Every finding on record at Ashley Rehabilitation and Health Care Center

Based on observation, interview and facility document review, the facility failed to ensure that the food preparation equipment and environment were maintained in a clean and sanitary condition to prevent contamination and potential development of foodborne pathogens in one of one kitchen observed. The findings include: During an observation of the lunch meal preparation on 05/13/2026 at 10:45 AM, [NAME] #6 was observed pureeing rice. [NAME] #6 took the lid off the chicken base put it upside down on the preparation table, obtained the needed amount of chicken base in the container with a plastic spoon and mixed it in a container of water. [NAME] #6 then put the lid on the container of chicken base and placed the spoon on the lid of the closed container, which touched the un-sanitized preparation table. [NAME] #6 then took the dirty blender, used for pureeing the rice to the dishwasher, ran it through the dishwasher, carried the blender back to the preparation table, and started pureeing the tortillas without washing her hands, or wearing gloves. [NAME] #6 opened the lid of the same chicken broth used for the rice puree, used the same plastic spoon, that was on top of the dirty chicken base lid, and without washing the spoon obtained the needed amount of chicken base, and placed the spoon's contents in another pan of warm water to puree the tortillas. During preparation of mechanically chopped fajitas, [NAME] #6 took the lid off the blender, placed it bottom side down on the food prep table, used an ungloved hand to pull the blade out of the blender, and placed the blade on top of the blender. [NAME] #6 then sprayed a pan with non-stick spray using an ungloved hand and poured the food into the pan. Without performing hand hygiene, [NAME] #6 then used an ungloved hand to put the blade back into the blender before preparing another batch of mechanically chopped fajita meat. During an observation of the lunch meal service on 05/13/2026 at 12:10 PM, [NAME] # 6 was observed having not performed handwashing before the meal service began. [NAME] #6 then opened a package of six-inch tortillas with ungloved hands, plated rice and beans with a scoop, took a tortilla out of the package with ungloved hands, and placed the tortilla on the plate. Gloves were not worn while handling and placing food on each plate. During an observation of lunch service on 05/13/2026 at 12:10 PM [NAME] #6 was observed pushing her glasses up onto her face, on two separate occasions, then taking a scoop that had fallen into the food to the sink, washing it off and replacing the scoop into the food. [NAME] #6 then wiped her hands on her apron and used the same ungloved hand to handle tortillas during preparing the plates. No hand hygiene was performed during this observation. During an interview on 05/13/2026 at 12:25 PM, the Dietary Manager (DM) stated staff were expected to wash their hands between dirty and clean tasks. The DM indicated that the outside of the tortilla wrapping was not sanitary and staff should have washed their hands or used a utensil to obtain the tortillas. During an interview on 05/14/2026 8:20 with [NAME] #6 stated I wash my hands after I touch everything to prevent cross contamination. Review of a facility policy on glove usage, dated May 2015 revealed to ensure safe and proper food handling during food preparation and service, food items should not be handled with bare hands. Hand washing per guidelines should occur between each task, gloves should be worn if handling food is necessary. Hands should be washed after handling dirty dishes and when changing task. Review of a facility policy titled, Handwashing, dated May 2015 listed the following guidelines: Roll down paper towels Turn on water and run until it is warm. Lather hands with antiseptic soap Wash hands, giving particular attention to the areas between fingers, around cuticles and fingernails. Wash forearms Rinse thoroughly with warm water, beginning at the top of the forearm Wipe hands dry with clean paper towel Turn off water with paper towel and dispose of paper towel Review of an employee in-service dated 03/01/2026 titled, Dietary infection Control, indicated to wash hands with soap and water, before beginning work, after handling raw food, after touching waste or trash and after touching face. [NAME] #6's signature was present as having attended the in-service. Review of an employee in-service dated 01/21/2026 titled, Glove use in Food Service, indicated to use gloves when handling ready to eat foods which will not be cooked to a safe temperature such as hamburger buns. [NAME] #6's signature was present as having attended the in-service.

Based on observations, interviews, facility policy, and record reviews, it was determined the facility did not consistently follow the supplied menu for 57 of 57 residents who received meals from the facility. The findings include: Review of the Spring/Summer 2026 menu revealed that on week one, day three, milk (1 cup) was to be served during breakfast, lunch, and dinner. During an observation of the lunch meal service on 05/13/2026 at 12:10 PM, it was observed that milk was not served to the residents. During an observation on 05/13/2026 at 23:30 PM, the refrigerator was observed to contain individual servings of milk. The refrigerator also contained seven gallons of 2% milk, four gallons of whole milk and four cases containing 25 individual chocolate milk cartons. Review of a detailed food order with a delivery date of Friday 05/08/2026 revealed the following milk was ordered for 57 residents to last until Monday 05/11/26. -2 cases which contained 25 containers of 8-ounce 1% chocolate milks. -2 cases which contained 25 containers of 8-ounce Homogenized fresh milks. -2 cases which contained 25 containers of 8-ounce 2% fresh milks. During an interview on 05/13/26 at 1:15 PM, the Dietary Manager [DM] reported that even though milk was on the menu, the facility only offered it twice a day. The DM reported she was not sure how much to order, so she just ordered milk but did not calculate the amount. During an interview on 05/14/2026 at 11:57 AM, the Administrator reported their expectations of the dietary staff were that staff were to follow the approved menu, and to order food supplies in advance and in an adequate supply to serve the facility residents what was listed on the menu. If the facility did not have milk available to serve to the residents, they expected the kitchen staff to notify the Administrator, then take the credit card and purchase milk for the residents. Review of a facility in-service titled, Menu Substitution Record, dated 01/21/2026, revealed a menu substitution record should be used when the facility was out of an item or used something else in place of the item that was out. An example of the menu substitution record was attached which included the date, scheduled food item, the reason for and what was substituted, and places for initials of the employee and registered dietician.

