Every finding on record at Ashby Care Center

Based on observation, interview and record review, the facility failed to provide an ongoing resident-centered activity program to support residents individualized activities needs for three of (Resident 1, 2 and 3 ) of three sampled residents when;Facility did not provide consistent resident-centered activities.Facility did not provide residents activities in the evening and on weekend.Facility did not address Resident 2's impaired cognition with individual activity care plan. Activities refers to any endeavor, in which a resident participates that is intended to enhance her/his sense of well-being and to promote or enhance physical, cognitive, and emotional health. These include, but are not limited to, activities that promote self-esteem, pleasure, comfort, education, creativity, success, and independence. This failure had the potential to cause residents emotional distress and decline in quality of life.During a concurrent observation and interview on 5/27/26, at 10:30 a.m., Resident 1 was seated up in wheelchair in her room watching television. Resident 1 stated facility had no activity program that was engaging. Resident 1 stated she watched television and sometimes stayed outside with a group of residents to talk in the sun. Resident 1 stated there were no group activities in the evenings and on the weekends.During a review of Resident 1's Minimum Data Set (MDS, a resident assessment instrument used to identify resident care problems to be addressed in an individualized care plan), dated 3/1/26, the MDS indicated Resident 1 was admitted to the facility on [DATE]. MDS indicated Resident 1's Basic Interview of Mental status (BIMS, a scoring system used to determine the resident's cognitive status regarding attention, orientation, and ability to register and recall information. A BIMS score of thirteen to fifteen is an indication of intact cognitive status.) score was 14 which indicated intact mental status. MDS indicated Resident 1's activity preferences indicated that listening to music was very important. MDS indicated Resident 1 had a clear speech, made self-understood and understand others. MDS indicated Resident 1's diagnoses included cerebrovascular accident (stroke).During an observation on 6/9/26, at 10:55 a.m., six residents were in the activity room watching television.During a review of Resident 2's Minimum Data Set (MDS, a resident assessment instrument used to identify resident care problems to be addressed in an individualized care plan), dated 3/28/26, the MDS indicated Resident 2 was admitted to the facility on [DATE]. MDS indicated Resident 2 had no speech and rarely or never understood. MDS indicated Resident 2's activity preferences included listening to music, spending time outdoors and participating in activities. MDS indicated Resident 2's diagnoses included Alzheimer's Dementia (memory loss).During an observation on 5/27/26, at 11:50 a.m., Resident 2 laid on her back in bed awake covered with blanket. Resident 2 was awake and non-verbal.During an interview on 5/27/26, at 12:00 p.m., with Certified Nursing Assistant (CNA 1), CNA 1 stated Resident 2 was nonverbal but understood when spoken with her. CNA 1 stated Resident 2 was always in bed and did not attend activities.During a review of facility's activity program calendar, poster on the wall in the hallway next to activity room, the activity calendar indicated that all activities in the facility ended at 3:30 PM.During a concurrent interview and record review on 5/27/26, at 12:15 p.m., with Registered Nurse/Administrator (RN/Admin), posted activity calendar was reviewed. RN/Admin stated residents could watch television in their rooms. Resident 2's MDS and care plans were reviewed. RN/Admin could not provide care plan that addressed Resident 2's activities need. RN/Admin said that Activity staff was not available.During a review of Resident 3's Minimum Data Set (MDS, a resident assessment instrument used to identify resident care problems to be addressed in an individualized care plan), dated 3/27/26, the MDS indicated Resident 3 was admitted to the facility on [DATE]. MDS indicated Resident 3's BIMS score was 15. The BIMS score indicated intact cognition. MDS indicated Resident 3's activity preferences included listening to music, reading books, group activities and attending religious services. MDS indicated Resident 3 had a clear speech, made self-understood and understood others.During a concurrent observation and interview on 6/9/26, at 10:58 a.m., Resident 3 was seated in the hallway next to the facility's entrance door. Resident 3 stated facility did not have a consistent activity program. Resident 3 stated she watched television. Resident 3 stated she would like to go outside for activities such as garage sale, gardening which facility did not provide. Resident 3 stated she watched television in her room because activities were not provided in the evenings.During a concurrent observation and interview on 6/9/26, at 11:00 a.m., Resident I was seated in the hallway by entrance door of the facility. Resident 1 stated facility had little or no activities. Resident 1 stated activities provided were not frequent enough. Resident 1 stated the activities provided were the same every day. Resident 1 stated she felt bored because the activities provided for her were not engaging. During an interview on 6/9/26, at 11:50 a.m., with CNA 2, CNA 2 stated he was assigned to provide residents some exercises and trivia activities. CNA 2 stated he had no training to provide residents' activities. CNA 2 stated in addition he was assigned to provide care for seven residents.During an interview on 6/9/26, at 12:23 p.m., RN/Admin stated CNA2 was assigned to provide residents activities. RN/Admin stated AD was not available.

Based on observation, interview and record review, for four of four sampled residents (Residents 1, 2, 3 and 4), the facility failed to ensure that activities were designed to meet the interests and the physical, mental, and psychosocial well-being of residents. This failure had the potential to result in residents not receiving individualized, meaningful activities that support their quality of life. During a review of Resident 1's admission Record (AR) dated 10/29/24, the AR indicated Resident 1 was admitted to the facility in October 2024 with diagnoses that included major depressive disorder (serious common mood disorder characterized by persistent sadness, loss of interest that significantly impacts daily functioning).During a review of Resident 1's Minimum Data Set (MDS, an assessment tool used to direct resident care) dated 2/7/26, the MDS indicated Brief Interview for Mental Status (BIMS, a scoring system used to determine the resident's cognitive status in regard to attention, orientation, and ability to register and recall information) score of 14. A BIMS score of 14 is an indication of intact cognitive status.During review of another MDS dated [DATE] the MDS, under Section F, Interview for Activity Preferences, indicated Resident 1 values listening to music, staying informed, and doing favorite activities. The MDS also indicated it was somewhat important for Resident 1 to go outside in good weather to get fresh air and participate in religious activities or practices.During an interview on 3/4/26 at 10:49 a.m. with Resident 1, Resident 1 stated wanting to transfer to another facility due to boredom and lack of activities. Resident 1 also stated it feels as though residents are sent to this facility to die.During a review of Resident 2's AR dated 1/16/26, the AR indicated Resident 2 was admitted to the facility on [DATE] with diagnoses that included major depressive disorder, delirium, and unspecified dementia (memory loss, confusion, and impaired judgment).During a review of Resident 2's MDS dated [DATE], the MDS indicated a BIMS score of 13. A BIMS score of 13 is an indication of intact cognitive response. The MDS also indicated, for Resident 2 values listening to preferred music, staying updated on news, engaging in favorite activities, and spending time outdoors.During a concurrent interview and record review on 3/4/26 at 12 noon with Administrator (ADM), ADM stated Resident 2's chart did not indicate an activity care plan and progress notes from activity staff regarding Resident 2's activity preferences. ADM stated Resident 2 prefers independence over group activities and enjoys watching cars in the parking lot. During an interview on 3/4/26 at 12:42 p.m. with Resident 2, Resident 2 stated the activity calendar posted was not followed, and that activities were often posted and advertised but not held. Resident 2 also stated interest in performing music for other residents but noted there were no opportunities to do so.During a concurrent observation and review of activities calendar between 2 p.m. and 2:45 p.m. in activity room, although baking was scheduled for 2 pm every Wednesday, only a few residents in wheelchairs were present throughout the day, and the baking activity did not take place.During a concurrent observation and interview on 3/4/26 at 2:27 p.m. with Resident 3, Resident 3 stated they did not bake today, the activity staff had already left, and CNAs only help with coffee before dinner. Resident 3 also stated residents did not go out to the patio even when the weather was good.During a review of Resident 3's AR dated 11/1/24, the AR indicated Resident 3 was admitted to the facility in November 2015. The MDS dated [DATE] indicated a BIMS score of 14.During an interview on 3/4/26 at 2:30 p.m. with Certified Nursing Assistant (CNA) 1, CNA 1 stated the residents remain in the activity room watching TV after the activity staff leaves, until the afternoon shift CNAs arrive.During an interview on 3/5/26 at 10:26 a.m. with Resident 4, Resident 4 stated going outside for fresh air two weeks ago when a friend visited. Resident 4 also stated staff are usually too busy to assist residents in going outside except during such visits.During an interview on 3/5/26 at 10:40 a.m. with CNA/Activity Staff (CNA/AS), CNA/AS stated she works both as a CNA and activity staff, arriving at 5:30 a.m. to prepare residents for the day before helping with activities. CNA/AS stated that yesterday, 3/4/26, baking was not offered and the activity calendar needed revision to reflect residents' preferences. CNA/AS does not work Friday to Sunday, so other CNAs handle weekend activities. During an interview on 3/5/26 at 11:07 a.m. with Director of Nursing (DON), DON stated there was no activity care plan or progress notes in Resident 4's clinical record.During an interview on 3/5/26 at 11:17 with CNA 2, CNA 2 stated, during the weekends, residents sit in the activity room without activities due to the absence of activity staff, while the CNA monitors them from outside the activity room near the entrance to prevent falls.During an interview on 3/5/26 at 11:20 a.m. with CNA/AS, CNA/AS stated she did not know Resident 2 loved to play violin and piano.During a review of Resident 4's AR dated 11/1/24, the AR indicated Resident 4 was admitted to the facility on [DATE]. MDS dated [DATE] indicated Resident 4 had a BIMS score of 15 and showed preferences for music, news, group activities, favorite hobbies, outdoor time, and participation in religious services.During a review of the facility's policy and procedure (P&P) titled Activity Director Policy and Procedure, undated, the P&P indicated the facility will provide ongoing activities to support residents' interests and psychosocial well-being. The Activity Director develops and coordinates group and individual activities, completes assessments, creates care plans, supervises staff, and maintains records. Upon admission, each resident is assessed; care plans are based on these assessments. Monthly calendars are posted, and group activities can include exercise, games, music, education, and social events. One-on-one engagement is offered if needed. Staff document participation, refusals, and resident responses to activities.

