Every finding on record at Astoria Place of Silverton

Based on observation, staff interview, and review of the facility documents and policy, the facility failed to maintain a clean and sanitary kitchen and failed to monitor temperatures of refrigerators and dish machines, and failed to monitor chemical concentration levels for the dish machine and for the three compartment sink. This had the potential to affect all of the residents residing in the facility with the exception of three facility-identified residents who did not receive meals prepared in the facility kitchen. The facility census was 75 residents. Findings include:1.Observation on 06/22/26 at 9:13 A.M. revealed there was a buildup of ice around the sprinkler head inside of the walk-in freezer with water with water dripping from the sprinkler head. Interviews on 06/22/26 at 9:13 A.M. with [NAME] #527 and on 06/22/26 at 9:25 A.M. with Dietary Manager (DM) #521 confirmed the buildup of ice in the walk-in freezer. Review of a facility policy titled Refrigerators and Freezers dated December 2014 revealed the facility would ensure safe refrigerator and freezer maintenance, temperatures, and sanitation. 2.Observation on 06/22/26 at 9:51 A.M. revealed there was a pool of water on the floor in the dish room. Interview on 06/22/26 at 9:51 A.M. with [NAME] #527 and DM #521 confirmed the pool of water on the floor in the dish room and stated the water had been an ongoing issue for the past few weeks. 3.Review of the refrigerator temperature logs for the small front refrigerator, the walk-in refrigerator, and the front 2 door refrigerator for April 2026 revealed from 04/04/26 through 04/30/26 all entries were entered and initialed by DM #521. Review of the dishwasher temperature and chemical concentration log for the facility's low temperature dishwasher for April 2026 revealed from 04/04/26 through 04/30/26 all entries were entered and initialed by DM #521. Review of the chemical concentration log for the three-compartment sink for April 2026 revealed from 04/01/26 through 04/30/26 all entries were entered and initialed by DM #521. Review of documents for recording chemical concentrations in the sanitizing bucket for April 2026 revealed that from 04/04/26 through 04/30/26 all entries were entered and initialed by DM #521. Interview on 06/23/26 at 2:10 P.M. with DM #521 confirmed she entered and initialed each temperature and chemical concentration for the April 2026 logs dated 04/04/26 to 04/30/26. DM #521 stated she was not present in the facility on weekends, and she entered information for the weekends because the staff had not done so. DM #521 stated she utilized averages from the previous week to determine what numbers/values to enter for the weekend dates not completed by the staff. DM #521 confirmed the temperature and chemical concentration she made for the following dates were not based on real-time data: 04/04/26, 04/05/26, 04/11/26, 04/12/26, 04/18/26, 04/19/26, 04/25/26, 04/26/26. Review of a facility policy titled Refrigerators and Freezers dated December 2014 revealed monthly tracking sheets for all refrigerators and freezers will be posted to record temperatures. Food service supervisors or a designated employee would check and record refrigerator and freezer temperatures daily with first opening and at closing in the evening. This deficiency represents noncompliance investigated under Complaint Number 3043527.

Based on medical record review, observation, resident interview, staff interview, and review of the facility policy, the facility failed to ensure a clean and safe environment for residents. This affected two (Residents #12 and #68) of 18 residents sampled. Based on medical record review, observation, staff interview, and review of the facility policy, the facility failed to ensure resident rooms were stocked with paper towels. This affected two (Residents #11 and #68) of 18 residents sampled. The facility census was 75 residents.Findings include: 1.Review of the medical record for Resident #12 revealed an admission date of 05/13/26 with diagnoses including chronic obstructive pulmonary disease, type two diabetes mellitus, and generalized anxiety disorder. Review of the Minimum Data Set (MDS) assessment for Resident #12 dated 05/19/26 revealed the resident was cognitively intact and required assistance with activities of daily living (ADLs.) Observation on 06/22/26 at 12:21 P.M of Resident #12's room revealed there was a wooden handrail propped up against the wall which was not attached to the wall for functional use. There was a screw protruding from the handrail and there were portions of four broken screws protruding from the wall where the handrail had previously been attached. Resident #12's commode was not securely fixed to the floor and could be shifted to the left and right with minimal force applied to the toilet. There was grab bar on the windowsill of the bathroom which had previously been attached the wall. The dry wall where the grab bar had been previously damaged. Observation revealed the handwashing sink in the resident's room had no paper towels available for staff to use to dry their hands. Interview on 06/22/26 at 12:21 P.M. with Resident #12 confirmed the wooden handrail in his room was not properly attached to the wall, the bathroom grab bar was not attached to the wall, and the toilet was not firmly attached to the floor. Interview on 06/22/26 at 1:32 P.M. with Certified Nursing Assistant (CNA) #526 confirmed the handrail in Resident #12's room was not attached to the wall and there was a screw protruding from the handrail, and there were portions of four additional broken screws protruding from the wall where the handrail had previously been attached. CNA #526 also verified the grab bar in the resident's bathroom was not attached to the wall for use and that the toilet was able to be shifted to the left and right with minimal force applied to the toilet. Interview on 06/23/26 at 2:48 P.M. Director of Maintenance (DOM) #562 confirmed the handrail in Resident #12's room was not attached to the wall and there was a screw protruding from the handrail, and there were additional broken screws protruding from the wall where the handrail had previously been attached. DOM #562 stated the grab bar in the resident's bathroom was not attached to the wall for use and that the toilet was able to be shifted to the left and right with minimal force applied to the toilet. DOM #562 verified no previous knowledge of the detached handrail, detached grab bar, and loose toilet in Resident #12's room. 2.Review of the medical record for Resident #68 revealed an admission date of 02/10/26 with a readmission date of 03/25/26 with diagnoses including cerebral infarction, epilepsy, and type two diabetes mellitus. Review of the MDS assessment for Resident #68 dated 05/19/26 revealed the resident was cognitively impaired and was dependent on assistance for all ADLs. Observation on 06/22/26 at 12:20 P.M. of Resident #68's room revealed there was an electrical outlet located to the left of the resident's bed which was not fastened to the wall. The outlet was protruding from the wall with exposed electrical wires and both electrical receptors to the outlet had electric devices plugged into them. Interview on 06/22/26 at 12:20 P.M. with Resident #68's representative confirmed concern about the condition of the electrical outlet to the left of the resident's bed and stated this concern had been reported to the facility although she didn't have an exact date and time. Interview on 06/22/26 at 2:20 P.M. with CNA #526 confirmed the outlet to the left of Resident #69's bed was not attached to the wall and electrical wires were exposed. Interview on 06/23/26 at 2:52 P.M. with DOM #562 verified the unsecured outlet in Resident #68's living space was brought to his attention the morning of 06/23/26. Observation on 06/24/26 at 8:23 A.M. revealed there were no paper towels available in Resident #68's room at the handwashing sink. Interview on 06/24/26 at 8:23 A.M. with Licensed Practical Nurse (LPN) #572 confirmed there were no paper towels stocked in paper towel dispenser in Resident #68's room. Review of the facility policy titled Quality of Life-Homelike Environment dated May 2017 revealed residents should be provided with a safe, clean, comfortable and homelike environment. 3. Review of the medical record for Resident #11 revealed an admission date of 05/22/26 with diagnoses including fracture of shaft of right tibia, rib fracture, and respiratory failure. Observation on 06/25/26 at 9:30 A.M. revealed there were no paper towels available at the handwashing sink in the resident's bathroom. Interview on 06/25/26 at 9:30 A.M. with LPN #367 confirmed there were no paper towels stocked in paper towel dispenser in Resident #11's room. Review of facility policy titled Handwashing/Hand Hygiene dated 04/29/24 revealed hand hygiene products and supplies (sinks, soap, towels, alcohol-based hand rub, etc.) should be readily accessible. This deficiency represents noncompliance investigated under Complaint Number 3048157 and Complaint Number 3038387 and Complaint Number 3032925.

Based on medical record review, staff interview, and review of the facility policy, the facility failed to ensure residents received wound care in a timely fashion. This affected one (Resident #11) of 18 residents sampled. The facility census was 75 residents.Findings include: Review of the medical record for Resident #11 revealed an admission date of 05/22/26 with diagnoses including respiratory failure, traumatic brain injury, and generalized anxiety disorder. Review of the Minimum Data Set (MDS) assessment for Resident #11 dated 05/29/26 revealed the resident was cognitively impaired and was dependent on staff assistance for all activities of daily living (ADLs). Review of the weekly skin assessment for Resident #11 dated 05/22/26 revealed upon admission the resident had the following areas of impaired skin integrity: a skin tear to the groin, a laceration to the front right lower leg, a laceration to the rear right lower leg, lacerations to the left toes. Review of the physician's orders for Resident #11 revealed the following orders dated 05/31/26: cleanse the skin tear to the right groin with normal saline, apply triad paste, and leave open to air every shift, cleanse the right lower leg wounds with normal saline, apply Xeroform, cover with ace bandage, and secure with Kerlix gauze once daily, cleanse the wounds to the left toes with normal saline, pat dry, apply Betadine, and leave open to air once daily Interview on 06/25/26 at 2:08 P.M. with Regional Director of Clinical Operations (RDCO) #701 confirmed Resident #11 was admitted to the facility on [DATE] with the following areas of impaired skin integrity: a skin tear to the groin, a laceration to the front right lower leg, a laceration to the rear right lower leg, lacerations to the left toes. RDCO #701 verified the facility did not initiate wound treatment orders until 05/31/26. Review of facility policy titled Wound Care dated October 2010 revealed wound treatments should be completed per physician's orders. This deficiency represents noncompliance investigated under Complaint Numbers 3048157, 3038387, 3027940, and 2989279.

Based on medical record review, staff interview, and review of the facility policy, the facility failed to ensure residents received treatment of pressure ulcers. This affected one (Resident #11) of two resident reviewed for pressure ulcers. The facility census was 75 residents.Findings include:Review of the medical record for Resident #11 revealed an admission date of 05/22/26 with diagnoses including respiratory failure, traumatic brain injury, and generalized anxiety disorder. Review of the Minimum Data Set (MDS) assessment for Resident #11 dated 05/29/26 revealed the resident was cognitively impaired and was dependent on staff assistance for all activities of daily living (ADLs). Review of the weekly skin assessment for Resident #11 dated 05/22/26 revealed upon admission the resident had a stage II pressure ulcer to his sacrum. Review of the physician's orders for Resident #11 revealed an order dated 05/31/26 to cleanse the pressure ulcer with normal saline, apply triad paste and leave open to air every shift. Review of the Treatment Administration Record (TAR) for Resident #11 dated May 2026 revealed the treatment for the resident's pressure ulcer was not initiated until 05/31/26. Interview on 06/25/26 at 2:08 P.M. with Regional Director of Clinical Operations (RDCO) #701 confirmed Resident #11 was admitted to the facility on [DATE] with a stage II sacral pressure ulcer and the facility did not initiate treatment to the wound until 05/31/26. Review of facility policy titled Wound Care dated October 2010 revealed wound treatments should be completed per physician's orders. This deficiency represents noncompliance investigated under Complaint Number 3048157, 3038387, 3032925, 3027940, and 2989279.