Based on observations, interviews, record review and facility policy review, it was determined that the facility failed to provide wound care in a manner to prevent infection for two (Resident #4 and Resident #5) of five residents reviewed for wound care. Specifically, staff performing wound care did not perform hand hygiene after contaminating their hands and before touching wound care supplies or applying ointments and dressings, and an impervious barrier was not used to prevent the contamination of wound care supplies. The findings include:Resident #4Review of Resident #4's Face Sheet, indicated the facility admitted Resident #4 on 03/19/2026 with diagnoses that included cellulitis, type 2 diabetes mellitus, protein-calorie malnutrition, venous insufficiency of the bilateral lower extremities, cognitive communication deficit, chronic venous hypertension with inflammation of bilateral lower extremities and candidiasis (fungal infection) of skin and nail.Review of an admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 03/21/2026, revealed Resident #4 had a Brief Interview of Mental Status (BIMS) score of 12 which indicated the resident had moderate cognitive impairment. The MDS also revealed Resident #4 was admitted with a stage 2 pressure ulcer, treatments included a pressure reducing device of the chair, pressure ulcer care, application of non-surgical dressing, and application of ointments/medications.Review of Resident #4's Care Plan dated 03/20/2026 revealed the resident had a stage 2 pressure ulcer to the sacrum, bilateral lower extremity cellulitis, and candidiasis to the groin. Interventions included treatment to site per orders and monitor and record signs or symptoms of deterioration or infection.Review of Physician Orders dated 04/27/2026 revealed Resident #4 had an order to cleanse the inner gluteal fold bilaterally with wound cleanser, pat dry, apply collagen to the wound areas, and cover with hydrocolloid dressing. Change every Monday, Wednesday, and Friday and as needed due to soilage or dislodgement.During an observation on 04/27/2026 at 10:21 AM, the Infection Preventionist (IP)/Treatment Nurse (TN) performed hand hygiene, pulled keys out of her pocket to unlock the treatment cart drawer, put her keys back in her pocket then retrieved a tube of ointment from the cart. She applied a glove to her left hand, cleansed the tube off with a wipe and rolled the tube down to squeeze the contents into a medicine cup. The TN then performed hand hygiene. TN applied Personal Protective Equipment (PPE) then cleaned the bathroom counter with soap and water using a paper towel. A second paper towel was used to dry the counter off. The TN then placed a non-impervious third paper towel down as a barrier for her supplies. The wound bled during wound cleaning. The TN stopped and contacted the provider for further orders. The TN returned to the treatment cart in the hallway and used her cell phone to call the provider for new orders. The new orders were placed into the computer system. The TN then retrieved the keys out of her pocket, unlocked the cart and replaced the keys in her pocket. She retrieved a 2x2 sheet of collagen and hydrocolloid dressing still in the package, placed gauze pads into a plastic cup and sprayed them with wound cleanser. No hand hygiene was performed after touching the keys from her pocket and no gloves were applied prior to touching the gauze pads in the cup. The TN applied a PPE gown and performed hand hygiene in the resident's bathroom then applied gloves. The packaging for the 2x2 sheet of collagen and hydrocolloid dressing were opened. Resident #4 pulled self-up with grab bar in bathroom and TN cleaned the wound with the gauze pads from the cup. The TN then changed her gloves and applied the collagen pad and dressing. No date or initials were added to the dressing. The TN did not perform hand hygiene after touching the phone, computer, or keys prior to gathering the supplies. The gauze was touched with ungloved hands then later used to cleanse the wound. Resident #5Review of Resident #5's Face Sheet, revealed the facility admitted Resident #5 on 06/30/2025 with diagnoses that included congestive heart failure, protein-calorie malnutrition, hypertension, gastric reflux disease, neuromuscular dysfunction of the bladder, stage 3 pressure ulcer of the right hip, calculus ureter, urethrocutaneous fistula urinary tract infection, and a heart attack. Review of a quarterly MDS, with ARD of 04/20/20226, revealed Resident #5 had a BIMS score of 12 which indicated the resident had moderate cognitive impairment. The MDS revealed Resident #4 had a stage 3 pressure ulcer. Treatments included a pressure reducing device for the chair, pressure ulcer care, application of a nonsurgical dressing, and application of ointments/medications. The MDS also revealed Resident #5 had an indwelling catheter. Review of Physician Orders revealed Resident #5 had an active order dated 04/17/2026 to cleanse the stage 3 pressure ulcer to the right hip with wound cleanser, pat dry, apply skin prep to peri wound, apply a hydrogel, and cover with a border foam dressing on Monday, Wednesday, and Fridays. An active order dated 04/21/2026 indicated to apply calcium alginate with silver to the wound bed related to copious amounts of exudate and secure with a bordered foam dressing every Monday, Wednesday, and Friday. During an observation on 04/27/2026 at 10:50 AM, the TN stated she cleaned her cart off this morning prior to the beginning of wound care observations. The TN pulled keys out of her pocket, opened the cart, put the keys back in her packet, and touched the computer. The TN stated she looked up the order which called for calcium alginate with silver and pulled one out of the drawer with a border foam dressing. The TN retrieved tape, a split drain gauzed, and scissors from the drawer. The TN then performed hand hygiene, applied gown, then got two plastic cups. TN put gloves on, put gauze pads in the cups and sprayed them with wound cleanser. TN took off her gloves. She entered the resident's room and retrieved a wet, soapy paper towel from the bathroom and cleaned off half of the resident's bedside table with the paper towel and soapy water, a second towel was used to dry the table. TN then placed a non-impervious third paper towel down as a barrier for her supplies. The other half of the resident's table had a basin bucket with many items including straws and cups. The straws were hanging over the wound supplies. TN then washed her hands in the bathroom for six seconds, dried her hands, and donned new gloves. The old dressing was removed from Resident #5's right hip and new gloves applied. No hand hygiene was performed from dirty to clean task. The gauze pad from one cup was used to clean the hip pressure ulcer, then without changing gloves or performing hand hygiene the gauze pads from the second cup were used to clean the resident's supra pubic catheter. The TN stated it had drainage and was cauterized last week. The TN removed her gloves, did not perform hand hygiene and placed the split drain gauze around the supra pubic catheter, placed the calcium alginate to wound bed of the right hip, and the border dressing to the right hip pressure ulcer. The TN left the room and placed the scissors on the cart and stated, I did not use these, so I don't have to clean them.During an interview on 04/27/2026 at 11:07 AM, the TN stated, she usually used the resident's bedside table to set up wound care supplies and made sure it was clean. She stated she also cleaned Resident #4's bathroom counter with soap and water and used a different towel to dry it. TN stated hand hygiene was performed when she entered the room and after touching anything dirty. TN acknowledged hand hygiene should be performed when she went from dirty to clean like touching personal belongings and before she left the room. The TN stated, I changed my gloves from pulling off the dressing but did not wash my hands. The TN indicated she should have changed gloves before going to secondary dressing. Also, I am IP and know that you should wash your hands when going from dirty to clean. I changed my gloves between taking off the hip dressing but did not wash my hands. The TN revealed she had not been given any wound care training. She volunteered when the facility had issues with wound care and needed someone. I am still learning. I need more practice.During a follow up interview on 04/27/2026 at 4:37 PM, the TN stated on Thursday 04/23/2026 she had asked facility administration about receiving some wound care training but had not received any answers. During an interview on 04/28/2026 at 9:38 AM, referring to Resident #5 the Nurse Practitioner (NP) stated, the nurse should clean the supra pubic catheter, and the pressure ulcer wound one at a time. The NP stated, I would not want to get what could be in a wound in the supra pubic catheter. The TN stated she believed setting up wound cleaning supplies next to personal items was not a common practice since it would be an infection control issue. The NP stated she expected the TN would have completed courses in wound care but did not know what the facility required.During an interview on 04/28/2026 at 12:35 PM, the Director of Nursing (DON) stated the TN had been doing wound care since around November of 2025. She had no certification in wound care, and no specific training was provided to her by the facility. The DON's expectations for wound care were to provide quality care and follow the providers' orders. The DON stated she believed the TN was a wound care nurse at another facility before the current facility. The DON stated she was a wound care nurse years ago and that TN could come to her anytime there was a question and the NP was readily available. I have watched her provide wound care and I had no concerns. The DON stated the TN should clean her hands and change gloves when going from dirty to clean tasks during wound care. The two different areas of the supra pubic catheter and the pressure ulcer should not be treated at the same time because of the concern for potential infection. Dressings should be dated as a standard of practice with wound care. Workspace areas such as bedside tables should be clean and uncluttered with no resident items on the bedside table. The DON stated the bedside tables should be cleaned with a disinfectant, soap and water would not be the same as being cleaned with a disinfectant. The DON suggested staff should wash hands to a common song for about 90 seconds and that washing for only six seconds was probably not an appropriate amount of time. Review of an undated facility policy titled Wound Care and Treatment revealed, Clean technique is used. Sterile technique would be used with fresh surgery wounds. Care must be taken to prevent contamination of the supplies and surfaces used in wound care. Supplies should be set up on a clean surface, and the surface should be covered with an impervious barrier before putting supplies down. Hand washing must be done as outlined in the guidelines. After removing dirty dressing gloves should be removed, and hands should be washed prior to putting on clean gloves. New dressings should be labeled with the nurse's initials, date, and time.Review of an undated facility policy titled Handwashing revealed steps to handwashing but did not specify a timeframe for hand washing.Review of an article from the Centers for Disease Control (CDC) titled, About Hand Hygiene for Patients in Healthcare Settings, recommendation dated 02/27/2024, revealed Patients in healthcare settings are at risk of getting infections while receiving treatment for other conditions. Steps to washing your hands with soap and water included wet hands, apply soap, rub your hands together until soap is lathered then rub all over including between hands and under fingernails. Continue rubbing for at least 15 seconds, rinse hands well, and dry hands. Wearing gloves alone is not enough for a healthcare worker to prevent the spread of infection.