Based on interview and record review, the facility failed to ensure that residents were provided the opportunity to participate in regular Resident Council meetings, as the facility did not hold scheduled or routine Resident Council meetings for a census of 27 residents.This failure had the potential to result in the inability of residents to voice their concerns or contribute to improving facility operations impacting their dignity and overall quality of life.During an interview on 3/4/26 at 2:13 p.m. with Administrator (ADM), ADM stated she was unaware of the location of resident council meeting minutes, provided a two-page list of resident names from the past two months and stated it was the attendance list for the past resident council meetings.During an interview on 3/5/26 at 10:51 a.m. with Certified Nursing Assistant/Activity Staff (CNA/AS), CNA/AS stated resident council meetings have not occurred since November 2025. CNA/AS stated the facility needs to consistently hold these monthly meetings. CNA/AS also stated there were no records of meeting minutes in the binder, and the list ADM provided on 3/4/26 only included residents who attended bingo.During a review of the facility's policy and procedure (P&P) titled Resident Council Policy and Procedure, undated, the P&P indicated the facility supports a Resident Council to encourage resident participation in decisions impacting their quality of life. Meetings are held monthly, with minutes and attendance recorded and maintained.

Based on observation, interview, and record review, the hospital failed to ensure the accuracy of controlled drug records as evidenced by: 1. The facility failed to ensure the scheduled (narcotic) medication records (Controlled Drug Record, MAR) were accurate. For three (Residents 160, 165, 167) out of three residents sampled, the Controlled Drug Record (inventory of scheduled drug) and the Medication Administration Record (MAR, record of drug administration) were not accurate. This failure resulted in the potential for residents to be exposed to avoidable medication errors. In addition, this failure resulted in the potential for scheduled drug diversion. 2. The facility failed to ensure the Consultant Pharmacist reviewed the scheduled (narcotic) medication records (Controlled Drug Record, MAR) for accuracy. For three (Residents 160, 165, 167) out of three residents sampled, the Controlled Drug Record (inventory of scheduled drug) and the Medication Administration Record (MAR, record of drug administration ) did not match. These inaccuracies were not identified by the Consultant Pharmacist. This failure resulted in the potential for residents to be exposed to avoidable medication errors. In addition, this failure resulted in the potential for controlled drug diversion. Findings: 1. During a concurrent observation, interview, and record review, on 5/19/25 at 1145, in the medication room, Licensed Vocational Nurse (LVN 3) identified Resident 167's morphine (narcotic pain reliever) 20 milligram (mg)/milliliter (ml) plastic bottle. Inspection of the bottle showed it contained 13 mls of morphine. LVN 3 inspected the bottle and stated it contained 13.75 mls of morphine. LVN 3 identified the Controlled Drug record for the morphine. Inspection of the Controlled Drug Record showed the amount in the bottle was 16 ml. Continued review of the Controlled Drug Record showed 0.25 mls were removed from the bottle four times between 5/1/25 and 5/11/25. LVN 3 identified the MAR for the morphine. Review of the May 2025 MAR did not show morphine 0.25 ml administered between 5/1/25 and 5/11/25. LVN 3 reviewed the Controlled Drug Record and the MAR and acknowledged the above information. During a concurrent observation, interview, and record review, on 5/19/25 at 1210, in the medication room, LVN 3 identified Resident 160's Hydrocodone (narcotic pain reliever)/APAP (acetaminophen pain reliever) 5/325 mg Controlled Drug Record and MAR. Inspection of the Controlled Drug Record showed Hydrocodone/APAP 5/325 removed on 4/6 for one tablet, and 4/8 for two tablets. Inspection of the MAR showed 0 tablets administered on 4/6, and one tablet administered on 4/8. LVN 3 reviewed the Controlled Drug Record and the MAR and acknowledged the above information. During a concurrent observation, interview, and record review, on 5/19/25 at 1405, in the medication room, LVN 3 identified Resident 165's Hydrocodone/APAP 5/325 Controlled Drug Record and MAR. Inspection of the MAR showed three tablets given every day from 5/1/25 through 5/18/25. Inspection of the Controlled Drug Record, from 5/1/25 through 5/18/25, did not show three tablets of medication removed every day. LVN 3 reviewed the Controlled Drug Record and the MAR and acknowledged the above information. During a concurrent interview and record review, on 5/21/25 at 1335, Director of Nursing (DON) inspected Resident 160, 165, and 167's Controlled Drug Records and the MARs identified above. DON acknowledged the Controlled Drug Records and MARs did not match. DON stated that it was her expectation the scheduled medication records were to be accurate. 2. During a concurrent observation, interview, and record review, on 5/19/25 at 1145, in the medication room, Licensed Vocational Nurse (LVN 3) identified Resident 167's morphine (narcotic pain reliever) 20 milligram (mg)/milliliter (ml) plastic bottle. Inspection of the bottle showed it contained 13 mls of morphine. LVN 3 inspected the bottle and stated it contained 13.75 mls of morphine. LVN 3 identified the Controlled Drug record for the morphine. Inspection of the Controlled Drug Record showed the amount in the bottle was 16 ml. Continued review of the Controlled Drug Record showed 0.25 mls were removed from the bottle four times between 5/1/25 and 5/11/25. LVN 3 identified the MAR for the morphine. Review of the May 2025 MAR did not show morphine 0.25 ml administered between 5/1/25 and 5/11/25. LVN 3 reviewed the Controlled Drug Record and the MAR and acknowledged the above information. During a concurrent observation, interview, and record review, on 5/19/25 at 1210, in the medication room, LVN 3 identified Resident 160's Hydrocodone (narcotic pain reliever)/APAP (acetaminophen pain reliever) 5/325 mg Controlled Drug Record and MAR. Inspection of the Controlled Drug Record showed Hydrocodone/APAP 5/325 removed on 4/6 for one tablet, and 4/8 for two tablets. Inspection of the MAR showed 0 tablets administered on 4/6, and one tablet administered on 4/8. LVN 3 reviewed the Controlled Drug Record and the MAR and acknowledged the above information. During a concurrent observation, interview, and record review, on 5/19/25 at 1405, in the medication room, LVN 3 identified Resident 165's Hydrocodone/APAP 5/325 Controlled Drug Record and MAR. Inspection of the MAR showed three tablets given every day from 5/1/25 through 5/18/25. Inspection of the Controlled Drug Record, from 5/1/25 through 5/18/25, did not show three tablets of medication removed every day. LVN 3 reviewed the Controlled Drug Record and the MAR and acknowledged the above information. On 5/20/25 at 1000, Administrator was requested to provide the Consultant Pharmacist reports (report on pharmacy services) for the past three months. During a concurrent interview and record review, on 5/21/25 at 1335, Director of Nursing (DON) inspected Resident 160, 165, and 167's Controlled Drug Records and the MARs identified above. DON acknowledged the Controlled Drug Records and MARs did not match. DON stated that it was her expectation the scheduled medication records were to be accurate. During a concurrent interview and record review, on 5/21/25 at 1400, DON identified the Executive Summary of Consultant Pharmacist's Medication Regimen Review (Consultant Pharmacist reports dated 4/18/25) provided by Administrator. Review of the document did not show issues with accuracy of the controlled medication documents. DON stated that it was her expectation that the pharmaceutical consultant identified issues with controlled medications. During an administrative record review, of the Executive Summary of Consultant Pharmacist's Medication Regime Review, reports dated 2/19/2025, 3/24/2025, and 4/18/2025, were reviewed. Review did not show issues with accuracy of the controlled medication documents. During an administrative record review, of the Pharmacy Services Policy 483.60 (undated) showed, F427, A licensed pharmacist provides consultation on all aspects of the provision of pharmacy services in the facility. The pharmaceutical services consultant establishes a system of records of receipt and disposition of all controlled drugs in sufficient detail to enable an accurate reconciliation.

Based on interview and record review, for six of six sampled residents (Residents 119, 118, 116, 112, 113 and 111), the facility failed to offer or ensure an advance directive (a written instruction for health care, recognized under State law, relating to the provision of health care when the individual is incapacitated) was on file, when the facility did not offer or help the residents/representatives to locate or complete the advance directive. This failure had the potential for Residents 119, 118, 116 112, 113 and 111's wishes regarding provision of health care to not be honored. Findings: 1. During a review of Resident 119's admission record, dated 11/1/24, indicated, Resident 119 was admitted to the facility on [DATE] with multiple diagnoses that included epilepsy (neurological conditions characterized by sudden, uncontrolled burst of electrical activity in the brain). During a review of Resident 119's clinical record titled, ADVANCE DIRECTIVE ACKNOWLEDGMENT, dated 6/27/22, indicated Resident 119 have executed an advance directive. 2. During a review of Resident 118's admission record, dated 11/1/24, indicated Resident 118 was admitted to the facility on [DATE] with multiple diagnoses that included Schizophrenia ( a severe mental illness that affects a person's ability to distinguish between what is real and what is not). 3. During a review of Resident 116's admission record, dated 4/24/25, indicated Resident 116 was admitted to the facility on [DATE] with multiple diagnoses that included cerebral infarction (stroke), atherosclerosis of aorta (buildup of mix of fat and other substances on the inner walls of the body's largest artery). During a review of Resident 116's clinical record titled, ADVANCE DIRECTIVE ACKNOWLEDGMENT, dated 4/18/25, indicated Resident 116 have executed an advance directive. 4. During a review of Resident 112's admission record, dated 11/1/24, indicated, Resident 112 was admitted to the facility on [DATE] with multiple diagnoses that included, Traumatic subdural hemorrhage with loss of consciousness (a serious condition where blood collects between the brain and its outer covering after a head injury). During a review of Resident 112's clinical record titled, ADVANCE DIRECTIVE ACKNOWLEDGMENT, dated 10/1/21, indicated Resident 112 wished to execute an Advance Directive. 5. During a review of Resident 113's admission record dated, 11/1/24, indicated Resident was admitted to the facility on [DATE] with multiple diagnoses that included Venous insufficiency (a condition where veins have trouble returning blood from the legs back to the heart). 6. During a review of Resident 111's admission record dated 11/1/24, indicated Resident 111 was admitted to the facility on [DATE] with multiple diagnoses that included adult failure to thrive (syndrome characterized by a decline in health and function in older adults, often involving weight loss, decreased appetite, and reduced activity). During a review of Resident 111's Physician Orders for Life-Sustaining Treatment (POLST, medical order that provide clear instructions to healthcare providers about the medical treatments a patient wants or does not want to receive in the event of a serious illness or medical emergency), dated 10/20/21, the POLST indicated Resident 111 had an advance directive. During a review of Resident 111's clinical record titled, ADVANCE DIRECTIVE ACKNOWLEDGMENT, dated 10/20/21, indicated Resident 111 have executed an advance directive. During a concurrent interview and record review on 5/20/25, at 12:08 p.m., with Administrator/Minimum Data Set Coordinator (ADM/MDSC), ADM/MDSC revealed, 119, 118, 116, 113 and 111 did not have advance directive in each paper chart or electronic health medical record nor were the Residents offered it. ADM/MDSC stated it was important to have advance directive on file in case of emergency situation and resident became incapacitated so we can carry out resident wish, it's their rights. During a record review of the facility's policy and procedure (P&P) titled, ASHBY CARE CENTER POLICY ON ADVANCE DIRECTIVES AND RESIDENT RIGHT TO ACCEPT OR REFUSE MEDICAL TREATMENT undated, indicated .2. The facility shall document in the individual's medical record whether or not the individual has executed an advance directive .Under procedure 3. Inquire about advance directive. During the admission process or as reasonably possible thereafter, the person who documents a resident's admission will ask the resident whether he/she has completed an advance directive. If an advance directive has been completed, the person who documents the resident's admission will ask for a copy of the advance directive so that it may be placed in the resident's medical record. If a copy of the resident's advance directive is not immediately available, the resident will be informed that it is his or her responsibility to provide a valid copy of the advance directive to the facility as soon as possible. 4. If an advance directive has not been completed, or if the resident is unfamiliar with advance directives, the person who documents the resident's admission will ask the resident whether he or she would like to receive further information on advance directives . Under Documentation .B. Whether the resident has an advance directive. A copy of the advance directive (if it is available) will be included in the medical record .