Based on medical record review, staff interview, and review of the facility policy, the facility failed to ensure residents received medications as ordered. This affected one (Resident #68) of 18 residents sampled. The facility census was 75 residents.Findings include:Review of the medical record for Resident #68 revealed an admission date of 02/10/26 with diagnoses including cerebral infarction, epilepsy, type two diabetes mellitus. Review of the Minimum Data Set (MDS) assessment for Resident #68 dated 05/19/26 revealed the resident was cognitively impaired and was dependent on staff assistance for all activities of daily living (ADLs). Review of physician's orders for Resident #68 revealed an order dated 05/24/26 for cefuroxime 250 milligram (mg) tablet give one tablet via gastrostomy tube (g-tube) two times a day for five days for pneumonia until 05/29/26 and an order for azithromycin 500mg tablet give one tablet via g-Tube at bedtime for pneumonia util 05/26/26. Review of Medication Administration Report (MAR) for Resident #68 dated May 2026 revealed the resident did not receive a morning or evening dose of cefuroxime on the following dates: 05/24/26, 05/25/26, 05/26/26, 05/27/26, 05/28/26. Resident #68 did not receive an evening dose of cefuroxime on 05/29/26. Resident #68 did not receive a dose of azithromycin on 05/24/26 or 05/25/26. Interview on 06/24/26 at 2:37 P.M. with Director of Clinical Operations (DCO) #700 confirmed Resident #68 missed 10 of 11 scheduled doses of cefuroxime and two of three scheduled doses of azithromycin. Review of the facility policy titled Administering Medications dated April 2019 revealed medications were to be administered in a safe and timely manner, and as prescribed. This deficiency represents noncompliance investigated under Complaint Numbers 3048157 and 3038387.Bottom of Form

Based on medical record review, observation, staff interview, and policy review, the facility failed to follow enhanced barrier precautions (EBP) while providing wound care. This affected one (Resident #56) of three residents reviewed for wound care. Based on observation, staff interview, and review of the facility policy, the facility failed to ensure staff performed appropriate hand hygiene during meal service. This affected six (Residents #71, #8, #10, #20, and #23) of 18 residents sampled. The facility census was 75. Findings include: 1.Review of medical record for Resident #56 reveled an admission date of 12/02/25 with diagnoses including gastrostomy status and traumatic brain injury. Review of the physician's orders for Resident #56 revealed an order dated 06/16/26 for the resident to be on EBP due to gastrostomy tube (g-tube) and an order for wound care. Review of the Minimum Data Set (MDS) assessment for Resident #56 dated 06/16/16 revealed the resident was moderately cognitively impaired and required substantial/maximal assistance activities of daily living (ADLs.) Observation on 06/24/26 at 3:00 P.M. of wound care for Resident #56 per Licensed Practical Nurse (LPN) #511 revealed the nurse provided wound care to the resident's left scalp and was not wearing a gown. Observation revealed there was a sign posted on Resident #56's door indicating the resident was on EBP and staff should wear personal protective equipment (PPE) while providing care to residents. Interview on 06/24/26 at 3:11 P.M. with LPN #511 confirmed he did not wear a gown while providing wound care to Resident #56 and also confirmed the resident had an active order for EBP and an EBP sign was posted on the resident's door. Review of the facility policy titled Enhanced Barrier Precautions dated August 2022 revealed enhanced barrier precautions employed targeted gown and glove use during high contact resident care activity including wound care. 2.Observation on 06/22/26 at 12:35 P.M. revealed Certified Nursing Assistant (CNA) #526 delivered lunch trays to Resident #71 in the dining room, and Residents #8, #10, #20, and #23 in their rooms. CNA #526 did not wash or sanitize her hands between the delivery of these food trays to residents. Interview on 06/22/26 at 12:46 P.M. with CNA #526 confirmed she did not wash or sanitize her hands between lunch tray deliveries to Residents #71, #8, #10, #20, and #23. Review of the facility policy titled Handwashing/Hand Hygiene dated October 2013 revealed the facility considered hand hygiene the primary means to prevent the spread of healthcare-associated infections. Hand hygiene was indicated after touching a resident and after touching the resident's environment.Bottom of Form

Based on observations, staff interviews, review of dishwasher logs, and facility policy review, the facility failed to ensure the dishwasher was maintained in working order. This had the potential to affect all 70 residents residing in the facility. The facility census was 70. Findings include:During an observation of the kitchen on 03/04/26 at 10:39 A.M. with Dietary Manager (DM) #64, revealed the dishwasher was not operational. DM #53 stated there had been problems with the dishwasher since February and the facility had been using disposable dishware and utensils for all meals. DM #64 stated it gets fixed, and will work for a few days, and then break again. DM #64 stated the dishwasher was dispensing chemicals at the incorrect time throughout the wash cycle and dishes were not coming out clean. DM #64 stated the facility had technicians out frequently to make repairs on the dishwasher. Observation at the same time with DM #53, revealed a technician was working on the dishwasher. During an interview on 03/05/26 at 11:19 A.M., Regional Director of Operations (RDO) #300 stated the technician was able to get the dishwasher to work the previous day; however, it was currently not working again. RDO #300 stated a new dishwasher was recently ordered; however, it would take six weeks to be delivered. Observation of the lunch service on 03/05/26 at 12:28 P.M., revealed the residents were being served lunch in Styrofoam containers with plastic cutlery. During an interview on 03/11/26 at 11:11 A.M., Resident #54 stated she did not like receiving her meals in the Styrofoam containers as it made it difficult to cut. Resident #54 stated that she would end up cutting through the Styrofoam while trying to eat. Observation of lunch service on 03/11/26 at 12:00 P.M., revealed the residents were being served lunch in Styrofoam containers with plastic utensils. Review of the Dishwasher Temperature Log, revealed that the dish machine was broken 11/21/25 through 11/31/25, 01/24/26 through 02/01/26, 02/07/26 through 03/01/26, and 03/04/26 through 03/17/26. Review of the facility policy titled Sanitization dated October 2008, revealed all equipment shall be maintained in good repair.

Based on observation, resident interview, staff interview, and policy review, the facility failed to treat residents with dignity and respect by providing disposable cutlery and dishware during meal services. This affected 67 residents as the facility identified three residents (#42, #56 and #73) who were nothing by mouth (NPO) and did not receive food from the kitchen. The facility census was 70. Findings include: During an observation of the kitchen on 03/04/26 at 10:39 A.M. with Dietary Manager (DM) #64, revealed the dishwasher was not operational. DM #53 stated there have been problems with the dishwasher since February and the facility has been using disposable dishware for all meals. DM #64 stated it gets fixed and will work for a few days and then break again. DM #64 stated the dishwasher was dispensing chemicals at the incorrect time throughout the wash cycle and dishes were not coming out clean. DM #64 stated the facility has had technicians out frequently to make repairs on the machine. Observation at the same time as the interview with DM #53 revealed a technician was working on the dishwasher. Observation of the lunch service on 03/05/26 at 12:28 P.M., revealed the residents were being served lunch in Styrofoam containers with plastic cutlery. During an interview on 03/11/26 at 11:11 A.M., Resident #54 stated she did not like receiving her meals in the Styrofoam containers as it made it difficult to cut. Resident #54 stated that she would end up cutting through the Styrofoam while trying to eat.Observation of lunch service on 03/11/26 at 12:00 P.M., revealed the residents were being served lunch in Styrofoam containers with plastic utensils. Review of the facility policy titled Quality of Life - Dignity dated August 2009, revealed each resident shall be cared for in a manner that promotes and enhances quality of life, dignity, respect, and individuality. Staff shall promote, maintain, and protect resident Privacy, including bodily privacy during assistance with personal care and during treatment procedures. This deficiency represents non-compliance investigated under Complaint Number 2699059.

Based on medical record review, review of care plans, observations, staff interviews, and policy review, the facility failed to have call lights within reach. This affected four Residents (#33, #53, #55, and #58) reviewed for call lights. The facility census was 70.Findings include: 1) Review of the medical record revealed Resident #107 was admitted to the facility on [DATE] and discharged on 02/09/26 as AMA. Diagnoses included chronic viral hepatitis c, polyneuropathy, dementia, manic episode without psychotic symptoms, bipolar disorder, depression and venous insufficiency. The resident had no Guardian at the time of discharge. Review of the most recent Minimum Data Set (MDS) 3.0 assessment dated [DATE], revealed Resident #107 had moderately impaired cognition, independent with eating, partial assistance with toileting, substantial assistance with bathing, and set up for personal hygiene. On 02/09/26, the resident was reassessed to have a Brief Interview Mental Status (BIMS) of 13, indicated the resident was cognitively intact. Review of a facility documented titled Unauthorized Discharge Release of Responsibility dated 02/09/26 revealed Resident #107 signed out of the facility AMA. The facility documented discussion of the risks of the resident leaving AMA and attempted to get the resident to say. During an interview on 03/16/26 at 1:48 P.M., Regional Clinical Director #205 verified the Medical Director/Provider was not notified when Resident #107 signed out of the facility AMA facility on 02/09/26. During an interview with the Medical Director #320 on 03/11/26 at 11:23 A.M., verified he was never notified of Resident #107's AMA discharge on [DATE]. 2) Review of the medical record revealed Resident #105 was admitted to the facility on [DATE] and discharged on 11/01/25 as AMA. Diagnoses included cerebrovascular disease, chronic obstructive pulmonary disease, major depressive disorder, and essential hypertension.Review of the most recent MDS assessment dated [DATE], revealed Resident #105 did not have a Brief Interview Mental Status (BIMS); however, the resident was independent with eating, dependent on staff for toileting, dependent for bathing, and partial assistance with personal hygiene. Review of the progress note for Resident #105 dated 11/01/25, revealed the resident was signed out AMA by the resident's Guardian.Review of the medical records for Resident #105 on 03/16/26 at 1:45 P.M., revealed no documented evidence that the Medical Director/Provider was notified when Residents #105 left the facility AMA.During an interview on 03/16/26 at 1:48 P.M., Regional Clinical Director #205 verified the Medical Director/Provider was not notified when Resident #105 was signed out of the facility AMA by the Guardian on 11/01/25. Review of the policy titled, Discharging a Resident Without a Physician's Approval, revealed should a resident, or the representative (sponsor), request a discharge earlier than outlined in the care plan and without the approval of the physician or provider ( Against Medical Advice), the resident's attending physician or provider is to be promptly notified. This deficiency represents non-compliance investigated under Complaint Number 2699059.