Number of residents sampled:5Number of residents cited:3Based on interviews, facility record and policy reviews the facility failed to ensure consistent behavior monitoring with antipsychotic medications; failed to ensure antipsychotic medications were prescribed for an indicated diagnosis; failed to gradually reduce or eliminate antipsychotic medications with no documented behaviors for 3 (Residents #4, #7 and #41) of 5 residents reviewed for unnecessary medications. The Findings are:Based on record review, interviews, and facility policy reviews, the facility failed to ensure antipsychotic medications were prescribed for an appropriate indicated diagnosis and failed to gradually reduce or eliminate antipsychotic medications for residents with no documented behaviors for two (Resident #4 and Resident #41) of five residents reviewed for unnecessary medications. The findings include: Resident #4 Review of a quarterly Minimum Data Set [MDS] with an Assessment Reference Date [ARD] of 10/28/2025 revealed, Resident #4 had a Brief Interview for Mental Status [BIMS] score of 00, which indicated Resident #4 was severely impaired. The MDS also indicated Resident #4 had diagnoses which included non-Alzheimer's dementia and that the resident had no behaviors within the lookback period. Review of a Care Plan Conference with a last reviewed date of 11/22/2025 revealed, Resident #4 had diagnoses which included dementia with agitation. Resident #4 had impaired cognition, impaired thought processes and impaired decision making. Intervention included, monitor as needed for any changes in cognition and mental status. Resident #4 used antipsychotic medications related to maladaptive behaviors with agitation. Interventions included, monitor antipsychotic medications as ordered by the physician, monitor for side effects, review behaviors with the provider and families for the ongoing need and monitor and document any adverse reactions, behavior symptoms not usual for the resident. Resident #4 was combative and resistant to care. Review of a Physician Order Report dated from 11/12/2025 through 12/12/2025 revealed Resident #4 had an order for behavior monitoring to be documented every shift. Resident #4 had additional diagnoses that included mental and behavioral disorders. An order for an atypical antipsychotic 25 milligram [mg] 2 tablets to equal 50 mg, diagnosis dementia with agitation once a day was indicated. As well as an order for an anticonvulsant 250 mg twice a day for mental and behavioral disorders. A review of a Request for Reduction of Anti-psychotic Medication Report dated September 2025 indicated antipsychotic 25 mg three tablets to equal 75 mg every morning and 200 mg every evening for dementia with agitation since 4/18/2025. A warning statement of Increased Mortality in elderly patients with dementia-related psychosis was indicated as follows; Elderly patients with dementia-related psychosis treated with antipsychotic drugs are at an increased risk of death. [Brand of atypical antipsychotic medication] is not approved for the treatment of patients with dementia-related psychosis. In the absence of current documentation indicating the need for the medication, consider reduction of the morning dose down to 50mg when the current supply is exhausted or document clinical rational for denial of the reduction. The form is unsigned, during an interview with the on 12/11/2025 at 1:26 PM, the Director of Nursing (DON) reported this document was a copy of the original document received and reviewed by the Medical Director. During an interview on 12/11/2025 at 1:26 PM, the DON reported behaviors and anxiety were not appropriate diagnoses for an antipsychotic to be ordered for residents. During an interview on 12/11/2025 at 1:27 PM, the Administrator reported anxiety, and behaviors were not appropriate diagnoses for an antipsychotic medication. During an interview on 12/12/25 at 9:07 AM, the DON reported that an antipsychotic was not indicated for the use in dementia and anxiety. Resident #4's Behavior Monitoring Sheets were provided for review which indicated there were no behaviors documented for the last year that would indicate the continued use or no Gradual Dose Reduction (GDR) of the antipsychotic medication. Resident #41 Review of a quarterly MDS with an ARD of 11/13/2025 revealed Resident #41 had a BIMS of 15, which indicated the resident was cognitively intact. The MDS also indicated Resident #41 had no behavior symptoms or rejection of care during the look back period. Review of a Care Conference Report for Resident #41 last reviewed date of 11/22/2025 revealed Resident #41 had diagnoses which included depression and anxiety. Resident #41 used an antidepressant related to a history of depression. Interventions included monitoring side effects and effectiveness every shift. Resident #41 received an antianxiety medication. Review of the Physician Order Report dated from 11/12/2025 through 12/12/2025 revealed antianxiety medication 5 mg 1 tablet by mouth for a diagnosis of anxiety disorder twice a day, initiated 11/25/2025. Antianxiety medication 10 mg 1 tablet by mouth for depressive episodes once a day, initiated 11/26/2025. Antianxiety medication 0.5 mg 1 tablet by mouth twice a day, for anxiety disorder initiated 10/27/2025. During an interview on 12/12/2025 at 9:07 AM, the DON reported they thought a dose reduction had been completed since September 2025. The Behavior Monitoring Sheets were provided for review, and the DON was asked to explain what the check marks and the 0's indicated. The DON reported on one Electronic Medical Record [EMR] from January 2025 through June 2025 the check marks indicated no behaviors. The behavior documentation from January through June of 2025 was reviewed and out of 543 shifts, 524 were checked as no behaviors. The 0's that were reviewed from July 2025 through November 30, 2025, indicated that 459 of 459 shifts documented had no behaviors to indicate the need for the antidepressant or the antianxiety medication. The DON also reported there were four indicators for the use of antipsychotic medication. They were schizoaffective disorder, bipolar depression and schizophrenia, the DON could not recall the fourth diagnosis. The DON reported that antipsychotic medication was not an appropriate treatment for anxiety. The DON reported that residents are evaluated for antipsychotic medication after assessments, observations, and a discussion with the provider. The DON indicated that if an antipsychotic was prescribed without an approved diagnosis, then they would have a discussion with the provider and get Geri-Psych involved if needed. The DON reported that for a change of antipsychotic medication, the change was discussed with the provider and the pharmacist. The DON reported if a medication was used other than the manufacturer's recommendation for use, clinical or evidence-based practice guidelines, or standards of practice, that the rational for use would be if it enhanced the resident's quality of life. The DON reported that without behaviors documented, the medications could have been reduced more or even eliminated. The DON reported that they expected facility staff to follow the facility policy. Review of a facility policy titled Medication Monitoring and Management with an effective date of July 2021 indicated, that to optimize the therapeutic benefit and minimize or prevent the potential for adverse reactions, facility staff, the provider, and the consultant pharmacist perform ongoing monitoring for appropriateness, effectiveness and safe use of the medications. When a resident had a new medication order, the order should have been evaluated to ensure the dose, duration and monitoring were consistent with the current clinical practices, guidelines and/or manufacturers specifications for use. The provider documented in the residents record the clinical rational for using a medication outside these stated guidelines. The medication should be re-evaluated periodically to determine if prolonged or indefinite use of the medication would be indicated. The provider, facility staff and consultant should document progress that would indicate maintenance of or regression from therapeutic goals. When a resident's clinical condition had improved or stabilized the resident should be evaluated for the appropriateness of tapering or a gradual dose reduction [GDR] of the medications. Antipsychotics, the facility must attempt a GDR in two separate quarters, with at least one month between the attempts, within the first year, unless there are documented contraindications. With other psychopharmacologic [a study of the effects of medication on the mind, mood or behavior] medications the facility must attempt a GDR during at least two separate quarters, with at least one month between attempts, unless there is a documented clinical contraindication [anything including a symptom or medical condition that is a reason for a person to not receive a particular treatment or procedure because it may be harmful]. Professional standard of practice regarding the contraindication of psychopharmacological medications emphasizes thorough patient evaluation, informed consent, comprehensive documentation, ongoing monitoring, and the use of the least restrictive, evidence-based treatment. Review of the Post Acute and Long-Term Care Association undated report information, from Post Acute and Long Term Care Organization [PALT.ORG], titled Professional Standard of Practice with Antipsychotic Medications revealed the professional standard of practice with antipsychotic medications involves a careful evaluation of the need for these medications, ensuring they are used only after a thorough diagnostic evaluation and clear consideration of the risks and benefits. The use of antipsychotic medications should be based on professional standards of practice. The Centers for Medicare and Medicaid Services guidance emphasizes the importance of documenting the clinical rationale for prescribing antipsychotic medications, including the indication for use, monitoring, and the absence of adverse effects. Additionally, the guidance includes protocols for the gradual reduction of psychotropic medications when appropriate, ensuring personalized assessment and ongoing evaluation of the resident's needs.

Based on observations, interviews, and facility document review, the facility failed to ensure the privacy and confidentiality of residents' protected health information (PHI) was maintained for 1 (200 hall) of 1 hall of the facility. The findings include: During an observation on 06/06/2025 at 8:45 AM, Registered Nurse (RN) #5 was in room [ROOM NUMBER]. An unattended medication cart was on the 200 hall. A computer was sitting on top of the medication cart with the screen open to an electronic medication administration screen for Resident #6. During an observation on 06/06/2025 at 8:56 AM, RN #5 prepared a medication for Resident #8, locked the medication cart, entered a resident ' s room and left the computer screen open to Residents #8 ' s medication administration screen. During the observation, residents and staff were ambulating on the hall past the medication cart. During an interview on 06/06/2025 at 8:59 AM, RN # 5 stated they had been a nurse for 13 years, and began working in this facility one year ago, this July. RN #5 stated the computer screen should have been locked so the resident information was not visible to anyone walking by, because it was a HIPAA [Health Insurance Portability and Accountability Act] violation. During an interview on 06/06/2025 at 11:28 AM, the Director of Nursing stated all staff received training in PHI upon hire, and PHI was emphasized during trainings. Staff should have locked the computer screen when they walked away, because it was a breach of confidentiality. During an interview on 06/09/2025 at 10:43 AM, the Administrator stated computer screens should be locked, and not visible, to protect resident medical information. A review of an undated facility document titled, Resident Rights, indicated, N. Information contained in a resident's record shall be kept confidential .O. Each resident shall be treated with consideration, respect and dignity, including privacy in treatment and care of personal needs. A review of an undated facility document titled, Resident Rights and Responsibilities, indicated, Privacy and Confidentiality: . Resident's medical records are maintained in order and . They are available to authorized personnel only.

Based on observation, interview, and facility policy review, it was determined the facility failed to ensure staff performed hand hygiene after care of a resident and before and after medication administration for three (Resident #6, #8, and #9) of three residents observed. The findings include: During an observation on 06/06/2025 at 8:45 AM, Registered Nurse (RN) #5 was in a resident's room and placed a call light in reach of Resident #9. RN #5 exited the room, with no hand hygiene, and returned to the medication cart. RN #5 removed a medication card from the cart and placed medication into a medication cup, then provided it to Resident #6. During an observation on 06/06/2025 at 8:52 AM, RN #5 removed a clean medication cup, opened a bottle of vitamin D, poured one pill into the palm of their right ungloved hand, and placed the pill into the medication cup. RN #5 completed placing additional medications into the cup, then provided the medication cup to Resident #8. No hand hygiene was performed between residents. During an interview on 06/06/2025 at 8:59 AM, RN #5 stated they had been a nurse for 13 years and had worked for the facility for one year, in July. RN #5 stated hands should be sanitized between residents, due to the possibility of spreading germs from one resident to another. RN #5 stated the vitamin D did not have a screw top lid. RN #5 removed the vitamin D bottle from the medication cart and demonstrated the lid was a flip top. RN #5 stated the vitamin D should have been placed directly into the medication cup, and not into their ungloved hand. During an interview on 06/06/2025 at 11:28 AM, the Director of Nursing (DON) stated hand hygiene should be done frequently, before and after contact with residents and RN #5 should have washed their hands before walking out of a resident room, and again before dispensing medication, and before and after the next resident. The DON stated the pill and bottles become contaminated if touching the hand, and RN #5 should have worn gloves. During an interview on 06/09/2025 at 10:43 AM, the Administrator stated the expectation was for staff to perform hand hygiene any time it was necessary. Sanitizer should be used between residents, unless they provided direct brief care, then they should wash their hands, due to the importance of infection control purposes, there is a risk for cross contamination. The Administrator stated trainings on hand hygiene were done monthly on the 15th, unless that fell on a weekend, then would be done on the following Monday. During an interview on 06/09/2025 at 11:30, the Infection Preventionist/Medical Records (IP/MR) stated staff should be performing hand hygiene between residents, before and after patient care, and depending on activity. A nurse passing medications should be washing their hands before and after care, administration of insulin or checking blood sugar. Sanitizer should be used between residents when passing medications. The IP/MR stated generally, staff were taught to wash after the three uses of sanitizer. When staff are in a resident's room moving a resident table, handing the resident their call light, or resident's water, staff should be sanitizing. The nurse should have sanitized between giving residents medications and should not pour medication into their hand. Hand hygiene is important to prevent the spread of infection, protection of the residents and themselves. A review of a facility policy titled, Medication, Administration Guidelines, revised 02/07/2013, indicated, Guidelines 1. Bring cart to resident room . 5. Wash hands. A review of a facility policy titled, Handwashing and Hand Hygiene, effective January 2009, indicated, Policy: This facility recognizes the importance of handwashing or use of alcohol-based rubs in controlling the spread and acquisition of nosocomial infections .Hand Hygiene: .Handwashing or use of alcohol-based hand rubs .most effective means of preventing and controlling the spread of infection .When: .1. Before and after contact with a resident .7. Before preparing medications and as appropriate throughout the medication distribution. A review of a facility policy titled, Hand Cleanser, Alcohol Based Hand Sanitizer, dated 2018, indicated, Purpose: Clean the hands between resident contacts Prevent spread of infection . Clean Your Hands Frequently! .Hand hygiene is the single most important step you can take to reduce transmission of infectious agents .Clean your hands before and after contact with a resident or resident's environment. This includes before and after entering a resident room .