6. During a concurrent medication administration observation and interview, on 5/20/25 at 7:45 a.m., Licensed Vocational Nurse (LVN 1) identified residents to receive medication. LVN 1 administered medications to residents in the order of Resident 161, 117, 118, and 160. For each resident, LVN 1 used a portable blood pressure (BP, vital sign) machine. The resident's BP measurement included placing an inflatable cuff around the arm. In between each resident, LVN 1 returned to the medication cart (cart to store medications) to prepare medications. After using the machine on Residents 161 and 117, LVN 1 placed the BP cuff directly on the top of the medication cart. During medication administration to the four residents, LVN 1 did not clean the BP cuff or the top of the medication cart. During a concurrent medication administration observation and interview, on 5/21/25 at 8:20 a.m., Licensed Vocational Nurse (LVN 2) identified residents to receive medication. LVN 2 administered medications to the residents in the order of Resident 1 and 114. For each resident, LVN 2 used a pole mounted blood pressure machine. The BP measurement included placing an inflatable cuff around the resident's arm. In between each resident, LVN 2 returned to the medication cart to prepare medications. LVN 2 did not clean the BP cuff between residents. During a concurrent interview and record review, on 5/21/25 at 2:04 p.m., Director of Nursing (DON) was asked if resident equipment (BP cuff, top of medication cart) was to be cleaned between residents. DON stated that it was the facility's expectation that equipment was cleaned between residents. DON identified the facility policy and procedure 7.2 Preparation for Medication Administration (1/23), Procedures, 2. :The nurse or authorized staff member on duty ensures equipment and supplies relating to medication storage and use are clean and orderly. Based on observation, interview, and record review, the facility failed to follow infection control prevention practices when: 1. House Keeping (HK)1 was in the hallway and in the dining room during resident mealtime wearing gown used for laundry services. 2. HK 1 did not have in-service training on environmental cleaning. 3. HK 1 did not know what to use for disinfecting high touch surface areas in resident rooms (i.e. bed rails, bedside table, doorknobs and light switches). 4. Clean linen were stored in the dirty area of laundry room. 5. Clean linen was covered with sheet protector that was touching the floor. 6. The facility failed to ensure equipment was cleaned between residents. For six (Residents 1, 114, 117, 118, 160, 161) out of six residents sampled, equipment was not clean. During resident medication administration, equipment was not cleaned between use. These failures had the potential for cross contamination and spread of infections among residents at the facility. Findings: 1. During a concurrent observation and interview on 5/19/25 at 12:20 p.m., HK 1 entered the dining room from the hallway during resident's lunch wearing protective gown. HK 1 interacted with residents in the dining room and then proceeded to walk to the hallway and then into the lobby. When asked why he was wearing gown, HK 1 stated he was not direct care staff. HK 1 added, he was assigned to laundry to wash resident clothes. HK 1 also added, he was wearing protective gown to protect his clothing from splash when doing laundry. During a concurrent interview and record review on 5/20/25, at 11:43 a.m., with the DON/IP, the facility's policy and procedures (P&P) titled, LAUNDRY DEPARTMENT, undated was reviewed. The P&P indicated under policy, Careful precautionary procedures must be followed by laundry personnel to prevent the spread of infectious diseases to other staff members, residents and visitors. All soiled linen is considered potentially infectious. Under personnel guidelines, All employees shall wear designated uniforms. Employees in the soiled areas shall wear an outer garment over their uniforms and gloves. Protective garments shall be removed and hands washed each time the employee leaves the soiled area. DON/IP stated, the gown HK 1 was wearing was used in laundry to protect HK's clothing from splash when washing resident clothes and sheets. DON/IP also stated the gown was contaminated and HK 1 was not supposed to wear outside the laundry room especially in the resident area. DON/IP further added, HK 1 could spread infection to other residents by wearing contaminated gown in the hallway and dining room. 2. During an interview on 5/20/25 at 1:58 p.m., with HK 1, HK 1 did not recall training regarding use of disinfectant and or use of protective gown in the laundry room. HK 1 added, he only remembers training on handwashing, Personal Protective Equipment (PPE) use, and environmental cleaning. 3. During a concurrent observation and interview on 5/20/25, at 2:12 p.m., with HK 1, HK 1 demonstrated facility process for disinfecting high touch surfaces. HK 1 took one sheet from a pack of premium washcloths, then stated he wiped resident's bedside table, handrails, and call lights with the wipes. During a concurrent interview and record review on 5/20/25, at 2:21 p.m., with DON/IP, DON/IP revealed HK 1 did not have in-service training on environmental cleaning since his hire date in 2022. DON/IP acknowledged HK 1 did not know how to disinfect high touch surfaces because HK 1 used adult wipes for incontinent care. DON/IP further added, adult wipes that HK 1 used were not effective to kill microbes. 4. During a concurrent observation and interview on 5/21/25, at 9:51 a.m., with HK 1, in the dirty area of laundry room, clean linen was stored in the shelves nearby where the dirty / soiled articles were rinsed prior to washing. HK 1 stated, he wore protective gown when rinsing dirty articles in this area. 5. During a concurrent observation and interview on 5/20/25, at 9:55 a.m., with DON/IP, in the presence of HK 1, DON stated, the linen stored in dirty area of laundry room was contaminated due to exposure to splash from dirty articles. DON/IP directed HK 1 to remove the clean linens to be rewashed. DON/IP also added, the clean linens covered in sheets that were touching the floor were also contaminated and needed to be rewashed. DON/IP added, she was not aware of the HK 1's practices and said, he needed in-service training on infection control. During a review of the facility's policy and procedures (P&P) titled, LAUNDRY DEPARTMENT, undated, the P&P indicated under policy, Careful precautionary procedures must be followed by laundry personnel to prevent the spread of infectious diseases to other staff members, residents and visitors. All soiled linen is considered potentially infectious.Under Laundry procedures, .Every laundry and housekeeping staff member will be trained to follow them. New personnel and older employees will attend inservice training programs in order to become familiar with new techniques and skills .All laundry employees will be expect4ed to attend inservice programs pertaining to infection control. During a review of the facility's P&P titled, BASIC INFECTION CONTROL IN HOUSEKEEPING AND LAUNDRY, dated 7/2003, the P&P indicated, .10. Schedule and hold regular in-service meetings for the department . 11. Design linen and laundry procedures to prevent cross-contamination. During a review of the facility's P&P titled, HOUSE KEEPING DEPARTMENT, undated, the P&P indicated under housekeeping policies, .Inservice training programs will be held for new personnel as well as older employees fo the purpose of introducing them to new techniques and skills.All housekeeping employees are expected to attend inservice programs pertaining to infection control. Under cleaning agents, .Reliable disinfectant germicides must be used in areas known to be contaminated with pathogenic bacteria (such as where active infection has been treated). These detergent germicides must be EPA registered, approved for the hard water conditions and health care or hospital tested.

Based on observation, interview, and record review, the facility failed to store and label food in the storage area (for the retention of food [before and after preparation] and associated dry goods), used for 13 out of 13 sampled residents' nourishment, not following their facility policy and procedure and professional standards of practice for food service safety. This failure has the potential for Residents not getting palatable food and nourishment, the potential for foodborne illnesses/outbreak, infection and potential for hospitalization. During a brief kitchen observation on 5/19/25, at 09:21 a.m., with the Dietary [NAME] (DC), Corn Flakes Cereal not in the original box, package labeled 6/9/2022. Bran Raisin package had been opened with no opened date labeled, and Oatmeal was still in its original manufacturer package and had no opened label on it. Opened food items stored in the one door freezer were not labeled with an opened date. The DC stated the food packaging had not been thoroughly checked for used by and opened date since he got employed with facility. The DC stated he had just started working at the facility about two weeks ago. The DC was the only assigned staff in the kitchen for the day shift. During an interview on 5/19/25, at 10:48 a.m., with DC, DC stated food and food packaging must be labeled immediately after opening, because it's the facility's policy, and also once food package has been opened, everything has a shelf life, based on when the item was opened. Food items may not be kept longer than they were supposed to be. DC also stated the food item might also be a potential throw away. During an interview on 5/22/25, at 12:21 p.m., with the Director of Nursing/Infection Preventionist (DON/IP), DON/IP stated when a food package has been opened, it should be labeled and dated, and that if it's not dated, the facility does not know whether the food item has expired. DON/IP further stated there were some foods that were good for this much date and expired food could not be served to residents for food sanitation and safety. During a review of facility's policy and procedure (P&P) titled, Dry Goods Storage Guidelines, dated 2018, the P&P indicated, food item, Cerael ready to eat, unopened on shelf 6 months, opened on shelf 2 months, opened refrigerated N/A . Cereal ready to cook, unopened on shelf 6 months, opened on shelf 6 months, opened refrigerated N/A. During a review of facility's policy and procedure (P&P) titled, Canned and Dry Goods storage, dated 2018, the P&P indicated, Grains and grains products, cereal ready to eat, recommended maximum storage period if unopened less than or equal to 85 degree Fahrenheit, 6 months, food-cereal, cooked, recommended maximum storage period if unopened less than or equals to 85 degree Fahrenheit, 8 months. During a review of facility's policy and procedure (P&P) titled, General Receiving of Delivery of Food and Supplies, dated 2018, the P&P indicated, food deliveries will be inspected to assure high quality food and supplies. They are to be received in proper condition . Check deliveries for intact packaging. Broken boxes, leaky packages, or dented cans may be signs off mishandling and could be grounds for rejecting the shipment . Deliveries are to be put away as quickly as possible. Begin with refrigerated items, then frozen and then dry goods. Label all items with the delivery date or use by date . 9. Dry food items which have been opened, such as pudding, gelatin, biscuit mix, pancake mix, dry cereal, spices, coffee, noodles, etc. will be tightly closed, labeled and dated. These items are to be used per times specified in the Dry Food Storage Guidelines.

