Distancing Measures . Implement aggressive social distancing measures (remaining at least 6 feet apart from others): Cancel communal dining and group activities, such as internal and external activities. Remind residents to practice social distancing, wear a cloth face covering (if tolerated), and perform hand hygiene. Accessed from: https://www.cdc.gov/coronavirus/2019-ncov/hcp/long-term-care.html?deliveryName=USCDC_425-DM According to the Centers for Disease Control and Prevention (CDC), People with Certain Medical Conditions . Updated Sept. 11, 2020 . People of any age with certain underlying medical conditions are at increased risk for severe illness from COVID-19 · [MEDICAL CONDITION] · [MEDICAL CONDITIONS] . · Obesity (body mass index (BMI) of 30 or higher) · Serious heart conditions, such as heart failure, [MEDICAL CONDITION], or [MEDICAL CONDITION] . · Type 2 diabetes mellitus . It is especially important for people at increased risk of severe illness from COVID-19 . to protect themselves from getting COVID-19 . Wear masks . Wash hands often . Limit contact with commonly touched surfaces or shared items . Accessed from: https://www.cdc.gov/coronavirus/2019-ncov/need-extra-precautions/people-with-medical-conditions.html In an interview on 09/15/20 at 3:00 P.M., Local Health Department Older Adult Services Director (LHDASD) AA was asked if communal dining and communal activites are permitted according to the Local Health Department guidance. LHDASD AA reported that communal dining and communal activites are a no go, meaning that no communal dining and no communal activites should occur at this time. Dining During a dining observation on 9/15/20 at 11:46 a.m. in the Activity Room Dining Area, noted a total of 4 round tables in the dining area with 3 residents seated per table (for a total of 12 residents in this area) - Resident #3, #16, #23, #25, #31, #39, #51, #53, #67, #77, #78, and #81. Residents were brought from rooms to the dining area with no face coverings. None of the residents were socially distanced from one another while seated at the table. During a dining observation 09/16/20 at 12:33 P.M. in the Activity Room Dining Area, again noted a total of 4 round tables in the dining area with 3 residents seated per table (for a total of 12 residents in this area) - Resident #3, #16, #23, #25, #31, #39, #51, #53, #67, #77, #78, and #81. None of the residents were socially distanced from one another. None of the 12 residents wore face covering on transport to the dining room. In an interview on 09/16/20 at 12:30 P.M. Social Worker (SW) I indicated residents were in the dining room because of a need to be fed or cued to eat or because of a need for supervision. SW I reported it was not feasible to have a staff member assigned to each resident for them to eat in their own room. In an interview on 09/17/20 at 12:11 P.M., Occupational Therapist (OT) S reported the residents eat in the Activity Room Dining Area because of a need for physical help, supervision, or cueing. OT S indicated do not have enough staff for everybody to be in their rooms for one on one meal assistance so the residents need to eat together. OT S indicated there was not enough room in the Activity Room Dining Area to adequately socially distance everyone. Resident #3 Review of a Face Sheet revealed Resident #3 was an [AGE] year-old female, originally admitted to the facility on [DATE], with pertinent [DIAGNOSES REDACTED]. Review of a Minimum Data Set (MDS) assessment for Resident #3, with a reference date of 06/12/20 revealed a Brief Interview for Mental Status (BIMS) score of 00, out of a total possible score of 15, which indicated Resident #3 was severely cognitively impaired. Review of ADL (Activities of Daily Living) Assistance section of MDS revealed Resident #3 required one-person extensive assistance eating. Resident #16 Review of a Face Sheet revealed Resident #16 was a [AGE] year-old female, originally admitted to the facility on [DATE], with pertinent [DIAGNOSES REDACTED]. blood as well as it should) , and [MEDICAL CONDITION] (a lung disease that results in difficulty breathing). Review of a Minimum Data Set (MDS) assessment for Resident #16, with a reference date of 06/19/20 revealed a Brief Interview for Mental Status (BIMS) score of 02, out of a total possible score of 15, which indicated Resident #16 severely was cognitively impaired. Review of ADL (Activities of Daily Living) Assistance section of MDS revealed Resident #16 one person limited physical assistance with eating. Resident #23 Review of a Face Sheet revealed Resident #23 was a [AGE] year-old female, originally admitted to the facility on [DATE], with pertinent [DIAGNOSES REDACTED]. Review of a Minimum Data Set (MDS) assessment for Resident #23, with a reference date of 07/03/20 revealed a Brief Interview for Mental Status (BIMS) score of 05, out of a total possible score of 15, which indicated Resident #23 was severely cognitively impaired. Review of ADL (Activities of Daily Living) Assistance section of MDS revealed Resident #23 required set-up and supervision with eating. Resident #25 Review of a Face Sheet revealed Resident #25 was a [AGE] year-old female, originally admitted to the facility on [DATE], with pertinent [DIAGNOSES REDACTED]. Review of a Minimum Data Set (MDS) assessment for Resident #25, with a reference date of 07/03/20 revealed a Brief Interview for Mental Status (BIMS) score of 00, out of a total possible score of 15, which indicated Resident #25 was severely cognitively impaired. Review of ADL (Activities of Daily Living) Assistance section of MDS revealed Resident #25 required setup and supervision with eating. Resident #31 Review of a Face Sheet revealed Resident #31 was an [AGE] year-old female, originally admitted to the facility on [DATE], with pertinent [DIAGNOSES REDACTED]. Review of a Minimum Data Set (MDS) assessment for Resident #31, with a reference date of 07/10/20 revealed a Brief Interview for Mental Status (BIMS) score of 00, out of a total possible score of 15, which indicated Resident #31 was severely cognitively impaired. Review of ADL (Activities of Daily Living) Assistance section of MDS revealed Resident #31 required setup and supervision with eating. Resident #39 Review of a Face Sheet revealed Resident #39 was a [AGE] year-old male, originally