Based on review of medical records, review of Controlled Substance Records, review of hospice notes, staff interview, and review of facility policy, the facility failed to ensure residents were free of any significant medication errors. This affected four Residents (#117, #53, #54, and #55) of the the four residents reviewed for medication administration. The facility census was 70. Findings include:1) Review of the medical record revealed Resident #117 was admitted to the facility on [DATE] and discharged on 12/25/25. Diagnoses included mood disorder, bipolar disorder, cauda equina syndrome, catatonic schizophrenia, and major depressive disorder. Review of the most recent Minimum Data Set (MDS) 3.0 assessment dated [DATE], revealed Resident #117 had severely impaired cognition, supervision with eating, substantial assistance with toileting, substantial assistance with bathing, and partial assistance with personal hygiene. Review of the physician order for Resident #117 dated 12/01/25, revealed the resident was ordered to receive Morphine sulfate (a rapid-acting, potent opioid analgesic used to treat severe acute or chronic pain) 100 milligrams (mg) per five milliliters (mL) and give 0.5 ml (10 mg) orally every two hours as needed (PRN). The order was discontinued on 12/03/25 and there were no additional orders for Morphine. Review of a physician order for Resident #117 dated 12/01/25, revealed the resident was ordered to receive lorazepam (short-term treatment of anxiety disorders, anxiety-related insomnia, and acute seizure disorders) oral concentrate two mg per ml and give 0.5 ml (one mg) every two hours PRN. The order was discontinued on 12/15/25 and there were no additional orders for lorazepam. Review of a nurse's progress note for Resident #117 dated 12/22/25 at 10:36 A.M., revealed the resident was difficult to arouse reference to his medications and the hospice nurse was in to see the resident. Review of the Hospice Note for Resident #117 dated 12/25/25 at 8:40 P.M. and authored by Registered Nurse (RN) #500, revealed the resident was seen as a PRN visit due to the resident being lethargic and minimally responsive. The resident was unresponsive although his eyes were open. The resident had a long history of psychiatric care, so unsure if resident was really lethargic or wanted to be left alone. RN #500 spoke with night shift Licensed Practical Nurse (LPN) #307 about the day shift nurse not medicating the resident. Medication adjustments were obtained from the Hospice Nurse Practitioner and approved by the facility provider. The medication adjustments included lorazepam 0.5 mg every two hours PRN and morphine 10 mg every two hours. LPN #307 administered both medications to Resident #117 during RN #500's visit. Review of the electronic triage messages (the facility's electronic messaging system between the facility staff and the providers) dated 12/25/25 and authored by LPN #307 with messages to NP #501, revealed an initial message was sent to NP #501 at 9:56 P.M., indicating Resident #117's lorazepam order was not active and asked if the orders could be put back in because the resident was breathing at 44 breathes per minute and needed to have the lorazepam increased to at least one mg because LPN #315 and RN #500 recommended the change. NP #501 messaged back and asked if the medications were on hand, at which time LPN #307 indicated the medications were on hand, but the resident hadn't been getting it so it might be safe to keep the dosage at 0.5 mg. LPN #315 indicated the resident had the medication administered on 12/09/25 and again on today's date. LPN #315 noted the resident was mottled (blotchy purple or reddish appearance indicating slowing circulation) and the staff were not getting any vital signs. NP #501 messaged back to clarify the dose and then closed the thread due to no responses from LPN #315. Review of the electronic triage messages dated 12/26/25 at 12:59 A.M. and authored by LPN #307 with messages to NP #501, revealed Resident #117 passed away at 11:53 P.M. (12/25/25). Review of the progress note for Resident #117 dated 12/26/25 at 6:05 A.M. and authored by LPN #307, revealed the resident was actively passing when the LPN started the shift. The Hospice nurse was called and came in to assess the resident. The resident was breathing at 44 breaths per minute, and the resident was given lorazepam and morphine. Review of the December 2025 medication administration record (MAR) for Resident #117, revealed no documentation the resident received any doses of morphine or lorazepam in December 2025. Review of the Individual Patient Controlled Substance Administration Record (Narcotic Log) for Resident #117 on 03/16/26 at 1:17 P.M. with the Regional Clinical Director #205,, revealed the resident was ordered to receive lorazepam oral concentrate two mg per mL give 0.5 ml by mouth every two hours PRN. The doses were documented as being administered on 12/18/25 at two different times and both entries were illegible. Two doses were documented as being administered on 12/25/25 and both entries were illegible. Interview with Regional Clinical Director #205 at the same time, verified lorazepam doses were given to Resident #117 on 12/18/25 and 12/25/25 without any active physician orders in place. Regional Clinical Director #205 also verified the entries on the Controlled Substance Record were illegible. Review of the Individual Patient Controlled Substance Administration Record (Narcotic Log) for Resident #117 on 03/16/26 at 1:17 P.M. with the Regional Clinical Director #205, revealed the resident was ordered to receive Morphine oral solution 0.5 mL by mouth every two hours as needed. The doses were documented as being administered on 12/09/25 and 12/18/25 and all entries were illegible. The doses were also documented as being administered on 12/25/25 at 9:00 P.M. and 11:00 P.M. Interview with Regional Clinical Director #205 at the same time, verified Morphine doses were given to Resident #117 on 12/09/25, 12/18/25 and 12/25/25 without any active physician orders in place. Regional Clinical Director #205 also verified the entries on 12/09/25 and 12/18/25 were illegible. 2) Review of the medical record for Resident #53 revealed an admission date of 02/03/25 with diagnoses including hemiplegia and hemiparesis affecting the left non-dominate side. Review of the physician order for Resident #53 dated 09/24/25, revealed the resident was ordered to receive Latanoprost Ophthalmic (treatment for eye pressures related to glaucoma) Solution 0.005 percent one drop in both eyes at 9:00 P.M. for high eye pressure. Review of the physician order for Resident #53 dated 10/24/25, revealed the resident was ordered Rhopressa Ophthalmic (treatment for eye pressures related to glaucoma) solution 0.02 percent one drop in right eye at 9:00 P.M. for high eye pressure and Brimonidine Tartrate Ophthalmic (treatment for eye pressures related to glaucoma) solution 0.025 percent one dop in right eye twice daily (9:00 A.M. and 9:00 P.M.) for high eye pressure. Review of the physician order for Resident #53 dated 10/25/25, revealed the resident was ordered Methazolamide (treatment for eye pressures related to glaucoma) 50 mg twice daily (9:00 A.M. and 9:00 P.M.) for high eye pressure. Review of the physician order for Resident #53 dated 11/03/25, revealed the resident was ordered Dorzolamide -Timolol Ophthalmic solution (treatment for eye pressures related to glaucoma) 2-0.5 percent one dop in both eyes twice daily (9:00 A.M. and 9:00 P.M.) for high eye pressure. Review of the MDS assessment dated [DATE], revealed Resident #53 was cognitively intact. Review of the February 2026 MAR for Resident #53, revealed the Latanoprost Ophthalmic Solution 0.005 percent and Rhopressa Ophthalmic solution 0.02 percent were not administered at the 9:00 P.M. doses on 02/07/26, 02/08/26, 02/09/26, 02/11/26, 02/12/26,02/14/26, 02/24/26, and 02/28/26. Review of the February 2026 MAR for Resident #53, revealed the Brimonidine Tartrate Ophthalmic Solution 0.025 percent, Dorzolamide -Timolol Mal ophthalmic solution and Methazolamide 50 mg was not administered at the 9:00 P.M. dose on 02/07/26, 02/08/26, 02/09/26, 02/11/26, 02/12/26, 02/14/26, 02/24/26, and 02/28/26 During an interview on 03/12/26 at 2:50 P.M., Regional Clinical Director #205 verified Resident #53's medications were not administered on the dates/times listed above. 3) Review of the medical record for Resident #54 revealed an admission date of 03/21/24 with diagnoses including hypertensive heart disease with heart failure, intervertebral disc degeneration, and chronic pain syndrome. Review of the MDS assessment dated [DATE], revealed Resident #54 was cognitively intact. Review of the physician order for Resident #54 dated 07/01/25, revealed the resident was ordered to receive Eliquis (anticoagulant) five mg tablet at 9:00 P.M. Review of the February 2026 MAR for Resident #54 revealed the Eliquis five mg was not administered on 02/07/26, 02/08/26, 02/09/26, 02/11/26, 02/12/26, 02/14/26, 02/24/26, and 02/28/26. During an interview on 03/12/26 at 2:50 P.M., Regional Clinical Director #205 verified Resident #54 missed the medications on the date/times listed above. 4) Review of the medical record for Resident #55 revealed an admission date of 06/14/13 with diagnoses including hemiplegia and hemiparesis affecting the left non-dominate side, epileptic seizures, and vascular dementia. Review of the physician orders for Resident #55 dated 02/20/17, revealed the resident was ordered topiramate 50 mg daily at 9:00 P.M. for epilepsy. Review of the MDS assessment dated [DATE] revealed Resident #55 is severely cognitively impaired. Review of the February 2026 MAR for Resident #55, revealed the 9:00 P.M. doses of topiramate 50 mg were not administered on 02/07/26, 02/08/26, 02/09/26, 02/11/26, 02/12/26, 02/14/26, 02/24/26, and 02/28/26. During an interview on 03/12/26 at 2:50 P.M., Regional Clinical Director #205 verified Resident #54 missed the medications on the date/times listed above. Review of the policy titled, Administering Medications, dated 02/14/24, revealed the individual administering the medication checks the label three times to verify the right resident, right medication, right dosage, right time, and right method (route) of administration before giving the medication. This deficiency represents non-compliance investigated under Complaint Numbers 2699059, 2710143, and 2587217.

Based on observation, staff interview, record review and policy review, the facility failed to store and destroy controlled substances appropriately. This affected four Residents (#117, #132, #119, and #118) but had the potential to affect 56 residents who the facility identified as being independently mobile. The facility census was 70.Findings include: During an interview with the Director of Nursing (DON) and Regional Clinical Director #205 on 03/12/26 at 10:48 A.M. inside the DON's office, revealed an observation of numerous narcotic medication bottles lying on the desk. The bottles include: 1) One package of lorazepam (anti-anxiety) oral concentrate 30 milliliter (mL) bottle (two milligram (mg)/ per mL) for Resident #117 with a fill date of 12/01/25 and 29 mL left in the bottle.2) One package of morphine sulfate (a rapid-acting, potent opioid analgesic used to treat severe acute or chronic pain) oral solution 30 mL bottle (100 mg per five mL) for Resident #117 with fill date of 12/02/25 and 12 mL left in bottle.3) Three bottles of morphine sulfate oral liquid 30 mL (100 mg per five mL) for Resident #132 (discharged on 11/26/25). The fill dates were 11/25/25, 11/28/25, and 11/30/25 and each had varying amounts of Morphine remaining in the bottles. 4) Three containers of lorazepam concentrate 30 mL (two mg/ml) for Resident 132. The fill dates were 10/11/25, 10/28/25, and 12/02/25 and each had varying amounts of lorazepam remaining in the bottles. 5) One bottle liquid morphine liquid 30 mL (100 mg per five mL) for Resident #119 (discharged on 01/17/26) with fill date of 01/10/26 and medication remained in the bottle. 6) Two bottles of morphine sulfate oral liquid 30 mL (100 mg per five mL) for Resident #118 (discharged on 01/09/26) both with fill dates of 01/03/26 and medication remained in the bottles. The DON verified the aforementioned controlled medications were unsecured and lying on her desk. The DON stated controlled medications should be secured in a permanently affixed compartment. The DON stated she was behind with destroying the controlled substances. The DON stated the controlled medications on her desk were for residents who had been released. Review of the policy titled, Controlled Substances, dated 05/30/25, revealed controlled substances are separately locked in permanently affixed compartments, except when using single unit package drug distribution systems in which the quantity stored is minimal and a missing dose can be readily detected. Controlled substances remaining in the facility after the order has been discontinued or the resident has been discharged would be securely locked in an area with restricted access until destroyed.Review of the policy titled, Discarding and Destroying Medications, dated 04/2019, revealed all unused controlled substances shall be retained in a securely locked area with restricted access until disposed of. Disposal of controlled substances must take place immediately (no longer than three days) after discontinuation of use by the resident.