Based on observation, interview, and record review, the facility failed to have a full time (working 35 or more hours a week) Certified Dietary Manager for food and nutrition services for 24 Residents residing in the facility, not following standards of practice. This failure had the potential of not meeting the resident's nutritional needs, and placing residents at risk of not receiving meals/diet in a safe and sanitary manner, with the potential for infection, pressure injury, and possibly hospitalization. Findings: During a brief kitchen observation task and an interview on 5/19/25, at 09:21 a.m., with the Dietary [NAME] (DC) 1, DC 1 was the only staff in the kitchen. The DC 1 stated the facility Dietary Manager (DM) was off for the day and he was the only assigned staff to the kitchen for the day. The DC 1 stated the DM only worked one or two days a week. During a telephone interview on 5/19/2025, at 09:28 a.m., with the DM, the DM stated he was off for the day, and he was employed by the facility for one or two days a week, on a part time basis. During an interview on 5/22/2025, at 12:07 p.m., with Dietary [NAME] (DC) 2, DC 2 stated the DM worked only on weekends, all day until 7:00 p.m., and that DC 2 worked at the facility two days a week. During a review of facility's detail payroll report for the DM, dated 3/02/2025 to 3/15/2025, the payroll indicated,'DM's workdays are Saturday and Sunday, total hours for pay period 23.25, weekly hours was16.25 hours, actual in, at 10:00 a.m., out at 06:30p.m., daily hours of 8 hours, regular 8 hours, overtime (OT) 0. During a review a facility's detail payroll report for the DM, dated from 4/1/2025 to 4/30/2025, the payroll indicated, DM workdays are Saturday and Sunday, in, 10:30 a.m., to 06:30 p.m., DM worked on dates 3/16/2025, 3/22/2025, and 3/23/2025, 3/29/2025, and 3/30/2025. During a review a facility's detail payroll report for the DM, dated 5/1/2025 to 5/16/2025, the payroll indicated, DM workdays is Saturday and Sunday, in, 10:00 a.m., to 06:30 p.m., DM worked on dates 5/4/2025, 5/10/2025, and 5/11/2025. During a review of facility's staff schedule, titled CNA schedule, the schedule indicated, DM is only scheduled to work two days a week, Saturday and Sunday. During an interview on 5/19/2025, at 1:02 p.m., with the Registered Dietitian (RD), the RD stated she was employed as a consultant and only worked for the facility a couple hours less than eight hours a week. The RD stated in most cases facility would reach her by phone. During an interview on 5/22/2025, at 12:21 p.m., with the Director of Nursing/Infection Preventionist (DON/IP) the DON/IP stated the DM was scheduled twice a week. DON/IP also stated the DM was needed on a full time basis to make sure the menus are followed correctly, for food sanitation, meeting resident's nutritional calories, and providing proper diet to residents. During a review of facility's policy and procedure (P&P), titled, Personnel Management, dated 02/2010, the P&P indicated, A qualified Dietary Services Supervisor, chosen by the Administrator, is responsible for total operation of the Dietary Department. All diabetic service is performed under their direction . If a person is not a Registered Dietitian, he must be a graduate of a state approved course that provides ninety or more hours of classroom instruction in Diabetic Service Supervision, and receive regular consultant from a Registered Dietitian, or have met equivalent requirements . Responsibilities of the dietary service Supervisor . Assuring that dietary personnel who exhibit signs of a communicable disease do not work . Complete residents dietary profile, nutritional screening, quarterly note, annual review and MDS . Visit all new residents to record food preference and allergies. During a review of facility's policy and procedure (P&P), titled, Dietary Supervisor Job Description, the P&P indicated, This position must provide management for the Dietary Department, ensuring quality food. The Dietary Supervisor will direct and assist the preparation and serving of regular meals and therapeutic diets, order food and supplies and maintain area and equipment in sanitation condition and assure the smooth operation with other nursing home departments.

Based on interview and record review, the facility failed to complete a performance review of all its nurse aide staff at least once every 12 months, not following its policy and procedures and standards of practice. This failure had the potential to have incompetent nurse aides caring for residents, poor quality of care and quality of life for residents, risk for injury, accidents, infection, hospitalization, and possibly death. Findings: During a concurrent interview and record review on 5/22/2025, at 10:21 a.m., with Administrator/Minimum Data Set Coordinator (ADM/MDSC), the nurse aide staff personnel files were reviewed. There was no record of annual performance reviews in all nurse aide staff personnel files. ADM stated facility does not have record of annual performance review for their nurse aide staff. ADM stated the importance of completing performance review for all nurse aide staff is so facility can provide quality care to the residents and give staff feedback on how they are doing. ADM further stated the facility's process was to complete performance review for each nurse aide annually.

Based on interview and record review, for five (Residents 118, 112, 164, 3, and 117) of five sampled residents, the facility failed to complete the quarterly Minimum Data Set assessments (MDS - Resident Assessment and care guide tool) according to the regulation. This failure had the potential to result in the delayed assessment of residents' needs, goals of care and inability to monitor each residents' progress over time. Findings: During a concurrent interview and record review on 5/21/25, at 1:19 p.m., with the Administrator/Minimum Data Set Coordinator (ADM/MDSC), the following MDS record reviews were not completed every three months as follows: Review of Resident 118's MDS assessment indicated Resident 118 did not have quarterly MDS assessment. Review of Resident 112's MDS assessment indicated Resident 112 did not have quarterly MDS assessment. Review of Resident 164's MDS assessment indicated there was no quarterly assessment completed from 11/2/23 thru 5/2/25. Review of Resident 3's MDS assessment indicated the last quarterly assessment was completed on 12/18/24. Review of Resident 117's MDS assessment indicated the last quarterly assessment was completed on 12/18/24. ADM/MDSC acknowledged that residents' MDS's were late and MDSC was responsible for the completion and transmission of all the residents' MDS assessments. ADM/MDSC stated it was important to complete the MDS assessments for reimbursement purposes and to ensure that resident needs were met. Review of the Long -Term Care Facility Resident Assessment Instrument 3.0 User's Manual CH 2: Assessments for the RAI, dated October 2024, indicated the quarterly assessment an OBRA non-comprehensive assessment for a resident that must be completed at least every 92 days following the previous OBRA assessment of any type. It is used to track a resident's status between comprehensive assessments to ensure critical indicators of gradual change in a resident's status are monitored. {Reference: https://downloads.cms.gov/files}

Based on interview, the facility failed to ensure the Infection Preventionists (infection control nurse or designee) had completed specialized training in infection prevention and control. This failure had the potential to contribute to the residents' development of contracting healthcare acquired infections (infections from receiving treatment at a facility). Findings: During a concurrent interview and record review on 5/20/25, at 2:44 p.m., with the Director of Nursing/Infection Preventionist (DON/IP), in the presence of Administrator/MDSC (ADM/MDSC), the DON/IP stated two staff members were designated Infection Preventionists, including DON and Administrator (ADM). DON/IP also stated she had not completed the specialized training in infection prevention. Furthermore, the ADM/MDSC revealed she also had not completed the specialized training in infection prevention.

Based on observation, interview, and record review the facility failed to ensure one of 13 sampled residents was free from physical restraints when the facility staff placed Resident 167 in a Geri chair with a hard table cover over the Geri chair (a large, padded chair that is designed to help seniors with limited mobility), preventing Resident 167's freedom of movement (change in place or position for the body or any part of the body that the person is physically able to control) and from getting in and out of the Geri chair at his own will. This failure placed Resident 167 at risk of self-injury, of not attaining and maintaining their highest practicable well-being or good quality of life. Findings: During a record review of Resident 167's Facesheet (FC), the FC indicated Resident 167 was admitted to the facility on [DATE]. FC also indicated Resident 167 had diagnoses of essential primary hypertension (a chronic condition of persistent high blood pressure with no identifiable cause), nontraumatic intracerebral hemorrhage (bleeding within the brain tissue without any direct trauma or injury), and mild cognitive impairment (brain condition in which people have more memory and thinking problems than other people their age. During a concurrent interview and record review on 5/19/25, at 1:27 p.m., with Administrator/Minimum Data Set Coordinator (ADM/MDSC), the Facility Matrix was reviewed. The Facility Matrix indicated facility had one Resident on physical restraints, Resident 167. ADM/MDSC stated Resident 167 was on physical restraints, which is the Geri chair, and the Geri chair was used to prevent falls, as Resident 167 had generalized weakness. ADM/MDSC further stated if Resident 167 was not placed in the Geri chair, Resident 167 would constantly try to get up and stand, which could result in a fall. ADM/MDCS also stated once Resident 167 was placed in the Geri chair, Resident 167 could not get himself in and out of the Geri chair, unless staff got him out. During a review of Resident 167's care plan, start date 3/17/25, the care plan only indicated, geri chair in place for safety, comfort, and mobility support, due to muscle weakness high fall risk. The care plan did not include other interventions for fall risk and muscle weakness. During a concurrent observation and an interview on 5/20/25, at 11:00 a.m., with Certified Nursing Assistant (CNA) 1, (CNA) 2, and Director of Nursing/Infection Preventionist (DON/IP), Resident 167 was sitting in a Geri chair in the dining room. The Geri chair had a hard table cover over it. CNA 1 and CNA 2 stated Resident could not remove the tray on the Geri chair by himself. Resident 167 was in a reclining position. CNA 2 stated facility staff needed to remove the Geri chair from the recline position in order for Resident 167 to get out of the Geri chair. CNA 1 also stated Resident 167 was placed in the Geri chair so staff could go care for other residents, such as change another resident's diaper. During a concurrent observation and an interview on 5/21/25, at 11:26 a.m., with CNA 3, Resident 167 was sitting in a reclined position in a Geri chair. The Geri chair had a tray attached to it, over his lap. CNA 3 stated Resident 167 would try to stand and then he would fall, and that Resident 167 cannot balance himself. CNA 3 stated Resident 167 cannot come out of the Geri chair by himself. During a review of facility's policy and procedure (P&P), the P&P titled, Restrants Policy, indicated, Geriatric Chair . The Geri-chair is considered a restraint . The resident must be repositioned and exercised 10 minutes out of every two hours . A physical restraints is defined as any manual method or physical or mechanical device, material, or equipment attached or adjacent to the resident's body that the individual cannot remove easily which restricts freedom of movement or normal access to one's body. These can include cloth vests, soft ties, soft mittens, wheelchair safety bars, geri-chairs and or other devices including side rails . Restraints can jeopardize the resident's feeling of dignity and self-worth. All other means of dealing with the problem must be exhausted before a restraint is applied. All measures tried prior to application of the restraints must be documented in the resident's medical record.