Based on record review, interview, and facility policy review the facility to administer Cardiopulmonary Resuscitation (CPR) upon discovering 1 (Resident #62) sampled resident pulseless and breathless despite the resident being a full code. The Facility notified of the Immediate Jeopardy on [DATE] at 1:40 PM. The Facility Plan of Removal (POR) noted the facility will continue CPR upon discovering a resident pulseless and breathless when the resident is a full code signed [DATE]. The findings include: According to the quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of [DATE] Resident #62 had a Brief Interview of Mental Status of 15 indicating cognitively intact. Resident #62 had diagnoses of heart failure and morbid obesity. A review of the plan of care for Resident #62 (initiate date: [DATE]) noted Resident #62 was full code if found pulseless and breathless imitate CPR until emergency medical services (EMS) arrive to take over. Resident #62's family signed a Physician Order for Life Sustaining Treatment (POLST) on [DATE] electing to receive CPR if needed. A review of a Health Status Note date [DATE] revealed about 6:19 AM Resident #62 discovered pulseless and breathless. Resident #62 was assessed by two other nurses in building. EMS was called and arrived 6:25 AM. EMS initiated CPR with 5 rounds of epinephrine, but no signs of life was found. Physician was called and updated on the resident status. A review of the medical records showed the last vital signs recorded was on [DATE]. The was no documentation within the medical records that CPR was initiated, or vital signs were taken on [DATE] when Resident #62 was found breathless and pulseless. On [DATE] at 8:50 AM, during an interview the Director of Nursing (DON) stated the Resident #62 was a full code and plan of care noted if the resident was found pulseless and breathless administer CPR until emergency personnel arrive to take over. The DON stated there was no documentation that CPR was administered. On [DATE] at 09:45 AM, the Surveyor requested the facility policy or procedure on when to initiated or withhold CPR. On [DATE] at 10:00 AM, the Surveyor was provided a policy on CPR administration. On [DATE] at 10:25 AM, the Surveyor requested the facility policy or procedure on when to withhold CPR. The Surveyor specifically asked for something stating the circumstances on when staff should not administer CPR. On [DATE] at 11:00 AM, the DON stated the facility does not have a policy and procedure on when CPR should be withheld. On [DATE] at 12:22 PM, during an interview the EMS dispatcher stated the EMS report noted when EMS arrived two staff members standing at the resident bedside not administering CPR and one of the staff members stated she had received an order to withhold CPR for the physician. On [DATE] 04:45 PM, the Director of Nursing stated that the nurse called the Physician that morning and he gave orders to withhold CPR. On [DATE] at 8:44 AM, during an interview the Physician stated he does not remember giving an order to withhold CPR for Resident #62 on [DATE]. On [DATE] at 12:37 PM, during an interview Licensed Practical Nurse (LPN) #8 stated she was coming on shift and when she entered the Resident #62's room [ROOM NUMBER] nurses were standing at the resident bedside no one was administering CPR. LPN #8 stated she touched the resident, and the resident was cold to touch so she called Physician and informed him the resident was cold to touch with no vitals. LPN #8 stated did Physician did not give any orders. LPN #8 stated she did not get vital signs, nor did she observe the resident's vital being taken. LPN #8 stated shortly after the Physician was called EMS arrived and initiated CPR. A policy titled Cardiopulmonary Resuscitation noted begin chest compression if the resident is not breathing. Onsite Verification: The IJ was removed on [DATE] at 2:16 PM after the survey team performed onsite verification that the Removal Plan had been implemented. Onsite verification of the Removal Plan began on [DATE] at 2:48 PM when a cardiopulmonary (CPR) in-service was initiated by the Director of Nursing (DON). DON reviewed all physician orders, care plans, and signed Do Not Resuscitate (DNR) documents for code status. Color coded name plates were placed outside resident doors, green for full code and red for DNR. An in-service was provided to staff and new hires regarding color coded name plates and monthly Quality Assurance and Performance Improvement (QAPI) is to ensure continued employee education. A total of 14 staff interviews were conducted with staff from all positions to verify training had been completed. The staff interviewed included Certified Nursing Assistants, Licensed Practical Nurses, a Registered Nurse, an Occupational Therapist, the Maintenance Supervisor, the Activities Director, and the Director of Nursing. The staff interviewed verified they had been trained on CPR initiation and how to identify DNR or full code residents. A review of in-service sheets provided indicated 34 of 64 had been provided training. Those staff who were not physically present to receive the in-services were messaged via telephone by the Administrator, with the in-service information provided and the employee acknowledging receipt and voicing understanding.

Based on observations, interviews, record review, document review, and facility policy review, the facility failed to ensure a resident was free from abuse for 1 (Resident #5) of 3 sampled residents reviewed for abuse. Specifically, the facility failed to ensure Resident #5 was free emotional abuse. The Immediate Jeopardy began on 09/02/2024, when CNA #4 made inappropriate statements to Resident #5 when she walked into the shower room while Resident #5 was taking a shower with help of CNA #4. CNA #4 and showed an inappropriate picture to Resident #5. The facility failed to investigate this incident until 09/09/2024. The facility had failed to train staff in abuse and neglect. The findings included: The Administrator became aware of the alleged abuse on 09/09/2024 and completed an Office of Long Term Care (OLTC) Incident and Accident (I&A) Report on 09/09/2024 at 11:10 AM. The report indicated that the alleged abuse occurred on 09/02/2024 and indicated that Resident #5 was taking a shower with the help of Certified Nursing Assistant (CNA) #5 when CNA #4 entered the shower room and commented that Resident #5 had a nice butt. The report shows that steps taken during the investigation were as follows: Immediately suspended pending investigation. Abuse and Neglect in-service conducted and that Resident #5's family came to facility and was taking the resident out of facility for a couple of days to de-sensitize him. During this survey it was found that CNA #4 was working in the facility again and had worked on the hall where Resident #5 resided during the night (11:00 PM-7:00 AM) on 10/31/2024. The Administrator and Director of Nursing Services were notified of the Immediate Jeopardy on 11/01/2024 at 1:46 PM. A Removal Plan was requested. Removal Plan was accepted on 11/04/2024. These are the findings: A Review a facility policy titled, Abuse and Neglect Policy and Procedure, revised on 11/20/2017, indicted, Guidelines will be established to protect residents from individuals that have allegedly committed abuse or have shown indication that would cause abuse. The quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 10/04/2024, revealed Resident #5 had a Brief Interview for Mental Status (BIMS) score of 12 which indicated the resident had moderate cognitive impairment. A review of Resident #5's care plan initiated on 03/24/2020, revealed the resident had an Activity of Daily Living (ADL) self-care performance deficit. Interventions included the resident could perform most ADL functions with one person supervision with limited assistance. Review of a Progress Note, dated 09/08/2024, indicated Resident #5 was upset regarding a situation that occurred earlier in the week with a staff member. Resident #5 had a nightmare last night about the incident and was not in a good mood and didn't want to leave his room. Review of a Progress Note, dated 09/09/2024, indicated that Resident #5 was observed leaving activities and being upset. Resident #5 was observed holding his left wrist to his mouth and biting it causing it to bleed and leaving a bite mark. A review of CNA #5's, OLTC Witness Statement dated 09/09/2024 at 9:55 PM, indicated the following: A co-worker (CNA #4) entered the shower room and made comments to Resident #5 that were inappropriate, and Resident #5 was traumatized by the incident. A review of Resident #5's, OLTC Witness Statement dated 09/09/2024 indicated the following: Resident #5 was taking a shower with the help of CNA #5 when CNA #4 entered the shower room and told resident he had a big, beautiful butt and that she had a big, beautiful butt and proceeded to show the resident a picture on her phone. During an interview on 10/31/2024 at 11:45 AM, the Administrator indicated that he was made aware of the situation and asked his Director of Nursing (DON) to talk to the Resident. The Administrator advised that he was going to suspend CNA #4 over this incident pending the investigation, but CNA #4 was involved in an automobile accident, so the Administrator used this time as her suspension. During an interview on 10/31/2024 at 11:45 AM, the Administrator indicated that he rehired CNA #4 and part of the plan to keep Resident #5 safe was that CNA #4 was to not work on the hall were Resident #5 resided or go into Resident #5's room. The Administrator was asked if CNA #4 worked last night (10/31/2024) and what hall she was assigned to. The Administrator indicated that CNA #4 did work last night (11:00 PM-7:00 AM shift) and that she was assigned to the hall Resident #5 resided on. The Administrator was asked why CNA #4 was assigned to the hall, where Resident #5 resided. The Administrator indicated that if CNA #4 did not work last night, he would not have had enough staff. During an interview on 11/01/2024 at 11:55 AM, the Surveyor spoke with Resident #5. Resident #5 was asked if anyone at the facility had upset the resident. Resident #5 indicated that CNA #4 showed the resident a picture and the resident didn't like it. When asked what the picture was of, Resident #5 indicated her (CNA #4) body with no clothes on her butt. Resident indicated while taking a shower with the help of CNA #5, CNA #4 walked into the shower room where the resident was taking a shower and told Resident #5 that the resident had a big, beautiful butt, and asked the resident if the resident wanted to see her big, beautiful butt. Resident #5 indicated that CNA #4 proceeded to show the resident a picture on her phone of herself with no clothes on her butt. Resident #5 indicated the resident didn't like it and wanted CNA #4 to leave. Resident #5 indicated a few days later the resident was coming out of an activity, and saw CNA #4, and it frustrated the resident so much that the resident bit himself hard on the wrist to the point the resident's wrist bled. During an interview on 11/01/2024 at 12:18 PM, the Administrator indicated that CNA #4 was never terminated, that they deemed her as self-terminated. The Administrator indicated that she was never taken out of the computer system, so they didn't have a re-hire date for CNA #4. The Administrator indicated that since CNA #4 was not a rehire, they didn't complete new background checks on her. The Administrator indicated that the facility did not have a policy on rehire of an employee. Removal Plan was accepted on 11/04/2024. The facility will ensure resident safety at all times. 1. Resident #5 was interviewed by social services director on 11/01/2024 and requested to talk to a psychiatrist and have a psychiatric evaluation. Evaluation is scheduled for 11/12/2024. Resident #5 currently attends a day group program at Ozark Community Hospital with a psychiatric Advanced Nurse Practitioner 2 times a week. 2. All current and future admitted residents will have a safety provided at all times. 3. CNA #4 has been terminated as of 11/01/2024. DON/Designee will in-service all staff on abuse and neglect as well as psychosocial well-being starting 11/01/2024 all will continue to in-service all employees prior to next start of shift. 4. This in-service will be done will all new hires and at least annually. 5. Any behaviors documented on resident #5 will be reviewed daily in stand-up ensuring that resident feels safe, and needs are being met. QA committee will monitor 3 x weekly in morning meeting to ensure new hire education on Abuse, neglect and psychosocial well-being will be reviewed, to ensure employees received education. All staff will be reviewed annually. Onsite Verification: The IJ was removed on 11/18/2024 at 2:16 PM after the survey team performed onsite verification that the Removal Plan had been implemented. Onsite verification of the Removal Plan began on 11/01/2024 at 2:00 PM when the Social Services Director interviewed Resident #5. Resident #5 had; a follow up psychiatrist appointment for evaluation scheduled, continued participation with a day program for counseling two times a week, and behavior monitoring with documentation every shift which was reported in the facility's morning meeting. The facility terminated CNA #4. The facility provided abuse, neglect, and psychological well-being in-service to all current staff and new hires; the Quality Assurance (QA) committee monitored three times a week employee in-service education. A total of 14 staff interviews were conducted with staff from all positions to verify training had been completed. The staff interviewed included Certified Nursing Assistants, Licensed Practical Nurses, a Registered Nurse, an Occupational Therapist, the Maintenance Supervisor, the Activities Director, and the Director of Nursing. The staff interviewed verified they had been trained on Abuse and Neglect. A review of in-service sheets provided indicated 47 of 64 staff had been provided training. Those staff who were not physically present to receive the in-services were messaged via telephone by the Administrator, with the in-service information provided and the employee acknowledging receipt and voicing understanding.