admitted to the facility on [DATE], with pertinent [DIAGNOSES REDACTED]. Review of a Minimum Data Set (MDS) assessment for Resident #39, with a reference date of 07/17/20 revealed a Brief Interview for Mental Status (BIMS) score of 00, out of a total possible score of 15, which indicated Resident #39 was severely cognitively impaired. Review of ADL (Activities of Daily Living) Assistance section of MDS revealed Resident #39 required setup and supervision with eating. Resident #51 Review of a Face Sheet revealed Resident #51 was an [AGE] year-old male, originally admitted to the facility on [DATE], with pertinent [DIAGNOSES REDACTED]. Review of a Minimum Data Set (MDS) assessment for Resident #51, with a reference date of 07/31/20 revealed a Brief Interview for Mental Status (BIMS) score of 09, out of a total possible score of 15, which indicated Resident #51 was moderately cognitively impaired. Review of ADL (Activities of Daily Living) Assistance section of MDS revealed Resident #51 required setup and supervision with eating. Resident #53 Review of a Face Sheet revealed Resident #53 was a [AGE] year-old female, originally admitted to the facility on [DATE], with pertinent [DIAGNOSES REDACTED]. Review of a Minimum Data Set (MDS) assessment for Resident #53, with a reference date of 07/31/20 revealed a Brief Interview for Mental Status (BIMS) score of 05, out of a total possible score of 15, which indicated Resident #53 was severely cognitively impaired. Review of ADL (Activities of Daily Living) Assistance section of MDS revealed Resident #53 required setup and supervision with eating. Resident #67 Review of a Face Sheet revealed Resident #67 was a [AGE] year-old female, originally admitted to the facility on [DATE], with pertinent [DIAGNOSES REDACTED]. Review of a Minimum Data Set (MDS) assessment for Resident #67, with a reference date of 08/13/20 revealed a Brief Interview for Mental Status (BIMS) score of 00, out of a total possible score of 15, which indicated Resident #67 was severely cognitively impaired. Review of ADL (Activities of Daily Living) Assistance section of MDS revealed Resident #67 required one-person limited assistance with eating. Resident #77 Review of a Face Sheet revealed Resident #77 was a [AGE] year-old female, originally admitted to the facility on [DATE], with pertinent [DIAGNOSES REDACTED]. Review of a Minimum Data Set (MDS) assessment for Resident #77, with a reference date of 08/21/20 revealed a Brief Interview for Mental Status (BIMS) score of 01, out of a total possible score of 15, which indicated Resident #77 was severely cognitively impaired. Review of ADL (Activities of Daily Living) Assistance section of MDS revealed Resident #77 required setup and supervision with eating. Resident #78 Review of a Face Sheet revealed Resident #78 was an [AGE] year-old male, originally admitted to the facility on [DATE], with pertinent [DIAGNOSES REDACTED].

Based on observation, interview, and record review, the facility failed to prevent multiple falls leading to a fall with fracture for 1 of 4 residents (Resident #67) review for falls, resulting in a [MEDICAL CONDITION]. Findings include: Review of an Admission Record revealed Resident #67 was a [AGE] year-old female, originally admitted to the facility on [DATE], with pertinent [DIAGNOSES REDACTED]. Review of a Minimum Data Set (MDS) assessment for Resident #67, with a reference date of 11/16/18, revealed a Brief Interview for Mental Status (BIMS) score of 11, out of a total possible score of 15, which indicated moderate cognitive impairment. Review of the Care Area Assessment (CAA) of MDS dated [DATE], revealed Resident #67 was living at home with (family). She was active outside pulling weeds in their garden. She was displaying poor decision making by performing unsafe activities with falls. Resident #67 is at risk for falls per fall assessment with history of fluctuating gait and skills and absent safety awareness. (sic) Review of the Fall Incident Report dated 03/18/18 at 10:40 AM, revealed Resident #67 location of fall residents room , Activity at time of fall or what was resident attempting to do? Coming back from the bathroom. While walking back to from bathroom, did not call for help. Didn't use coming back from bathroom (call light) Was resident using an assistive device (yes) (walker) (Rolling walker) no alarm sounding. CNA just coming on shift. Last toileted before shift. Unwitnessed fall. Bed lowered to floor. Care plan reviewed and updated. (sic) Review of the Un-Witnessed Fall Report dated 5/17/18 at 10:44 AM, revealed This nurse was called to room by staff. Observed resident sitting on floor in front of her recliner .Resident states was going to sit in her recliner and missed. Resulting in sitting on floor. Denies hitting her head. Head to toe assessment completed. Redness noted to right elbow. Good range of motion. Denies any pain. Assisted x 2 to recliner. Predisposing Situation Factors. Improper Footwear, Ambulating without Assist, Using wheeled Walker. 5/17/19 Notes Rehab review of fall incident indicates Res with usual mobility. Care plan followed for independent ambulation in room with device. Res with occasional falls with decreased safety awareness related to Dementia. For this incident Res had removed shoes prior to trying to sit in room recliner. res with missed sit with failure to back completely to chair . Corrective will involve monitoring for shoes on/off in room with Nursing staff and Restorative will work with Res in room on skill with Turing/backing/sitting for correct sequencing. Rehab will con't to monitor post fall for changes or declines. (sic) Review of the Un-Witnessed Fall Report dated 7/5/18 at 1:13 AM, revealed This nurse was called to the residents room by CNA to observe resident lying on the floor on her left side. Assisted x2 resident to recliner after initial assessment. Further assessment completed with resident in recliner, then assisted X2 to bed. I don't know what happened, I think I was going home. Rehab review of fall incident indicates 3rd fall this year with history of occasional falls and high risk per fall assess. Resident has no memory of falling. No indications of needs prior to fall with no call light or walker used. No injuries noted. No recent med changes or recent illness, but Resident's family