Based on observation, interview and record review, the facility had six resident rooms (Rooms 1, 3, 5, 7, 8, and 9) with multiple beds that provided less than 80 square feet (sq. ft) per resident who occupied these rooms. This deficient practice had the potential to result in inadequate space for the delivery of care to each of the residents in each room, or for storage of the residents' belongings. Findings: During an observation on 5/19/25 at 9:30 a.m., the following Resident (Rt) rooms and corresponding square footage (sq. ft) were identified: Room Activity Room Size Floor Area 1 Rt Room 299.63 sq.ft 74.9 sq.ft/bed 3 Rt Room 293.25 sq.ft 73.32 sq.ft/bed 5 Rt Room 299 sq.ft 74.75 sq.ft/bed 7 Rt Room 299 sq.ft 74.75 sq.ft/bed 8 Rt Room 299 sq.ft 74.75 sq.ft/bed 9 Rt Room 299 sq.ft 74.75 sq.ft/bed During a concurrent observation and interview on 5/19/25, at 9:35 a.m., with Certified Nursing Assistant (CNA) 1, CNA 1 stated, rooms with four Residents had enough space to provide resident care. CNA 1 also stated, there was enough space even for residents using wheelchairs. During a concurrent observation and interview on 5/19/25, at 9:42 a.m., Resident 17 was seen wheeling self towards bedside from the hallway. Resident 17 stated there was enough space to wheel herself in and out of room. Resident 17 also stated staff were able to provide care without problem. During an interview on 5/21/25, at 12: 25 p.m., with the Administrator/Minimum Data Set Coordinator (ADM/MDSC), ADM/MDSC stated there were no changes in room sizes since the last survey. ADM/MDSC confirmed, (Rooms 1, 3, 5, 7, 8, and 9) with multiple beds that provided less than 80 square feet (sq. ft) per resident who occupied these rooms.

The facility failed to ensure infection control measures were followed when: 1. Outside resident room [ROOM NUMBER] was an open lid bin which contained a used yellow gown. Next to this open bin was a container of unused personal protective equipment (PPE) supplies 2. Inside the medication room, a bag of adult brief pads was found on the floor 3. Inside the medication room, under the sink was a half-full container of water and located next to two containers of chemical agents, one of which was perineal wash. 4. Biohazard door was unlocked. This failure can potentially result to cross contamination of clean product items and impact the physical health, safety and well-being of all 29 residents. Findings: 1. During a concurrent observation and interview on 12/4/24, at 10:15 a.m., with Licensed Vocational Nurse (LVN) 1, in the hallway was an open lid bin with used yellow gown was noted outside of resident room [ROOM NUMBER]. Next to this open lid bin was a container with unused PPE supplies. LVN 1 stated the lid should have been closed for infection control. During an interview on 5/8/25, at 9:30 a.m., with Director of Nursing (DON), the DON stated the open lid bin containing used PPE should have been closed for infection control, as clean PPEs could be contaminated. 2. During a concurrent observation and interview on 12/4/24, at 10:15 a.m., with LVN 1, a bag of Presto Pads, 15 count XL (extra-large), was noted to be on the floor in the medication room. During an interview on 5/8/25, at 9:30 a.m., with DON, the DON stated the bag of briefs should not have been on the floor due to infection control. 3. During a concurrent observation and interview on 12/4/24, at 10:15 a.m., with LVN 1, a half-full container of water was found under the sink in the medication room. LVN 1 stated water was used by residents. During an interview on 5/8/25, at 9:30 a.m., with DON, the DON stated the water should not be next to chemicals as it could be missed and swallowed by anyone. 4. During a concurrent observation and interview on 12/4/24, at 10:15 a.m., with LVN 1, the Biohazard door was unlocked. LVN 1 stated door should be locked. LVN 1 left the door unlocked. During an interview on 5/8/25, at 9:30 a.m., with DON, DON stated Biohazard room should be locked as the room had used needles and someone could go in the room.

The facility failed to ensure proper medication storage when: 1. Medication refrigerator was not padlocked 2. Medication room dry storage temperature log did not have entries for December 2 and 3, 2024 3. Medication room refrigerator had nutritional supplements along with food items that were not labeled with names and dates 4. The medication room had a staff's clothing item hanging on the door. This failure can potentially result in unsafe medication storage practices and impact the safety and well-being of all 29 residents. Findings: 1. During a concurrent observation and interview on 12/4/24, at 10:15 a.m., with Licensed Vocational Nurse (LVN) 1, the medication refrigerator in the medication room was found not padlocked. During a concurrent observation and interview on 12/4/24, at 11:10 a.m., with Administrator (ADM), ADM stated the medication refrigerator should have been padlocked. During an interview on 5/8/25, at 9:30 a.m., with Director of Nursing (DON), the DON stated the medication refrigerator should have been padlocked as it had E-kit (emergency kit containing medications) in it. The DON further stated the danger of the refrigerator not being padlocked is that medications can be touched by any staff. 2. During a concurrent observation and interview on 12/4/24, at 10:15 a.m., with LVN 1, the medication room dry storage temperature log did not have day and evening entries for 12/2/24 and 12/3/24 under the columns Storeroom and Nursing Sig (signatures). During an interview on 5/8/25, at 9:30 a.m., with DON, the DON stated the temperature log should be completed, otherwise it (refrigerator) may not be meeting temperature requirements. Per the DON, licensed nurse is responsible for keeping the temperature log. 3. During a concurrent observation and interview on 12/4/24, at 10:15 a.m., with LVN 1, the dry storage refrigerator, which had a label Medication Only contained non-medication food items. On the inside door of the refrigerator, the top shelf had nutritional supplements. On the bottom shelf were the following four items: a bag of whole mixed olives, an unmarked half-full jar of green marmalade-like item, a half-full container of creamed honey, and a half full bottle of apple cider vinegar vinaigrette. These four items were not labeled with names or dates. During an interview on 5/8/25, at 9:30 a.m., with the DON, the DON stated she did not know what these items were. Per DON, food items inside the refrigerator should have names, covered, and dated. DON further stated she did not know who the items belonged to. 4. During a concurrent observation and interview on 12/4/24, at 10:15 a.m., with LVN 1, a white vest was found hanging on the door of the medication room. LVN 1 stated the clothing item belonged to an employee. During an interview on 12/4/24, at 11:10 a.m., with ADM, the ADM stated the white vest belonged to the DON. ADM stated it was the medication room and not the DON's closet and the clothing item should not have been stored there. During a review of the facility's policy and procedure titled, Medication Storage, dated 2007, the P&P indicated, Medication rooms, cabinets and medication supplies should remain locked when not in use or attended by persons with authorized access . A temperature log or tracking mechanism is maintained to verify that temperature has remained within accepted limits . Refrigerated medications should be kept in closed and labeled containers . segregated from fruit juices, applesauce, and other foods used in administering medications. Any other foods such as employee lunches and activity department refreshments should not be stored in this refrigerator.