Based on observation, interview, and record review, the facility failed to post the daily nurse staffing information, to include the facility name, the current date, the number and actual hours worked by staff, and the resident census. The deficient practice had the potential to affect all residents. The total census was 60. A Shift Staffing Schedule, dated 10/28/2024 for the 7:00 AM to 3:00 PM shift, was reviewed and did not have the facility's name, the number and actual hours worked by staff, the resident census or the licensed staff scheduled to work. The shift staffing schedule, dated 10/28/2024 for the 11:00 PM to 7:00 AM shift, was reviewed and only one Certified Nursing Assistant's (CNA's) name was listed on the sheet. On 11/01/2024 at 6:40 PM, the Director of Nursing (DON) was interviewed by another surveyor about the nurse staffing. The surveyor indicated the DON stated the staffing sheets, which included the facility name, date, census and total and actual number of hours worked per shift for nursing staff, were no longer required and therefore were not done.

Based on interview and record review, the facility failed to ensure a policy was developed and implemented pertaining to the governing body and failed to ensure the governing body was active in the development and implementation of the facility assessment. The findings are: The Facility Assessment, provided by the Administrator on 10/28/2024, was reviewed and missing necessary components. On 11/01/2024, the Administrator was interviewed, and stated no member of the governing body assisted with the completion of the facility assessment. He was asked to provide a policy for the governing body and documented on an extended survey list the facility did not have a policy for the governing body.

Based on interview and record review, the facility failed to ensure there was sufficient nursing staff to meet the residents' needs for 7 shifts reviewed from 09/01/2024 through 09/30/2024. On 10/28/2024 at 3:42 PM, Resident #29 was interviewed and stated the resident believed the daytime [shift] was understaffed because residents do not receive showers as they should. Resident #29 stated the resident's scheduled bath/shower days were Tuesday, Thursday, and Saturday. Resident #29 stated the resident did not receive a shower on Saturday, 10/26/24, due to the facility on ly had one Certified Nursing Assistant (CNA) working the hall the resident resided. The resident alleged the facility has two CNAs working in the building some nights. The grievance logs, provided by the Administrator on 10/28/2024, were reviewed and indicated multiple grievances were filed in August 2024, September 2024 and October 2024 concerning residents not receiving baths/showers on their scheduled days. The nursing staffs' schedules and timecards, provided by the Administrator, were reviewed and indicated the following: -09/01/2024 shift staffing schedule indicated CNA #10 and CNA #11 were scheduled to work the night shift, 11:00 PM to 7:00 AM (11p/7a). Registered Nurse (RN) #12 and RN #13's employee time sheets were reviewed and indicated both staff worked the night shift, totaling 4 staff members. -09/02/2024 shift staffing schedule indicated CNA #10 and CNA #11 were scheduled for the 11PM to 7AM shift. RN #13 and Licensed Practical Nurse (LPN) #15 employee time sheets indicated both staff worked the night shift, totaling 4 staff members. -09/04/2024 employee time sheets for CNA #10, RN #13 and LPN #15 indicated all 3 staff members worked 11p/7a. CNA #5 and CNA #11 employee time sheets indicated both staff worked 11p to 3:00 AM, leaving 1 CNA and 2 nurses after 3 AM for the rest of the shift. -09/11/2024 shift staffing schedule indicated CNA #10 was scheduled to work. Employee time sheets indicated LPN #15 and RN #13 both worked 11p/7a, totaling 3 staff members. -09/15/2024 there were no CNAs in the facility for the 11p/7a shift. RN #12, RN #13, LPN #19 and LPN #21 employee time sheets indicated all four staff members worked 11p/7a shift. CNA #10 was removed from the CNA schedule on 09/15/2024 through 10/12/2024 for the 11p/7a shift. -09/16/2024 employee time sheets indicated LPN #15, LPN #21 and RN #13 worked the 11p/7a shift, totaling 3 staff members. LPN #8's time sheet indicated she worked 11p to 2:00 AM (2 hours). -09/17/2024 employee time sheets indicated RN #13 and LPN #15 worked the 11p/7a shift, totaling 2 staff members. There was no shift staffing schedule sheet provided. The CNA schedule for 09/17/2024 did not list any CNAs. On 10/30/2024 at 11:50 AM, CNA #4 was interviewed by another surveyor and stated often there is one aide on the hall with a float to help with the lift transfers and does not feel there is enough time to get work done. She stated she is unable to complete the scheduled showers on the halls when she works alone. She stated if the resident had a shower the previous shower day, she does not give that resident a shower. On 10/31/2024 at 3:30 PM, LPN #8 was interviewed by another surveyor and stated often there are only 2 nurses scheduled to work a shift. She stated there is not enough time for her to complete her work when there are only 2 nurses scheduled. The Facility Assessment, provided by the Administrator on 10/28/2024 and dated 08/08/2024, was reviewed and did not indicate what the facility's contingency plan was for staff. On 11/01/2024 at 7:21 PM, the Administrator was interviewed and stated the facility was trying to hire more CNAs, but he did not indicate what was being done to retain them.

Based on observations, interviews, record review and facility document review, it was deterred that the facility failed to ensure the Arbitration agreement contained all necessary components including the right to resend the agreement within the first 30 days of admission. The failed practice had the ability to affect all the residents who had signed the arbitration agreement. Findings include: A review of a facility admission agreement on 10/30/2024 at 3:30 PM, revealed, Arbitration, on page 5 section f, This provision for arbitration may be revoked by written notice delivered to the other parties within twenty-one (21) days of signature. The Administrator was provided a copy of the admission packet, on 11/01/2024 at 4:50 PM. The Administrator was asked to locate within the document the right to resend within 30 days. Administrator indicated the Arbitration Agreement may be revoked within 21 days. Administrator indicated the facility did not have a policy for arbitration.