Based on observation, resident interview, staff interviews, review of the menu, review of the substitution log, and policy review, the facility failed to ensure they had an adequate supply of food to follow the menu. This affected 67 residents as the facility identified three Residents (#42, #56 and #73) who were nothing by mouth (NPO) and did not receive food from the kitchen. The facility census was 70. Findings include:Observation of the dry stock area of the kitchen on 03/04/26 at 11:30 A.M. with Dietary Manager (DM) #64, revealed the facility had a low stock of food. Interview with DM #64 at the same time verified there was a low stock of food and stated the facility received a truck delivery with food once a week and if the facility ran out of food, she would go to the local store and get food. DM #64 verified that there was not an emergency stock of food available. Observation of today's lunch menu on 03/05/26 at 11:32 P.M., revealed the residents would receive beef and noodles, broccoli florets, and two baked cookies. Observation of the food line on 03/05/26 at 12:28 P.M., revealed the residents with a regular diet received only one cookie. Residents on a mechanical soft and puree diet received pudding. During an interview on 03/05/26 at 12:35 P.M., DM #64 verified that she did not have enough cookies made to follow the menu. DM #64 verified the menu indicated the residents should have received two cookies. During an interview on 03/09/26 at 10:21 A.M., Resident #51 stated she does not always get everything listed on her meal tickets. During an interview on 03/09/26 at 10:30 A.M., Resident #36 stated the facility does not follow the meal tickets and he feels like he is not getting enough food to meet his daily calorie needs. Observation of the substitution logs on 03/09/26 at 12:14 P.M. with DM #64, revealed the menu substitution log was last filled out in July of 2025. Interview with DM #64 verified she does not keep a substitution log or documentation of meals that have been served. Review of the facility policy titled Menus dated October 2017, revealed menus are created to meet the nutritional needs of residents and should be followed. Any deviations from the menu should be recorded and archived. Review of the facility policy titled Dietary Considerations for Residents dated January 2011, revealed the facility should have food available to last a minimum of seven days. This deficiency represents non-compliance investigated under Complaint Number 2646616.

Based on observation, staff interviews, and review of the facility policy, the facility failed to ensure food was stored, prepared and served in a safe and sanitary manner to prevent foodborne illness. This affected 67 residents as the facility identified three Residents (#42, #56 and #73) who were nothing by mouth (NPO) and did not receive food from the kitchen. The facility census was 70. Findings include:Observation of the kitchen on 03/04/26 at 9:45 A.M. with [NAME] #67, revealed an air vent in the ceiling leaking water, with droplets falling onto the floor below. Immediately adjacent to this location was a food preparation table that was actively being used. Below the preparation table, clean dishes were stored and water droplets were splashing off the floor and onto the dishes. Interview at the time of the observation with [NAME] #67 verified that the air vent was leaking next to the preparation area and near the clean dishes. During an interview on 03/02/26 at 9:47 A.M., Maintenance Supervisor (MS) #91 stated the air vent was connected to the air conditioning unit and it was leaking condensation water. Observation of the kitchen on 03/04/26 at 9:50 A.M. with [NAME] #67, revealed dust on the ceiling and a black residue on the fan shields in the walk-in cooler. Interview at the time of the observation with [NAME] #67 verified that the walk-in cooler was unclean. Observation on 03/04/26 at 10:02 A.M., revealed Activities Assistant (AA) #04 was passing drinks to the residents. Further observation revealed a metal water dispenser that was unclean with a brown residue and had discolored tape on the lid. Interview at the time of the observation with AA #04 revealed that the water dispenser was taped because the lid would frequently come off. AA #04 verified the dispenser was unclean and that it was difficult to clean due to the tape. Observation of the kitchen on 03/04/26 at 11:07 A.M. with Dietary Manager (DM) #64, revealed a sheet of wood covering the floor under the preparation area. The wood appeared to be unclean with a black residue covering it. Interview with DM #64 at the time stated the facility had plumbing work completed a few months prior and that the wood was covering a hole in the floor. DM #64 verified that the wood was unclean with black residue covering it and could not be cleaned. Observation of the kitchen on 03/04/26 at 11:14 A.M. with DM #64, revealed two knives with the tip of the blade broken off and two knives with a painted blade had chipped paint being stored on the magnetic knife storage strip. Interview with DM #64 at the same time verified the knives were not safe to use and should not be stored in the kitchen. Observation of the kitchen on 03/05/26 at 12:11 P.M., revealed [NAME] #52 with gloved hands, grabbed a container of steamed broccoli, adjusted his glasses with his hand, and then started pureeing the broccoli. Interview with [NAME] #52 verified that he adjusted his glasses with gloved hands and that he should have washed his hands afterwards. Observation of the kitchen on 03/05/26 at 12:14 P.M., revealed [NAME] #52 was cleaning a rubber spatula in the three-compartment sink. After cleaning and rinsing the spatula, [NAME] #52 dipped the spatula in sanitizer and then brought it back to the preparation area to use. [NAME] #52 donned gloves and began preparing food. Interview with [NAME] #52 verified that he did allow the spatula to sit in the sanitizer for the required amount of time and he should have washed his hands before returning to food preparation. During an interview on 03/05/26 at 12:27 P.M., DM #64 verified that when cleaning dishes, they were required to have a contact time of one minute in the sanitizer and they should be fully air dried before use. Observation of the tray line on 03/05/26 at 12:58 P.M., revealed the food and utensils were being placed on wet trays. Interview with DM #64, verified that the trays were wet with sanitizer from when they were cleaned. DM #64 stated the trays were stacked while wet after cleaning in the three-compartment sink and they did not have a place to allow them to air dry. Review of the facility policy titled, Sanitization dated October 2008, revealed the kitchen areas shall be kept clean. All utensils and equipment shall be kept clean, maintained in good repair and shall be free from breaks, corrosions, open seams, cracks and chipped areas. Equipment and utensils will be allowed to air dry. This deficiency represents non-compliance investigated under Complaint Number 2566761.

Based on staff interview, record review and policy review, the facility failed to ensure care conferences were conducted. This affected two Residents (#107 and #117) of the three residents reviewed for care conferences. The facility census was 70.Findings include:1) Review of the medical record revealed Resident #107 was admitted to the facility on [DATE] and discharged on 02/09/26 as Against medical Advice (AMA). Diagnoses included chronic viral hepatitis-c, polyneuropathy, dementia, manic episode without psychotic symptoms, bipolar disorder, depression and venous insufficiency. The resident had no Guardian at the time of discharge. Review of the most recent Minimum Data Set (MDS) 3.0 assessment dated [DATE], revealed Resident #107 had moderately impaired cognition, independent with eating, partial assistance with toileting, substantial assistance with bathing, and set up for personal hygiene. On 02/09/26, the resident was reassessed to have a Brief Interview Mental Status (BIMS) of 13 indicating the resident was cognitively intact. Review of the medical record for Resident #107 on 03/10/26 at 10:03 with Social Services (SS) #85, revealed no care conferences were conducted. During an interview with SS #85 at the same time, verified there were no care conferences conducted for Resident #107. 2) Review of the medical record revealed Resident #117 was admitted to the facility on [DATE] and discharge on [DATE]. Diagnoses included mood disorder, bipolar disorder, cauda equina syndrome, catatonic schizophrenia, and major depressive disorder. Review of the most recent MDS assessment dated [DATE], revealed Resident #117 had severely impaired cognition and required assistance with activities of daily living (ADL).Review of the medical record for Resident #117 on 03/10/26 at 1:00 P.M. with Social Services (SS) #85, revealed no care conferences were conducted. During an interview with SS #85 at the same time, verified there were no care conferences conducted for Resident #117. Review of the policy titled, Comprehensive Care Plans, revealed each resident's comprehensive person-centered care plan is consistent with the resident's rights to participate in the development and implementation of his or her plan of care, including the right to participate in the planning process. If the participation of the resident and his or her resident representative in developing the resident's care plan is determined to not be practicable, an explanation is documented in the resident's medical record. The explanation should include what steps were taken to include the resident or representative in the process.This deficiency represents non-compliance investigated under Complaint Number 2691577.

Based on record review, staff interview and policy review, the facility failed to notify the Medical Director/ Provider of residents leaving the facility Against Medical Advice (AMA). This affected two Residents (#105 and #107) of the three reviewed. The facility census was 70.Findings include: 1) Review of the medical record revealed Resident #107 was admitted to the facility on [DATE] and discharged on 02/09/26 as AMA. Diagnoses included chronic viral hepatitis c, polyneuropathy, dementia, manic episode without psychotic symptoms, bipolar disorder, depression and venous insufficiency. The resident had no Guardian at the time of discharge. Review of the most recent Minimum Data Set (MDS) 3.0 assessment dated [DATE], revealed Resident #107 had moderately impaired cognition, independent with eating, partial assistance with toileting, substantial assistance with bathing, and set up for personal hygiene. On 02/09/26, the resident was reassessed to have a Brief Interview Mental Status (BIMS) of 13, indicated the resident was cognitively intact. Review of a facility documented titled Unauthorized Discharge Release of Responsibility dated 02/09/26 revealed Resident #107 signed out of the facility AMA. The facility documented discussion of the risks of the resident leaving AMA and attempted to get the resident to say. During an interview on 03/16/26 at 1:48 P.M., Regional Clinical Director #205 verified the Medical Director/Provider was not notified when Resident #107 signed out of the facility AMA facility on 02/09/26. During an interview with the Medical Director #320 on 03/11/26 at 11:23 A.M., verified he was never notified of Resident #107's AMA discharge on [DATE]. 2) Review of the medical record revealed Resident #105 was admitted to the facility on [DATE] and discharged on 11/01/25 as AMA. Diagnoses included cerebrovascular disease, chronic obstructive pulmonary disease, major depressive disorder, and essential hypertension.Review of the most recent MDS assessment dated [DATE], revealed Resident #105 did not have a Brief Interview Mental Status (BIMS); however, the resident was independent with eating, dependent on staff for toileting, dependent for bathing, and partial assistance with personal hygiene. Review of the progress note for Resident #105 dated 11/01/25, revealed the resident was signed out AMA by the resident's Guardian.Review of the medical records for Resident #105 on 03/16/26 at 1:45 P.M., revealed no documented evidence that the Medical Director/Provider was notified when Residents #105 left the facility AMA.During an interview on 03/16/26 at 1:48 P.M., Regional Clinical Director #205 verified the Medical Director/Provider was not notified when Resident #105 was signed out of the facility AMA by the Guardian on 11/01/25. Review of the policy titled, Discharging a Resident Without a Physician's Approval, revealed should a resident, or the representative (sponsor), request a discharge earlier than outlined in the care plan and without the approval of the physician or provider ( Against Medical Advice), the resident's attending physician or provider is to be promptly notified. This deficiency represents non-compliance investigated under Complaint Number 2793259.