Based on observation, interview, and record review, the facility did not provide the necessary pain medication for one of three sampled residents (Resident 3) Resident 3 required wound dressing changes, three times per week, which were painful and required premedication. The licensed nursing staff did not administer the required pain medication before wound care. This caused unnecessary pain and distress for Resident 3. Findings: Review of the Admission Record showed the facility admitted Resident 3 on 3/11/2023. The diagnoses included dementia (memory difficulty). Resident 3 received hospice services (end-of-life comfort care) while at the facility. During an interview on 12/18/2023 at 10:35 a.m., the facility's Director of Nursing (DON) stated Resident 3's dressings were being changed three times per week and the hospice agency, Calls us ahead of time so we know when they are coming. DON stated licensed staff would then pre-medicate Resident 3 with pain medication prior to hospice's arrival so that Resident 3 felt minimal to no pain during the wound dressing changes. During an interview on 12/18/2023 at 10:22 a.m., Resident 3 did not respond to this surveyor's questions and was not interviewable. On 12/18/2023 at 1:45 p.m., the hospice registered nurse (HRN) was observed changing Resident 3's dressings on her leg, knee and foot. Resident 3 was observed moaning in pain as the old dressings were removed. Review of the document (not titled) MD orders (undated), showed Resident 3 had orders from the doctor for Morphine (pain medication) 5 mg (milligram) every 4 hours as needed for shortness of breath or pain. The start date was 9/12/2023. Review of the Charts/Clinical Notes (not dated), showed hospice had visited Resident 3 on 11/6/2023. Resident 3 was yelling Ouch now stop that during wound care. The wounds were described as Significantly worse. Review of the Hospice Home Instructions, dated 11/6/2023, showed facility staff were to Pre-medicate with morphine prior to dressing change. Hospice nurses would call the facility ahead of time to let staff know when they were coming and to administer the pain medication before arrival. Review of the document Hospice Routine Visit, dated 11/13/2023, showed Resident 3 had .Pain with wound care. Multiple rapidly worsening wounds with purulent (pus), malodorous drainage (foul smelling). Review of the Medication Administration Record (MAR), dated November 2023, showed the facility had not administered Morphine to Patient 3 on 11/13/2023 (prior to the wound dressing changes). Review of the Controlled Drug Record (not dated) showed no Morphine had been signed out of the narcotic drawer for Resident 3 on 11/13/2023. In a concurrent interview, DON confirmed there had not been any Morphine administered to Resident 3 on 11/13/2023 prior to the wound dressing change. Review of the Charts/Clinical Notes, dated 11/20/2023, showed the hospice nurse visited Resident 3 on 11/20/2023 at 4 p.m. Patient 3 was found to have mild to moderate pain and had not been pre-medicated with Morphine prior to the visit. Review of the MAR dated November 2023 showed Resident 3 had not been given Morphine on 11/20/2023. Review of the Controlled Drug Record (not dated) showed Resident 3 had received Morphine at 5 p.m. on 11/20/2023, one hour after the start of the hospice visit. Review of the Charts/Clinical Notes (not dated), showed the hospice agency Registered Nurse (RN) visited Resident 3 on 11/30/2023 at 12:30 p.m. for a wound dressing change. The visit note showed, Attempted wound care - pt developed severe pain, screaming, stating no stop do not touch me repeatedly. Pt was medicated with Morphine 5 mg around 11:30-12 per DON and wound care occurred one hour later at 12:30-1. Record review of the MAR dated November 2023 showed no Morphine had been administered to Resident 3 on 11/30/2023. Review of the Controlled Drug Record showed Morphine was signed out for Resident 3, on 11/30/23 at 7 p.m., six hours following the wound dressing change. Review of the Supplemental Order, dated 12/11/2023, showed the Morphine had been increased to 30 mg and was to be given one hour prior to Resident 3's dressing changes. Review of the MAR dated 12/20/23 showed Resident 3 had not received the Morphine 30 mg since the order was written on 12/11/2023. During a concurrent interview, with DON, DON confirmed Resident 3 had not been receiving the Morphine 30 mg and was Not sure why. Review of the Controlled Drug Record (not dated) showed Resident 3 had received Morphine 5 mg on 12/9/2023 and 30 mg on 12/18/2023 (date of investigation). During an interview on 12/18/2023 at 1:15 p.m., DON stated the hospice agency staff had Never discussed pain control problems with me. They just send over the orders. During an interview on 12/18/2023 at 2:15 p.m., HRN stated she discussed the plan of care with DON regarding pre-medicating Resident 3 with Morphine. HRN stated DON had reported she helps to control Resident 3's pain, More gently by asking Resident 3 to Count down while doing the dressing change instead of administering the medication. HRN said she made a plan with DON to meet on 12/8/2023 to discuss the plan (pain control), but DON was a No show. HRN said she then wrote DON a letter discussing the importance of the plan since Resident 3 was in Tremendous pain. During an interview on 12/18/2023 at 2:26 p.m., HRN stated she became concerned that Resident 3 was not receiving the pain medication as ordered. HRN stated Resident 3 should have received the increased dosage to 30 mg on 12/14/23, 12/16/23, and 12/18/2023. During an interview on 1/26/2024 at 1:55 p.m., the hospice Social Worker (HSW) stated she had talked with the facility's DON regarding the need to keep Resident 3 comfortable. HSW stated DON agreed this was the goal. DON reported to HSW that she Didn't need to pre-medicate Resident 3 because she could get her to, Count backwards from 100 to calm her down before the dressing change. HSW stated she was concerned about how a hospice patient could be expected to count backwards from 100 and how that could be effective in controlling the pain. HSW had suggested DON speak with the hospice doctor regarding the importance of pre-medication. HSW stated DON told her that she (DON) did not require a doctor's opinion. HSW asked DON if she was committed to following the plan of care for Resident 3 and DON Would not commit. HSW further stated she had seen Resident 3 be pre-medicated during previous dressing changes and she was still yelling out, Please stop. Help Me! HSW stated Resident 3 had fragile skin and knew it was very important for her to be effectively pre-medicated. During an interview on 12/18/2023 at 1:10 p.m., DON stated the potential consequence of not giving the prescribed amount of premedication prior to Resident 8's dressing changes was Pain. Review of the Policy and Procedure, Pain Assessment/Management, (not dated) showed it was the facility's policy to, Respect and support every patient's right to optimal pain relief through education, initial and ongoing assessment, and effective and appropriate pain management. Review of the Skilled Nursing Facility Memorandum of Understanding Routine Level of Care, dated 2/23/2023, showed the facility, Shall comply with Hospice Patient's Plan of Care and shall ensure Hospice Patients are kept comfortable, clean, well-groomed and protected from negligent and intentional harm including, but not limited to, accident, injury and infection.

Based on observation, interview, and record review, the facility failed to provide an ongoing activity program to support residents in their choice of activities. The facility did not have an active activity program or staff responsible for providing assistance with the activities program. This failure had the potential to cause residents emotional distress and decline in their quality of life. Findings: 1. Review of Annual Minimum Data Set (MDS - an assessment screening tool used to guide care), dated 4/21/23, indicated: Resident 3's Basic Interview of Mental status (BIMS- score was 14 meaning cognitively intact). Resident 3's activity preferences included listening to music, doing things with groups of people and participate in religious services or practices that were very important. Resident 3's diagnoses included schizophrenia (a disorder that affects a person's ability to think, feel and behave clearly). Review of the activity care plan initiated on 7/1/21 indicated for staff to invite Resident 3 to participate in activities. During an interview on 10/16/23 at 9:44 a.m., Resident 3 stated there was no group activities since COVID-19 lockdown in 2020. Resident 3 stated he watched television to pass time and stayed in his room. During an observation and concurrent interview on 10/16/23 at 10:14 a.m., Resident 3 was sitting up in bed in his room looking out the door. Resident 3 said there was nothing to do. 2. Review of the MDS dated [DATE], indicated: Resident 5's BIMS score was 10 meaning mild, cognitive impairment. Resident 5 had clear speech, makes self understood, and understands others. Resident 5's activity preferences indicated having books, newspapers and magazines to read, listen to music, keep up with news, doing things with groups of people and participate in religious services or practices were very important. Review of the activity care plan initiated 10/8/2019 indicated Resident 5 has activity needs related to anoxic (lack of oxygen) brain damage and interventions included to invite resident to participate in activities. During an observation and concurrent interview on 10/17/23 at 8:27 a.m., Resident 5 was in a wheelchair watching television in her room. Resident 5 stated she got up daily to watch television and likes reading books, music , singing, story telling, and exercises. Resident 5 further stated before the COVID-19 lockdown in 2020, they used to have books and did not know where the books were kept. 3. Review of the MDS, dated [DATE], indicated Resident 61's BIMS score was 15, meaning cognitively intact. Resident 61's activity preferences indicated having books, newspapers and magazines to read, listening to music, be around animals such as pets, and go outside to get fresh air when the weather is good, and participate in religious services or practices were very important. Review of the activity care plan initiated 7/1/21 indicated Resident 61's activity interventions included to invite resident to participate in activities. During an observation and concurrent interview on 10/16/23 at 9:23 a.m., Resident 61 was up in a wheelchair watching television in her room. Resident 61 stated she watched television every day, walked up and down the hallways, and walk to her bathroom and back for exercise. Resident 61 stated there had been no activity program since COVID-19 lockdown in 2020, and it would be fun to have activities and engage with other residents sometimes. Resident 61 further stated she likes music, singing, exercise and story telling. Resident 61 stated the facility used to have books in the dining area and did not know where the books were kept. 4. Review of the MDS dated [DATE] indicated Resident 62's BIMS score was 15, meaning cognitively intact. Resident 62's activity preferences were having books, newspapers and magazines to read, and keeping up with the news. During and observation and concurrent interview on 10/17/23 at 8:32 a.m., Resident 62 was in bed in her room, awake and verbally responsive. Resident 62 stated the activities program was stopped during COVID-19 lockdown. Resident 62 further stated she watched television every day but would like to sing with others and do some exercises. During an interview on 10/17/23 08:48 a.m., the Registered Nurse/Administrator (RN/Admin) stated the activity staff last worked at the facility in March 2020. RN/Admin stated the books in the dining room area were thrown away because the books were old. RN/Admin stated Resident 62 had no activity care plan. During an interview on 10/19/23 at 11:11 a.m., RN/Admin stated the facility had no activity staff and no activity program since COVID-19 lock down in 2020, because staff had been busy providing bedside care and had no time to set up activities. Review of the Residents Rights, undated document indicated the facility must care for its residents in a manner and in an environment that promotes maintenance or enhancement of each residents's quality of life. The resident has the right to choice activities, schedules, and healthcare consistent with his or her interests, assessments and plan of care. 46487 5. A review of Resident 163's clinical record indicated she was admitted on [DATE]. During an interview on 10/19/23, at 2:06 p.m., Resident 163 stated the facility used to have a lot of group activities for the residents before the strict COVID-19 outbreak isolation rules in 2020, and the group activities had to stop. Stated she wanted to attend facility group activities again, like church and bible studies. 6. A review of Resident 167's clinical record indicated she was admitted on [DATE]. A review of Resident 167's MDS, dated [DATE] indicated the resident's cognition was mildly impaired. During an interview on 10/19/23, at 2:10 p.m., with Resident 167, Resident 167 stated she wanted to attend facility group activities again. During a review of the facility's policy and procedure (P&P) titled, (Quality of Life), the P&P indicated, . A resident has the right to participate in social, religious, and community activities that do not interfere with the rights of other residents in the facility .The facility must provide for an ongoing program of activities designed to meet, in accordance with the comprehensive assessment, the interest and the physical, mental and psychosocial well-being of each resident .

