Every finding on record at Arcadia Valley Skilled Nursing and Rehabilitation

Based on observation, interview, and policy review the facility failed to ensure food was stored in accordance with professional standards for food service safety. This had the potential to affect 37 residents. The census was 37.Findings include: Observation of the kitchen beginning at 8:34 A.M. on 03/23/26 revealed two packs of nickels hot dog buns expired as of 03/08/26, two packs of hamburger buns expired as of 03/15/26.In the stand up freezer one open improperly sealed, undated, and unlabeled bag of 2 meat patties was observed.One bag containing several portioned pieces of cookie dough were opened, improperly sealed, unsealed, and unlabeled.One bag containing several hot dogs was opened, and unsealed.One bag containing 5 chicken patties was undated.One half- pound package of ground turkey was opened and improperly sealed with the raw turkey outside of the package.In the stand up refrigerator in the kitchen one gallon of whole milk had expired as of 03/21/26, and undated unlabeled bowl of an unknown substance covered with tin foil with MM written on it was present.One container of undated salad, and one container of 3.5 liter of green Jell-o was present and unlabeled, and undated. Interview on 03/23/26 at 8:53 A.M. with Dietary [NAME] #240 confirmed unlabeled, undated, improperly sealed, and expired items within the freezers and refrigerator, and hot dog/ hamburger buns were out of expiration.Review of the undated facility policy titled Food Storage revealed food storage areas shall be clean at all times, all packaged food, canned foods, or food items stored shall be kept clean and dry at all times.

Based on observation, interview, and policy review, the facility failed to ensure multi-use insulin flex pens were stored properly prior to use, insulin flex pens were dated when first used, and inhalers were not left at the bedside unless there was a physician's order to do so. This affected three residents (#3, #4, and #18) of three residents identified by the facility as having the use of insulin that was stored in the [NAME] Unit medication administration cart, and one resident (#5) of five residents observed during medication administration. Findings include: 1. On 03/26/26 at 9:45 A.M., an observation of the medication administration cart for the [NAME] Unit (Rooms 21-37) revealed there were insulin Flex Pens (multi-dose insulin injectable dispensing pen) noted to be stored in the top drawer of the medication administration cart that had not been used yet and/ or without dates written on them when they had been put in use. 1 a.) Resident #3 was noted to have a Semglee (Glargine Insulin) 100 units (u)/ milliliter (ml) Flex Pen that was in the top drawer of the medication administration cart that had been filled on 03/04/26. The Semglee (a long acting insulin used to lower blood sugar levels) Flex Pen had been used, but did not have a date written on it to indicate when the insulin Flex Pen had been removed from the refrigerator and used for the first time. Findings were verified by Registered Nurse (RN) #124. 1 b.) Resident #4 was noted to have a Lantus insulin (a long acting insulin used to lower blood sugar levels) Flex Pen 100 u/ ml stored in the top drawer of the medication administration cart that had been filled on 01/26/26. The Flex Pen had not been used yet, but was not being properly stored in the refrigerator until use. Findings were verified by RN #124. 1 c.) Resident #18 was noted to have a Lantus insulin Flex Pen 100u/ml stored in the top of the medication administration cart that had been filled on 03/11/26. It had not been used and was not being stored in the refrigerator, as it should have been. Findings were verified by RN #124. On 03/26/26 at 9:48 A.M., an interview with RN #124 confirmed insulin Flex pens should be stored in the refrigerator, until they were put in use. They were also to be dated when first used so the nurses knew how long the insulin was good for and when it should be discarded. She stated she believed they were only good for 30 days or so when removed from the refrigerator after their first use. Review of the product information for Lantus insulin for storage, stability, and disposal revealed an unopened vial/ cartridge of LANTUS should be stored in a refrigerator, between 2 degrees C and 8 degrees C. Opened Lantus vials/ cartridges could be kept refrigerated or unrefrigerated (15 to 30 degrees C) for up to 28 days away from direct heat and light, as long as the temperature is not greater than 30 degrees C. Opened LANTUS vials/ cartridges, whether or not refrigerated, must be discarded after 28 days even if they contain insulin. Review of the facility's Storage of Medication policy dated September 2010 revealed insulin products should be stored in the refrigerator until opened. They were to note the date on the label for insulin vials and pens when first used. Opened insulin pens must be stored at room temperature. 2. Record review revealed Resident #5 was admitted to the facility on [DATE] with diagnoses including chronic obstructive pulmonary disease (COPD), ischemic cardiomyopathy, depression, pulmonary fibrosis, and hypertension. Review of Resident #5's quarterly minimum data set (MDS) completed on 03/02/26 revealed a brief interview for mental status score of 15. The resident required continuous oxygen therapy. Review of Resident #5's care plan completed on 03/17/26 revealed the resident had an alteration in respiratory function and required oxygen, interventions included providing inhalers as ordered. Review of Resident #5's orders revealed an order placed on 10/24/25 for Incruse Ellipta Inhalation Aerosol Powder Breath Activated 62.5 micrograms (mcg) / each actuation (spray) (ACT) (Umeclidinium Bromide). One inhalation inhale orally in the morning for COPD. Review of Resident #5's record revealed no documentation of the resident being permitted to have medications at the bed side, or self-administer medications. Observation on 03/25/26 at 8:35 A.M. revealed an Incruse inhaler on the residents' bedside table within reach. Observation and interview on 02/25/26 at 8:45 A.M. with Registered Nurse (RN) #124 confirmed Resident #5's Incruse Ellipta Inhalation Aerosol Powder Breath Activated 62.5 mcg / ACT (Umeclidinium Bromide) was located on the resident's bedside table.

Based on record review and staff interview, the facility failed to ensure a resident and/ or their representative gave informed consent for the use of psychotropic medications. This affected one resident (#44) of five residents reviewed for unnecessary medications. Findings include:Review of Resident #44's medical record revealed she was admitted to the facility on [DATE]. Her diagnoses included a malignant neoplasm of an unspecified part of an unspecified lung, malignant neoplasm of the vulva, basal cell carcinoma of the skin, depression, and anxiety disorder. Review of Resident #44's physician's orders revealed the resident had orders to receive Diazepam (an anti-anxiety medication) 5 milligrams (mg) by mouth (po) every 12 hours as needed (prn) for anxiety. The order originated on 03/18/26. She also had an order to receive Venlafaxine HCL (an anti-depressant) 75 mg po every morning for depression. That order was present upon her admission. Review of Resident #44's medication administration record (MAR) for March 2026 revealed the resident was receiving her Venlafaxine HCL 75 mg po daily as ordered. The Diazepam was ordered prn but the resident had not received a dose since the order went into effect on 03/18/26. Further review of Resident #44's medical record revealed it was absent for any documented evidence of the resident and/ or her representative having provided the facility with an informed consent, after the facility had educated them on the risks and benefits associated with those psychotropic medications. Findings were verified by the facility's Director of Nursing (DON). On 03/24/26 at 11:55 A.M., an interview with the facility's DON confirmed they did not have evidence of Resident #44 or her resident representative having been given education on the risks/ benefits of taking Venlafaxine or Diazepam to be able to give an informed consent for the use of those psychotropic medications. She provided an Informed Consent For Use of Psychotropic Medications pertaining to the Venlafaxine and Diazepam, that had been provided to the resident that day (03/24/26), which covered the necessary information for the resident to be able to give an informed consent. She stated she did not know what happened to the prior consents and they should have been completed upon the resident's admission. They had several admissions occurring around that time, when Resident #44 was admitted , and was not sure what happened with it. The facility's Regional Nurse Consultant #300 denied the facility had a policy specific to the use of Psychotropic medications when requested.

Based on record review and interview, the facility failed to ensure residents received copies of their quarterly statements from their resident fund accounts. This affected one resident (#37) of five residents reviewed for resident fund accounts. The facility census was 37. Findings include:Record review revealed Resident #37 was admitted to the facility on [DATE] with diagnoses including multiple sclerosis and chronic obstructive pulmonary disease. Review of a minimum data set (MDS) dated [DATE] revealed Resident #37's cognition remained intact and she had no behaviors. Review of Resident Council minutes dated 02/10/26 revealed there was a concern residents were not receiving statements from their personal account. Interview on 03/23/26 at 1:29 P.M. with Resident #37 revealed she does not receive a copy of her personal statements, but information was reviewed verbally. Resident #37 stated she would prefer a paper copy of her statement. Review of Resident #37's resident fund account revealed no evidence of a signed quarterly statement for the first three quarters of 2025. Interview on 03/26/26 at 10:17 A.M. with Business Office Manager (BOM) #500 confirmed there was no evidence of signed quarterly statements for Resident #37 for the first three quarters of 2025.

Based on record review, policy review, and interview, the facility failed to ensure a resident's physician was notified the resident's equipment used for treatment of lymphedema was broken for over a month impacting the treatment the resident was to receive. This affected one resident (#37) of one resident reviewed for lymphedema pumps. The facility census was 37. Findings include:Record review revealed Resident #37 was admitted to the facility on [DATE] with diagnoses including multiple sclerosis and chronic obstructive pulmonary disease.Review of a minimum data set assessment dated [DATE] revealed Resident #27's cognition remained intact, she had no behaviors, was dependent on staff for toileting hygiene, and was occasionally incontinent of bowel and bladder.Review of a care plan dated 09/03/25 revealed Resident #37 had edema to lower extremities related to lymphedema. The goal was to maintain current level of socialization and maintain current physical level abilities. Interventions included bilateral lower extremity wraps as ordered and as tolerated; staff to monitor and notify physician of any decline; and use lymphedema pumps as ordered and as tolerated.Review of orders revealed Resident #37 had an order in place dated 04/14/25 for lymphedema pumps on for 60 minutes every morning and at bedtime for lymphedema to bilateral lower extremities with the pressure set at 40. Additionally, Resident #37 had an order dated 04/14/25 for lymphedema pumps to come off after 60 minutes every morning and at bedtime for lymphedema to bilateral lower extremities.Review of an electronic medication administration record (eMAR) note dated 10/20/25 at 2:43 P.M. revealed Resident #37 stated her lymphedema pumps were broken and she was awaiting UPS to pick them up. The physician was made aware.Review of an eMAR note dated 10/26/25 revealed Resident #37 stated her lymphedema pumps were broken and she was awaiting UPS to pick them up.Review of an eMAR note dated 10/30/25 at 12:35 P.M. revealed Resident #37 stated her lymphedema pumps were broken and she was awaiting UPS to pick them up.Review of an eMAR note dated 11/03/25 at 1:33 P.M. revealed Resident #37 stated her lymphedema pumps were broken and she was awaiting UPS to pick them up.Review of an eMAR note dated 11/04/25 at 6:47 P.M. by Licensed Practical Nurse (LPN) #136 revealed Resident #37's lymphedema pumps were broken.Review of an eMAR note dated 11/07/25 at 9:44 A.M. by LPN #136 revealed Resident #37's lymphedema pumps were broken.Review of an eMAR note dated 11/08/25 at 12:39 P.M. revealed Resident #37's lymphedema pumps were broken.Review of an eMAR note dated 11/09/25 at 12:06 P.M. by LPN #136 revealed Resident #37's lymphedema pumps were broken.Review of an eMAR note dated 11/10/25 at 9:37 A.M. by LPN #136 revealed Resident #37's lymphedema pumps were broken.Review of an eMAR note dated 11/11/25 at 12:35 P.M. by LPN #220 revealed Resident #37's lymphedema pumps were broken.Review of an eMAR note dated 11/12/25 at 12:33 P.M. revealed Resident #37's lymphedema pumps were broken.Review of an eMAR note dated 11/17/25 at 10:29 A.M. by Registered Nurse (RN) #302 revealed Resident #37's lymphedema pumps were broken.Review of an eMAR note dated 11/18/25 at 1:51 P.M. by RN #302 revealed Resident #37's lymphedema pumps were broken.Review of an eMAR note dated 11/21/25 at 10:55 A.M. revealed Resident #37's lymphedema pumps were broken.Review of an eMAR note dated 11/22/25 at 9:37 A.M. revealed Resident #37's lymphedema pumps were broken.Review of an eMAR note dated 11/23/25 at 10:43 A.M. revealed Resident #37's lymphedema pumps were broken.Review of an eMAR note dated 11/26/25 at 11:12 A.M. revealed Resident #37's lymphedema pumps were broken.Review of an eMAR note dated 11/27/25 at 10:30 A.M. revealed Resident #37's lymphedema pumps were broken.Review of an eMAR note dated 12/01/25 at 9 A.M. revealed revealed Resident #37's lymphedema pumps were broken.Review of an eMAR note dated 12/02/25 at 9:07 A.M. revealed Resident #37's lymphedema pumps were broken.Review of an eMAR note dated 12/30/25 at 11:37 P.M. revealed Resident #37's lymphedema pumps were taken off, no behaviors noted at this time, and staff would continue to monitor.Interview on 03/26/26 at 7:33 A.M. with Director of Nursing (DON) revealed she had found out the lymphedema pumps were broken by reviewing the shift reports, she spoke with Resident #37 who told her the company the pumps came from. The DON stated at some point someone from the company came in to fix the pumps and they were working again, then it stopped airing up like it was supposed to and had to be sent out to the company. The DON confirmed she was not sure the exact time the pumps quit working because no one informed her but she did educate the resident to ensure she was notified in the future. The DON confirmed if the pumps were broken twice, it was only documented once (10/20/25) in the medical record the physician was notified and there was no evidence to support whether the physician knew the lymphedema pumps were broken for more than a month.Review of an undated policy titled Status Change in Resident Condition - Notification revealed the facility will promptly notify the resident, his/her attending physician and the responsible party of changes in the resident's condition and/or status.