with recent death and attendance (rare LOA) to funeral days before. History of cyclical up/down activity level and was started on physical therapy (PT) treatment prior to fall per her request to do better by myself. Care plan updated post fall for continued stand by assist for ambulation skills with device. PT treatment to continue. All staff alerted to fall and current increased fall risk . (sic) Review of the Nursing note dated 12/16/2018 at 10:05 AM, revealed Incident Note CNA called nurse to room where resident is sitting/laying on the floor in front of her recliner. She was wearing her gripper socks but the floor is extremely slippery. Resident states she did not hit her head. Resident able to move all extremities without difficulty. Complaining of some back pain but states this is her normal pain. No apparent injuries. VS taken: BP 165/93, HR 89, RR 18. Review of the Un-Witnessed Fall Report dated 12/16/18 at 9:58 PM, revealed Certified Nursing Assistant (CNA) called nurse to room where resident is sitting/laying on the floor in front of her recliner. She was wearing her gripper socks but the floor is extremely slippery. Resident states she did not his her head. Resident states that she was going to bed and the walker was going faster that she wished it would and so she just stopped going and let herself go to the floor, landing on her bottom. Immediate Action Taken: Resident able to move all extremities without difficulty. Complaining of some back pain but states this is her normal pain. No apparent injuries. Predisposing Physiological Factors: Impaired Memory Predisposing Situation Factors: Ambulating without assist, using walker. Other information: Slippery floor. Notes 1/11/19 Rehab review of incident indicates Res experienced fall to buttocks in room with attempts to transfer/ambulate independently with own 4 wheel walker without assist. No injury noted. Res with non-skid socks and using with walker, but did not request or wait for assist. (last BIMS-11/15) This is Resident 3rd fall this year. All have occurred in her room where she spends majority of each day per preference. Res continues on [MEDICATION NAME] Patch, [MEDICATION NAME], and Neurotin meds. She continues to need hands on assist for safe ambulation skills with poor safety awareness. Previous trials of alarms were unsuccessful with increased behavior and heightened risk for fall. Fall discussed with Res (Family) and staff educated and encouraged Res in use of call light and waiting for assist. No change in level of care at this time. Staff alerted to fall and directed to give daily/every shift reminders to Res for use of call light and frequent room checks throughout each shift. Care plan current. Res to continue restorative program and monitoring by Nursing and Rehab staff. (sic) Review of the Interdisciplinary Nursing Note (INN) dated 12/17/2018 at 6:51 PM , revealed Behavior Note 1500 resident was nonresponsive and when the aids stood her up to clean stool off her backside she stood and then put full weight on aids, all while moaning and being non responsive. This nurse removed residents [MEDICATION NAME] at 1630 (4:30 PM). B/P 130/60 pulse 78 resp. 18 pupils responsive to light. within 20 min. of removal of patch resident was responsive and asking for pain medicine. Reapplied [MEDICATION NAME] at 6:45 PM. Will cont. to monitor. (sic) Review of the INN dated 12/26/2018 at 6:47 PM, revealed Incident Note This writer was called to Resident #67's room because she was on the floor, asked her what happened she stated she dropped a piece of candy that cost a lot of money and she was not going to loose it. She stated that she moved herself to the floor, and proceeded to show this writer she was not hurt by crawling around on the floor. Had another nurse talk to her and she told the same set of events and even explained to her the moves that it took to get to the floor. She is sitting on the edge of the bed in a very good mood. Review of the Behavior Care Solution Report dated 1/16/19, revealed Resident #67 was seen and had no complaints. Review of the INN dated 1/30/2019 at 10:38 AM, revealed Health Status Note: Resident observed lying on her right side on the bathroom floor of her bedroom. States she was attempting to washup when she fell holding onto the toilet rail until she could no longer hang on, she fell backwards with back scraping the garbage can. Resident noted with large red abrasion to mid lower back 8.5cm x 6.5cm. Site cleansed with SNS ABD pad applied for comfort/tenderness. (Family member) called left message for him to call facility regarding incident. Review of the Un-Witnessed Fall Report dated 1/30/19 at 9:39 AM, revealed Resident observed lying on right side in bathroom of bedroom. Resident states that she was attempting to washup when she lost her balance falling to the floor she held the toilet rail until she no longer could hang on before she went back wards resulting in back scraping the garbage can. Immediate Action Taken: Resident assessed, vs taken and resident helped up and into bed. Predisposing Physiological Factors: Weakness/Fainted, Predisposing Situation Factors: Improper Footwear, Using Wheeled Walker, Ambulating without Assist, Notes 1/30/19 New order for pressure pas in bed. Staff instructed if pressure (Personal Safety Alarm/Pressure (PAS)) creates behaviors to discontinue it. Res has history of increased behaviors in past when PAS applied. Will trial pressure PAS and talk with staff tomorrow to see how it goes for next 24 hours. Res has history of fall and not asking staff for help. Res was ill with pneumonia a few months back and has been in bed frequently. Up occasionally walking with staff to therapy room to exercise. Res is on ambulation program and restorative program but frequently refuses. All staff aware of fall. Notes 2/1/19 Res angry about Pressure pas and refused to allow staff to put on her bed. Notes 2/5/19 All care plans reviewed and updated. Bed at knee height and walker in reach at all times due to resident is spontaneous and trying to keep her safe when she gets self up. Resident is not going to use call light to ask for help and has a high desire to be independent.