Based on observation, interview, and medical review, the facility failed to provide pharmaceutical services to meet the needs of four of 14 sampled residents (Residents 63, 162, 163, and 170) when the facility failed to perform daily glucometer (small machine that measures blood glucose or sugar level) quality control checks to ensure accurate readings. This failure had the potential risk of adverse consequences associated with the glucometer used for Residents 163 and 170 whose insulin dosage (medication that lowers the blood glucose) were dependent on the accuracy of the glucometer readings. For Residents 63 and 162, this had the risk of incorrect blood glucose readings and inappropriate medical interventions for Residents 63 and 162. Findings: 1. During a concurrent interview and record review on [DATE], at 11:50 a.m., with Administrator (Adm), the glucometer quality control log was reviewed. There was no record of the glucometer quality control checks being done since [DATE]. Adm confirmed the findings and stated the facility was only using one FreeStyle Freedom Lite glucometer for Residents 63,162,163, and 170. Adm stated the risk of using an uncalibrated (not adjusted)glucometer were inaccurate blood glucose results for Residents 63,162,163, and 170. Review of Resident 163 's medical record showed Resident 163 was admitted to the facility on [DATE], with diagnoses including diabetes (blood sugar disorder). Review of the monthly physician orders dated ,d+[DATE], showed an order dated [DATE], for blood sugar readings to be checked before breakfast and at bedtime daily, and to call the physician if blood sugar was less than 80 or greater than 400. Another order dated [DATE], indicated Novolin N insulin (works in the body for 24 hours), 15 units subcutaneously (inject under the skin), every morning and to hold if blood sugar was less than 100. Also, an order dated [DATE], indicated Lantus insulin (works in the body for 24-hours), five units subcutaneously at bedtime and hold if blood sugar was less than 100. 2. Review of Resident 170's medical record showed Resident 170 was admitted to the facility on [DATE], with diagnoses including diabetes. Review of the monthly physician orders dated [DATE], showed an order dated [DATE], for blood sugar readings to be checked daily at bedtime. An order dated [DATE], indicated glucose gel (treats low blood sugar) 5 mg (milligram) by mouth if blood sugar was less than 60 PRN (as needed). Another order dated [DATE], indicated Levemir insulin (works in the body for 24 hours) 14 units subcutaneously at bedtime, hold if blood sugar was less than 100. 3. Review of Resident 162's medical record showed Resident 162 was admitted to the facility on [DATE], with diagnoses including diabetes. Review of the monthly physician orders dated [DATE], indicated an order dated [DATE], for blood sugar readings to be checked two times a week, Mondays and Thursdays in the morning. 4. Review of Resident 63's medical record showed Resident 63 was admitted to the facility on [DATE], with diagnoses including diabetes. Review of the monthly physician orders dated [DATE], indicated an order dated [DATE], for blood sugar readings to be checked once a week on Mondays. During an interview on [DATE], at 11:06 a.m., with Licensed Vocational Nurse (LVN) 1, LVN 1 verified, Residents 163 and 170 had insulin administered based on blood sugar results obtained using the FreeStyle Freedom Lite glucometer. LVN also stated, the facility started using the glucometer for maybe less than a year and was aware the glucometer quality control checks were supposed to be done daily. LVN further stated, the risk of not performing the control checks could be life threatening to residents who were receiving insulin because the wrong dose of insulin could be given due to inaccurate blood sugar results. During an interview on [DATE], at 11:06 a.m., with the Pharmacist Consultant (PC), PC stated, she did not know the facility was not performing the glucometer quality control checks. PC stated the calibration of the glucometer must be done daily to ensure accuracy of the blood glucose readings. PC further stated the risk of not doing daily glucometer control checks would be giving wrong doses of insulin to the residents due to wrong blood glucose results. Review of the FreeStyle Freedom Lite glucometer manual, pages 21 and 22 indicated, The purpose of doing a control solution test is: . To confirm that the meter and test strips work together properly . Causes of out-of-range results include . Expired or bad test strip . Meter malfunction, Test strip deterioration . During a review of the facility's policy and procedure (P&P) titled, (Glucometer Maintenance), the P&P indicated, . the purpose of this policy is to set forth the requirements to ensure the proper functioning of the glucometer through daily quality control tests .The glucometer will be tested daily . with test results documented on the Glucometer Quality Control Record. In addition, glucometer should be tested : 1. Before using the system for the first time, 2. When opening a new vial of strips, 3. If test results seem unusually high or low based on the patient's condition, 4. If strip vial has been left open or exposed to extreme heat, cold or humidity, 5. Whenever a check on the performance of the system is needed, or 6. If meter damage is suspected (meter dropped, crashed, wet, etc.)

Based on observation, interview, and record review, the facility failed to have Registered Dietitian (RD) oversight of the kitchen and clinical nutrition care (ensuring residents are consuming an adequate amount of nutrients for good health) since 7/28/23. There was no full-time Dietary Manager (DM) to manage kitchen operations when the menu was not being followed (cross-reference 803), unsanitary conditions in the kitchen (cross-reference 812), no pest control program (cross-reference 925), and the nutrition status of one (Resident 159) was not being maintained (cross-reference 692). These failures placed 26 of 26 residents who received food from the kitchen at risk for compromised nutritional status and had the potential for transmission of food borne illness. Findings: During an interview on 10/16/23 at 09:30 a.m., with the Dietary Cook (Cook), Cook stated the facility did not have a Dietary Manager (DM) for the past three years and the RD had not come into the facility for the past three months. Cook stated he was solely responsible for the cooking, cleaning, and ordering the food for the entire facility. During a telephone interview on 10/18/23 at 12:06 p.m., with the Registered Dietitian (RD) who was the COO (Chief Operating Officer) of the [Company Name], RD stated they haven't been at the facility for the last three months, because the facility had not signed an updated contract or were current with their payments. RD stated the facility had been informed on a recurrent basis of the state requirement for having a DM on staff. RD further stated the facility just re-signed a contract on 10/16/23. The Registered Dietitian 1 (RD 1) first day in the building was on 10/18/23. During an interview on 10/18/23 at 2:44 p.m. with Administrator (Admin), Admin stated the facility has not had an RD because the contract company said they did not sign the contract. Admin stated they had trouble filling the DM position because the facility cannot offer a full-time positon. During a review of the facility's position description for Dietary Services Manager (DM), undated, the DM position indicated, the DM ensured the delivery of meals, hydration, and nourishment in accordance with assessed needs and nutritional plans while under the direction of a Registered Dietitian.

Based on observation, interviews, and record review, the facility failed to facilitate the resident's right to organize resident group (council) meetings. The group council meetings stopped during the COVID-19 (a respiratory virus that is easily spread causing mild, moderate, or serious illness) lockdown and were never resumed. There was no designated staff person approved by the residents to be responsible for assisting and responding to the resident's concerns or requests that result from group meetings. This failure had the potential to cause residents emotional distress and a decline in their quality of life. Findings: During an interview on 10/16/23 at 9:44 a.m., Resident 3 stated the resident council meeting was not held for a long time since the COVID-19 lockdown in 2020 because there was no staff to assist with meeting arrangements. Resident 3 further stated he would like the residents 'council meetings restarted to discuss activities and concerns. Review of the Minimum Data Set (MDS - an assessment screening tool used to guide care), dated 4/21/23, indicated Resident 3's Basic Interview of Mental status (BIMS, a scoring system to determine cognitive status) score was 14 (meaning cognitively intact and able to understand others and be understood. During an interview on 10/17/23 at 9:48 a.m., with the Registered Nurse/Administrator (RN/Admin), RN Admin stated the facility had no active resident council meetings since COVID-19 lockdown in 2020 because staff were busy providing bedside care. During an interview on 10/19/23 at 12:15 p.m., RN/Admin stated activity staff were responsible to aid with resident council meetings and had no activity staff since COVID-19 lock down in 2020. RN/Admin further stated the Director of Nursing (DON) was responsible to hire activity staff. DON was not available for an interview. Review of the resident council meeting attendance binder indicated the last meeting was held on 3/9/2020. Review of Resident 163's clinical record indicated she was admitted on [DATE]. During an interview on 10/19/23, at 2:06 p.m., with Resident 163, Resident 163 stated the residents used to have Resident council meetings once a month for years, until COVID-19 in 2020 and the resident council meetings stopped. Resident 163 further stated attending the resident council meetings was good because the residents could talk about anything and could express their emotions. We had activities like church on Sundays, bible study on Monday, and a catholic woman came on Wednesday to give communion. I miss that. Review of Resident 167 clinical record indicated she was admitted on [DATE]. A review of Resident 167's MDS, dated [DATE] indicated the resident's cognition was mildly impaired. During an interview on 10/19/23, at 2:10 p.m., with Resident 167, Resident 167 stated she wanted to attend resident council meetings. During a review of the facility's policy and procedure (P&P) titled, (Quality of Life), the P&P indicated, . A resident has the right to organize and participate in resident groups in the facility; . the facility must provide a designated staff person responsible for providing assistance and responding to written requests that result from group meetings .