Based on review of a Beneficiary Notice list, review of a Skilled Nursing Facility (SNF) Beneficiary Protection Notification Review form, review of liability notices, and staff interview, the facility failed to ensure a resident received the appropriate liability notices, when their Medicare (MCR) Part A services ended, and they remained in the facility. This affected one resident (#11) of three residents reviewed for beneficiary notices. Findings include: Review of a Beneficiary Notice list of all residents, who were discharged from a MCR covered Part A stay, with benefit days still remaining in the past six months revealed Resident #11 was identified as having a discharge date from MCR Part A services on 10/21/25. She was also indicated on that list to have remained in the facility following her discharge from MCR Part A services. Review of a Skilled Nursing Facility (SNF) Beneficiary Protection Notification Review form completed by the facility revealed Resident #11 began receiving MCR Part A skilled services on 09/11/25. Her last covered day of MCR Part A services was on 10/21/25. The provider (facility) indicated the facility initiated the resident's discharge from MCR Part A services, when the resident's benefit days had not been exhausted. They indicated on that form that the resident was given a Notice of MCR Non-Coverage (NOMNC), CMS Form 10123, but did not provide the resident with a SNF Advanced Beneficiary Notice (ABN), CMS Form 10055, despite the resident remaining in the facility after being cut from MCR Part A services. The facility was supposed to explain on the form why the resident was not given that notice, but no explanation was provided. On 03/26/26 at 8:55 A.M., an interview with Social Service Designee #132 revealed she was not sure why Resident #11 was not provided a CMS Form 10055, when her MCR Part A services ended on 10/21/25 and she remained in the facility. She stated she would have to check with the business office manager to see why the resident was not given that notice. On 03/26/26 at 9:05 A.M., an interview with the facility's Administrator revealed Resident #11 did not receive a SNF ABN (CMS Form 10055) because she remained in the facility and did not wish to continue Part B therapy services. That was the directive they received from their corporate office and had been following what they had been told. She acknowledged residents that had been cut from MCR Part A services should receive the SNF ABN (CMS Form 10055) to notify them of the right to appeal the facility's decision to discharge them from MCR Part A services. The resident should be afforded the right to continue to receive those skilled services pending the appeal with the responsibility of paying for those skilled services in the event their appeal was denied. The resident was to mark on that form if they wanted to continue to receive those skilled services that were ending or if they wanted to opt out of the appeal process. Regional Nurse Consultant #300 revealed the facility did not have a policy specific to liability notices. She stated they just followed the regulations pertaining to liability notices.

Based on observation and interview the facility failed to provide a safe, clean, comfortable environment for residents. This affected two residents (#20, #4). The census was 37.Findings include:1.Interview on 03/23/26 at 10:22 A.M. with Resident #20's Representative #800 revealed there were some environmental concerns with the resident's room. The door does not close all the way, you have to slam it to shut it. The light above the resident's bed does not work, there is no string to pull it, so they have to turn the light on above the other bed. The walls look bad, there are scuff marks everywhere on doors, walls, damage to the dry wall, paint peeled off. The drawers don't close all the way, and there are drawers without fronts on them, so they're not useable.Observation on 03/23/26 at 10:25 A.M. revealed Resident #20's room had several scuff marks on the bathroom door and along the walls. Above the resident's head of bed on the wall revealed torn paint and dry wall, and scuff marks. The overhead light above the resident bed did not have a draw string and was unable to be turned on. Upon closing the resident's door it was unable to be shut without aggressive force resulting in a loud disruptive sound.2. Interview on 03/23/26 at 12:47 P.M. with Resident #4 revealed the scuffs and torn wall behind the head of bed need repaired. Resident #4 stated they have been waiting a long time for them to get repaired. Resident #4 stated her drawers do not have fronts on them so she can not use them.Observation on 03/23/26 at 12:48 P.M. revealed scuffed and torn wall above the head of Resident #4's bed. Observation of the residents' drawers revealed the 2nd drawer on the left hand side does not have a front and is unable to be used.Interview and observation with the facility Administrator on 03/25/26 at 9:49 A.M. confirmed environmental issues across several resident rooms including peeled paint, torn dry wall, scuff marks along walls and doors, doors unable to be properly closed, and overhead lights unable to be turned on due to not having a draw string.

Based on record review, policy review, and interview the facility failed to ensure residents or their representative received a bed hold notice upon transfer. This affected one resident (#20) of three residents reviewed for hospitalization. The census was 37.Findings include:Record review revealed Resident #20 was admitted to the facility on [DATE] with diagnoses including cerebral infarction, dysphagia, chronic kidney disease stage 3, anemia, and supraventricular tachycardia. Interview on 03/23/26 at 10:19 A.M. with Resident #20's power of attorney revealed the resident was sent to the hospital on [DATE] due to pulling out her feeding tube (Jejunostomy tube (J-tube). Resident #20's power of attorney revealed they did not receive a bed hold notice upon transfer/ discharge. Review of Resident #20's progress notes revealed a note dated 03/19/26 at 11:53 P.M. that Resident #20 was being sent to the Emergency Department due to pulling out her J-tube. Review of Resident #20's progress notes revealed a note dated 03/23/26 at 3:49 P.M. that Resident #20 was being sent to the Emergency Department due to her J-tube being dislodged. Review of Resident #20's record revealed no documentation a bed hold notice was completed for Resident #20 during her hospital stays. Interview on 03/25/26 at 2:30 P.M. the facility Administrator confirmed Resident #20's representatives was not given a bed hold notice upon the resident's transfer to the hospital. Review of the undated facility policy titled Bed Hold Policy revealed Pursuant to Ohio law, the facility will offer Medicaid residents the opportunity to hold the bed for a maximum of 30 days per calendar year. After admission to the nursing home, and before a resident is transferred or leaves the facility the facility will provide the resident and/or their sponsor with the following Information in writing, the bed hold policy of the state and facility policy.

Based on record review and interview the facility failed to develop and implement a comprehensive person-centered care plan for a resident with post traumatic stress disorder (PTSD). This affected one resident (#2) of three residents reviewed for development and implementation of the comprehensive care plan. The census was 37. Findings include:Record review revealed Resident #2 was admitted to the facility on [DATE] with diagnoses including diabetes, asthma, aphasia, multiple sclerosis, von Willebrand disease, insomnia, urinary retention, anxiety, post traumatic stress disorder, and major depressive disorder.Review of Resident #2's quarterly Minimum Data Set (MDS) assessment completed on 02/09/26 revealed diagnoses of peripheral vascular disease, urinary tract infections, hyperlipidemia, aphasia, multiple sclerosis, anxiety, depression, and post-traumatic stress disorder. Review of the resident's record revealed no documentation of a care plan related to post traumatic stress disorder including goals and interventions to meet the resident's mental and psychosocial needs.Interview on 03/25/26 at 3:45 P.M. with the Assistant Director of Nursing confirmed Resident #2 does not have a care plan in place related to post traumatic stress disorder including goals and interventions to meet the resident's mental and psychosocial needs, specific to her trauma and trigger.

Based on record review, interview, and policy review, the facility failed to ensure care conferences were scheduled in conjunction with the minimum data set (MDS) assessments quarterly. This affected one resident (#1) of two residents reviewed for care conferences. The facility census was 37. Findings include:Record review revealed Resident #1 was admitted to the facility on [DATE] with diagnoses including paranoid schizophrenia, type II diabetes, and chronic obstructive pulmonary disease. Review of a minimum data set (MDS) assessment dated [DATE] revealed Resident #1's cognition remained intact and he had behaviors including hallucinations, delusions, and refusing care one to three days during the review period. Review of the MDS listing revealed Resident #1 had assessments completed 07/12/25, 10/12/25, 01/12/26, and one scheduled for 04/12/26. Review of care conferences revealed Resident #1 had care conferences on 07/16/25, 10/10/25, and 02/13/26. Interview on 03/24/26 at 11:19 A.M. with Social Worker (SW) #132 revealed care conferences are completed quarterly, within 72 hours of admission, and for significant changes. SW #132 stated she followed the MDS schedule to ensure care conferences were completed quarterly. Follow up interview on 03/25/26 at 8:44 A.M. with SW #132 confirmed Resident #1's care conferences were not completed quarterly in conjunction with the MDS assessments. Review of an undated facility policy titled Care Conference revealed the MDS nurse is responsible for coordinating the routine schedule of resident's care conference and the MDS assessment, care areas and triggers as well as interventions for each area would be discussed.