(sic) Review of the INN dated 2/13/2019 at 6:45 AM, Behavior Note Resident seen walking in hallway, yelling out, I need to get my babies. This nurse stood by resident as she walked towards the front entrance wanting to leave to get her babies. This nurse was able to re-direct resident back to her room. Resident was upset throughout the morning. Review of the INN dated 2/15/2019 at 1:39 PM, Rehab / Therapy Note Res is frequently incontinent of bladder and occasionally incontinent of bowel. Wears briefs for protection with checks every 2 hours and changes prn. Res requires limited-ext assist with toileting needs and frequently takes self to toilet without asking staff for assist. PAS was trialed and caused increase behaviors. I am currently and have a H . (sic) Review of the INN dated 2/27/2019 at 8:09 AM, revealed Incident Note This nurse called to resident room via cena, resident observed lying on right side on floor near resident bed. Head to toe assessment initiated. Resident with hematoma to back of head, with complaint of 8/10 pain to left hip.N.P. in facility to assess. New order to send resident to hospital due to excessive complains of pain to left hip. Family member . notified. Neuro and orthos checks initiated. Review of the Un-Witnessed Fall Report dated 2/27/19 at 8:00 AM, revealed This nurse called to resident room via CNA. Resident observed lying on right side on floor near resident bed. Immediate Action Taken: Head to toe assessment initiated, neuro check initiated, Resident sent to hospital due to complaint of 8/10 left hip and head pain. Predisposing Physiological Factors: Gait Imbalance, Impaired Memory, Weakness/Fainted, Predisposing Situation Factors: Using Wheeled Walker, Notes 3/1/19 Review of Res incident indicates Res had been again (historical) up independent in room with 4 wheel walker. Res requires limited assist safe ambulation with device. She is usually in bed majority of each day and rarely leaves room. (see SW notes) Had loss of balance (LOB) and fall a bedside and roommate alerted staff to fall. Per staff/roommate, Res had been using wheeled walker for some ambulating safety. Res has Dementia with low safety awareness, but also with behaviors with unsuccessful attempts to use alarms for safety. Res on right side on floor with injury noted to head and high pain in left hip. She was sent to hospital for evaluation. Last fall 1/30/19 in room bathroom. Note BIMS 7/15. Note recent increase in [MEDICATION NAME] on 2/25/19 and continued use of [MEDICATION NAME] for chronic pain. PT on Occupational Therapy (OT) to evaluate for new safety approaches per status. (sic) Review of the X-ray Report dated 2/27/19 at 11:00 AM, revealed Resident #67 x-ray hip complete 2-3 views left, indication: Fall today with left pain. Findings: Bones: Nondisplaced [MEDICAL CONDITION] of the proximal left femur. Conclusion: Nondisplaced [MEDICAL CONDITION] of the proximal left femur. Review of the Hospital Progress Note dated 2/28/19 at 7:01 AM, revealed Resident #67 underwent left hp surgery 12/27/19, A urine specimen sent yesterday showed evidence of a urinary tract infection . Review of the INN dated 3/6/2019 at 1:45 PM, Skilled Progress Notes .resident fell today at 0910 see fall report. No injuries noted. Review of the Un-Witnessed Fall Report dated 3/6/19 at 9:10 AM, revealed resident was in her room sitting in her geri chair when she fell trying to get up to use the bathroom. Immediate Action Taken: This nurse did a head to toe assessment to check for injuries, res states is in no pain and didn't hit her head. No new apparent injuries at this time. Predisposing Physiological Factors: Incontinent, Predisposing Situation Factors: Ambulating without Assist, Notes 3/7/19 Res was left in geri chair in room after breakfast and tried to get up by self and fell . Staff was educated she was not to be left unsupervised when in geri chair. She was to stay in after meal program or by nurses station until staff could transfer her back to bed. Res has alarm and now has PAS for wheelchair. Corrective is to not leave resident up in chair unsupervised and PAS in wheelchair. All staff aware of fall. Res had recent fall with [MEDICAL CONDITION]. (sic) Review of the INN dated 3/8/2019 at 9:06 AM, Skilled Progress Notes resident continues to try and get up and transfer herself. resident needs assist x1 with ADLs and transfers. resident is not to be left unattended in w/c. Review of the INN dated 3/8/2019 at 12:44 PM, revealed Health Status Note (Physician) in and assessed resident. Reviewed hospital notes. He spoke to Resident #67 for quite awhile. She stated she did this to herself. They told me not to get up by myself and that is why I fell No new orders at this time. During interviews with Registered Nurse (RN) O on 3/13/19 at 8: 40 AM and 12:32 PM, a care plan with all revisions was requested, to show each time any changes were initiated and resolved for Resident #67. RN O supplied the following care plans. Review of the [MEDICAL CONDITION] Care Plan dated 12/14/16, revealed under Approaches/Tasks no changes have been initiated since 12/14/16. Review of the Self Care and Mobility Deficit Care Plan dated 6/7/18, revealed under Approaches/Tasks ·TOILET USE: Ext assist with current use of bedpan for Bladder/Bowel as tolerate. Now able to complete 2 ext assist pivot to bed side commode BSC or toilet via w/c. Offer/cue toileting assist upon rising, before meals, PRN. Briefs daily with checks Q2hrs and changes PRN. Date Initiated: 06/07/2018 Revision on: 03/11/2019 Encourage the resident to use call light and wait for assistance. Date Initiated: 06/07/2018 Revision on: 03/06/2019. Review of the Fall Care Plan dated 6/7/18, revealed under Approaches/Tasks Revision were made on 3/6/19 and 3/11/19.