Based on observation, interview, and record review, the facility failed to correctly identify one (Resident 1) of three sampled residents as a high fall risk and revise the fall care plan accordingly and as needed to maintain Resident 1's physical well-being. This failure resulted in an uwitnessed fall and Resident 1 sustained a subdural hematoma (a collection of blood in the top of the brain), left humeral head fracture (broken upper arm bone) and fracture of the pubic ramus (broken bone in the pelvis) requiring hospitalization . Findings: A review of Resident 1's admission record indicated resident was admitted to the facility on [DATE] with diagnoses that included muscle weakness, cancer of the spine, difficulty in walking, abnormalities of gait (manner of walking), and mobility. A review of Resident 1's Minimum Data Set (MDS, a resident assessment tool) dated 6/26/23 indicated Resident 1 was cognitively intact. Furthermore, Resident 1 needed supervision when the resident moved between surfaces including to and from bed and into a standing position. A review of Resident 1's Change in Condition assessment dated , 7/26/23 at 4:20 a.m., by Licensed Vocational Nurse 1 (LVN 1), indicated Resident 1 had an unwitnessed fall and was found lying in bed with an injury to the left eyebrow and left forehead. A review of Resident 1's hospital History and Physical notes, dated, 7/26/23 at 5:07 a.m., indicated the resident was admitted to the Intensive Care unit (ICU, which provides treatment for critically ill patients) with diagnoses of subdural hematoma, left humeral head fracture and fracture of the pubic ramus. During an interview on 8/3/23, at 11:30 a.m., with Resident 1, Resident 1 had a hard time remembering the incident that caused his injuries. During an interview on 8/3/23, at 11: 57 a.m., with Certified Nursing Assistant (CNA) 1, CNA 1 stated, on 7/26/23 at 4:15 a.m., she was sitting in the hallway, and was approximately five feet away from the door of Resident 1's room. CNA 1 stated she heard the sound of Resident 1's walker but did not see Resident 1 get up to the bathroom and again later heard the sound of his walker. CNA 1 stated, she did not assist Resident 1 because the resident was independent in ambulating with a walker and was not a fall risk. CNA 1 further stated after two to three minutes, Resident 1's call light was turned on and when CNA 1 answered the call light, she stated she saw Resident 1 lying in his bed holding the call light with both hands. CNA 1 further stated she saw Resident 1 with a cut on his left eyebrow and a bump on his left, upper forehead. Resident 1 was refusing to move his left arm. CNA 1 stated Resident 1 was never confused in the past and was confused. Resident 1 was only able to state his name, did not know where he was, did not know his birthdate or how he fell . CNA 1 stated she did not hear Resident 1 fall but found a smear of blood outside the door of Resident 1's bathroom. CNA 1 stated Licensed Vocational Nurse (LVN)1 assessed the resident and called 9-1-1. A review of the 9-1-1 first responder, Emergency Medical Technician- Paramedic (EMT-P, a medical professional who specializes in emergency treatment) notes dated, 7/26/23 at 5:36 a.m., indicated, Per staff, patient had an unwitnessed fall at some point during the night and was found lying on his back next to his bed. Patient was assisted to his bed and staff called 9-1-1 due to increased ALOC (altered level of consciousness) and the injury to the patient's head .Staff reports that patient is normally alert and oriented x 3 (aware of time, place, and person) walking and talking. A review of Resident 1's Nurse's Note dated, 7/26/23 at 4:20 a.m., by LVN 1 indicated, Resident 1 was sent to the hospital emergency room via 9-1-1 for further medical evaluation. A review of the physician's order dated 7/27/23 at 5:00 a.m., indicated, May send resident to the ER (emergency room ) for further evaluation via 9-1-1. During a concurrent interview and record review, on 8/3/23 at 12:52 p.m., with the Administrator registered nurse (ADM), Resident 1's Fall Risk Assessment (a screening tool used to assess Resident 1's risk of falling), dated 6/17/23 was reviewed. The fall risk assessment indicated a score of 7 (10 was considered high risk for fall). The fall risk assessment indicated, Resident 1's balance problem while walking (additional score of 1) and Resident 1's medications of Losartan (a medication to control high blood pressure) and Spironolactone (a medication which makes the body get rid of extra fluids), for an additional score of 2, were not added to the initial fall risk assessment score of 7. ADM acknowledged Resident 1's fall risk assessment score should have been 10 (high risk) for falls and was scored incorrectly. ADM also stated Resident 1 was referred for physical therapy evaluation on 7/10/23 because Resident 1 was leaning forward when using the walker. A review of Resident 1's care plan, titled Falls, dated 3/13/23 indicated the resident was at risk for falls due to cardiac dysrhythmia (abnormal heartbeat) and hypotension (low blood pressure). The care plan indicated a goal that Resident 1 will be free from injuries and the interventions were, to assist Resident 1 with ADLs (activities of daily living) as needed, evaluate resident's physical abilities at least on a quarterly (every 3 months) basis .and provide cueing/supervision as needed. A review of Resident 1's care plan titled, Cognition, dated 3/13/23 indicated the resident had poor cognitive skills as evidenced by poor/lack of safety awareness with risk of injury. During an interview on 9/22/23, at 10:45 a.m., with Director of Nursing (DON), DON stated CNA 1 should have checked on Resident 1 when CNA 1 heard the resident go to the bathroom. DON stated staff were educated by the facility on fall prevention but was unable to show documentation of fall prevention training. A review of the Physician's Order dated 7/10/23 indicated for Resident 1 to have a physical therapy (PT) evaluation for gait training and muscle weakness. During an interview on 8/18/23, at 2:45 p.m., with Physical Therapist (PT) 1, PT 1 stated she did the PT evaluation on Resident 1 and Resident 1 was a high risk for falls. PT 1 further stated Resident 1 needed contact guard assist or someone had to be there to assist the resident in transferring and walking with the four-wheel-walker and told the Rehabilitation Director (RD). A review of Resident 1's Physical Therapy Evaluation and Plan of Treatment (PTEPOT), dated 7/14/23 by PT 1, indicated the goals for Resident 1 were to be safe and reduce fall risks. Also, Resident 1 needed contact guard assist (CGA, the caregiver places one or two hands on the patient's body to help with balance) in transfers and in ambulation with the four-wheel walker (FWW). During an interview on 8/29/23, at 1: 57 p.m., with RD, RD stated Resident 1 was referred for rehabilitation due to being a high fall risk and reported to ADM the result of PT 1's evaluation. During another interview, on 9/25/23 at 4:21 p.m., with ADM, ADM confirmed RD communicated Resident 1 was identified as high fall risk. A review of Resident 1 ' s fall care plan, dated 3/13/23, was not revised after PT 1's evaluation on 7/14/23 for high fall risk interventions. During a review of the facility's policy and procedure (P&P) titled, Fall Prevention Policy and Procedure, the P&P indicated, Staff will incorporate appropriate safety interventions, in the least restrictive environment, to help reduce the incidence of falls . The interdisciplinary (group of healthcare professionals working together) clinical team will use their initial assessment to determine how to provide the safest environment for each patient . Safety education is provided to patients, family, and staff . Upon admission Nursing staff will assess each resident and determine if they are a fall risk. A care plan will be initiated and carried out.

Based on observation, interview, and record review, for one of fourteen sampled residents (Resident 131) the facility failed to ensure staff provided immediate and continuous life saving measures (cardio [MEDICAL CONDITION] resuscitation (CPR) - any medical intervention used to restore circulatory and/or respiratory function that has ceased) when Resident 131 was found in bed without vital signs (clinical measurements of breaths, blood pressure, heart rate and temperature). Licensed Vocation Nurse (LVN) 3 did not continuously provide CPR. LVN 3 left Resident 131 in bed for an undetermined amount of time prior to the arrival of emergency personnel. As a result of LVN 3's inaction, Resident 131 subsequently died . The failure of LVN 3 to provide continuous CPR until the arrival of emergency personnel was determined to constitute an Immediate Jeopardy (IJ) situation. The interim Administrator (ADM) and Director of Nursing (DON) were verbally notified of the IJ on [DATE] at 1 p.m. The facility failed to ensure that staff provided basic life support in a continuous manner in an emergency situation. Through observations and interviews with the staff members and record reviews of the facility's training records, the facility showed they initiated the plan of action through training of employees regarding CPR in-service course and how to initiate a response in an emergency situation. The IJ was lifted on [DATE] at 4:23 p.m. Findings: Review of Resident 131's Admission Face Sheet, printed [DATE], indicated Resident 131 was admitted to the facility with [DIAGNOSES REDACTED]. Review of Resident 131's POLST (Physicians Order for Life Sustaining Treatment - directs individual end-of-life preferences during a medical emergency), dated [DATE], was signed by Resident 131's legally recognized decision-maker and his physician. The POLST form included .Cardiopulmonary Resuscitation (CPR) .If patient has no pulse and is not breathing .Attempt Resuscitation/CPR Review of Resident 131's (MONTH) 2019 physician's orders [REDACTED].(was) Full Code (Attempt resuscitation/CPR and other lifesaving measures). During an observation on [DATE], at 7:59 a.m., Paramedics were walking through the hallway. At 8:01 a.m. the Paramedics began CPR on Resident 131. Emergency Personnel (EP) 1 came out of Resident 131's room looking for facility staff to come in and give them information regarding Resident 131. LVN 3 walked into Resident 131's room and told EP 1 that at around 7:15 a.m. she went into the room to feed Resident 131 his breakfast and found him non-responsive. LVN 3 told EP 1 she checked Resident 131's vital signs, there were no readings, and called for help, and did CPR (on Resident 131) for three to five minutes and then stopped. In an interview with Emergency Personnel (EP 1), on [DATE], at 8:41 a.m., EP 1 stated a dispatch call for resident non-responsive was received at 7:53 a.m. and emergency personnel were on the scene (at the facility) at 7:58 a.m. EP 1 stated the emergency personnel team started CPR on Resident 131 at 8:01 a.m., performed Advanced Cardiac Life Support (ACLS - a set of clinical algorithms for the urgent treatment of [REDACTED]. During an interview with LVN 3 on [DATE], at 8:39 a.m., LVN 3 stated she was the nurse in charge for Resident 131 from 11 p.m. on [DATE] to 7:30 a.m. on [DATE]. LVN 3 stated that on [DATE], when she went to feed Resident 131 breakfast around 7:30 a.m., she found him not responsive. LVN 3 stated she immediately checked Resident 131's vital signs - there was no reading for his blood pressure, she could not feel any pulse, and there was no reading for oxygen saturation (blood oxygen level - a normal reading is typically between 95 and 100 percent), but Resident 131's body was warm to the touch. LVN 3 stated she did CPR for only three to five minutes. LVN 3 further stated at that point, the morning shift charge nurse (LVN 1) came to help assess Resident 131. LVN 3 stated LVN 1 then called 911 (emergency personnel), Resident 131's brother, and Resident 131's physician. During an interview with LVN 1 on [DATE], at 9 a.m., LVN 1 stated that he came to work on [DATE] at 7 a.m. LVN 1 stated that around 7:30 a.m. he heard LVN 3 yelling for help, so he went to check on her and saw LVN 3 assessing (check vital signs) Resident 131. LVN 1 further stated he went to check Resident 131's chart for his code status and to call 911. LVN 1 stated he also called Resident 131's responsible party, and his physician. Resident 131's unsigned Nurses Notes, dated [DATE], documented, .medications were given as ordered this morning around 6:30 a.m., and he took it. When breakfast time around 7:30 a.m., I found patient (Resident 131) not respond to me. I checked his vital signs with blood pressure machine and (oxygen) finger application, there was no reading, then I notified the a.m. charge nurse (LVN 1), and we checked the patient's chart. He is full code. I did the CPR for 5 (minutes) till I got exhausted and the a.m. nurse (LVN 1) called 911. Around 7:45 a.m., 911 came. 911 did half an hour CPR for (Resident 131). He passed away at 8:30 a.m. During an interview with Director of Nursing (DON) on [DATE], at 12:17 p.m., DON stated she received a call from LVN 1 around 7:30 a.m. stating that he was going to call 911, because Resident 131 was not responding. DON stated in an emergency, staff were expected to do CPR immediately and call 911. Review of the facility's policy and procedure titled, Emergency/Cardio [MEDICAL CONDITION] Resuscitation (CPR), undated, indicated .Purpose .To ventilate the resident until adequate circulation to the brain is re-established .Procedure .1. Summon medical aid. 2. Begin external cardiac massage (kind of external squeezing of the heart causing its voiding and filling to a certain extent and thus preserving cardiac output and blood flow to vital body organs for the duration of the resuscitation) and assisted ventilation (any artificial method of ventilation in which air is forced into and out of the lungs of a person who has stopped breathing) within four minutes immediately after the following symptoms occur .a. No pulse. b. No respirations. c. No heartbeat. d. Unconsciousness .ESSENTIAL POINTS .Once CPR is initiated, it must be continued until help arrives