Based on observations, record review, interview, and policy review, the facility failed to ensure residents requiring assistance with Activities of Daily Living (ADLs) received nail care and showers as scheduled. This affected two residents (#33 and #44) of four residents reviewed for ADL assistance. The facility census was 37. Findings include:1.Record review revealed Resident #33 was admitted to the facility on [DATE] with diagnoses including metabolic encephalopathy, type II diabetes, and dementia. Review of a care plan dated 07/03/25 revealed Resident #33 required assistance with ADLs related to cognitive impairment, dementia, and weakness. The goals were to continue to participate in ADLs as able and have no decline in ADLs through the review, and remain clean, dry, odor free and appropriately dressed through the review date. Interventions included but were not limited to requiring non-weight bearing assistance (including steadying, contact guard assistance or guided maneuvering) with shower, and staff will assist as needed with daily hygiene and will assist with showering residents as per facility policy weekly. Review of a minimum data set (MDS) assessment dated [DATE] revealed Resident #33 had severely impaired cognition, had physical and verbal behaviors one to three days, refused care four to six days, and assistance needed for showering/bathing was marked not applicable. Review of a shower schedule revealed Resident #33 received showers on Mondays and Thursdays on nightshift. Review of showers revealed Resident #33 did not receive a shower as scheduled on 01/01/26, 01/05/26, and 02/12/26. Observation on 03/23/26 at 2:37 P.M. revealed Resident #33 was seated in her wheelchair in the dining room and her hair appeared to be slightly greasy. Interview on 03/25/26 at 9:55 A.M. with Licensed Practical Nurse (LPN) #137 revealed she thought Resident #33's hair was damp due to wetting her hair when she was getting out of bed. LPN #137 touched Resident #33's hair and confirmed it was a little bit greasy. Interview on 03/25/26 at 10:00 A.M. with the Director of Nursing (DON) confirmed Resident #33 missed showers on 01/01/26, 01/05/26, and 02/12/26. Review of an undated policy titled Personal Care/Bathing revealed residents will receive personal care in the facility according to the resident's plan of care to promote dignity, cleanliness, and general well-being. Resident are interviewed during the admission process, quarterly and as needed regarding the frequency they want for bathing. Nail care, oral care, and shaving are also offering during routine personal care and bathing, and as needed. If the resident in unable to relay this information, attempts are made to obtain information from the responsible party. 2. Review of Resident #44's medical record revealed the resident was admitted to the facility on [DATE]. Her diagnoses included a malignant neoplasm of an unspecified part of an unspecified lung, malignant neoplasm of vulva, basal cell carcinoma of the skin, chronic obstructive pulmonary disease, adult onset diabetes mellitus, difficulty walking, osteoarthritis, depression, and anxiety disorder. Review of Resident #44's Minimum Data Set (MDS) assessments revealed her admission MDS was still in process. Her initial care plans included an activities of daily living (ADL) care plan that indicated the resident required assistance with ADL's related to weakness. The goal was for the resident to remain clean, dry, odor free, and appropriately dressed through the review date. She was also to continue to participate in ADL's as able and have no decline in ADL's through the review date. The interventions included the need for the staff to adjust care as needed to meet the resident's needs, staff were to encourage the resident to participate in ADL's during care, and staff would assist as needed with daily hygiene. Review of Resident #44's shower/ bathing documentation revealed the resident was documented as having been provided a bed bath five times since her admission to the facility. Her last documented bed bath was on 03/23/26. It did not specify what, if any, other personal hygiene care was provided as part of those bed baths. On 03/23/26 at 10:30 A.M. an observation of Resident #44 noted her to be lying in bed in a supine position with the head of the bed raised. She had her eyes closed and her fingernails were noted to be long and in need of a trimming. On 03/24/26 at 10:35 A.M., a follow up observation of Resident #44 noted the resident to be sitting up in her wheelchair in her room. Her fingernails remained long and in need of being trimmed. An interview with the resident, at the time of the observation, revealed it was her preference to have her fingernails kept trimmed. She did not like to have them grown out and denied anyone had helped her trim them, since she was admitted to the facility on [DATE]. On 03/24/26 at 11:02 A.M., an interview with Certified Nursing Assistant (CNA) #266 revealed the aides were responsible for performing nail care on the residents, even if the resident was a diabetic. She stated a podiatrist would have to do their toenails, but the aides could trim their fingernails. She reported Resident #44 needed assistance with personal hygiene to include nail care. She was not sure what days the resident was scheduled to receive her shower/ bath. She had worked the past two days and denied the resident had been on their list to get a shower/ bath the past two days. She checked her shower schedule they had in a binder at the nurses' station and was not able to find the resident's name on the current shower schedule. She was informed the resident reported she would like assistance with trimming her fingernails. She thanked the surveyor for bringing that to her attention and said she would get some nail clippers and go trim them right then. She confirmed Resident #44's fingernails were long and it was obvious they had not been trimmed in the week the resident had been there. Review of the facility's policy on Personal Care/ Bathing (not dated) revealed the purpose of the policy was to receive personal care in the facility according to the resident's plan of care to promote dignity, cleanliness, and general well-being. Nail care was to be offered during routine personal care and bathing, and as needed.

Based on record review, interview, and policy review, the facility failed to ensure the bowel protocol was followed when residents did not have bowel movements for three days or longer. This affected two residents (#37, #44) of five residents reviewed for unnecessary medications. Additionally, the facility failed to ensure a resident received physician ordered treatment for lymphedema. This affected one resident (#37) of one resident reviewed for lymphedema pumps. The facility census was 37. Findings include:1a.Record review revealed Resident #37 admitted to the facility on [DATE] with diagnoses including multiple sclerosis and chronic obstructive pulmonary disease. Review of a minimum data set assessment dated [DATE] revealed Resident #27's cognition remained intact, she had no behaviors, was dependent on staff for toileting hygiene, and was occasionally incontinent of bowel and bladder. Review of the bowel record revealed Resident #37 did not have a bowel movement from 03/01/26 through 03/06/26 or 03/08/26 through 03/11/26. Review of orders revealed Resident #37 had an order dated 03/12/26 for senna 8.6 milligrams (mg) one tablet by mouth every afternoon. Review of orders revealed Resident #37 had an order dated 03/20/26 for miralax powder 17 grams per scoop give one scoop in the afternoon for constipation. Interview on 03/26/26 at 11:08 A.M. with Administrator confirmed Resident #37 did not have a bowel movement from 03/01/26 through 03/06/26 and from 03/08/26 through 03/11/26 and did not have any intervention after three days of constipation. Administrator also confirmed the bowel management protocol for the facility was not followed. Review of an undated policy titled Bowel Management and Treatment revealed resident who have not had a bowel movement for three consecutive days will have the following protocol initiated, unless the resident has individual orders specific to bowel management, or where the orders below would be contraindicated for the resident: -Initial nurse receiving shift alert and identifying the lack of bowel movement for three days will begin the following bowel protocol for the residents on the list: assess bowel sounds; administer 30 milliliters (ml) of milk of magnesia; if the resident refuses the milk of magnesia the nurse will notify the attending physician and document such on the medication administration record (MAR) and in the nurses' notes; document on the MAR and in the nurses' notes when the resident has a bowel movement and then the resident will be placed on the modified promotional bowel regimen. -The medication nurse on the next shift will check the list upon the beginning of their shift and the following with be performed: assess for bowel sounds; if the resident does not have a bowel movement on the prior shift after receiving the milk of magnesia, the licensed nurse will administer a suppository (type and amount to be determined by the physician or medical director); if the resident refuses the suppository, the nurse will notify the attending physician and document on the MAR and nurses' notes; document on the MAR and in the nurses' notes when the resident has a bowel movement and then the resident will be placed on the promotional bowel regimen. -The medication nurse for the third consecutive shift/next shift will check the list at the start of their shift and the following will be performed: assess bowel sounds' if the resident did not have a bowel movement on the previous shift after receiving the suppository, the nurse will administer an enema per the physician's order; if the resident refuses the enema, the nurse will notify the physician and document on the MAR and nurses' noted; document on the MAR and nurses' notes when the resident has a bowel movement and then place the resident on the promotional bowel regimen; if the resident does not have a bowel movement within one hour of receiving the enema, notify the attending physician for further instruction and document such in the MAR and nurses' notes. The promotional bowel protocol includes the following: review medications the resident is currently receiving; obtain physician orders to hold all laxative and enema orders including stool softeners and bulk laxatives; daily administration of natural laxative or prune/fiber mixture with medication pass; increase fluid intake for the resident; and offer half a cup of yogurt to the resident daily. Assess bowel sounds each shift and document and each shift the nurse documents on the MAR/treatment administration record (TAR) when the resident has had a bowel movement. 1b. Record review revealed Resident #37 admitted to the facility on [DATE] with diagnoses including multiple sclerosis and chronic obstructive pulmonary disease. Review of a minimum data set assessment dated [DATE] revealed Resident #37's cognition remained intact, she had no behaviors, was dependent on staff for toileting hygiene, and was occasionally incontinent of bowel and bladder. Review of a care plan dated 09/03/25 revealed Resident #37 had edema to lower extremities related to lymphedema. The goal was to maintain current level of socialization and maintain current physical level abilities. Interventions included bilateral lower extremity wraps as ordered and as tolerated; staff to monitor and notify physician of any decline; and use lymphedema pumps as ordered and as tolerated. Review of orders revealed Resident #37 had an order in place dated 04/14/25 for lymphedema pumps on for 60 minutes every morning and at bedtime for lymphedema to bilateral lower extremities with the pressure set at 40. Additionally, Resident #37 had an order dated 04/14/25 for lymphedema pumps to come off after 60 minutes every morning and at bedtime for lymphedema to bilateral lower extremities. Review of an electronic medication administration record (eMAR) note dated 10/20/25 at 2:43 P.M. revealed Resident #37 stated her lymphedema pumps were broken and she was awaiting UPS to pick them up. The physician was made aware. Review of an eMAR note dated 10/26/25 revealed Resident #37 stated her lymphedema pumps were broken and she was awaiting UPS to pick them up. Review of an eMAR note dated 10/30/25 at 12:35 P.M. revealed Resident #37 stated her lymphedema pumps were broken and she was awaiting UPS to pick them up. Review of an eMAR note dated 11/03/25 at 1:33 P.M. revealed Resident #37 stated her lymphedema pumps were broken and she was awaiting UPS to pick them up. Review of an eMAR note dated 11/04/25 at 6:47 P.M. by Licensed Practical Nurse (LPN) #136 revealed Resident #37's lymphedema pumps were broken. Review of an eMAR note dated 11/07/25 at 9:44 A.M. by LPN #136 revealed Resident #37's lymphedema pumps were broken. Review of an eMAR note dated 11/08/25 at 12:39 P.M. revealed Resident #37's lymphedema pumps were broken. Review of an eMAR note dated 11/09/25 at 12:06 P.M. by LPN #136 revealed Resident #37's lymphedema pumps were broken. Review of an eMAR note dated 11/10/25 at 9:37 A.M. LPN #136 revealed Resident #37's lymphedema pumps were broken. Review of an eMAR note dated 11/11/25 at 12:35 P.M. by LPN #220 revealed Resident #37's lymphedema pumps were broken. Review of an eMAR note dated 11/12/25 at 12:33 P.M. revealed Resident #37's lymphedema pumps were broken. Review of an eMAR note dated 11/17/25 at 10:29 A.M. by Registered Nurse (RN) #302 revealed Resident #37's lymphedema pumps were broken. Review of an eMAR note dated 11/18/25 at 1:51 P.M. by RN #302 revealed Resident #37's lymphedema pumps were broken. Review of an eMAR note dated 11/21/25 at 10:55 A.M. revealed Resident #37's lymphedema pumps were broken. Review of an eMAR note dated 11/22/25 at 9:37 A.M. revealed Resident #37's lymphedema pumps were broken. Review of an eMAR note dated 11/23/25 at 10:43 A.M. revealed Resident #37's lymphedema pumps were broken. Review of an eMAR note dated 11/26/25 at 11:12 A.M. revealed Resident #37's lymphedema pumps were broken. Review of an eMAR note dated 11/27/25 at 10:30 A.M. revealed Resident #37's lymphedema pumps were broken. Review of an eMAR note dated 12/01/25 at 9 A.M. revealed revealed Resident #37's lymphedema pumps were broken. Review of an eMAR note dated 12/02/25 at 9:07 A.M. revealed Resident #37's lymphedema pumps were broken. Review of an eMAR note dated 12/30/25 at 11:37 P.M. revealed Resident #37's lymphedema pumps were taken off, no behaviors noted at this time, and staff would continue to monitor. Interview on 03/26/26 at 7:33 A.M. with the Director of Nursing (DON) revealed she had found out the lymphedema pumps were broken by reviewing the shift reports, she spoke with Resident #37 who stated the company the pumps came from. The DON stated at some point someone from the company came in to fix the pumps and it was working again, then it stopped airing up like it was supposed to and had to be sent out to the company. The DON confirmed she was not sure the exact time the pumps quit working because no one informed her but she did educate the resident to ensure she was notified in the future. Interview on 03/26/26 at 8:04 A.M. with the Administrator revealed the documentation is unclear as to when the pumps were broken and fixed. 2. Review of Resident #44's medical record revealed she was admitted to the facility on [DATE]. Her diagnoses included a malignant neoplasm of an unspecified part of an unspecified bronchus/ lung, malignant neoplasm of vulva, osteoarthritis, polyneuropathy, age related physical debility, and difficulty walking. Review of Resident #44's physician's orders revealed the resident had an order to receive Miralax (a bulk forming laxative) 17 grams by mouth (po) every morning for constipation. She also had an order to receive Sennosides (a stimulant laxative) 8.6 milligrams po twice a day for constipation. There were no laxatives ordered for the resident to be used on an as needed (prn) basis. Review of Resident #44's bowel movement record documented under the task tab of the electronic medical record (EMR) from 03/17/26 thru 03/24/26 revealed the resident's last recorded bowel movement occurred on 03/18/26. No bowel movements had been documented as having occurred between 03/19/26 thru 03/24/26 (six days). Review of Resident #44's medication administration record (MAR) for March 2026 revealed the resident had been given her Miralax and Sennosides on a scheduled basis as ordered. There was no documented evidence of the resident having been given any additional medications to help promote a bowel movement on or around 03/21/26 (three days since her last bowel movement). Review of Resident #44's progress notes revealed there was no documented evidence of the facility's nurses reaching out to the physician to notify him of the resident's lack of a bowel movement greater than three days. There was also no evidence of any new orders being received to help promote the resident to have a bowel movement through use of any other laxatives to include Milk of Magnesia (MOM), suppositories, or enemas. On 03/24/26 at 11:05 A.M., an interview with the facility's Director of Nursing (DON) and Regional Nurse Consultant #300 revealed the facility did not document bowel movements anywhere else, other than under the task tab of the EMR. They acknowledged Resident #44 was not documented as having had a bowel movement for six days without evidence of any interventions to help promote her to have a bowel movement. Review of the facility's policy on Bowel Management and Treatment (not dated) revealed the purpose of the policy was to achieve control of bowel evacuation on a routine basis which may be indicated by an independent or assisted stool every two to three days. Its purpose was also to avoid constipation. For residents that have not had a bowel movement for three consecutive days, they would have the following protocol initiated: 1. The initial nurse receiving the alert and identifying the lack of BM for three days, would assess the resident's bowel sounds, administer 30 milliliters (ml) of MOM; if the resident refuses the MOM, the nurse would notify the attending physician and document such on the MAR and in the progress notes; document on the MAR and in the nurses notes when the resident had a bowel movement. 2. The medication nurse on the next shift would check the list upon beginning of her shift and would again assess for bowel sounds; if the resident did not have a bowel movement on the prior shift, after receiving the MOM, the licensed nurse would administer a suppository per physician's orders; if the resident refused the suppository, the nurse would notify the attending physician and document such on the MAR's and in the progress notes; they were to document on the MAR and in the nurses' notes when the resident had a bowel movement. 3. The medication nurse for the third consecutive shift/ next shift would check the list at the start of her shift and would assess bowel sounds; if the resident did not have a bowel movement on the prior shift, after receiving the suppository, the nurse would administer an enema per physician's order; if the resident refused the enema, the nurse would notify the attending physician and document such on the MAR and in the nurses' notes; document on the MAR and in the nurses notes when the resident had a bowel movement; if the resident did not have a bowel movement within one hour of receiving the enema, notify the attending physician for further instruction and document such in the MAR and in the nurses' notes.