·SUPERVISION: Res to be in supervised areas only when up in chair. ALL STAFF AWARE. Date Initiated: 03/11/2019 ·TRANSFERS: 2 ext assist standing pivot with gait belt. Date Initiated: 06/07/2018 Revision on: 03/11/2019 ·Anticipate and meet The resident's needs. Date Initiated: 06/07/2018 ·Be sure The resident's call light is within reach and encourage the resident to use it for assistance as needed. The resident needs prompt response to all requests for assistance. Date Initiated: 06/07/2018 MONITOR - Personal Safety Alarm/Pressure PAS in bed at all times. PAS IN W/C Date Initiated: 01/30/2019 Revision on: 03/07/2019 · SAFETY - Bed in lowest position Date Initiated: 03/04/2019 · SAFETY - Floor Mat when in bed Date Initiated: 03/04/2019. During an interview on 3/13/19 at 4:11 PM, Occupation Therapy Administration (OTA) QQ reported that before the fall Resident #67 had several falls she could not be kept down, did not want to wear the personal safety alarm, she was up and down had shown bad judgement. OTA QQ reported that on 3/6/19 when Resident #67 fell a housekeeper had taken her back to her room after the meal, and therapy had not anticipated her getting up out of her chair yet as she was not active so no PAS had been placed in the chair, but there was one in place now. OTA QQ reported Resident #67 preferred to stay in her room and that at this time she was still recovering from the [MEDICAL CONDITION] that occurred on 2/27/19 so she was less active and accepting the PAS alarm, but when she was stronger they may need to consider moving her closer to the nursing station, because she does not use her call light, refuses the PAS, and wants to be independent. OTA QQ reported that there appeared to be more falls in the nursing notes than therapy was alerted to and they should have been aware of all of the falls. During an interview on 03/13/19 at 11:37 AM, Licensed Practical Nurse (LPN) CC reported that Resident #67 had the fall with the [MEDICAL CONDITION] on 2/27/19, she got up on her own was at her closet, the CNA was across the hall in another resident room and found her and called for me. LPN CC reported that Resident #67 was non compliant with using the call light, the facility had tried tab alarms, and not sure about pressure alarms, but Resident #67 was able to take the alarms off and did not like them. LPN CC was not aware of any falls since Resident #67 had returned from the hospital after her [MEDICAL CONDITION]. During an interview on 3/13/19 at 11:44 AM, CNA DD reported Resident #67 did not like getting up until after breakfast she liked to sit on the edge of her bed and eat. CNA DD reported that right before breakfast the roommate of Resident #67 called out Hey my roommate is on the floor. CNA DD found Resident #67 on the floor, she reoported that Resident #67 told her she had gotten up to get clothes out, CNA DD reported that she told Resident #67 we had this discussion about you getting up by yourself. CNA DD reported that staff had tried alarms and she had taken them off or thrown a fit about about them, the bed was close to the floor at that time, but Resident #67 would try to stand, the clip alarm was tried, but CNA DD was not sure if they tried pressure alarms, she reported that Resident #67 had been very independent before she came here, she had fallen before she came in the 1st time after she had a broken leg a few years ago and still was trying to get up, she has not changed.

Based on observation, interview, and record review, the facility failed to promptly follow up with dental services and and have an oral surgery consult, and dental recommendation for extraction of two abscess teeth in 1 of 10 sampled residents (Resident #5) reviewed for dental services, from a total sample of 17 residents, resulting in a delay in care and services for Resident #5 who had ongoing pain, repeated abscesses and antibiotic use, and the potential [MEDICAL CONDITION] from abscess teeth. Findings include: Abscess tooth: Signs and symptoms of a tooth abscess include: · Severe, persistent, throbbing toothache that can radiate to the jawbone, neck or ear · Sensitivity to hot and cold temperatures · Sensitivity to the pressure of chewing or biting · Fever · Swelling in your face or cheek · Tender, swollen lymph nodes under your jaw or in your neck · Sudden rush of foul-smelling and foul-tasting, salty fluid in your mouth and pain relief if the abscess ruptures. When to see a doctor: See your dentist promptly if you have any signs or symptoms of a tooth abscess. If you have a fever and swelling in your face and you can't reach your dentist, go to an emergency room . Also go to the emergency room if you have trouble breathing or swallowing. These symptoms may indicate that the infection has spread deeper into your jaw and surrounding tissue or even to other areas of your body. Complications: A tooth abscess won't go away without treatment. If the abscess ruptures, the pain may decrease significantly - but you still need dental treatment. If the abscess doesn't drain, the infection may spread to your jaw and to other areas of your head and neck. You might even [MEDICAL CONDITION] - a life-threatening infection that spreads throughout your body. If you have a weakened immune system and you leave a tooth abscess untreated, your risk of a spreading infection increases even more. (retrieved 3/8/17 from www.mayoclinic.org) Resident #5 Review of a facility Face Sheet revealed Resident #5 was a [AGE] year old female originally admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A Minimum Data Set (MDS) assessment completed on 2/17/17 revealed Resident #5 was a total assist with 2 staff for transfers, and bathing, and a total assist with 1 staff for hygiene, and eating. A Brief Interview for Mental Status (BIMS) revealed Resident #5 was unable to complete which indicated Resident #5 was severely cognitively impaired. During an interview on 3/8/17 at 9:30 a.m., Director of Nursing (DON) B indicated Resident #5 had a chronic abscesses in two teeth, on the bottom left side of her mouth. DON B indicated the infection had been ongoing, and had been treated with antibiotics on and off as the infection came and went. DON B indicated Resident #5 is non-verbal, and when staff notices her facial grimaces and pain, along with crying episodes, the facility dentist KK will order antibiotics. Review of a facility Infection Control Log dated for the month of February 2016, March 2016, November, 2016, December 2016, and February 2017 revealed Resident #5 was receiving [MEDICATION NAME] (antibiotic) for a tooth abscess. In a column on the document labeled infection related to [DIAGNOSES REDACTED]. Review of facility Dental progress notes revealed that from 12/2/14-12/27/16, Resident #5 was found to have recurrent abscess and swelling to two teeth (#17 and #18) and was seen by the facility dentist 8 times, was ordered antibiotics 3 times by the dentist and was recommended to see an oral surgeon 6 times. Review of a facility Nursing progress note dated 7/14/16 