Based on interviews, record review, and facility policy review the facility failed to implement consistent infection surveillance to prevent the spread of possible communicable diseases. The facility also failed to develop and implement a water management plan to prevent the growth and/or spread of waterborne pathogens. The findings include: On 10/30/2024 at 9:00 AM, a review of forms in the binder provided by the facility revealed incomplete forms title Infection Control data Source: infection Control Log analysis should include Trends & Root cause Analysis and blank diagram of the facility for each month. On 10/30/2024 at 3:00 PM, the Surveyor requested any material the facility had on its' water management plan for Legionella. On 10/30/2024 at 3:10 PM, the Administrator stated the facility does not have any policy, procedures, preventions, or management for legionella in place. On 10/30/24 at 03:20 PM, The Infection Control Nurse stated I remember learning about legionella, but I do not know if we have anything in place for it. The Infection Control Nurse stated there was not an infection surveillance process being done at the time. A policy titled Infection Prevention and Control Program noted a facility wide surveillance will be performed to identify opportunities to prevent and/or reduce the rate of infection in our residents, employees and visitors.

Based on interviews, record review, and facility policy review the facility failed ensure there was a consistent antibiotic stewardship to determine if the antibiotic is indicated or adjustments to the therapy should be made. The findings include: According to the admission Minimum Data Set (MDS) with the Assessment Reference Date (ARD) of 7/12/2024 Resident #215 had a Brief Interview of Mental Status (BIMS) score of 15 indication cognitively intact. A review of the order summary report Resident #215 had a diagnosis of cutaneous abscess of right foot and an order for an antibiotic to be given intravenous every 24 hours On 10/30/24 at 9:00 AM, a review of the forms in the binder provided by the facility revealed infection control assessment tools not completed for the months of August, September, and October. On 10/30/24 at 03:20 PM, the Infection Control Nurse stated the infection control assessment are not completed for the months August, September, and October. Infection Control Nurse stated I have no paper evidence that the facility has ensure the antibiotic was indicated or if adjustments should have been made. Infection Control Nurse stated I cannot say if the resident had a true infection if I am not doing the work to investigate. On 10/31/24 at 09:00 AM, the Director of Nursing stated I was told I cannot touch that. A policy titled Surveillance noted Antibiotic Stewardship Program (ASP) objectives were optimizing antimicrobial use for treatment and prophylaxis of infections among patients/residents to improve clinical outcomes, provide the most cost-effective treatment and reduce adverse events that are associated with antimicrobial use. Control antimicrobial resistance through proper use of antimicrobials. Reducing the occurrence of super bugs, which can often be multi-drug resistant.

Based on interview and record review, the facility failed to ensure required annual in-service trainings were performed to ensure staff received the required information/education needed to care for residents. The findings are: On 11/01/2024, the Administrator was asked to provide the in-services for the past 12 months conducted in the facility. The Administrator provided a binder which included in-services for the year of 2023 and 2024. In-services from 09/30/2023 to 10/27/2024 were reviewed and there were no in-services completed for communication. The Administrator provided a statement which was reviewed and indicated he was only able to provide an in-service completed on resident rights. On 11/01/2024 at 6:55 PM, the Director of Nursing (DON) was interviewed, and she stated the Administrator was responsible for conducting the mandatory in-services for staff and was unaware why some had not been completed. She stated she had been working on completing the in-services since she had been there. The DON provided a monthly all staff in-service, dated 10/16/2024, which was reviewed and included the areas of resident rights/abuse and neglect and enhanced barrier precautions.

Based on interview and record review, the facility failed to ensure required annual in-service trainings were performed to ensure staff received the required information/education needed to care for residents. The findings are: On 11/01/2024, the Administrator was asked to provide the in-services for the past 12 months conducted in the facility. The Administrator provided a binder which included in-services for the year of 2023 and 2024. In-services from 09/30/2023 to 10/27/2024 were reviewed and there were no in-services completed for dementia care. The Administrator provided a statement which was reviewed and indicated he was only able to provide an in-service completed on resident rights. On 11/01/2024 at 6:55 PM, the Director of Nursing was interviewed, and she stated the Administrator was responsible for conducting the mandatory in-services for staff and was unaware why some had not been completed. She stated she had been working on completing the in-services since she had been there.

Based on interview and record review, the facility failed to ensure the arbitration documentation includes the selection of a neutral arbitrator and a location that is convenient for all. The failed practice had the ability to affect all 47 residents who currently reside in the facility. The findings are: During an interview on 11/01/2024 at 4:50 PM, the Administrator was asked to identify the language in the Admission Agreement, page 5, section f, of the admission agreement that describes the process for selecting an arbitrator and the neutral location where the arbitration will take place. After examination the Administrator stated, I don't see it. During an interview the Administrator indicated that they did not have a policy for Arbitration. On 10/30/24 at 3:30 PM, a review of the facility arbitration agreement revealed that the facility's admission agreement, section f, pertains to Arbitration. During an interview on 11/01/24 at 4:50 PM, the Admission Director (AD) was asked to identify the language in section f. of the admission agreement that describes the process for selecting an arbitrator and the location where the arbitration will take place. After examination the AD stated, I don't see that in there. During an interview on 11/01/24 at 4:50 PM, the Surveyor asked the Administrator to locate in section f. of the admission agreement where it describes how an arbitrator, and a location is chosen. The Administrator stated, It's in the new part. I didn't see it in the admission agreement. During an interview on 11/01/24 at 4:50 PM, the Administrator reported that the facility has no policy pertaining to arbitration agreements.

Based on observation, record review, interview, and facility policy review, the facility failed to ensure food items stored in the freezer, refrigerator and dry storage areas were covered or sealed; expired food items were promptly removed/discard by the expiration or use by dates as when it was delivered,; 1 of 1 ice machines was maintained in clean and sanitary condition, staff washed their hands, and dietary staff washed their hands and between clean tasks when contaminated. The findings are: 1. On [DATE] at 10:54 AM, the following observations were made on a shelf in the walk-in freezer. a. An opened box of cookie dough. The box was not covered or sealed. b. An opened box of garlic bread sticks. The box was not covered or sealed. c. An opened box of Salisbury steak. The box was not covered or sealed. d. An opened container of sugar was under the food preparation counter with no lid on it. e. An opened container of flour was under the food preparation counter. There was no lid on it. The Dietary Manager confirmed the containers should have been covered. 2. The following observations were made on the spice rack in the kitchen. a. An opened container of cinnamon had best used by [DATE]. b. A container of ground ginger with best used by [DATE]. c. An opened container of mustard had an expiration date of [DATE]. d. Two opened containers of poultry seasoning with an expiration date of [DATE]. f. [DATE] 10:57 AM, the following observations were made on a shelf below the food preparation counter. i). An opened gallon of soy sauce. The manufacture specification on the bottle indicated to refrigerate after opening ii). A can of coffee with an expiration date of [DATE]. iii) A container of cinnamon with an expiration date of ,d+[DATE]. iv. A container of poultry seasonings with an expiration date of [DATE]' 2. On [DATE] at 11: 30 AM, the plastic panel on the right- and left side corners of the ice machine, close to the ice had wet black residue on them. The Dietary Manager was asked if she could wipe the wet black greasy residue. She did so, the black residue easily transferred to the tissue. The Dietary Manager interviewed stated they clean the machine every month and CNAs [Certified Nursing Assistants] use it for the water pitchers in the residents' rooms. confirmed the left, and the right-side corners of the ice machine panels close to the ice had wet greasy black residue close to the ice. 3. On [DATE] at 11:40 AM, the following observations were made in the refrigerator in the nourishment room leading to the 300-hall. A bottle of nutritional dink, there was no date when received or opened on the bottle. 4. A cup of spaghetti with meat sauce did not have a date of when it was opened or received. 5. An opened bottle of pineapple juice, there was no date when received or opened on the bottle. 6. A container of club sandwich and a container of toss salad, there was no date when received or opened on the containers. 7. A container of fried chicken, there was no name or date when received on the bag. 8. A clear bag that contained discolored spaghetti. The Dietary Manager confirmed it was discolored and old. 9 One carton of strawberry parfait, there no name or received date on the carton. 10. one carton of almond milk had expiration date of [DATE]. 11. A bowl of vegetable soup, there was no name or received date on the bowl. 12. A container of strawberry short cake, there was no name or received date on the container. It had [NAME] color and was melting. The Dietary Manager interviewed stated it is old and was melting. 13. An opened bag of dried fruits with an expiration date of,d+[DATE]. The bag had no name, no opened and or received date. 14. One container of carrot cake. was in the freezer; the container had no received date. 15. One container of turkey slices, the container had no name, no opened, and no received date on it. 16. One package of pepper cheese jack had no received or opened date on it. 17. On [DATE] at 11:45 AM, the following observations were made in the freezer. a. An opened box of burritos with beans and cheese, the box was not covered. b. One box blackened chicken Alfredo, there was no date when received on the bag. c. One container of strawberry cheesecake, there was no name, no date when received or opened on the container. The Dietary Manager interviewed stated they supposed to write names, when received and when opened. 18. On [DATE] at 11:51 AM, the Dietary [NAME] #1 pushed a cart that contained clean dishes towards the food preparation counter and used a rag to wipe off spilled food. Without washing her hands, she picked up a clean blade and attached it to the base of the blender to be used in pureeing food items to be served to the residents on the pureed [NAME] diets for lunch. 19. On [DATE] at 12:23 PM, picked up the water hose with bare hands, used it to spray leftover food from inside of the blender. Dietary Aide (DA) #2 placed dirty dishes in the racks and pushed the rack into the dish washing machine to wash. After the dishes stopped washing, DA #2 moved to the clean side of the dishwasher area and picked up a clean blade and attached it to the base of the blender to be used in pureeing foods to be served to the residents who received pureed diets for lunch. DA #2 then picked up clean dishes and stacked them in a rubber container on the cart to be used in portioning food items to be served to the residents for lunch. DA #2 interviewed stated she should have washed her hands 20. On [DATE] at 12:26 PM, was on the tray line serving lunch meal, she picked up tray cards and placed them on the trays. Without washing hands, DC #1 picked up bowls and plates and placed them on the trays to be used in portioning food items to be served to the residents for lunch with her fingers inside of them. DC #1 interviewed stated she should have washed her hands. 21 On [DATE] at 12:30 PM, the Dietary Aide #2 was on the tray line assisting with lunch meal service, picked up condiments, cartons of milk, shakes, cans of soda and placed them on the trays. Without washing hands, DA #2 picked up glasses that contained beverages by their rims and placed them on the meal trays to be served to the residents for lunch. 22. On [DATE] at7:09 AM, the Dietary Aide #3 was on the tray line assisting with breakfast meal service, picked up condiments, cartons of milk, shakes and placed them on the trays. At 7:17 AM, the Dietary Aide #3 removed supplements from the refrigerator and placed them on the trays. Without washing hands, DA #3 picked up glasses that contained beverages by their rims and placed them on the meal trays to be served to the residents for lunch. 23. On [DATE] at 10:33 AM, The DC #1 washed the blender bowl and blade in the 3-compartment sink. After washing them, she turned off the faucet with her bare hand. Without washing her hands, she picked up a clean blade and attached it to the base of the blender to be used in pureeing food items to be served to the residents who required pureed diets for lunch. At 10:34 AM When DC #1 was ready to put pork chops into the blender. The DC #1 interviewed stated she should you have washed hands. 24. On [DATE] at 10:45 AM, the Dietary Aide #3 removed a box of pie from the freezer and placed it on the counter. DA #3 removed gloves from the glove box and placed them on her hands, pulled her sleeves up, then removed cake from the original container and placed it on the cutting board, contaminating the gloves. Without changing gloves and washing her hands, DA #3 sliced the cake and placed them on the plates to be served to the residents for lunch. The DA #3 interviewed stated she should have washed her hands. 25. A review of facility policy titled, Hand washing and Hand Hygiene, initiated 2018, provided by the Dietary Manager on [DATE] indicated, hands should be washed before, during and after food preparation.