Based on record review, observation, and interview, the facility failed to ensure interventions to prevent pressure injuries were in place. This affected one resident (#6) of two residents reviewed for pressure injuries. The facility census was 37. Findings include: Record review revealed Resident #6 was admitted to the facility on [DATE] with diagnoses including dementia and hypertension. Review of an order dated 09/17/25 revealed Resident #6 had a pressure reducing mattress to bed. Review of a care plan dated 09/23/25 revealed Resident #6 was at risk for impaired skin integrity/pressure ulcers related to concussion and decreased mobility. Goals included skin to be free of breakdown and open areas will be healed without complications. Interventions included but were not limited to air mattress to bed at all times, elevate heels off mattress, inspect skin during routine daily care, liquid protein daily for wound healing, lotion to skin as needed, medications as ordered, pad and protect skin as needed, peri-care after each episode of incontinence, pillows for positioning, pressure reduction cushion to chair as tolerated, pressure reduction devices as ordered, and skin assessment as ordered. Review of a minimum data set (MDS) assessment dated [DATE] revealed Resident #6's cognition was severely impaired, she had no behaviors, was dependent on staff for bed mobility, had no pressure areas, and had pressure reducing devices in place for wheelchair and bed. Review of a Braden Scale for Predicting Pressure Sore Risk assessment was completed on 01/14/26 and revealed resident scored a nine indicating very high risk. Review of a weight from 03/01/26 at 10:31 A.M. revealed Resident #6 weighed 101.1 pounds. Review of an order dated 03/04/26 revealed Resident #6 would have wound to coccyx cleansed with soap and water, triad paste applied and leave open to air. Review of a skin check assessment dated [DATE] revealed Resident #6 had pressure area/reddened area to coccyx. Observation on 03/23/26 at 9:45 A.M. revealed Resident #6's alternating air mattress was set to the weight of 270 pounds. Observation and Interview on 03/23/26 at 3:42 P.M. with Registered Nurse (RN) #145 confirmed Resident #6's alternating air mattress was set to 270 pounds. Review of an undated policy titled Pressure Ulcer Prevention Intervention revealed the resident's skin will be assessed and monitored on a routine basis as is outline in the skin assessment protocols. Preventative measure will be implemented in accordance with the residents' assessed risk level and for developed of skin integrity impairment and risk factors that may enhance the residents' ability to develop skin integrity impairment.

Based on interview and record review the facility failed to provide indwelling urinary catheter care. This affected one resident (#20) of six residents reviewed with indwelling urinary catheters. The census was 37.Findings include:Medical record review revealed Resident #20 was admitted to the facility on [DATE] with diagnoses including cerebral infarction, dysphagia, chronic kidney disease stage 3, anemia, and supraventricular tachycardia.Review of Resident #20's admission minimum data set (MDS) assessment completed on 03/12/26 revealed the resident had an indwelling urinary catheter.Review of Resident #20's care plan dated 03/10/26 revealed the resident is at risk for infection or worsening infection due to indwelling medical devices, urinary catheter, and J-tube for nutrition.Review of Resident #20's care plan revealed completed on 03/10/26 revealed the resident has an alteration in elimination related to indwelling urinary catheter. Interventions include Foley catheter care every shift and as needed (PRN).Review of Resident #20's record revealed no evidence of indwelling urinary catheter care being completed for the resident.Interview on 03/26/26 at 12:44 PM with the facility Director of Nursing (DON) confirmed there was no documentation of indwelling catheter care being completed for Resident #20. Review of the undated facility policy titled Foley Catheter Care revealed the nursing staff will provide indwelling urinary catheter care in the morning, before the hour of sleep, and as needed per physician order.

Based on record review and interview, the facility failed to ensure residents received dental services. This affected one resident (#14) of three residents reviewed for dental services. The facility census was 37. Findings include:Record review revealed Resident #14 was admitted to the facility on [DATE] with diagnoses including dementia and anemia. Review of an order dated 08/27/24 revealed Resident #14 may see audiology, vision, dental, and podiatry. Review of a care plan revised on 03/26/25 revealed Resident #14 was at risk for oral/dental health problems related to natural teeth. The goal was to remain free from oral/dental complications through the next review date. Interventions included coordinate arrangements for dental care and transportation as needed/ordered (07/24/24); require oral inspections with oral care and report changes to a nurse (07/24/24); monitor/document/report to physician as needed signs and symptoms or oral problems needing attention: pain, abscess, debris in mouth, lips cracked or bleeding, teeth missing, loose, or broken, eroded, decayed teeth, tongue (black coated, inflamed, white, smooth), ulcers, lesions (07/24/24); and provide mouth care (07/24/24). Review of a minimum data set (MDS) assessment dated [DATE] revealed Resident #14's cognition was severely impaired, she refused care four to six days, required set-up help for oral hygiene, and had no obvious or likely cavity or broken natural teeth. Review of a quarterly nursing assessment dated [DATE] revealed Resident #14 had no dental concerns. Review of an oral assessment dated [DATE] revealed Resident #14 had decayed or broken teeth. Interview on 03/23/26 at 11:03 A.M. with Resident #14's representative revealed the resident had admitted to the facility with a chipped tooth but she was not sure if the facility had arranged dental services for her. Interview on 03/24/26 at 2:41 P.M. with the Administrator revealed Resident #14 had not seen a dentist since 10/2024, the facility changed dental providers, and she was not re-enrolled with the new provider. Interview on 03/24/26 at 4:38 P.M. with the Director of Nursing (DON) revealed she completed an oral assessment and Resident #14 had three broken teeth and one chipped tooth. The DON confirmed an MDS was completed in 01/23/26 but no corresponding oral assessment was completed. Review of a note dated 03/24/26 at 4:52 P.M. by Social Worker (SW) #137 revealed she spoke with Resident #14's representative via phone and received consent for resident to be seen by the dentist and audiologist. Review of a nursing note dated 03/24/26 at 4:52 P.M. by the Director of Nursing (DON) revealed a dental evaluation was completed and referral to dentist was initiated. All were aware. Review of an undated policy titled Oral Health Care and Assessment revealed an oral assessment should be completed upon admission, quarterly, and significant change. The licensed nurse will report any unusual findings discovered on the oral/dental assessment to the attending physician, responsible party, and registered dietician. New interventions should be implemented as needed. The social worker should assist in appointments for on-going dental needs with the consulting dentist routinely and in the event of an emergency.