revealed: (Resident #5)-not swallowing meals, all liquids running right back out of mouth,will continue to monitor. Review of a facility Nursing progress note dated 7/21/16 revealed: (Resident #5)-extensive drooling from left side of mouth. (Resident #5) would not open mouth for observation on internal jaw lines, will continue to monitor. Review of a facility Nursing progress note dated 7/25/16, 7/26/16 and 7/27/16 revealed revealed Resident #5 had yellowish drainage coming out of left side of mouth. Review of a facility Nursing progress note 11/16/16 revealed: Certified Nurse Aide (CNA) reported (Resident #5) crying at supper. (Resident #5) indicated mouth was hurting. Review of a facility Nursing progress note 11/20/16 revealed: (Resident #5)-continues to have problems with mouth. noted face and jawline slightly swollen. Review of a facility Nursing progress note 11/24/16 revealed: (Resident #5)-observed crying, along with facial grimacing. Review of a facility Nursing progress note 11/25/16 revealed: (Resident #5)-some facial grimacing noted this shift. Review of a facility Nursing progress note 11/27/16 revealed: (Resident #5)-continues on antibiotic for tooth abscess, facial grimacing and crying noted this shift. Review of a facility Nursing progress note 11/28/16 revealed: (Resident #5)-low grade fever. Review of a facility Nursing progress note 11/30/16 revealed: (Resident #5)-99.1 fever. Review of a facility Nursing progress note 12/1/16 revealed: (Resident #5)-slight swelling to jawline, resident very tearful and crying. Review of a facility Social Work progress note dated 12/1/16 revealed: (Resident #5)- pain with tooth abscess. Review of a facility Progress Note dated 12/6/16 revealed: (Resident #5) with chronic abscessed of whom was recently treated with antibiotics for 10 days with last dose 12/1/16. Staff report (Resident #5) demonstrated increased signs of pain after drinking cold liquids this morning. staff reports (Resident #5) continues with facial grimace and crying and requested evaluation. case discussed with nursing. Review of a facility Nursing progress note 12/7/16 revealed: (Resident #5)-ice pack to face and jaw to help with swelling and reduce pain. Review of a facility Nursing progress note 12/8/16 revealed: (Resident #5)-spoke to NP SS about signs and symptoms of pain-crying, shaking and decreased oral intake due to oral abscess. Review of a facility Nursing progress note 12/11/16 revealed: (Resident #5)-continues on antibiotic for tooth abscess, very tearful around lunch. Review of a facility Nursing progress note 12/16/16 revealed: (Resident #5)-was tearful on and off around 8:30-9:00 a.m. Review of a facility Nursing progress note 12/18/16 revealed: (Resident #5)-was moaning and tearful this shift. Review of a facility Nursing progress note 2/9/17 revealed: (Resident #5)-Left jawline swollen. consumed half of dinner will continue to monitor. Review of a facility Nursing progress note 2/10/17 revealed: (Resident #5)-continue antibiotics for tooth infection. left jawline swollen. Review of a facility Progress Note dated 2/10/17 revealed: (Resident #5) with chronic abscessed tooth is observed with left lower jaw [MEDICAL CONDITION] and staff request evaluation. case discussed with nursing staff. The document was signed by facility nurse practitioner (NP) SS. Review of a facility Nursing progress note 2/13/17 revealed: (Resident #5)-continues on antibiotic for oral infection. (Resident #5) crying at dinner. Review of a facility Nursing progress note 2/16/17 revealed: (Resident #5)-continues on antibiotic for oral infection. (Resident #5) tearful. Review of a facility Nursing progress note 2/17/17 revealed: (Resident #5)-continues on antibiotic for tooth infection. (Resident #5) tearful and tapping left foot on wheelchair pad. Review of a facility Nursing progress note 2/20/17 revealed: (Resident #5)-continues on antibiotic for tooth infection. tearful at times. Review of a facility Social Work progress note dated 2/21/17 revealed: (Resident #5)- dental problems continue with re-occurring abscess. Review of a facility Nursing progress note 2/21/17 revealed: (Resident #5)-continues on antibiotic for oral infection. tearful in the a.m. Review of a facility Nursing progress note 3/2/17 revealed: (Resident #5)-very tearful this morning around 10:30 a.m., unable to state what is wrong. Review of a facility Nursing progress note 3/3/17 revealed: (Resident #5)-spoke with physician this a.m., regarding resident scheduled for oral surgery on 3/10/17 for tooth extraction for frequent abscess. Review of a Physicians Order dated 3/7/17 revealed: administer [MEDICATION NAME] 5 mg (sedative) 1/2 tab (2.5 mg) 2 hours prior to dental procedure on 3/10/17. The order was signed by facility (NP) SS Review of a Physicians Order dated 3/7/17 revealed: discontinue previous [MEDICATION NAME] 5 mg order due to dental procedure being canceled. The order was signed by facility (NP) SS During an interview on 3/8/17 Social Worker (SW) F indicated she had made the appointment with an oral surgeon for Resident #5 because its been an ongoing problem and appointments SW F has made for her in the past have been canceled by upper management. SW F indicated Resident #5 is in extreme pain, and is very tearful, a lot of the time. SW F indicated the physicians orders are to have Resident #5 get an evaluation for extraction of the teeth. SW F indicated the evaluation has never happened and something always comes up. SW F indicated it has been mentioned to her that it is due to cost. During an interview on 3/8/17 at 2:00 p.m., Director of Nursing (DON) B indicated Resident #5 had an oral surgery appointment scheduled for 3/10/17 to have the two teeth (#17 & #18) extracted due to chronic abscesses. DON B indicated he spoke with the oral surgeons receptionist on 3/7/17. DON B indicated at that time the oral surgery for [REDACTED]. During an interview on 3/8/17 at 2:57 p.m., Dentist (D) KK indicated the first time he assessed Resident #5 was in late December of 2014. D 'KK indicated at that time, he treated Resident #5 for an abscess to 2 teeth (#17 & #18). D KK indicated he has been seeing Resident #5 since that time, and she has had chronic abscesses with these teeth. D KK indicted he has written numerous orders to have an oral surgeon consult for removal of the teeth. D KK indicated he is not an oral surgeon. D KK indicated the teeth should have been removed a long time ago, due to potential serious complications from abscess teeth and pain that comes along with abscess teeth. D KK indicated he was told Resident #5 was unable to pay for the extraction, so the appointment was canceled. D KK stated ultimately, its a cost thing, but the teeth have to come out, and she has to be safely sedated to do so. This situation, and the abscesses will not go completely away with antibiotics. D KK indicated treating with the antibiotics was a temporary solution.