Based on record review, staff interview, and review of facility policy, the facility failed to ensure physician orders were following when administering medications to residents. This affected three Residents (#53, #54, and #55) of the four residents reviewed for medication administration. The facility census was 70. Findings include: 1) Review of the medical record for Resident #53 revealed an admission date of 02/03/25 with diagnoses including hemiplegia and hemiparesis affecting the left non-dominate side, gastro esophageal reflux disease (GERD), and chronic pain. Review of the Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #53 was cognitively intact. Review of the physician orders for Resident #53 dated 07/01/25, revealed the resident was ordered to receive a Pain Relief Maximum Strength external topical pain patch (Lidocaine) to be applied at 9:00 P.M. (bedtime), diclofenac Sodium external gel (pain relief) one percent four times daily (8:00 A.M., 11:00 A.M., 4:00 P.M. and 9:00 P.M., cyclobenzaprine (muscle relaxer) 10 milligrams (mg) tablet every eight hours at 6:00 A.M., 2:00 P.M. and 10:00 P.M., and atorvastatin calcium (high cholesterol) 80 mg daily at 9:00 P.M Review of the physician order for Resident #53 dated 07/02/25, revealed the resident was ordered to receive omeprazole (GERD) 20 mg daily at 5:00 A.M. Review of the physician order for Resident #53 dated 07/24/25, revealed the resident was ordered to receive Melatonin (sleep aid) three mg daily at 9:00 P.M. Review of the physician order for Resident #53 dated 07/28/25, revealed the resident was ordered to receive Senna S (Laxative) 8.6-50 mg twice daily at 9:00 A.M. and 9:00 P.M. for constipation. Review of the physician orders for Resident #53 dated 11/17/25, revealed the resident was ordered to receive methocarbamol (muscle relaxer) 750 mg tablet every eight hours at 6:00 A.M., 2:00 P.M. and 10:00 P.M. and Tylenol (pain) Extra Strength 500 mg two tablets every eight hours. Review of the February 2026 MAR for Resident #53, revealed the cyclobenzaprine 10 mg, methocarbamol 750 mg and Tylenol 1,000 mg were not administered at the 6:00 A.M. dose on 02/08/26, 02/09/26, 02/10/26, 02/12/26, 02/13/26, 02/15/26, and 02/28/26. The cyclobenzaprine, methocarbamol and Tylenol were not administered at the 10:00 P.M. dose 02/07/26, 02/08/26, 02/09/26, 02/11/26, 02/12/26, 02/14/26, 02/24/26, and 02/28/26.Review of the February 2026 MAR for Resident #53, revealed the omeprazole was not administered on 02/08/26, 02/09/26, 02/10/26, 02/12/26, 02/13/26, 02/15/26, and 02/25/26. Review of the February 2026 MAR for Resident #53, revealed the Lidocaine patch, diclofenac sodium external gel one percent, Senna S 8.6-50 mg, atorvastatin calcium, and Melatonin was not administered at the 9:00 P.M. dose on 02/07/26, 02/08/26, 02/09/26, 02/11/26, 02/12/26, 02/14/26, 02/24/26, and 02/28/26.During an interview on 03/12/26 at 2:50 P.M., Regional Clinical Director #205 verified Resident #53's medications were not administered on the dates/times listed above. 2) Review of the medical record for Resident #54 revealed an admission date of 03/21/24 with diagnoses including hypertensive heart disease with heart failure, intervertebral disc degeneration, and chronic pain syndrome.Review of the physician orders for Resident #54 dated 07/01/25, revealed the resident was ordered atorvastatin calcium (high cholesterol) daily at 9:00 P.M., tamsulosin (benign prostatic hyperplasia) 0.4 mg daily at 9:00 P.M. for angina pectoris, trazodone (sleep aid/antidepressant) 150 mg daily at 9:00 P.M., Advair Diskus (asthma/COPD) inhalation aerosol powder 250-50 micrograms (mcg) one puff orally every 12 hours (9:00 A.M. and 9:00 P.M.)., Lyrica (controlled medication for neuropathy) 100 mg twice daily at 9:00 A.M. and 9:00 P.M. sodium chloride one gram (gm) twice daily at 9:00 A.M. and 9:00 P.M. for supplement, valsartan (hypertension) 80 mg twice daily twice daily at 9:00 A.M. and 9:00 P.M., buspirone (anxiety) 15 mg three times daily at 6:00 A.M., 2:00 P.M. and 10:00 P.M., and cyclobenzaprine (muscle relaxer) 10 mg three times daily at 6:00 A.M., 2:00 P.M. and 10:00 P.M. Review of the physician order for Resident #54 dated 07/02/25, revealed the resident was ordered metoprolol succinate (hypertension/heart rate control) extended release (ER) daily at 9:00 A.M. and Pataday Ophthalmic Solution 0.2 percent one drop in both eyes daily at 5:00 A.M. Review of the physician order for Resident #54 dated 08/19/25, revealed the resident was ordered Biotene dry mouth throw liquid (mouthwashes) 30 mg/milliliter (mL) twice daily at 9:00 and 9:00 P.M.Review of the physician order for Resident #54 dated 10/25/25, revealed the resident was ordered levothyroxine (thyroid replacement) 112 mcg daily at 6:00 A.M. Review of the physician order for Resident #54 dated 11/17/25, revealed the resident was ordered to receive Senna S (laxative) oral table 8.6-50 mg twice daily at 9:00 A.M. and 9:00 P.M. Review of the MDS assessment dated [DATE], revealed Resident #54 was cognitively intact. Review of the physician order for Resident #54 dated 12/18/25, revealed the resident was ordered to receive Naproxen 500 mg twice daily at 9:00 A.M and 9:00 P.M. related to painReview of the physician order for Resident #54 dated 01/19/26, revealed the resident was ordered to receive omeprazole 20 mg twice daily 9:00 A.M. and 9:00 P.M for heartburn. Review of the physician order for Resident #54 dated 01/30/26, revealed the resident was ordered to receive Mucinex ER twice daily at 9:00 A.M. and 9:00 P.M. related to influenza.Review of the February 2026 MAR for Resident #54, revealed atorvastatin, Trazodone, tamsulosin, Advair Diskus, Biotene, Lyrica, Mucinex ER, Naproxen, omeprazole, Senna S, sodium Chloride, and valsartan were not administered at the 9:00 P.M. dose on 02/07/26, 02/08/26, 02/09/26, 02/11/26, 02/12/26, 02/14/26, 02/24/26, and 02/28/26.Review of the February 2026 MAR for Resident #54, revealed Buspar and cyclobenzaprine were not administered at the 10:00 P.M. dose on 02/08/26, 02/09/26, 02/10/26, 02/12/26, 02/13/26, 02/15/26, and 02/25/26 at the 6:00 A.M. dose, and 02/07/26, 02/08/26, 02/09/26, 02/11/26, 02/12/26, 02/14/26, 02/24/26 and 02/28/26.Review of the February 2026 MAR for Resident #54, revealed levothyroxine was not administered on 02/08/26, 02/09/26, 02/10/26, 02/12/26, 02/13/26, 02/15/26, and 02/25/26 at the 6:00 A.M. dose. Review of the February 2026 MAR for Resident #54, revealed the Pataday Ophthalmic solution 0.2 percent was not administered on 02/08/26, 02/09/26, 02/10/26, 02/12/26, 02/13/26, 02/15/26, and 02/25/26 at the 5:00A.M. dose. During an interview on 03/12/26 at 2:50 P.M., Regional Clinical Director #205 verified Resident #54 missed medications on the date/times listed above. 3) Review of the medical record for Resident #55 revealed an admission date of 06/14/13 with diagnoses including hemiplegia and hemiparesis affecting the left non-dominate side, epileptic seizures, and vascular dementia. Review of the MDS assessment dated [DATE], revealed Resident #55 is severely cognitively impaired. Review of the physician orders for Resident #55 dated 07/01/25, revealed the resident was ordered melatonin (sleep aid) five mg daily at 9:00 P.M., baclofen 10 mg twice daily 9:00 A.M. and 9:00 P.M. for muscle spasms, and Depakote sprinkles 250 mg twice daily at 9:00 A.M and 9:00 P.M. for dementia, artificial tears 0.4 percent twice daily at 9:00 A.M and 9:00 P.M. for dry eyes, house supplement plus twice daily at 9:00 A.M and 9:00 P.M. for protein calorie malnutrition, hydrocodone-acetaminophen (narcotic pain medication) 5-325 mg with pain level assessment every three times daily at 6:00 A.M., 2:00 P.M., and 10:00 P.M. Review of the physician orders for Resident #55 dated 07/02/25, revealed the resident was ordered levothyroxine (thyroid replacement) 100 mcg daily at 6:00 A.M.Review of the physician orders for Resident #55 dated 11/01/25, revealed the resident was ordered famotidine (GERD) 10 mg daily at 9:00 P.M., Review of the February 2026 MAR for Resident #55, revealed the famotidine, melatonin, artificial tear, baclofen, Depakote Sprinkles, and house supplement were not administered at the 9:00 P.M. doses on 02/07/26, 02/08/26, 02/09/26, 02/11/26, 02/12/26, 02/14/26, 02/24/26, and 02/28/26.Review of the February 2026 MAR for Resident #55, revealed levothyroxine 100 mcg was not administered on 02/08/26, 02/09/26, 02/10/26, 02/12/26, 02/13/26, 02/15/26, and 02/25/26.Review of the February 2026 MAR for Resident #55, revealed the 6:00 A.M. doses of hydrocodone 5-235 mg were not administered on 02/08/26, 02/09/26, 02/10/26, 02/12/26, 02/13/26, 02/15/26, and the 10:00 P.M. doses were not administered on 02/25/26, 02/07/26, 02/08/26, 02/09/26, 02/11/26, 02/12/26, 02/14/26, 02/24/26, and 02/28/26.During an interview on 03/12/26 at 2:50 P.M., Regional Clinical Director #205 verified Resident #54 missed the medications on the date/times listed above. Review of the policy titled, Administering Medications, dated 02/14/24, revealed the individual administering the medication checks the label three times to verify the right resident, right medication, right dosage, right time, and right method (route) of administration before giving the medication.This deficiency represents non-compliance investigated under Complaint Numbers 2699059, 2710143, and 2587217.

Based on observation and interview, the facility failed to ensure the kitchen was maintained in a clean and sanitary manner. This had the potential to affect 70 out of 71 residents in the facility. One resident (#67) was unable to consume food from the kitchen per diet order. The census was 71.Observation on 07/07/25 at 10:15 A.M. of the kitchen revealed the floor of the walk-in refrigerator had a pooling of water with a brownish tint. Interview on 07/07/25 at 10:15 A.M. with Dietary Manager (DM) #710 verified the pooling of water on the floor in the walk-in refrigerator. DM #710 stated she was newer to the position and had no information regarding the issue in the walk-in refrigerator. This deficiency represents non-compliance investigated under Complaint Number 1308977.

Based on record review, observations, staff interviews, and policy review, the facility failed to maintain a clean, safe, and homelike environment. This affected one resident (#72) and had the potential to affect all residents residing in the facility. The census was 71.Findings include:1. Observation on 07/07/25 at 8:24 A.M. revealed an area of the handrail on the 200 hall was missing. There was a wooden box between the two sections of handrail that was half-way secured to the wall. At the time of the observation, Maintenance Director (MD) #990 verified the missing section of handrail. MD #990 stated there was a water fountain that was removed from the wall, and the wooden box contained some plumbing parts. MD #990 expressed the plan was to remove the plumbing parts and replace the handrail. 2. Observation on 07/07/25 at 9:55 A.M. revealed a broken handrail on the 400 hall. The front portion of the handrail was cracked and separated from the rest of the handrail and had a sharp edge, which was verified by State Tested Nursing Assistant (STNA) #440 at 9:57 A.M. on 07/07/25. 3. Observation on 07/07/25 at 9:58 A.M. of the ceiling tiles in the hallway where the shower room is located revealed several ceiling tiles had multiple brown stains and black spots, which were confirmed by Human Resources Director #680 at the time of the observation. 4. Observation on 07/07/25 at 10:02 A.M. on the secured unit revealed several ceiling tiles near the door to the unit were cracked with various brown and black spots, which were verified by Registered Nurse (RN) #105 when observed. 5. Observation on 07/07/25 at 10:11 A.M. on the 300 hall revealed blankets on the floor that were folded up and pressed against the bottom of a ventilation unit. There was also a puddle of water near the blankets, and brownish water coming up from under the flooring. These observations were verified on 07/07/25 at 10:12 A.M. by Activities Staff #530. 6. Observation on 07/07/25 at 2:39 P.M. of the shower room revealed a blue shower chair that was broken and leaned back. STNA #220 verified the shower chair was broken and still being used. 7. Observation on 07/09/25 at 8:17 A.M. of the shower room revealed black discoloration between the tiles on the shower wall. The outer edge of the shower frame was cracked and missing pieces. There was also a hole in the ceiling of the shower room near the toilet. These observations were verified at the time of the observations with Housekeeping Staff #175. 8. Review of the medical for Resident #72 revealed an admission date of 07/07/23. Diagnoses included congestive heart failure, lobar pneumonia, acute kidney failure, type two diabetes mellitus without complications, chronic obstructive pulmonary disease, anxiety disorder, major depressive disorder, and schizophrenia. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #72 was cognitively intact and was assessed to require partial/moderate assistance with toileting and bathing, supervision with personal hygiene and transfer, and was independent with eating, oral hygiene, dressing, and bed mobility. Observation on 07/09/25 at 9:11 A.M. in Resident #72's room revealed the edge of the column of wall between the closet and dresser was missing pieces. A piece of material had been screwed into the wall to cover some of the missing wall but there were still areas of the wall that were rough and missing. Interview on 07/09/25 at 9:15 A.M. with RN #145 verified the wall was missing drywall. Observation on 07/09/25 at 9:16 A.M. in Resident #72's room revealed the edge of the wall near the door frame was breaking off, and the flooring outside of the room was missing a section. These observations were verified on 07/09/25 at 9:17 A.M. by Housekeeping Staff #780. Review of the facility policy titled Safe, Clean, Comfortable Homelike Environment, reviewed 01/01/25, revealed it was the policy of the facility to provide a safe, clean, comfortable homelike environment for residents.This deficiency represents non-compliance investigated under Complaint Numbers 1308974, 1308976, and 1308977.