Based on observation, staff interview, and policy review, the facility failed to ensure a resident's indwelling urinary catheter's collection bag was maintained off the floor reducing the risk of infection. This affected one resident (#44) of two residents reviewed for indwelling urinary catheters. Findings include:Review of Resident #44's medical record revealed she was admitted to the facility on [DATE]. Her diagnoses included a malignant neoplasm of an unspecified part of an unspecified bronchus or lung, malignant neoplasm of the vulva, neuromuscular dysfunction of the bladder, retention of urine, and difficulty walking. Review of Resident #44's physician's orders revealed the resident had an order to maintain an indwelling urinary catheter related to the diagnosis of retention of urine. The order had been in place since the resident was admitted to the facility on [DATE]. There was also an order to change her catheter bag every week on Tuesdays. Review of Resident #44's active care plans revealed the resident had a care plan in place for an alteration in elimination related to the use of an indwelling urinary catheter. The care plan originated on 03/18/26 and the goal was for the resident to be free from complications related to appliance use through the review date. The interventions included the need to maintain the indwelling urinary catheter bag to gravity drain. They were to keep the catheter bag below the level of the resident's bladder and to secure the catheter tubing to prevent accidental dislodgement. There were no interventions specific to maintaining the indwelling urinary catheter's collection bag off of the the floor in an effort to prevent infections. On 03/23/26 at 10:31 A.M. an observation of Resident #44 noted her to be lying in bed. Her indwelling urinary catheter's collection bag was lying directly on the floor, under the bed. It had a privacy cover on the front side of the collection bag but the back side of the collection bag was uncovered and resting on the floor. Some of the catheter's tubing leading to the collection bag was also on the floor. Findings were verified by Registered Nurse (RN) #145. On 03/23/26 at 10:32 A.M., an interview with RN #145 confirmed indwelling urinary catheter's collection bags should be maintained below the level of the resident's bladder and secured off the floor. She verbalized the need to keep it off the floor to prevent infections. She secured Resident #44's indwelling urinary catheter collection bag so it was up and off the floor by securing it to the bed frame using the clip that was attached on the top of the collection bag. On 03/24/26 at 9:25 A.M., a follow up observation of Resident #44 noted her to be up in a wheelchair in the therapy room. Her indwelling urinary catheter's collection bag was again noted to be in direct contact with the floor. The urinary catheter's tubing to the collection bag was also on the floor, underneath the wheelchair. They had the collection bag to the urinary catheter secured to the frame of the wheelchair below the seat, but it still allowed the collection bag to come into contact with the floor. Findings were verified by the facility's Director of Nursing (DON). On 03/24/26 at 9:27 A.M., an interview with the DON revealed indwelling urinary catheter bags should be maintained below the level of the resident's bladder and the tubing and collection bag should be kept off the floor. When asked what the importance was with maintaining the collection bag off the floor, she reported to prevent infection. She indicated she would secure the collection bag off the floor by putting it in a cover bag. Review of the facility's policy on Foley Catheter Care (not dated) revealed the purpose of the policy was for the facility to promote urinary health and management to the resident with an indwelling urinary catheter to provide the resident with dignity and to prevent the potential for urinary tract infection. The procedure indicated the staff were directed to position the indwelling urinary catheter bag below the level of the bladder, while keeping the bag and the tubing off the floor at all times.

Based on record review, observation, and interview the facility failed to ensure all mechanical, electrical, and patient equipment was in safe operating condition. This affected one resident (#37) of seven residents who are dependent on mechanical lifts for transfer. The census was 37.Findings include:Medical record review revealed Resident #37 was admitted to the facility on [DATE] with diagnoses including multiple sclerosis, chronic obstructive pulmonary disease, and muscle weakness.Review of Resident #37's minimum data set (MDS) assessment completed on12/02/25 revealed a Brief Interview for Mental Status (BIMS) score of 15, indicating the resident was cognitively intact. Resident #37's minimum data set revealed the resident was dependent of staff for toileting, personal hygiene, and bed mobility and transfers. Observation on 03/26/26 at 8:51 A.M. revealed Resident #37 being transferred from bed to chair with a mechanical lift with Certified nurses aide (CNA) #128, and CNA#164. Upon lifting the resident from the bed, the mechanical lift stopped working, leaving Resident #37 hovering above the bed inside the mechanical lift. CNA #164 left the room to get a replacement battery.Interview on 03/26/26 at 8:55 A.M. with Resident #37 confirmed the resident is dependent on mechanical lift for transfers. Resident #37 stated almost always the lift stops working, and someone has to leave the room to get a new battery, at least half of the time. Resident #37 stated it is scary when it stops when they are in the air, you aren't sure if its going to work, what's going to happen, if its going to work [the mechanical lift]. Resident #37 stated yesterday, 03/25/26 the staff members had to change the batteries out four times on the mechanical lift before it would work.Interview on 03/26/26 at 9:03 A.M. with CNA #128 confirmed there was an issue with the mechanical lifts, they think just with the batteries, but they are unsure. CNA #128 stated during resident transfers the mechanical lifts with stop, leaving the resident in the air at times, and a staff member has to leave the room to get another battery, leaving one staff member in the room with the resident while they are in the air in the mechanical lift. CNA #128 stated they are worried a resident may get stuck or get scared.Interview on 03/26/26 at 9:10 A.M. with CNA #164 confirmed there has been a problem with the reliability of the mechanical lifts. The lifts will stop working in the middle of a resident transfer, you have to switch the batteries out, sometimes multiple times, even if they [the batteries] say they have full charge. It worries you if something is going to happen during a transfer such as a resident getting injured or you are unable to transfer them to where they need/want to go [bed, chair].

THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on closed record review, review of the facility's timeline and related investigation, review of an emergency medical services (EMS) run report, staff interview, review of employee files, and policy review, the facility failed to provide basic life support, including CPR, to Resident #44 as per the resident's advance directives, when the resident was found unresponsive and without a pulse/ heartbeat. This resulted in Immediate Jeopardy and serious life-threatening harm, negative health outcomes, and subsequent death on [DATE] at 10:30 P.M. when Resident #44 did not receive CPR, due to the facility staff inaccurately identifying the resident's code status as being a Do Not Resuscitate Comfort Care Arrest (DNRCC-A) from a report sheet, instead of a full code that was identified in her medical record and what she elected, as part of her advanced directives upon admission to the facility. CPR was not initiated, and Emergency Medical Services (EMS) were not called until approximately an hour and fifteen minutes after the resident was found unresponsive and without a pulse. Resident #44 was subsequently transported to the hospital and was pronounced deceased upon her arrival. This affected one resident (#44) of three residents reviewed for death in the facility. The facility census was 43 residents. On [DATE] at 8:57 A.M., the Administrator, Director of Nursing (DON), Regional Director of Operations (RDO) #225, and Director of Quality Assurance #250 were notified Immediate Jeopardy began on [DATE] at approximately 10:30 P.M. when Resident #44 was found in her bed unresponsive and without an obtainable pulse. Nursing staff on duty did not correctly identify the resident's code status as they used information documented on an internal staff report sheet that inaccurately identified the resident as a DNRCC-A, when the resident elected to be a full code upon her admission. The resident's actual code status as a full code was not determined until later that night, when a facility nurse was reviewing the resident's electronic medical record for next of kin information and funeral home preference. The facility nurse then contacted the DON who directed staff to initiate CPR and to call 911. CPR was initiated one hour and 15 minutes after the resident was initially found unresponsive and without any obtainable pulses. The resident was transported to the hospital where she was pronounced deceased upon her arrival. The Immediate Jeopardy was removed and corrected on [DATE] when the facility implemented the following corrective actions: On [DATE] at 11:45 P.M., Licensed Practical Nurse (LPN) #150 was reviewing Resident #44's electronic medical record to obtain next of kin information and funeral home preference when she discovered Resident #44's code status was a full code. The DON was notified, and a directive was given to initiate CPR and to call 911. CPR was initiated and EMS were called. On [DATE] at 12:11 A.M , Resident #44 was transported out of facility via EMS. On [DATE] at 2:00 A.M., one Registered Nurse (RN), two LPNs, two State tested Nursing Assistants (STNAs) on site were re-educated by the DON on timely delivery of services and care, change of condition, and notification, and where to find code status orders (in Point Click Care (PCC)). RN #100 (the staff member identified to be responsible for the error in not initiating CPR timely) was suspended pending investigation. On [DATE] 9:01 A.M., All staff re-education was initiated related to change in condition, timely delivery of care and services, documentation, where to find code status orders (in PCC), and notification by the DON, ADON, and Regional Quality Assurance Registered Nurse via in person or telephone. Staff trained included five RNs, nine LPNs, 19 STNAs, three housekeeping staff, three dietary staff, and one activity personnel. On [DATE] at 10:00 A.M., the Social Service Designee attempted to contact Resident #44's family without success. A voicemail was left. The Social Services Designee and preceptor began an audit of all 43 resident's advance directives' orders and advance directives on file in chart. Each was verified and cross-referenced for accuracy. Any identified findings were corrected upon discovery. On [DATE] at 10:10 A.M., the Human Resource Director verified CPR certification of RN #100 and LPN #150 and began audits of all licensed nurses (five RNs and nine LPNs) CPR certifications. Any identified findings were addressed immediately. On [DATE] at 10:30 A.M., All current report sheets were removed from the facility and replaced with new report sheets that did not include the resident's code status by Regional Director of Quality Assurance RN. On [DATE] at 11:37 A.M., the facility Medical Director was notified by the DON of the incident involving Resident #44 and the delay in CPR initiation and current process of correction. On [DATE] at 12:52 P.M., All staff on shift interviews were completed with RN #100, LPN #150, STNA #175, and STNA #200, who were all of the staff on duty on [DATE] when Resident #44 was found unresponsive and without an obtainable pulse. Re-education was provided related to change in condition, timely delivery of care and services, documentation, where to find code status orders (in PCC), and notification by the Regional Director of Quality Assurance RN. On [DATE] at 4:00 P.M., All licensed nurses not CPR certified (two RNs and three LPNs) were removed from direct patient care by the Administrator and not utilized in the role as a licensed nurse until their CPR certification was current. On [DATE] at 5:15 P.M., All staff re-education (which included five RNs, nine LPNs, 19 STNAs, three housekeeping staff, three dietary staff, and one activity personnel) was completed by the DON, ADON, and Regional QA nurse related to change in condition, timely delivery of care and services, documentation, where to find code status orders (in PCC), and notification. On [DATE] at 6:56 P.M., the advance directives/code status for all 43 facility residents was verified and cross referenced, orders in PCC verified, and audit completed by Social Services Designee. On [DATE] at 9:00 A.M., a crash cart (cart with emergency supplies/equipment) audit was completed by the DON to ensure all required supplies were present on the cart and the cart was replenished. On [DATE] 11:00 A.M., all licensed nurses (five RNs and nine LPNs) CPR certifications were current and valid. An Ad hoc Quality Assurance (QA) meeting was held. The facility implemented a plan for all licensed nursing staff CPR certifications to be verified upon hire, annually, and evaluated during annual performance evaluations. Interviews with RN #300 on [DATE] at 8:08 A.M., RN #300 on [DATE] at 8:12 A.M., and STNA #370 on [DATE] at 12:30 P.M., confirmed they received re-education following the incident involving Resident #44 on [DATE]. Re-education was provided by [DATE] and included what to do when finding a resident unresponsive and without an obtainable pulse, timely CPR, where to find code status orders (in PCC), and physician/ family notification. Findings include: Review of Resident #44's closed record revealed the resident was admitted to the facility on [DATE] with the diagnoses of sepsis, urinary tract infection, pressure ulcer of the sacrum, chronic obstructive pulmonary disease (COPD), acute congestive heart failure (CHF), adult-onset diabetes mellitus, atrial fibrillation with flutter, hypertension, history of pulmonary embolism, and malignant neoplasm of the endometrium. Review of Resident #44's physician's orders revealed the resident was a full code (advance directives). The order originated on [DATE] (date of admission). Record review revealed a plan of care, initiated on [DATE] indicating the resident's advance directives included she was a full code per the resident's wishes. The goals were for the resident to be kept safe and comfortable, receive artificial resuscitation, and for her to remain a full code. Interventions indicated advanced directives would be placed on the chart, call 911 for emergency help if needed, code status to be reviewed at least quarterly/ annually/ and as needed (prn) with resident/ family/ responsible party, staff would initiate CPR until EMS arrived, staff would notify physician of resident wishes and carry out orders, and staff would update family/ responsible party of resident wishes. Review of Resident #44's admission Minimum Data Set (MDS) assessment dated [DATE] revealed the resident did not have any communication issues and was able to make herself understood and was able to understand others. The assessment revealed the resident was cognitively intact and was not known to display any behaviors or reject care during the seven days of the assessment period. Review of Resident #44's nursing progress note dated [DATE] at 10:25 A.M. and authored by the DON revealed the resident was swabbed for COVID-19, as part of the facility's outbreak testing, and was found to be positive. The physician and the resident's family were notified. The resident was placed in droplet isolation precautions. Review of the census tab in Resident #44's electronic medical record (EMR) revealed (on [DATE]) after testing positive for COVID-19, the resident was moved from her current room to a different room. No additional room changes occurred after this date. A nursing progress note dated [DATE] at approximately 10:35 P.M. and authored by RN #100 revealed she was called to Resident #44's room by STNA #175. LPN #150 was already in the resident's room. Resident #44 was found unresponsive with no pulse able to be palpated at that time. A physical assessment was completed with no heartbeat able to be auscultated. No vital signs were noted to be present. Findings were verified by both nurses (RN #100 and LPN #150). The note indicated the resident was thought to be a DNRCC-A, and no further action was taken at that time. Review of a nursing progress note dated [DATE] at 12:00 A.M. and authored by RN #100 revealed at 11:50 P.M. Resident #44's code status was verified, CPR was initiated, and Emergency Medical Services (EMS) were called (approximately an hour and 15 minutes after the resident was found to be unresponsive and absent for any obtainable pulses or vital signs). The resident left the facility at approximately 12:11 A.M. via EMS enroute to the local hospital. Review of the EMS run report dated [DATE] with incident #5024007014 revealed the ambulance service responded to the facility for a cardiac arrest. The call was received at 11:45 P.M., they were enroute to the facility at 11:47 P.M., on site at 11:49 P.M., and providing services on the resident (Resident #44) at 11:51 P.M. The duration of the cardiac arrest was indicated to be 10 minutes. Resident #44 was found by EMS unresponsive upon their arrival. She was transported to the local emergency room (ER) arriving there at 12:23 A.M. Advanced life support was provided enroute to the hospital. The emergency departments reported complaint on the EMS run sheet was cardiac arrest/ death. The resident's condition at the destination (ER) was indicated to be unchanged. Review of the facility's timeline of Resident #44's unresponsiveness with no obtainable pulse and delayed CPR revealed the following: On [DATE] at 10:35 P.M., Resident #44 was found by an STNA, STNA #175 unresponsive. Two nurses (RN #100 and LPN #150) verified the absence of vital signs, respirations, and pulse on the resident. The resident's code status was verified at time via report sheet, and she was thought to be a DNRCC-A. Time of resident's death was called and verified by the two nurses. On [DATE] at 11:40 P.M., LPN #150, who was assisting RN #100 with contacting family/ funeral home etc., pulled Resident #44's face sheet (profile) from the facility's computer software program (point click care) looking for additional family contacts and funeral home election when she noticed the resident was a full code. She contacted the facility's DON, who instructed them (staff) to start CPR immediately and call 911. On [DATE] at 11:50 P.M., LPN #150 instructed STNA #200 to call 911 and she alerted nurse RN #100, and they initiated CPR. Both nurses provided CPR without cessation. On [DATE] at 12:11 A.M., EMS arrived at the facility and care of Resident #44 was transferred (to EMS). CPR remained in progress by EMS and the resident was transported to the emergency room (ER) by EMS. On [DATE] at 1:00 A.M., the hospital contacted the facility's nurse and informed them Resident #44 had expired. On [DATE] at 11:37 A.M., the facility's DON contacted the medical director and informed him of the occurrence and Resident #44's expiration. Review of the facility's related investigation into Resident #44's death in the facility revealed the following statements and staff interviews were obtained: A Personal Witness Statement from STNA #175 dated [DATE] for an incident date of [DATE] and time of 10:30 P.M. revealed she was standing outside (room number provided) putting on personal protective equipment (PPE) and knocked on the door and opened it. She saw Resident #44 lying in bed pale, eyes opened and fixed. She yelled for a nurse. LPN #150 came, and they pulled the resident up in bed. The nurse listened for heart sounds/ pulse. STNA #175 ran to get the resident's nurse (RN #100), who was down the hallway. LPN #150 asked what the resident's code status was. STNA #175 looked on the report sheet that she had, and it identified the resident as being a DNRCC-A. RN #100 repeated the resident was a DNRCC-A. They pulled the curtain and provided privacy. STNA #175 then indicated in her statement she left the room to answer other multiple (resident) call lights. A written interview with STNA #175 conducted by the facility's Administrator revealed the STNA was interviewed on [DATE] at 11:05 A.M. She was asked when the last time was, she had seen Resident #44 and was told by the STNA that she could not recall exactly. She had seen the resident once prior probably around 8:00 P.M. The resident reported to be okay at that time and responded appropriately. She then asked the STNA when she found the resident unresponsive and what did she do. The STNA reported she went into her room to obtain vital signs around 10:30 P.M. and the resident did not look okay. She rubbed on the resident's chest and was calling her name. The resident did not respond, so she immediately yelled for a nurse. LPN #150 came first. LPN #150 yelled for RN #100 and RN #100 came running. RN #100 checked her as well as LPN #150. RN #100 then left the room to look for the resident's code status. STNA #175 had a report sheet and showed RN #100 her report sheet, which included the resident's code status. At that point, RN #100 said the resident was a DNRCC-A and nothing further happened. The STNA was then asked what happened later. STNA #175 told the Administrator LPN #150 was at the desk and realized the resident was a full code. LPN #150 then yelled for RN #100. The STNA was asked by the Administrator if she assisted in CPR and said no, she stayed outside the room and waited for direction. A Personal Witness Statement from RN #100 dated [DATE] for an incident date of [DATE] at 10:30 P.M. revealed she arrived at the room at 10:30 P.M., after STNA #175 was yelling for help. LPN #150 was also present. A physical assessment was completed on Resident #44 and no pulse was able to be palpated. RN #100 indicated she checked the report sheet, and a DNRCC-A was reported. CPR was not initiated at that time, as the resident was thought to be a DNRCC-A. At 11:50 P.M., she spoke to LPN #150, who stated the resident's code status was confirmed as being a full code. CPR was initiated at that time and the squad was called. On [DATE] at 12:00 A.M., the squad arrived and took over the code. The resident was transported out of the facility at 12:10 A.M. to the local hospital. The hospital informed the facility staff at 1:00 A.M. that the resident was deceased . A written interview with RN #100 that was conducted by the facility's Administrator on [DATE] at 10:41 A.M. revealed the nurse last saw Resident #44 around 9:20 P.M. for medication administration, assessment, and personal care being performed. At approximately 10:35 P.M., STNA #175 reported the resident was found unresponsive. LPN #150 responded first and then they yelled for her (RN #100) to respond. She stated she had rushed to the room and seen the resident was unresponsive. She went to verify the code status and looked on her report sheet and the resident was listed as being a DNRCC-A. She went back to the bedside and alerted the other nurse. She did a head-to-toe assessment and verified the absence of vital signs with the other nurse as the second verifier. She went back to complete her medication pass. Later, LPN #150 offered to assist with family notification and contacting the funeral home. LPN #150 discovered that the resident was a full code in PCC. At that time, they both assisted in starting CPR. That was at 11:50 P.M. LPN #150 then instructed STNA #200 to call 911. CPR continued until the squad arrived and took over. RN #100 was asked if she had verified the resident's code status in any other way, other than by the report sheet. She denied that she had done so. She indicated the other nurse (LPN #150) tried to notify the resident's family but got no answer. She also was asked if she had notified the physician and denied that she had done so. The nurse indicated in her interview with the Administrator that was the first time she took care of the resident. The resident was alert and oriented to person, place, and time when she was assessed earlier in the night. The resident was known to be COVID-19 positive, and her assessment revealed minimal signs and symptoms of COVID-19 and notable wheezes (lung sounds) bilaterally. The resident reported she was at her normal presentation. She did have a small cough. The nurse was asked how the resident appeared when she was first found to be unresponsive. She reported the resident was in bed, she was warm by skin, pale and cyanotic. She was mottled on her bilateral lower extremities (BLE) from the knees down. A Personal Witness Statement from LPN #150 dated [DATE] for an incident date of [DATE] at 10:30 P.M. revealed she was at the end of the East Hall, when STNA #175 yelled for a nurse. She ran to (room number provided) and upon entering the room Resident #44 was pale, eyes open, and fixed. The nurse and the aide pulled the resident up in bed and the resident was unresponsive. The aide them left the room to get the resident's nurse. While remaining in the room, the nurse heard that the resident was a DNRCC. She listened for an apical pulse and checked her brachial area for a pulse. No pulses were noted. She then had RN #100 listen for an absence of an apical pulse to call the time of death. At that time, she went back to her hall to finish her medication pass. Later, she went back to ask RN #100 if there was anything she could do to help her. She got the resident's chart and there were no profile sheets or code status sheet in the hard chart. She then had to go onto the computer to find the next of kin information and the name of the funeral home. While going through her paperwork, she noticed on the back of the profile sheet that it said the resident was a full code. She spoke to the DON, and she then initiated CPR and called 911. A written interview obtained from LPN #150 on [DATE] at 12:52 P.M. by the facility's Administrator revealed she was alerted to Resident #44's room by STNA #175 as she was yelling for a nurse, so she responded. The resident was found to be pale, eyes open and fixated, slumped forward in bed and her hand on her bed rail. The resident was noted to be mottled from her knees down and her mouth was open. She had no color in her face or lips. Her assessment revealed no respirations, no breath sounds, no pulses, no apical/ heartbeat, and her body was limp. RN #100 was the one who verified the resident's code status, and it was reported as being a DNRCC-A. She was asked what happened next and the nurse replied nothing. The resident appeared deceased without any vital signs and time of death was called. She went back to her unit and completed her medication pass. She was then asked how and who discovered the resident was a full code. She replied, after her medication pass, she went to check on RN #100 to see if there was anything she could help her with. The nurse stated she was in PCC trying to find an alternate contact because she could not reach the family listed and that was when she noticed her profile sheet said she was a full code. She called the DON to alert her of what happened and was instructed to start CPR and call 911. She yelled for RN #100 to assist and instructed STNA #200 to call 911. She immediately started compressions, and CPR was continued until the squad arrived and took over the code. She was asked what time that took place, and she indicated it was about one hour to one hour and a half after initially finding her. She denied she had verified the resident's code status prior to that, as RN #100 did. She also denied she had notified the resident's physician. A written interview conducted with STNA #200 on [DATE] at 12:12 P.M. by the facility's Administrator revealed she had no involvement and had not seen Resident #44 prior to the incident when she was found unresponsive. She was told by LPN #150 to yell for the other nurse, which she did. RN #100 came to the resident's room and came back out and was rushing around. RN #100 then stated the resident was a DNRCC-A and everything stopped. CPR was not started until around 11:45 P.M. She was instructed to call 911 and assisted with transferring the resident over to the cot. She reported the resident was very pale and limp when she assisted with her transfer. Review of the Arcadia Valley Report sheet included in the facility's investigation file revealed the sheet included the residents' names, room number, and code status. There were two report sheets in the investigative file. One report sheet was not dated but was noted to include Resident #29. The code status on the undated report sheet indicated Resident #29's code status was DNRCC-A. The second report sheet provided included a date of [DATE] and reflected Resident #29 had been moved to (room number provided). A code status (full code) for a prior resident (Resident #44) that resided in this room, before Resident #29 had been moved in, was marked out with a line and DNR was handwritten next to it. Resident #44's name had been added to the report sheet for (room number provided). The prior resident's (Resident #29) name was covered with white-out and Resident #44's name was handwritten over top of the white-out. The code status of DNRCC-A that was printed in was not marked out or covered with white-out, when Resident #29 had been moved out of the room. The row for this room and the column made for code status still reflected the resident in that room's code status was a DNRCC-A (which was identified to be inaccurate) as Resident #44's elected code status of a full code was not added as it should have been, when she was moved to that room. On [DATE] at 11:25 A.M., an interview with the DON and Director of Quality Assurance #250 revealed Resident #44 was moved to a different room (room number provided) after she tested positive for COVID-19 and the facility had to make some room changes. They verified staff had used white out on the report sheets to cover the name of Resident #29, who was previously in that room, and hand wrote the name of Resident #44 over top of Resident #29 name. The code status for the previous resident (Resident #29), which was a DNRCC-A, was not changed to reflect Resident #44's code status of a full code. The administrative staff revealed this was how the mix up occurred on [DATE], when Resident #44 was found unresponsive, and CPR was not initiated timely. They stated they were not able to tell who used white out to cover the prior resident's name when adding Resident #44's name on the report sheet, and after the room change had occurred. They confirmed the prior resident's (Resident #29) code status, who was in that room, was left on the report sheet instead of the code status of Resident #44 being added at the time her name was added. Review of the employee file for RN #100 revealed the nurse was suspended on [DATE] pending a nursing investigation. Her employment at the facility was then terminated on [DATE] (day after the incident). The reason for the termination included a violation of company policy, failure to follow assigned nursing protocol and job duties as assigned. The nurse's license was in good standing, and she was certified in AHA's Advanced Cardiovascular Life Support (ACLS) program at the time of the incident. On [DATE] at 1:53 P.M., an interview with Physician #500 revealed he was made aware of the occurrence with Resident #44, after the fact. He stated he was told the resident coded and was found dead. The nurses thought the resident was a DNR and had called the DON, who informed them the resident was a full code. They initiated the code then. He was not contacted when the resident was found unresponsive and was not aware of how much time had elapsed between when the resident was found deceased , when the DON was contacted, and when CPR was initiated. He stated staff would have had to initiate CPR, when it was made known Resident #44 was a full code, even though it would have been futile to attempt CPR by that time. On [DATE] at 3:06 P.M., a telephone interview with STNA #175 confirmed she worked on [DATE] and was assigned Resident #44's hall, when the resident was found unresponsive. She recalled working that night with RN #100, LPN #150, and STNA #200. She further confirmed that she was the STNA who found the resident unresponsive in bed at 10:30 P.M. She reported the resident did not look right when she went in the room. The resident's head of the bed was elevated, and she had one leg in bed and the other hanging over the side of the bed. She thought the resident was deceased , as she had a grayish color to her. She stated she tried to do a sternal rub on the resident, but she did not respond. She then called out for help and LPN #150 was the first one that responded. She assisted the nurse with pulling the resident up in bed and then left the room to find the other nurse. The other nurse (RN #100) was down at the end of the hall and was coming out of a resident's room, when she told her to come now. As they were responding back to the room, she was running, and the nurse was a little behind her. The nurse was asking her what Resident #44's code status was. She stated she looked at her report sheet and told the nurse the resident's code status was a DNRCC-A, as that was what was listed. The two nurses were in the room and were checking the resident for a pulse. They determined the resident was deceased at that time. The STNA stated it was chaotic. The resident was then covered up and she left the room and proceeded to go get vital signs on other residents, while the nurses proceeded to pass their medications to other residents. It was later when one of the nurses realized the resident was a full code and CPR was initiated. She was not sure how much time had elapsed between the time the resident was found unresponsive and without a pulse before they realized the resident was a full code and initiated CPR. She stated it was a while. On [DATE] at 3:18 P.M., a telephone interview with LPN #150 revealed she was one of the nurses who worked on [DATE] for the evening shift when Resident #44 was found unresponsive. She stated she knew the resident was deceased upon entering her room. She checked her for heart sounds, and they were absent. STNA #175 went to get the other nurse (RN #100). She asked what the resident's code status was and was told it was a DNRCC-A by the RN #100 and STNA #175. She told the nurse she needed to check the resident, as two nurses needed to check for a pulse when determining someone had expired. They pronounced the resident as having expired at 10:36 P.M. She reported she continued with her medication pass leaving the aide and the other nurse in the room. She stated they cleaned the resident and covered her in bed and pulled the curtain for privacy. She suspected the other nurse went on to pass her medications as well. When she finished her medication pass, she offered help to RN #100. RN #100 told her she was getting ready to reach out to Resident #44's next of kin. She assisted RN #100 in doing so. She could not find a profile sheet in the hard chart, so she obtained one from the computer. As she flipped it over to see what funeral home the resident preferred, she saw where the resident was supposed to be a full code. She called the DON and was instructed to initiate CPR and call 911. She approximated it was about an hour to an hour and a half between the time they initially pronounced the resident dead until they initiated CPR on her. She told the other nurse the resident was a full code, and they needed to initiate CPR. She started in with chest compressions while the other nurse went to get the crash cart. She was asked how a nurse would identify a resident's code status in the event the resident was found unresponsive and without a pulse or respirations. She indicated the nurse should look in the resident's electronic medical record. The LPN indicated there was COVID-19 in the facility and they had been moving resident rooms around. The other nurse and the aide looked at the report sheet when trying to determine what the resident's code status was and it erroneously said DNRCC-A. When the residents involved in the room change were moved, not all of their information on the report sheet was changed with the moves. She suspected that was how the report sheet had the incorrect code status for Resident #44. Review of the facility undated policy on Advanced Directives revealed the facility would inform the resident about initiating an advanced directive and the facility would maintain written standards and practice guidelines regarding advanced directives to assure the resident's wishes were honored. The facility would determine the existence of advanced directives upon admission. The facility staff would document in the clinical record whether the resident had executed an advanced directive. The facility staff would provide education for staff on the healthcare facilities standards and practice guidelines on advanced directives at least annually, and they will maintain documentation of such. The physician would write an appropriate order for the resident relating to their advanced directive. All pertinent information related to advanced directives was to be documented in the resident clinical record. Review of the facility undated Emergency Care/ Code Management policy revealed the purpose of the policy was for the licensed staff of Continuing Healthcare Solutions to be prepared for resident specific emergency situations as they occur to promote the most optimal resident outcomes. Procedures included the licensed staff member would determine if the resident was unconscious. If the resident was determined not to have a palpable pulse or respirations, the licensed nurse would call for assistance, verify the resident's advanced directives/ code status in the individual resident clinical record, and if the resident was a full code, the licensed nurse would initiate CPR. The physician and the responsible party would be notified of the resident's change in condition. An order would be obtained from the physician to [NAME] [TRUNCATED]