Based on record review and interview, the facility failed to ensure the facility assessment contained pertinent information to assure the necessary care and resources were allocated to meet the needs of the residents. This deficient practice had the potential to affect all residents of the facility. The total census was 60. The findings are: The Facility Assessment, dated as approved on 08/08/2024 and provided by the Administrator on 10/28/2024, was reviewed and indicated the purpose of the assessment was to determine what resources were necessary to care for the residents competently during day-to-day operations and emergencies. The facility assessment was missing the following components: -resident population -facility resources - facility-based and community risk assessment with an all-hazards approach - staff responsible for completing the assessment - staffing needs to ensure sufficient staff was available to meet the residents' needs - staff training/education and competencies - policies and procedures for provision of care - physical environment and building information - list of contracts and other third-party agreements - list of health information technology resources On 11/01/2024 at 7:21 PM, the Administrator was interviewed and stated he, the Administrator, was responsible for completing the facility assessment. He stated the purpose for the facility assessment was to assess how to care for residents, what training was needed for staff to adequately care for the residents, and to describe the resident population. He stated neither the governing body member or medical director had input in the completion of the facility assessment, and this was the first facility assessment he has completed.

Based on interview and record review, the facility failed to ensure required annual in-service trainings were performed to ensure staff received the required information/education needed to care for residents. The findings are: On 11/01/2024, the Administrator was asked to provide the in-services for the past 12 months conducted in the facility. The Administrator provided a binder which included in-services for the year of 2023 and 2024. In-services from 09/30/2023 to 10/27/2024 were reviewed and there were no in-services completed for compliance and ethics. The Administrator provided a statement which was reviewed and indicated he was only able to provide an in-service completed on resident rights. On 11/01/2024 at 6:55 PM, the Director of Nursing (DON) was interviewed, and she stated the Administrator was responsible for conducting the mandatory in-services for staff and was unaware why some had not been completed. She stated she had been working on completing the in-services since she has been there.