Based on record review, staff interview, and review of facility policy, the facility failed to ensure care and services to prevent falls were implemented timely and appropriately. This affected one resident (#13) of 23 residents reviewed for falls. The facility census was 71. Record review for Resident #13 revealed the resident was admitted to the facility on [DATE] and had diagnoses which included Alzheimer's disease, dementia with behavioral disturbances, and hypertension. Review of the facility Fall Risk Assessment, dated 04/15/25, revealed the resident was assessed to be at moderate risk for falls. Review of the facility incident log revealed Resident #13 experienced a fall in the facility on 05/10/25. Review of the plan of care for Resident #13 revealed a plan of care and interventions to reduce the risk of falls had not been implemented for the resident until 05/14/25, four days after the resident experienced a fall at the facility. Interview with Minimum Data Set (MDS) Nurse #390 on 07/08/25 at 3:08 P.M. confirmed a plan of care to include interventions to prevent falls should be implemented for all residents assessed to be at risk for falls. Interview with MDS Nurse #390 on 07/09/25 at 9:30 A.M. confirmed a plan of care and interventions to prevent falls had not been implemented for Resident #13 until 05/14/25, four days after the resident fell while residing in the facility. Review of the facility policy titled Fall Policy, reviewed on 01/01/25, revealed all residents will receive adequate supervision, assistance, and assistive devices to prevent falls. Each resident will be evaluated for safety risks, including falls and accidents. Care plans will be created and implemented based on the individual's risk factors to aid in preventing falls. This deficiency represents non-compliance investigated under Complaint Numbers 1308974, 1308976, and 1308977.

Based on record review, observation, interview and review of the medication administration policy the facility failed to provide medications while adhering to proper infection control procedures during administration. This affected one resident (Resident #53) out of three observed during medication administration. The facility census was 71.Findings include:Record review of Resident #53 revealed this resident was admitted to the facility on [DATE] with the following medical diagnoses: Alzheimer's disease, seizures, depression, dysphagia, supraventricular tachycardia, atrial fibrillation, and benign prostatic hyperplagia. Review of the Minimum Data Set(MDS) assessment completed on 06/05/25 revealed this resident had minimal cognitive impairments. Review of Physician Orders revealed this resident was receiving the following medications observed during administration: Vitamin B12 100 milligrams (mg) 1 tablet, Zinc 50 mg 1 tablet, Sertraline 50 mg 1 tablet, Multivitamin 1 tablet, Folic Acid 800 mg 1 tablet, Flecainide Acetate 100 mg 1 tablet, Diazepam 120 mg 1 tablet, and Carbazepine 200 mg 1 tablet during the morning administration. Observation of medication administration for Resident #53 on 07/08/25 at 7:50 A.M. revealed all medications were prepared by Medication Tech #770. All medications were collected from their individual packaging by the preparer with the use of bare hands into the medication cup for administration. Hand washing was not completed prior to or following administration. Interview with Medication Tech #770 on 07/08/25 at 7:50 A.M. verified she had handled all eight medications with her bare hands, and also verified she did not wash her hands prior to or following administration to Resident #53. She stated she should not have touched the medications to put them in the medication cup. Review of the Medication Administration Policy revised on 01/01/25 revealed hand hygiene is to be performed prior to handling any medication. The policy also states if a medication becomes contaminated or compromised, the medication is discarded.

THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY Based on medical record review, review of a Self-Reported Incident (SRI), staff interviews, review of employee timeclock punch reports, review of the local police report, review of witness statements, review of an employee personnel file and facility policy review, the facility failed to ensure one cognitively impaired resident (#20) was free from physical abuse by facility staff. This resulted in Immediate Jeopardy and the potential for serious physical injuries and psychosocial harm for Resident #20 when on 12/10/23, State tested Nursing Assistant (STNA) #800 was witnessed by Activities Aide #400 to physically restrain Resident #20 in his wheelchair and then slapped the resident on the left side of his head/face causing the resident's glasses to fall off and the lenses came out of the frame. This affected one (#20) of three residents reviewed for abuse. The facility census was 62. On 12/27/23 at 3:53 P.M., the Administrator, and the Director of Nursing (DON) were notified that Immediate Jeopardy began on 12/10/23 at approximately 12:10 P.M., when Activities Aide #400 revealed she was playing cards with residents in the dining room of the men's secured unit on 12/10/23 when she heard Resident #20 and STNA #800 arguing because Resident #20 wanted to go to his room and STNA #800 did not want Resident #20 to go to his room. Activities Aide #400 stated she heard Resident #20 say do not hit me so she got up and saw STNA #800 restraining Resident #20 in his wheelchair. Activities Aide #400 stated STNA #800 was holding Resident #20 by his upper arm and then he slapped him on the left side of his head with his right hand. Activities Aide #400 stated Resident #20's glasses fell off his face and onto the floor. Activities Aide #400 reported Resident #20 as not trying to hit STNA #800 and his wheelchair was in the middle of the hallway. Activities Aide #400 stated she got in the middle of Resident #20 and STNA #800 upon witnessing the incident. Activities Aide #400 reported Resident #20 stated did you see him slap me? after the incident. Activities Aide #400 reported she called her supervisor and notified Registered Nurse (RN) Supervisor #27 in person of the incident. Although the Immediate Jeopardy was removed on 12/11/23, the facility remained out of compliance at Severity Level 2 (no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) until the deficiency was corrected on 12/20/23 when the facility implemented the following corrective actions: On 12/10/23 at 12:10 P.M., Activity Aide #400 witnessed STNA #800 restrain and slap Resident #20 on the left side of his head causing the resident's glasses to fall off and the lens popped out. Activity Aide #400 separated STNA #800 and Resident #20 immediately. On 12/10/23 at 12:15 P.M., RN Supervisor #27 escorted STNA #800 to the timeclock and then off the premises. On 12/10/23 at approximately 12:30 P.M., neurological (neuro) checks were initiated for Resident #20 and continued for five days. No issues were identified. On 12/10/23 at 12:45 P.M., the DON arrived at the facility to begin the investigation. On 12/10/23 at 12:57 P.M., an SRI was created by the Administrator off-site. The SRI for staff to resident abuse was completed on 12/15/23 at 11:36 A.M. and was substantiated. On 12/10/23 at 1:00 P.M., the DON interviewed Resident #20 about the incident and the Administrator was on speaker phone during the interview. Resident #20 stated it was not pretty; I was trying to do one thing and he wanted me to do another; he took a shot at me and knocked my glasses off. On 12/10/23 at 1:10 P.M., the DON completed a skin assessment, pain assessment and a psychosocial assessment on Resident #20 with no concerns noted. On 12/10/23 at 1:15 P.M., Resident #20's wife/power-of-attorney (POA) was notified of the abuse incident. The resident's wife chose not to press any charges on STNA #800. Resident #20's wife wanted STNA #800 removed from the facility permanently. On 12/10/23 at 1:20 P.M., the Police Department arrived at the building to interview Activity Aide #400, Resident #20, and Resident #20's wife. Due to the relationship between STNA #800 and Resident #20, the offense would be increased to a felony of the fourth degree. Both Resident #20 and his wife declined prosecution against STNA #800. The Police Officer advised both Resident #20 and his wife that if they changed their mind about pursuing charges, to call the Police Department and the case could be reopened. On 12/10/23 at 1:30 P.M., the DON interviewed 18 out of 18 residents on the back unit (men's secured unit) to ensure they felt safe in the facility and if they specifically had any issues with STNA #800 and no concerns were identified. On 12/10/23 at 1:30 P.M., the DON collected a witness statement from Activities Aide #400. On 12/10/23 at 1:40 P.M., 57 out of 57 current residents were interviewed to ensure they felt safe in the facility and if they specifically had any issues with STNA #800 and no concerns were noted. Skin assessments were completed on all like residents (men's secured unit) by the DON. On 12/10/23 at approximately 3:00 P.M, Medical Director (MD) #500 was contacted and notified of the incident and there were no new orders received. Nurse Practitioner (NP) #501 saw Resident #20 on 12/20/23 and there were no new orders. On 12/11/23 at 8:30 A.M., 80 out of 80 facility staff members were in-serviced on the facility abuse policy via in-person and via text messages. All text messages were received and did not bounce back to the sender. On 12/11/23 at 8:30 A.M., the facility implemented audits to ensure the residents felt safe at the facility. The audits were to occur three times weekly for four weeks. Any resident who did not feel safe or feels abused will have an SRI filed immediately. On 12/11/23 at 8:30 A.M., the facility implemented audits for testing employee knowledge of the facility's abuse policy. Audits were to occur three times weekly for four weeks. Any employee who answered the abuse policy questions incorrectly would be re-educated immediately by the Administrator/Designee. On 12/11/23 at approximately 11:00 A.M., Crisis Prevention Intervention (CPI) training was scheduled for the staff and the training will take place on 01/08/23 at 9:00 A.M. as an ongoing effort to prevent abuse in facility. On 12/11/23 at 11:30 A.M., the abuse policy was reviewed by the Interdisciplinary Team (IDT) and no changes were made. On 12/11/23 at 1:00 P.M., Social Worker (SW) #63 and Minimum Data Set (MDS)/Licensed Practical Nurse (LPN) #48 met with Resident #20 and no issues were identified. SW #63 made a referral to counseling for a follow-up since Resident #20 was already an established patient/resident. On 12/11/23, SW #63 implemented follow-ups with Resident #20 daily for four weeks and a referral was made for counseling for a follow-up since the resident was already an established resident/patient. On 12/11/23 at 3:30 P.M., abuse rounds were started by the DON. Abuse rounds consisted of interviewing all of the residents to ensure they feel safe in their home and to ensure they have not experienced any abuse. This is an ongoing process the facility participates in. On 12/13/23 at 1:00 P.M., Counseling Source Counselor #502 saw Resident #20 post-incident with no concerns noted. On 12/18/23 at approximately 8:00 A.M., STNA #800 was reported to the Nurse Aide Registry by the Administrator. The Registry contact person stated that the facility's substantiated SRI would automatically trigger an investigation into STNA #800's license. On 12/20/23 at 12:00 P.M., a secondary abuse in-service for 80 out of 80 employees was completed with an abuse post-test. No issues were identified. On 12/20/23 at 1:00 P.M., an Ad HOC Quality Assurance Performance Improvement (QAPI) meeting was held to discuss the abuse in-service and ongoing interventions. The managers in attendance included the Administrator, the DON, LPN #48, Human Resources #08, SW #63, Business Office Manager (BOM) #55, and Activities Director (AD) #46. MD #500 attended by phone and was unavailable to be on-site. On 01/10/24, the QAPI team will meet again to review the results of the audits. On 12/27/23, review of the facility's audits by the surveyor completed on 12/11/23, 12/13/23, 12/15/23, 12/16/23, 12/18/23, 12/19/23, 12/21/23, and 12/22/23, 12/24/23, 12/25/23, and 12/26/23 revealed the audits were conducted as reported and no issues were identified. On 12/27/23 from 9:00 A.M. to 2:00 P.M., interviews with LPN #62, STNA #12, STNA #53, and Housekeeper #70 revealed they had recently received education on abuse and were knowledgeable about what abuse was, what to do if they witnessed abuse occurring, and who to report abuse allegations too. On 12/27/23 and 12/28/23, review of the medical records for Residents (#16, #21 and #23) reviewed for abuse, revealed no concerns related to abuse of a resident. Proper assessments, care plans and appropriate interventions were noted in the medical records of the residents. Findings include: Review of the medical record for Resident #20 revealed the resident was admitted to the facility on [DATE]. Diagnoses included multiple sclerosis (MS), chronic respiratory failure with hypercapnia, chronic obstructive pulmonary disease (COPD), dysphagia, Alzheimer's disease, paraplegia, unspecified dementia unspecified severity with other behavioral disturbance, muscle weakness, hypertension, anxiety disorder, mood disorder and polyneuropathy. Review of the dementia care plan dated 10/16/23 for Resident #20 revealed the resident had a history of poor impulse control and harming others at his previous facility. Interventions included administer medications as ordered, assess and address for contributing sensory deficits, assess and anticipate the resident's needs, provide physical and verbal cues to alleviate anxiety, give the resident as many choices as possible about care and activities, place the resident on one-on-one (1:1), monitor and report changes as needed, and the resident to reside on a locked unit. Review of the quarterly MDS 3.0 assessment dated [DATE] for Resident #20 revealed the resident was severely cognitively impaired and used a manual wheelchair. Resident #20 was not assessed to have any behaviors. Review of STNA #800's time punch dated 12/10/23 revealed STNA #800 worked from 6:48 A.M. to 12:19 P.M. on that date. Review of the staff schedule dated 12/10/23 revealed STNA #800 was scheduled to work on the men's secured unit from 7:00 A.M. to 7:00 P.M. Review of Activities Aide #400's witness statement dated 12/10/23 at 12:15 P.M., revealed Activities Aide #400 was playing cards with the residents in the dining room on the men's unit and she heard STNA #800 telling Resident #20 that he could not go to his room. They began arguing. Resident #16 got up from the table to go see what was going on and Activities Aide #400 heard Resident #20 say stop hitting me. Activities Aide #400 then got up to see what was going on and when she turned onto the hall, STNA #800 was restraining Resident #20 and then slapped him upside the left side of his head knocking his glasses off. Activities Aide #400 got in between them and then left the unit to call her supervisor. Activities Aide #400 was then told RN Supervisor #27 was on duty and reported it to him. Review of the pain comprehensive evaluation for Resident #20 dated 12/10/23 at 12:21 P.M. revealed the resident was assessed to have a pain score of a three (pain scale of zero indicates no pain and 10 indicates severe pain). Review of the skin observation tool assessment dated [DATE] at 12:43 P.M. for Resident #20 revealed the resident had no new skin areas. Review of the facility's SRI dated 12/10/23 and timed 12:57 P.M., revealed the DON received a report that a physical altercation happened between Resident #20 and STNA #800. The altercation was witnessed by Activity Aide #400 and Resident #16. The DON asked RN Supervisor #27 to remove STNA #800 from the building immediately. The DON reported the incident to the Administrator and an investigation was started. Further review of the SRI revealed the allegation of physical abuse was substantiated and the SRI was marked completed on 12/15/23 at 11:36 A.M. Review of the police report dated 12/10/23 at 2:07 P.M., revealed the Police Officer was dispatched to the facility on [DATE] at 2:07 P.M. for an assault. The police were met by the DON and the DON stated staff alerted her to a physical altercation between a resident and an employee. The DON stated STNA #800 hit Resident #20 in the face. The DON stated she did not see what transpired but Activities Aide #400 did. Activities Aide #400 stated around noon she was working in the memory unit and heard a verbal altercation transpiring between Resident #20 and STNA #800. When Activities Aide #400 turned down the hallway, she saw STNA #800 restraining Resident #20 in his wheelchair by holding his arms. STNA #800 hit Resident #20 in the face with his left hand with an open palm and Resident #20's glasses were knocked off his face and landed on the ground. Resident #20's story aligned with Activities Aide #400's story and Resident #20 stated that STNA #800 did not make contact with his face but did come close enough to knock his glasses off. No visible marks were noted on Resident #20's face. STNA #800 had been terminated and escorted off the property prior to police arrival. Due to the relationship between STNA #800 and Resident #20, the offense would be increased to a felony of the fourth degree. Both Resident #20 and his wife declined prosecution against STNA #800. Police advised both Resident #20 and his wife that if they changed their minds to call back and the case could be reopened. Review of the nurse's progress note dated 12/10/23 at 2:31 P.M. for Resident #20, revealed LPN #62 was informed when she got back from a break that there was some type of altercation involving Resident #20 and a staff member (identified as STNA #800). The altercation was reported to the supervisor on duty and was dissolved by the supervisor. The supervisor walked the staff member to the time clock and sent them home. The supervisor reported the incident to the nurse and the nurse conducted a skin assessment on the resident with no new areas found. The DON was notified, and the DON notified the family. Review of Resident #20's witness statement dated 12/10/23 and untimed, revealed it wasn't pretty. I was trying to do one thing and he wanted me to do another. He took a shot at me and knocked my glasses off. Review of RN Supervisor #27's witness statement dated 12/10/23 and untimed, revealed RN Supervisor #27 escorted STNA #800 out of the building and reported it to the DON immediately upon notification of the accusation. Review of STNA #54's undated witness statement revealed STNA #54 worked on the men's unit on 12/10/23 and did not witness any altercation between STNA #800 and Resident #20 but STNA #54 did hear a commotion and thought it was residents going back and forth. STNA #54 went to investigate and by that time nothing was going on anymore. Review of the interdisciplinary team (IDT) progress note dated 12/11/23 at 12:18 P.M. for Resident #20, revealed the DON became aware that there was physical aggression contact with a staff member on 12/10/23. The DON immediately directed the supervisor to escort the staff member out of the facility. The assigned nurse did a skin and pain assessment with no residual effects noted. All parties were made aware. Review of the nurse's progress note dated 12/11/23 at 3:33 P.M. for Resident #20, revealed LPN #39 spoke with the resident's wife on the phone. Resident #20 was compliant with all care provided that shift and was noted with verbal aggression earlier in the shift. The staff redirected and spoke with the resident 1:1 with no further behaviors noted after the intervention was provided. Resident #20's wife stated that the resident was complaining about his glasses and requested for the facility staff to provide assistance. LPN #39 spoke with the medical records office and Resident #20 would be seen by the eye doctor on 12/14/23. Review of the disciplinary action form dated 12/11/23 for STNA #800, revealed on 12/10/23 in the memory care unit, the employee failed to conduct self in a professional manner. This employee failed to control himself and was noted to use physical force when frustrated with a resident. The employee was terminated. Review of the Optometrist's eye care chart note dated 12/19/23, revealed Resident #20 had an eye evaluation and new glasses were to be ordered pending insurance approval and a follow up in 12 to 15 months. Interview on 12/27/23 at 9:17 P.M. with RN Supervisor #27, revealed Activities Aide #400 came to him upset and crying a few weeks ago and stated STNA #800 had slapped a resident. RN Supervisor #27 stated he could not recall the resident's name but stated he called the DON immediately upon being notified of the incident by Activities Aide #400. RN Supervisor #27 also stated he escorted STNA #800 out of the facility and the DON came to the facility and took over the investigation. Interview on 12/27/23 at 9:22 A.M. with LPN #62, revealed she was working at the facility on 12/10/23 with STNA #800 and STNA #54. LPN #62 stated she did not witness the incident between STNA #800 and Resident #20 because she was out of the facility at lunch. LPN #62 reported STNA #800 had been removed from the facility prior to her return from lunch. LPN #62 stated STNA #800 called her to give report on the residents later that day and STNA #800 stated that Resident #20 was having increased behaviors and Resident #20 had put his hands on STNA #800. LPN #62 reported that STNA #800 told her that he snap reacted and pushed Resident #20's head with his hand when Resident #20 put his hands on him, and Resident #20's glasses fell off his face. LPN #62 stated STNA #54 was currently out on maternity leave. Interview on 12/27/23 at 9:28 A.M. with Resident #20 revealed the resident denied being abused by any staff member at the facility and Resident #20 denied ever being hit or slapped by STNA #800. Resident #20 stated staff would not want to hit him because he would hit them back. Telephone interview on 12/27/23 at 9:55 A.M. with STNA #800 revealed STNA #800 was out of town, and he wanted to call the surveyor back. STNA #800 declined to provide any information related to the incident. Telephone interview on 12/27/23 at 10:15 A.M. with Activities Aide #400, revealed she was playing cards with residents in the dining room of the men's secured unit on 12/10/23 when she heard Resident #20 and STNA #800 arguing because Resident #20 wanted to go to his room and STNA #800 did not want Resident #20 to go to his room. Activities Aide #400 stated she heard Resident #20 say do not hit me so she got up and saw STNA #800 restraining Resident #20 in his wheelchair. Activities Aide #400 stated STNA #800 was holding Resident #20 by his upper arm and then he slapped him on the left side of his head with his right hand. Activities Aide #400 stated Resident #20's glasses fell off his face and onto the floor. Activities Aide #400 reported Resident #20 as not trying to hit STNA #800 and his wheelchair was in the middle of the hallway. Activities Aide #400 stated she got in the middle of Resident #20 and STNA #800 upon witnessing the incident. Activities Aide #400 reported Resident #20 stated did you see him slap me? after the incident. Activities Aide #400 reported she called her supervisor and notified RN Supervisor #27 in person of the incident. Activities Aide #400 stated RN Supervisor #27 escorted STNA #800 out of the facility and the police came to the facility and interviewed her regarding the incident. Interview on 12/27/23 at 10:31 A.M. with the Administrator revealed Activities Aide #400 notified Activities Director (AD) #46 and RN Supervisor #27 that she had observed STNA #800 slap Resident #20 in the head. The Administrator stated AD #46 called the DON and the DON notified the Administrator of the incident. RN Supervisor #27 removed STNA #800 from the building immediately and an SRI was filed on 12/10/23. The Administrator also reported the incident to the police and Resident #20's wife was called on 12/10/23 but Resident #20 and Resident #20's wife did not want to press any charges. The Administrator stated all residents were interviewed on 12/10/23. Interview on 12/27/23 at 10:38 A.M. with the DON revealed she received a phone call from RN Supervisor #27 stating that STNA #800 had slapped Resident #20 and the incident was witnessed by Activities Aide #400. The DON directed RN Supervisor #27 to remove STNA #800 from the property. The DON stated she came to the facility, and she interviewed all residents, conducted skin assessments on the residents, and called the police. The DON reported that Resident #20 did not have any injuries, but his glasses were broken because the lens popped out, but he was able to pop it back in. The DON stated that he interviewed Resident #20 on 12/10/23 and Resident #20 stated it wasn't pretty. I was trying to do one thing and he wanted me to do another. He took a shot at me and knocked my glasses off. Interview on 12/27/23 at 12:28 P.M. with Resident #16 revealed the resident had never seen any residents be hit, slapped, or abused at the facility. Review of STNA #800's personnel file on 12/27/23 at 2:00 P.M., revealed STNA #800 was hired on 09/28/22 and signed the abuse prevention program acknowledgement form and the Declaration of the Resident's [NAME] of Rights. Review of the abuse, neglect, exploitation, and misappropriation of resident property policy dated 11/21/16, revealed abuse was the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish. It includes physical abuse. The facility will investigate all alleged violations involving abuse. Review of the facility's abuse policy revised on 10/24/22 revealed residents will be free from abuse. Abuse includes physical abuse. Physical abuse includes hitting, slapping, pinching, and kicking. It also includes controlling behavior through corporal punishment. This deficiency represents non-compliance investigated under Complaint Number OH00149327.