Based on interview and record review, the facility failed to identify, communicate and implement interventions to prevent a fall, and to thoroughly investigate after a fall for 1 resident (#17) of 7 residents reviewed for falls, from a total sample of 19 residents, resulting in a fracture of left upper arm. Findings include: The professional standard for quality for analyzing falls is "The facility's staff and practitioners attempt to identify causes of the condition or problem...the facility's staff and practitioners use the information to decide how to best manage a resident's condition, symptom, or situation." (Clinical Process Guideline: Evaluation of Falls/Fall Risk, memorandum dated 2/13/04, MDCH Clinical Advisory Panel) According to The Fundamentals of Nursing (Potter and Perry, 6th Edition, 2005), "Nursing interventions are prioritized to provide safe and efficient care...The client's mobility problem is an obvious priority because of its influence on skin integrity and risks for falls. The nurse plans individualized interventions based on the severity of risk factors and the client's developmental stage, level of health, lifestyle, and culture...nursing interventions are directed toward maintaining the client's safety in all types of settings. Nursing measures for providing a safe environment include health promotion, developmental interventions, and environmental interventions...To promote an individual's health, it is necessary for the individual to be in a safe environment to practice a life style that minimizes risk of injury". The facility's policy titled "Fall and Prevention Assessment Policy", undated, "The purpose of this protocol is: ...2. To identify precipitating events leading up to falls that do occur...4. To maintain residents choice and desire for independence within safety approaches...". "Instruments needed: 1. Staff reports of change in condition or safety concerns...". "Fall Risk Assessment: ...Residents will be considered at high risk for fall when they score at high risk according to specific instrument. Following incident all staff notified and on observation for continuing effectiveness of any new approaches and report to charge nurse and rehab staff for follow up. If residents are at high risk for falls, they will receive continuing assessment to identify the cause of the fall(s). Intervention for reducing the residents risk for falls will be resident specific and based on assessment findings and care planned". "Fall Management: When a resident falls...Rehab staff completes investigations of incident form...They investigate through interview with nursing staff, family and in any involved staff member including reviewing medical record and med changes". According to the facility "Resident Admission Record", dated 3/27/14, and the "Physician Orders", dated 3/26/14, Resident #17 was an [AGE] year old female, admitted to the facility 3/26/14 with [DIAGNOSES REDACTED]. According to the admission Minimum Data Set (MDS, an assessment) dated 4/7/14, Resident #17 had a BIMS score (Brief Interview for Mental Status, a cognitive assessment) of 15 out of 15, indicating Resident #17 was cognitively intact, alert and oriented to person, place and time. Resident #17 required supervision (oversight, encouragement or cueing) of 1 staff member with transfer and walking in room. Resident #17 required supervision and physical assist of 1 staff member with walking in corridor, on and off nursing unit, dressing and toileting. Resident #17's balance during transitions and walking was noted to be a 1 (not steady, but able to stabilize without staff assistance). Resident #17 used a walker for mobility. Resident #17 was occasionally incontinent of urine and had history of falls prior to admission to the facility. According to the "Fall Risk Assessment", a tool used to determine if resident is at risk for falls so that interventions can be placed to prevent occurrence of falls, dated 3/26/14, Resident #17 fall risk score was 14 ( a score of 8-10 = high risk). According to the nursing "Admission Assessment", dated 3/26/14, under "Psychosocial Functioning", "States she gets anxiety at night...". According to Resident #17's initial falls care plan, with problem start date 3/30/14 and created: 4/2/14, reflected "Problem: Potential for falls AEB (as evidenced by) recent fall(s) with weakness and visual challenges with new onset of right eye blindness S/P (status [REDACTED]. "Goal: No fall requiring tx (treatment) outside the facility". "Approach" or interventions to prevent falls, all with the Approach start date of 3/30/14 included: Ambulate with SBA (stand by assistance) with own 4 wheel walker, equipment use: see ADL (activities of daily living) assess (sic), fall assess: initial, quarterly and PRN (as needed) with changes, PT/OT tx (treatment) 5 x (times) wk (week) for strengthening and mobility, toiletng program: see bowel and bladder care plan, transfer with: SBA with own 4 wh (Wheel) walker and routine fall risk precautions at all x's, see attached. Review of the facility's "Routine Fall Precautions" included: All staff, all departments...all observe for unsafe situations, intervene.. and report to charge nurse/rehab. According to the "CENA Flow Sheet" dated 3/14, a document that communicates to CNA's how to care for a resident, it did not reflect that Resident #17 was at high risk for falls. Routine fall precautions in place at all times was checked. There were not any individual interventions to prevent falls documented. Under "Psychosocial" Resident #17 was checked for alert and oriented, it was not documented that Resident #17 had increase anxiety at night. According to the "CNA Reporting for Resident's Functional