Based on observation and interview, the facility failed to store and prepare food in a sanitary manner. This had the potential to affect 42 of 42 residents at the facility. Findings included: Observation during an initial tour of the kitchen with Dietary Manager (DM) #142 on 05/13/24 at 8:54 A.M. revealed two bags of salad with a best by date of 05/12/24 in the refrigerator. DM #142 confirmed findings. Continuous observations of the lunch tray line were made on 05/15/24 from 12:14 P.M. to 12:44 P.M. revealed: 1. Dietary Aide (DA) #109 used the back of her right wrist to rub her nose. DA #109 did not change her gloves or wash her hands. 2. Seven trays were sent out to be served on the [NAME] hallway with bowls of grapes left open to air. 3. Dietary Cook (DC) #123 sorted meal tickets to be placed on trays. While sorting, DC #123 licked her fingers to help separate papers. The tickets then went onto resident trays. 4. DA #109 took her right glove off, wiped her right hand on her pants, then applied a new glove without performing hand hygiene. 5. DA #109 used the back of her right wrist to wipe her forehead and did not change gloves or perform hand hygiene. Interview on 05/15/24 at 2:54 P.M. with DM #142 confirmed the findings of the lunch tray line. Observation on 05/16/24 at 7:53 A.M. revealed the freezer temperature from two internal thermometers was reading 14 degrees Fahrenheit. DC #123 confirmed the temperature of the freezer. Review of a policy titled General Food Preparation and Handling (dated 2021) revealed employees should wash their hands prior to putting on gloves and after taking them off. Review of a policy titled Food Storage (dated 2021) revealed all foods should be consumed by their safe use by dates, frozen, or discarded.