Complaint # was substantiated (all or in part) in these findings. Based on record review and interview, the facility failed to ensure necessary care and services were provided upon a change in condition for 1 (Resident #1) of 3 (Residents #1, #4 and #5) case mix residents who experienced a change in condition. The facility failed ensure a thorough assessment was performed when Resident #1 began complaining of nausea, started vomiting blood and experienced abdominal pain and failed to ensure the physician was immediately consulted when Resident #1 experienced abdominal pain, which resulted in a delay in treatment and actual harm for Resident #1. The failed practice was likely to affect 38 residents who had experienced a change of condition in the past 30 days, according to the Administrator on [DATE] at 9:50 a.m. The findings are: Resident #1 had [DIAGNOSES REDACTED]. The Minimum Data Set ((MDS) dated [DATE] documented the resident scored 15 (,[DATE] cognitively intact) on the brief interview for mental status (BIMS) and required limited to extensive assistance with activities of daily living. a. The Departmental Note dated [DATE] at 12:00 a.m. and written by the Physical Therapy Assistant (PTA) documented, "...Pt (patient) stated that he was nauseous this am (a.m.) and was unsure if he would be able to participate in therapy today. CPM (continuous passive machine) applied with ice wrap and set to 103 degrees of (left) knee flexion. ...CPM removed after two hours and pt. still c/o (complains of) being nauseous. Pt checked on this PM (p.m.) and stated he had been throwing up blood. This PTA checked with patient's nurse and stated pts INR (International Normalized Ratio) level was low and pt should be held from therapy until nausea subsided." On [DATE] at 10:50 a.m., the PTA was asked to refer to his documentation on [DATE]. He was asked, "Did you type this note at 12:00 a.m.?" He stated, no, that the computer would do that (document the time). He was asked if he could recall the time of day he provided the treatment for [REDACTED]. The PTA stated, "...It was between 8 and 9:00 a.m., when I checked on him. He just seemed tired to me, nothing alarming to me. About 2 hours later (between 10:00 a.m. and 11:00 a.m.) he was still nauseated. After lunch, I checked on him around 3 - 4 p.m., he stated he had been throwing up blood. The PTA stated the resident had an emesis basin next to him and it was lined with paper towels. I didn't see anything..." b. The Departmental Note dated [DATE] at 12:00 a.m. and written by the Occupational Therapist Assistant (OTA) documented, "Tx (treatment) session held in pt's room due to pt vomiting and complaining of stomach pain today. Acts taken very slowly with rest breaks during and between exercises..." On [DATE] at 10:55 a.m., the OTA was asked to refer to her documentation on [DATE]. She was asked, "Did you type this note at 12:00 a.m.?" She stated no. She was asked if she could recall the time of day she provided treatment for [REDACTED]. The OTA stated she could not recall the time. She stated, "I didn't see him vomit. He (Resident #1) said he did and that his stomach was bothering him. He had an emesis basin on the bed by him. I didn't see anything that alarmed me in anyway." c. The Departmental Note dated [DATE] at 1:47 p.m. and written by Licensed Practical Nurse (LPN) #1 documented, "Resident complains of n/v (nausea and vomiting). Resident states he has thrown up blood however no CNA (Certified Nursing Assistant) or nurse has been witness to this. CNA did state that they have seen resident 'dry heave.' (Name of Physician) notified of complaints and new order received. [MEDICATION NAME] 25 mg suppository. One suppository inserted rectally q6h (every 6 hours) PRN (as necessary) for nausea/vomiting. Resident and family made aware. When son notified of new orders he stated he saw resident vomit up blood twice. When asked how much blood he stated a "spoonful." Son also stated 'something better be done about it and that he would be at facility later to make sure issue was addressed'..." 1) On [DATE] at 4:00 p.m., during a telephone interview with LPN #3, she stated she worked with the resident on the 7:00 a.m. to 3:00 p.m. shift on [DATE]. She stated, "I went down in the room. The first time he complained of being nauseated and dry heaving, the same time his son requested him to have a [MEDICATION NAME] suppository. I told the son we would call (name of physician). I reported to (LPN #1) shortly after the son called me again to the room and I looked in the basin. It was the same as before, there was nothing in the basin. He (son) was getting impatient with me. The son was acting like we weren't going fast enough and I told him we were waiting for (name of physician) and that (name of physician) was good about getting back to us and if that ([MEDICATION NAME]) was not effective the Dr. (doctor) would go from there." LPN #3 was asked if the resident had any diarrhea that day. She stated, "He did at the end of the shift, had loose stools. (Assistant Director of Nursing (ADON)) said (Resident #1) had an explosion in the bathroom." The LPN was asked, "Did (Resident #1) vomit blood that day?" LPN #3 stated, "He complained of vomiting blood. I reported it to (LPN #1) and she reported it to (name of physician). I was told by (LPN #1) that (name of physician) said since it was a small amount, unless it was a significant amount of blood, he wasn't concerned. When asked if she saw the blood she stated, "...It was a small amount of mucus, quarter size, blood tinged. ...He (Resident #1) was saying it was blood. ...Son said he had vomited blood. But it was cloudy white mucus, very small amount of blood tinge in it." LPN #3 was asked if she assessed the resident, such as listen for bowel sounds, check to see if his abdomen was distended or if there was any abdominal pain. The LPN stated, "I don't remember." The LPN was asked, "Did you check his vital signs?" She stated, "I don't think I did. ...Honestly I don't remember if I had them do vital signs or not. If I didn't have them do vital signs, it's because I didn't see any changes in him." 2) On [DATE] at 12:05 p.m., CNA #2 (worked with the resident on the 7:00 to 3:00 p.m. shift) stated, "That day ([DATE]) he (Resident #1) wasn't eating. I tended to him a lot... He had been sick for a couple of days. They thought he was sick because of the resident in the room with him. The family was upset. I was trying to calm him down." CNA #2 was asked if she could remember if the resident had vomited blood that day. The CNA stated, "It wasn't blood. It was really dark brown. At the beginning of the shift, he puked a couple of times and he had a massive BM (bowel movement) in the bathroom. I asked the nurse to come to see the blood. The nurse (LPN #1) saw the blood. He threw up 3 times. It was spit up, like a loogie, more than puking. He couldn't keep anything down, I reported to the nurse. I think it was (LPN #1)." 3) On [DATE] at 12:25 p.m., CNA #1 stated, "I do remember one time, he (Resident #1) had called on his light. He said he was vomiting blood. I think it was after breakfast, before lunch. We gave him a tub (emesis basin), I didn't see any blood. I still let the nurse know about it." She was asked if she remembered getting any vital signs and stated, "I don't remember doing vital signs..." 4) On [DATE] at 3:26 p.m., CNA #3 (worked with the resident on the 7:00 a.m. to 3:00 p.m. shift on [DATE]) stated, "I remember he was spitting up some black stuff, wiping off his face consoling him. He seemed concerned. He didn't feel well. That's all I remember telling the nurse." The CNA was asked, "Who was the nurse?" She stated, "I don't remember. We have several nurses working that hall. It's hard to remember." She was asked if she was told to get vital signs on (Resident #1). CNA #3 stated, "I don't recall. I know it's required of us." The CNA was asked, "When you saw the black stuff, did it alarm you?" She stated, "Yes, because it was black; that did mean something to me. I'm not an expert, I just know it wasn't good. I told the nurse (LPN #1) what I saw. I do remember she did go in and see it. I didn't flush it; I didn't do anything with it." CNA #3 stated she could not remember what time during the shift she saw the black substance. 5) On [DATE] at 5:05 p.m., LPN #1 stated that on [DATE], she worked as the supervisor on the day shift (7:00 a.m. to 3:00 p.m.). She stated she was thinking that LPN #3 asked her to go to Resident #1's room. She stated the resident reported he was vomiting up blood. The LPN stated she went in the room and saw two brown paper towels in a basin that looked wet with water. She stated the resident reported he coughed up mucus, "but it was light brown, nothing that looked liked blood. It looked like mucus ... He (Resident #1) kept saying it was blood. I didn't see any blood. I talked to the aides and other nurses. But no one said they saw anything like blood. He (Resident #1) said it was about a spoonful." The LPN was asked, "When the resident told you he was vomiting blood, did you assess the resident, such as use a stethoscope to listen for bowel sounds, check to see if his abdomen was distended, see if there was any pain on palpation?" She stated, "No, but I asked him if he was in any pain." The LPN was asked, "Did you check his skin turgor?" She stated, "His skin turgor was good. He was standing up at one point, sitting in his wheelchair, he looked really good." The LPN was asked, "Did you get vital signs?" She stated, "I can't remember. But I assumed I did. But if I didn't document it, I know the rules..." LPN #1 was asked when the resident reported the blood to her. She stated, "It probably occurred between 12:30 and 1:47 p.m." When asked if she spoke to CNA #3, the LPN stated, "I really can't remember." d. The Departmental Note dated [DATE] at 4:43 p.m. and written by the Assistant Director of Nursing (ADON) documented, "Resident having watery stool while ambulating towards toilet in his bathroom. Two CNAs alerted me to this fact. Message left on Doctor's phone to return my call to address loose stool issue as well as resident's son's concern that the resident vomited blood earlier in the day. Will attempt to contact again." The Departmental Note dated [DATE] at 4:48 p.m. and written by the ADON documented, "Doctor on phone new orders received: 1. [MEDICATION NAME] 500 mg po TID (three times a day) for 14 days. 2. [MEDICATION NAME] 4 mg po after each loose stool. Max (maximum) four pills daily. 3. CBC (complete blood count), BMP (basic metabolic profile), and PT ([MEDICATION NAME] time) / INR in am. Son here in facility and aware of orders..." e. The Departmental Notes dated [DATE] at 9:30 p.m. and written by LPN #2 documented, "1730 (5:30 p.m.) son met this nurse in hallway demanding that his father be sent to the hospital. When I asked if there was something that I could do blood work here tonight he stated that he would just prefer for him to go ahead and go tonight just in case it was more serious then it looked. This nurse assessed patient to find him resting in bed, skin color slightly pallor but near normal appearance. HRRR (heart regular rate and rhythm), LCTA (lungs clear to auscultation), hyperactive bowel sounds times 4, ABD (abdomen) soft but tender to touch. Resident stated that his stomach was really hurting, spoke with him about possible side effects of [MEDICAL CONDITIONS], one being stomach aching or cramping. Resident stated that he didn't really see why he needed to go to the hospital but that his boys really wanted him to go. Left knee incision clean and dry with no redness or s/s (sign or symptoms) of infection, no [MEDICAL CONDITION] noted to extremities. CNAs stated that he had been having loose stools times 4 this evening. Spoke with family again and MD (medical doctor) notified. N.O. (new order) send to ER (emergency room ) for eval (evaluation) and treat due to diarrhea, nausea and increased confusion. Family pleased. (Name of ambulance company) transfer notified for transportation, report called to ER. EMTs (Emergency Medical Technicians) arrived at 600 (p.m.) and loaded resident up onto gurney using universal precautions. All bed linens stripped, noted that sons were taking books and pictures when leaving room..." 1) On [DATE] at 11:15 a.m., the resident's son stated, "On [DATE], my Dad threw up (vomited) between 10:00 - 1:00 p.m. and I told (LPN #3) three times he vomited blood. It was in a gray tub (basin), stringy red thick blood was in it. She (LPN #3) dismissed it three times, while I was there..." 2) On [DATE] at 1:56 p.m., the Medical Director was asked if he could recall the resident. The Medical Director stated, "...He had some blood, they said it was about a teaspoon. ...I questioned about coffee ground emesis, dark tarry stool and the answer was no. When the son came up to visit, the resident was having abdominal pain as well. ...I was not aware of there being 3 incidents (of vomiting blood), just the one. The pain was what was significant to me." The Medical Director was asked, "When did the facility report to you (Resident #1) had complained of abdominal pain?" The Physician stated, "That was a second phone call later. The son was extremely upset...When I was told that, we sent him out." f. The hospital encounter report dated [DATE] documented, "Reason for visit: vomiting blood, acute abdominal pain. Visit Diagnosis: [REDACTED]. 1) The hospital History of Present Illness documented, "Arrival time: [DATE] at 6:52 p.m. ...The history is provided by the patient. Vomiting: The emesis has an appearance of stomach contents and bright red blood. ...The abdominal pain is generalized. ...Associated with: Exposure to [MEDICAL CONDITION]. The patient has had a change in bowel habit. ...Gastrointestinal: Positive for nausea, vomiting, abdominal pain, abdominal distention... He has a sickly appearance. He appears ill. He appears distressed. ...There is pallor. ...Diagnostics: Results for orders placed during the hospital encounter of [DATE] at 1904 (7:04 p.m.) (from the past 24 hours): BUN (blood urea nitrogen) - 72 (normal range is ,[DATE]), Creatinine - 3.3 (normal range is XXX,[DATE].3) POC (Point of care) Occult blood - positive ...Radiology: abxr (abdominal x-ray) - the patient has a very distended colon with some air fluid levels indicating a large bowel obstruction Ct (computer tomography)-no obstruction, diffuse [MEDICAL CONDITION]. ...NG ([MEDICAL CONDITION]) placement: ...Dark blood suctioned via medium suction. ...Clinical Impression: Acute abdominal Pain, GI (gastrointestinal) Bleed,[MEDICAL CONDITIONS], enteritis, and gastroenteritis of presumed infectious origin..." 2) The hospital Discharge Summary dated [DATE] documented, "admitted : [DATE]. Hospital Course: (Resident #1) is a 81 y.o. (year old) male who presented with a history of hematemesis, abdominal pain. The patient's family said that he threw up dark blood about 3 tablespoons on the day of admission. ...He had had diarrhea for several days and his roommate at the SNF (skilled nursing facility) was diagnosed with [REDACTED]. documented as to what his [MEDICAL CONDITION] was secondary. It was presumed to be [MEDICAL CONDITION] at that point. ...He was given [MEDICATION NAME] and [MEDICATION NAME] in the ED (emergency department) and [MEDICATION NAME] was added in the ICU (Intensive Care Unit). Aggressive saline resuscitation was initiated. He complained of abdominal pain and he was given [MEDICATION NAME] 1 mg and a 2nd 1 mg an hour later. He was given an additional 1 mg of [MEDICATION NAME] IV (intravenous) as well another hour later and he seem more comfortable. His vitals were stable at this point. Short time later the nurse noticed (at 0358) that the pulse wasn't reading and she went to check him and he wasn't breathing. His pulse dropped to 30 and [MEDICATION NAME] was given and he was then noted to be pulseless. A code was called and attempts to resuscitate were unsuccessful. He was pronounced dead at ([DATE]) 0433 (4:33 a.m.)." g. Facility staff became aware of the resident's complaints of nausea, vomiting blood and abdominal pain at approximately 10:00 a.m. The resident arrived at the emergency department on [DATE] at 6:52 p.m., approximately eight and one-half hours later. The resident expired approximately 8 and one-half hours after arriving at the hospital.