Status", a document CNA's use to communicate resident needs to nursing and therapy, reflected the following untimed narratives: 3/26/14 "Resident non compliant with call light", 3/28/14 "Resident non compliant with call light", 3/29/14 "Resident non compliant with call light (arrow up) by self several x's (times), 3/30/14 "Resident non compliant with call light", 4/1/14 "Resident non compliant with call light. confused and doesn't see the need to call for help", 4/2/14 "Resident is non compliant with call light", 4/11/14 "Resident non compliant with call light, walks around in room", 4/12/14 "Resident non compliant with call light at times", 4/13/14 "Resident non compliant with call light", 4/14/14 "Resident non compliant with call light", 4/15/14 "Resident non compliant with call light" 4/16/14 "Resident non compliant with call light", 4/18/14 "Resident non compliant with call light (arrow up) by self several x's", 4/19/14 "Resident has been non compliant with call light", 4/19/14 "Resident was in a lot of pain due to falling in the middle of the night. Nurse ended up sending her tot he hospital...", 4/19/14 "(arrow up) pain upon return from hospital...used 3 aides to put on commode". According to the "Physical/Therapy Daily/Weekly Progress Notes" dated 4/1/14 "...T/F (transfer) sit to stand with 4 ww (wheeled Walker) supervision with V/C (verbal cues) for safety precautions due to impulsive and (arrow down) memory. According to the "Nurses Notes" with the following dates reflected: 4/11/14 at 0550 (5:50 a.m.) "...Independent x's 3 for toileting...", 4/12/14 2200 (10:00 p.m.) "Resident functions independently for toileting and ambulation in room..." 4/13/14 2200 "Resident is non compliant with call light, resident functions independently for ambulation in room and toileting...", 4/14/14 0500 (5:00 a.m.) "Resident remains non compliant with call light...". 4/16/14 2130 (9:30 p.m.) "Resident non compliant with call light...", 4/18/14 2240 (10:40 p.m.) "...resident has been non compliant with call light and transfers this shift". According to the facility "Fall Incident Report" dated 4/19/14 at 0430 (4:30 a.m.), Under description of what happened, Resident #17 was "yelling 'help' CNA walked into rm (room), res (resident) lying on floor...slight change in ROM (range of motion) to L (left) shoulder 'aching'...prn Tylenol given at 0435". Under resident's description of what happened, "I got up to use the bathroom and I started to pee and I slipped". Under Immediate corrective measures "res toileted, bed lowered, informed resident to use call light, supervision for toileting". According to the "CNA incident report", dated 4/19/14 at 0430, under question 6, "current safety approaches are you using with this resident", it reflected "hilo bed and supervision plan" were checked. "Assigned CNA comment and review of incident:" it reflected written in by cna "resident has been non compliant with call light". According to the "Nurses Notes", dated 4/19/14 at 0630 (6:30 a.m.) it reflected, "...complaint of left shoulder pain noted with large lump to left posterior elbow and left posterior wrist with some ecchymosis (discoloration of skin) noted at shoulder complaint of pain 7/10 (scale used to assess severity of pain) states 'I can't move it, it hurts to move it'." At 0635 (6:35 a.m.) it reflected "...Resident stated is unable to walk or transfer to commode, complaint body hurts all over". At 0640 (6:40 a.m.) "T.O. (telephone order) to send to ER (emergency room ) for evaluation and treatment". According to the hospital emergency department record, dated 4/19/14, under "[DIAGNOSES REDACTED]. Closed commuinuted (a broken bone that has three or more fragments) left proximal humerus (the ball of shoulder joint) fracture. 2. Left knee contusion (bruise) and strain 3. Left hip strain". According to the undated and unsigned document "Fall Review for fall with fracture",the facilities investigation of the fall, attached to the facility incident and accident Report for resident # 17 reflected, "...resident showed H/O (history of) good use of the call light in room until strength and mobility improved with updated skills prior to D/C (discharge) of PT (physical therapy) to include regional supervision in room with consistent use of own 4 wheeled walker with demonstrated good use of sequencing and use of walker brakes as well as ability to ambulate 300 ft without fatigue...was with out brief per usual protocol for open air to maintain skin integrity...". A phone interview with the CNA (certified nurse aide) "M" on 5/15/14 at 10:00 a.m. was conducted, CNA "M" stated that she worked with Resident #17 on the midnight shift routinely since Resident #17 was admitted to the facility and that she was the CNA assigned to Resident #17 that night. CNA "M" stated that Resident #17 had a history of [REDACTED]. CNA "M" stated that she had documented on Resident #17's "blue sheet and 24 hour report". It was not communicated to CNA "M" that Resident #17 required more supervision or that she was at high risk for falls other than "routine fall precautions" Resident #17 required one assist with all transfers ambulation and toilet use. CNA "M" stated that Resident #17 usually wore underwear with a panty liner at night but that Resident #17 was found at times to remove soiled pads roll them up and place in her drawer of the bedside stand. A phone interview with LPN (Licensed Practical Nurse ) "N" on 5/15/14 at 11:00 a.m. was conducted, LPN "N" stated that prior to the date of Resident #17's fall, Resident #17 would normally use her call light, but LPN "N" only worked on the rehab unit approximately once every two weeks. An interview with PTA (Physical Therapy Assistant) "K" on 5/15/14 at 11:30 a.m. in the therapy room was conducted, PTA "K" stated "I remember that she (Resident #17) became more confused as the day went on" and that Resident #17 was impulsive at times and would not use the call light prior to transfers. An interview on 5/14/14 at 4 p.m. in the conference room with the Rehab Director "H", revealed Rehab Director "H" was the designated staff member who investigated and evaluated all falls within the facility. Rehab Director "H" stated that based on her investigation the fall resulting in the fracture was an "isolated occurrence" and could not have been prevented.