Based on medical record review, review of beneficiary protection notification review form, interview, and policy review, the facility failed to ensure Resident #40 and #41 were provided appropriate liability notices when cut from Medicare Part-A services with benefit days remaining and remained in the facility. This affected two residents (#40 and #41) of two residents reviewed who remained in the facility after being cut from Medicare Part-A services. Findings included: 1. Record review revealed Resident #40 was admitted to the facility on [DATE] with diagnoses including acute bronchitis, need for assistance with personal care, muscle weakness, pain in thoracic spine, difficulty in waking, and altered mental status. Review of the beneficiary protection notification review form (undated) revealed Resident #40 was discharged from Medicare Part A with benefit days remaining on 02/18/24 and remained in the facility. The resident did not receive an Advance Beneficiary Notice (ABN) form CMS-10055 due to the facility did not issue one. 2. Record review revealed Resident #41 was admitted to the facility on [DATE] with diagnoses including multiple sclerosis, cellulitis, muscle weakness, muscle wasting and atrophy, osteoarthritis, restless leg syndrome, and spinal stenosis. Review of the beneficiary protection notification review form undated revealed Resident #41 was discharged from Medicare Part A with benefit days remaining on 04/20/24 and remained in the facility. The resident did not receive an Advance Beneficiary Notice (ABN) form CMS-10055 due to the facility did not issue one. Further view of the beneficiary protection notification review form revealed the last time a resident was discharged from Medicare Part A with benefit days remaining was resident R#41 on 04/20/24. Interview on 05/20/24 at 8:42 A.M. with the Administrator, who was also the Business Office Manager (BOM) and responsible for the liability notices, revealed there was some miscommunication between the therapy department and the facility on who was responsible for completing the ABN form. Therapy was originally completing the forms and then felt it should be the facility responsibility per the Administrator. The Administrator reported on Monday 05/13/24, after the survey team had entered, she had developed a quality assurance/performance improvement (QAPI) plan for ABN's. The Administrator provided the surveyor with a copy of the QAPI plan and the supporting documentation. The Administrator confirmed the QAPI plan only had one intervention to audit all cut notices from skilled services weekly to determine if ABN was required and if the ABN was required to note the date ABN was issued. There was no evidence that a house audit was completed, staff educated, or when the audits would be evaluated. The Administrator provided additional emails dated 04/25/24 and 05/13/24 confirming with therapy that the facility was responsible for completing the ABN's and discussing the service rate to document on the form. The QAPI plan also included one audit that was completed on 05/14/24 (the second day of the survey). The Administrator confirmed she provided the surveyor with all the QAPI information which included the plan, emails, one audit dated 05/14/24 with that included three residents' names, if an ABN was required, and date issues, and a copy of the beneficiary notice guidelines. The Administrator confirmed the QAPI plan did not include an initial audit or staff education, however she felt the emails discussing the rate and who was responsible for providing the ABN was her education. Review of the facility policy titled Skilled Nursing Facility Advanced Beneficiary Notices and Advanced Beneficiary Notice Standard of Practice (dated 04/01/18) revealed the CMS-10055/ABN was a written notice that would be provided to the resident or representative two days prior to services being terminated The purpose of the form was to inform the resident that the services may not be paid for and to let them make an inform decision if they would like to continue services that they may have to pay for out of pocked or through other insurance. The resident or representative must sign the box acknowledging that they have read and understood the notice.

Based on medical record review, policy review, and staff interview, the facility failed to provide treatment and care for one resident (Resident #45) who presented with with elevated blood sugars, decreased meal intake, and refusal of medications (including oral medication to lower blood sugar) from 06/29/20 to 07/07/20. This resulted in actual harm to Resident #45 who required hospitalization for treatment of [REDACTED]. The resident received intravenous fluids, insulin, antibiotics, and had a feeding tube surgically inserted at the hospital. In addition, the facility failed to maintain ongoing monitoring/measurements of non pressure skin issues. This affected one of six sampled residents (Resident #45). The facility census was 44. Findings include: 1. Review of the closed medical record for Resident #45 revealed an admission date of [DATE]. The resident was admitted from the hospital after back surgery. Other [DIAGNOSES REDACTED]. On admission the resident had physician's orders for insulin at bedtime and an oral medication to lower blood sugar daily ([MEDICATION NAME]). On 06/22/20 the resident had an order to check his blood sugar twice daily with no coverage of insulin. The resident was on a consistent carbohydrate diet. Review of the Minimum Data Set Assessment 2.0 (MDS) completed 06/28/20 indicated the resident had long and short term memory problems, required extensive assistance from staff with bed mobility, transfers, dressing, toileting, hygiene, and bathing, and required limited assistance from staff with eating. Review of blood sugar records revealed that between 06/22/20 and 06/30/20 only one of 17 blood sugars was above 300. The remainder were in the range of 142-279. However, review of blood sugar records for 07/01/20 to 07/07/20 revealed 11 of 13 blood sugars were above 300 mg/dL as follows: 07/01/20 376; 07/02/20 376 and 389; 07/03/20 372; 07/04/20 398 and 325; 07/05/20 360 and 349; 07/06/20 378 and 349; 07/07/20 322. There was no evidence of any type of treatment to lower the blood sugars above 300. There was no documented evidence the physician was notified. Review of a nutritional assessment completed 06/25/20 revealed Resident #45's average intake was 25-50%. However, review of meal intake records revealed between 07/03/20 and 07/06/20 the resident had 10 of 12 meals with intake of 0-25%. There was no evidence of any interventions related to the decreased intake except a nutritional supplement was started once daily on 07/03/20 based on an assessment completed by the dietician on 06/25/20 indicating weight loss on admission. Review of medication administration records for June 2020 revealed on 06/29/20 and 06/30/20 Resident #45 refused his morning oral medications, including his [MEDICATION NAME] (used to lower blood sugar). The resident did take his insulin. On 07/03/20 he refused eight of his morning oral medications. There was no evidence of any action by the facility due to the resident's refusal of medications. There was no documented evidence the physician was notified. Review of physical therapy notes on 06/30/20 at 1:11 P.M. revealed Physical Therapy Assistant (PTA) #52 documented Resident #45 was difficult to arouse. On 07/01/20 at 11:29 A.M. PTA #52 documented the resident was unable to arouse and nursing was notified. However, review of nurses progress notes on 06/30/20 and 07/01/20 revealed no action taken regarding the resident's condition. There was no documented evidence the physician was notified. Interview with PTA #52 on 07/16/20 at 1:10 P.M. revealed she had worked with Resident #45. She confirmed he was more lethargic on 06/30/20-07/02/20. She stated she had reported this to nursing. Review of nurse progress notes on 07/06/20 at 10:22 A.M. by Assistant Director of Nursing #50 revealed a message was left with the neurosurgeon and the nurse practitioner who managed the resident's [MEDICAL CONDITION] regarding his general decline in condition. However, there was no evidence staff ever spoke to either practitioner. There was also no evidence Resident #45's attending physician was notified of the decline in condition noted. Review of a nurse progress note on 07/07/20 at 7:31 A.M. revealed Licensed Practical Nurse (LPN) #51 documented that a nursing assistant reported to her that Resident #45's oxygen saturation level was 80% on room air. The head of the bed was elevated. Oxygen was started at 2 liters per nasal cannula with the oxygen saturation level coming up to 93%. The resident was less responsive than the norm. The resident's blood pressure was 99/55, respirations 22, pulse 78, temperature 96.4. Lungs sounds with wheezes and rhonci. The resident's blood sugar was noted as 322 on the morning of 07/07/20. The physician was notified and the resident was sent to the hospital for evaluation. Review of hospital records revealed on 07/07/20 the resident was treated at the emergency room at the hospital. Resident #45 had a temperature of 100.3 and a blood sugar of 442 (normal listed as 70-100). Blood tests done which can indicate dehydration were sodium level: 156 (normal 136-145); chloride 120 (normal 98-107); BUN (blood, urea, nitrogen) 92.6 (normal 8-23); and creatinine 3.77 (normal 0.67-1.17). The resident was treated with insulin to lower the blood sugar, breathing treatments, intravenous fluids to rehydrate, and antibiotics for aspiration pneumonia. Differential [DIAGNOSES REDACTED]. The resident was transferred to a different hospital on [DATE]. Review of those hospital records revealed a progress note on 07/12/20 which stated the resident had aspiration pneumonia, labs stable for acute kidney injury, and blood sugar had been lowered. A tube feeding was surgically inserted for nutrition. The resident remained hospitalized as of 07/12/20. Interview with LPN #51 on 07/16/20 at 1:25 P.M. revealed she was concerned if a resident had a blood sugar higher than 300. Interview with Assistant Director of Nursing #50 on 07/16/20 at 1:45 P.M. confirmed the nurse progress note that she had left a message with Resident #45's surgeon and nurse practitioner who manages [MEDICAL CONDITION] on 07/06/20 regarding a decline in condition. She described the decline in condition as not opening his eyes or talking anymore, decreased appetite, decreased fluid intake. She confirmed there was no evidence that anyone spoke to any physician regarding the resident's decline in condition. She stated the physician was to be notified if a resident's blood sugar was above 301. Review of the facility policy titled Blood Glucose Testing dated 12/03/13 revealed staff are to notify the physician if the blood sugar is above or below normal limits or as ordered. Interview with the Director of Nursing on 07/20/20 at 8:20 A.M. revealed the facility did not have a policy to indicate when a physician was to be notified of elevated blood sugars. She stated the policy stated to notify the physician if blood sugar above or below normal limits or as ordered. She confirmed Resident #45 did not have an order of when to notify the physician of blood sugars. She further confirmed Resident #45's blood sugars were elevated the week of 07/01/20 to 07/07/20 in comparison to the previous week. She confirmed the resident's consistent decreased intake from 07/03/20 to 07/06/20. She stated she was aware he had been refusing his medications. She confirmed there was no evidence of any action taken until 07/07/20 (sent to the hospital) regarding his decline in condition beginning around 06/30/20. Review of the facility policy titled Change in Condition Notifications dated 07/16 revealed the facility will immediately or at least within 24 hours inform the resident, consult with the resident's physician, and if known, notify the resident's legal representative when there is a significant change in the resident's physical, mental, or psychosocial status (i.e.: a deterioration in health); A need to alter treatment (discontinue or start new form of treatment). 2. Record review revealed Resident #45 had a fall on 06/26/20 at 10:19 A.M. The resident was noted with abrasions on his left and right toes. He was also noted with a skin tear on the right elbow. However, there was no evidence of any assessment, measuring, or monitoring of the areas on the toes or elbow. A treatment was not obtained for the toes until 06/29/20. The order said to cleanse second digit on right and left second toe with wound cleanser, apply antibiotic ointment, and dry dressing every day. A nurses note on 06/27/20 at 10:14 A.M. stated a dressing to the right elbow was intact. However, there was no evidence of a physician's order for a dressing to the right elbow. On 06/28/20 at 11:49 A.M. the resident fell and was noted with a red area on the right outer ankle. A physician's order on 06/28/20 stated to monitor red area to right outer ankle every shift. However, there was no evidence of any measurements or description of the area after 06/28/20. A policy on measuring/monitoring non pressure skin areas was requested but not provided. Interview with the Director of Nursing on 07/20/20 at 8:20 AM. revealed staff are to do a weekly skin grid to include measurements and description of non pressure skin areas. She confirmed weekly skin assessments were not completed for Resident #45 for areas on the toes, right ankle, and right elbow. She confirmed there was no physician's order for a dressing to the right elbow even though a dressing was documented in the nurses notes. She confirmed the treatment to the toes started on 06/29/20 when the injury occurred on 06/26/20. This deficiency substantiates Complaint Number OH 104.