Based on record review, observation, resident and staff interview, review of facility policy, and review of guidelines from the National Pressure Injury Advisory Panel (NPIAP), the facility failed to conduct adequate skin assessments and failed to implement interventions to prevent the development of pressure ulcers and/or aid in the healing of existing pressure ulcers as recommended by the physician. This resulted in Actual Harm when Resident #38 was found to have a pressure ulcer which was first identified as a stage IV pressure ulcer. This affected one (#38) of three residents reviewed for pressure ulcers. The census was 63. Findings include: Review of the medical record for Resident #38 revealed an admitted [DATE] with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Minimum Data Set (MDS) for Resident #38 dated 08/10/22 revealed the resident was cognitively intact and required limited assistance with activities of daily living. Further review of the MDS revealed the resident was coded as positive for the presence of an unstageable pressure ulcer which was not present upon admission. Resident #38 was coded as being at risk for the development of pressure ulcers. Review of the care plan for Resident #38 revised 08/16/22 revealed the resident had the potential for skin breakdown related to immobility and incontinence and had an unstageable pressure ulcer to her right heel. Interventions included the following: administer treatments as ordered, staff will monitor skin with care for changes, discoloration, excoriation, etc., dietary consult as needed, pressure reduction mattress to bed, staff will assist with turning and repositioning as needed. Review of the pressure ulcer risk assessment for Resident #38 dated 07/31/22 revealed the resident was at moderate risk for the development of pressure ulcers. Review of the weekly skin assessment per licensed nurse for Resident #38 dated 07/27/22 revealed resident's skin was intact. Review of the weekly skin assessment per licensed nurse for Resident #38 dated 08/03/22 revealed an unstageable pressure injury was found to the resident's calcaneus which measured 2.5 centimeters (cm) in length by 2.5 cm in width with eschar present in the wound bed. Review of wound assessment for Resident #38 dated 08/05/22 revealed the resident had an open lesion to the right plantar foot which measured 1.4 centimeter (cm) in length by 1.2 cm in width by 0.4 am in depth. The wound bed was 30 percent (%) slough, 20% eschar with serous drainage. Review of the wound physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . Wound was classified as 0.7 cm in length by 0.9 in width by 0.3 cm in depth. The wound was excised at the bedside by the physician on this date to remove necrotic tissue in the wound bed. Review of the wound physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . Wound was classified as a stage IV pressure ulcer of greater than 54 days duration and measured 0.6 cm in length by 1.0 cm in width by 0.2 cm in depth. There was thick adherent devitalized necrotic tissue to 10 % of the wound bed and slough tissue to 60% of the wound bed. Review of the October 2022 monthly physician orders for Resident #38 revealed there were no orders for EZ boots or other type of heel protection or orders to offload resident's heels. Review of the orders revealed an order dated 09/30/22 to cleanse wound of right plantar lateral heel with normal saline, pat dry, apply Santyl, cover with dry dressing daily. Review of the October 2022 Treatment Administration Record for Resident #38 revealed the treatment to Resident #38's right heel was documented as completed per physician order. Observation on 10/04/22 at 1:59 P.M. of Resident #38 revealed the resident was in her room and was seated in her wheelchair without footrests. Resident #38 had socks on both feet and was not wearing shoes or any type of heel protection. Interview on 10/04/22 at 1:59 P.M. with Resident #38 confirmed the staff had found a sore on her heel back at the beginning of August 2022 and the wound doctor told her she should be wearing some boots on her feet to help the sore heal. Resident #38 stated she told Social Service Designee (SSD) #345 about the need for the boots because she knew SSD also was the central supply person. Resident #38 confirmed she had been asking for the boots for a couple weeks now. Resident #38 confirmed the nurse had done her dressing change to her right heel earlier in the day and the dressing was intact underneath her sock and she didn't want her sock removed. Interview on 10/04/22 at 2:05 P.M. with Licensed Practical Nurse (LPN) #430 confirmed she changed Resident #38's dressing in the morning and also confirmed Resident #38's heels were not offloaded. LPN #430 confirmed Resident #38 had been asking for some heel protector boots but SSD #345 was on vacation, and they were going to ask the SSD #345 to order some boots when she returned. Observation on 10/06/22 at 10:00 A.M. of wound care for Resident #38 per LPN #430 revealed the resident had a quarter sized open area to the lateral aspect of her right heel. There was a small amount of serous drainage on the old dressing. Resident #38 did not have EZ boots or other heel protection in place. Interview on 10/06/22 at 10:05 A.M. with LPN #430 confirmed Resident #38 was being treated by the facility wound physician and the wound was classified as a stage IV pressure ulcer. LPN #430 confirmed Resident #38 did not have EZ boots or other heel protection in place. Interview on 10/05/22 at 10:51 A.M. with SSD #345 confirmed she also performed the central supply function for the facility and if a resident needed heel protectors or other devices the request should come from nursing or from therapy. SSD #345 confirmed no one had asked her to order heel protectors or any such devices for Resident #38. SSD #345 did confirm Resident #38 had told her a couple of weeks ago that she needed heel boots, but she wasn't sure why the resident wanted them. SSD #345 confirmed she was not aware if Resident #38 had skin breakdown or not. Interview on 10/05/22 at 12:45 P.M. with the Director of Nursing (DON) confirmed wound physician notes dated 09/09/22 and 09/30/22 had recommendations for EZ boots for Resident #38 but the recommendations had not been implemented. DON confirmed Resident #38's skin assessment on 07/27/22 noted resident's skin was intact and on 08/03/22 the nurse noted an open area to the right heel with slough and necrotic tissue present. DON confirmed the wound physician classified the ulcer to resident's right heel as a stage IV pressure ulcer. Review of the facility policy titled Wound Management Wound Prevention and Treatment dated 02/04/21 revealed the licensed nurse will conduct weekly skin checks and would provide pressure relief with pillows or other supportive devices. Interventions would be implemented in the resident's care plan to prevent deterioration and promote the pressure ulcer's healing. Review of the NPIAP guidelines dated 2014 pages 70-71 at https://npiap.com/general/custom.asp?page=2014Guidelines revealed facilities should educate health professionals on how to undertake a comprehensive skin assessment that includes the techniques for identifying blanching response, localized heat, [CONDITION(S)], and induration. Further review of the guidelines revealed ongoing assessment of the skin was necessary in order to detect early signs of pressure damage. Visual assessment for [CONDITION(S)] (redness of the skin) was the first component of every skin inspection. Skin redness and tissue [CONDITION(S)] resulting from capillary occlusion was a response to pressure, especially over bony prominences. Staff should conduct a head-to-toe assessment with particular focus on skin overlying bony prominences including the sacrum, ischial tuberosities, greater trochanters and heels and each time the patient was repositioned was an opportunity to conduct a brief skin assessment. This deficiency substantiates Complaint Number OH 814.

Based on record review, observation, resident and staff interview, and review of the facility policy, the facility failed conduct thorough investigations to determine root cause analysis to identify potential hazards and resident-specific interventions to reduce and/or eliminate falls and falls with injury. The facility also failed to ensure fall prevention interventions were in place per the resident's plan of care. This resulted in Actual Harm when Resident #20 experienced repeated falls resulting in a fractured arm which required surgery. This affected one (#20) out of three residents reviewed for falls. The census was 63. Findings include: Review of the medical record for Resident #20 revealed an admitted [DATE] with a diagnoses of [CONDITION(S)] and [CONDITION(S)]. Review of the Minimum Data Set (MDS) for Resident #20 dated 07/27/22 revealed the resident was cognitively impaired and required extensive assistance of one staff with activities of daily living (ADL's.) Review of the fall risk assessments for Resident #20 dated 08/23/22 and 09/18/22 revealed the resident was at high risk for falls. Review of the fall care plan for Resident #20 updated 09/19/22 revealed the resident was at risk for falls with potential for injury due to multiple fall risk factors including impaired vision, psychoactive medication use, unsteady gait, impaired balance, and fluctuations in cognition/mood, and behavior. Interventions included the following: assist resident with transfer, call light and personal items within reach when in room, maintain a clear pathway, maintain bed in lowest position with brakes locked, use high low bed with floor mat when in bed (added 08/23/22), non-skid strips to the floor by resident's bed (added 05/09/22), staff to assist resident to lay down for 30 minutes after meals (added 09/18/22). Review of the fall risk assessments for Resident #20 dated 07/10/22, 08/23/22 and 09/18/22 revealed resident was at high risk for falls. Review of nurse progress note for Resident #20 dated 08/03/22 timed at 8:02 A.M. per agency nurse revealed at 2:00 A.M. nurse found the resident face down on fall mat beside her bed. Nurse and aide used a Hoyer lift to assist resident back into bed. Resident #20 was assessed for injuries with none noted and the resident denied pain. The note did not include documentation of physician or resident representative notification of the fall. Review of the facility incident log for August 2022 revealed it did not include a fall for Resident #20 on 08/03/22. Further review of facility documentation revealed there was no evidence of an investigation into Resident #20's fall dated 08/02/22. Review of the progress note for Resident #20 dated 08/23/22 revealed the resident was found on the floor by the aide who went to resident's room after hearing a loud thud sound. Resident #20 reported to nurse she had rolled out of bed onto her fall mat. Bed was in lowest position. Resident #20 complained of pain to her right hip and was sent out via emergency medical personnel for an evaluation at the hospital. Review of hospital records for Resident #20 dated 08/23/22 to 08/28/22 revealed Resident #20 presented to the emergency roiagnom on [DATE] following a fall. In the emergency room upper extremity x-rays showed bilateral displaced humeral surgical neck fractures and she was admitted for further management of fractures. Orthopedic surgery was consulted and thought that having bilateral shoulder surgery would be too much for her from a physiologic and recovery standpoint. They recommended open reduction with internal fixation of her dominant right shoulder which was performed on 08/25/22. Review of follow up orthopedic consult note for Resident #20 dated 09/28/22 revealed the resident was examined and had x-rays taken which showed the surgical site to her right shoulder/upper arm was healing. Review of the facility's fall investigation for Resident #20 dated 08/23/22 revealed the fall occurred when resident fell from her bed onto the fall mat and sustained a fracture. Bed was in lowest position and fall mat was in place. Review of progress note for Resident #20 dated 09/18/22 timed at 3:00 P.M. revealed the resident was found lying face up on the floor alongside the bed, in between the bed and wheelchair. The nurse asked Resident #20 what happened, and the resident stated she was trying to get back in bed and had fallen. Review of the facility fall investigation for Resident #20 dated 09/18/22 revealed the resident had a fall without injury on 09/18/22 when she tried to transfer herself from wheelchair to bed. Bed was in normal position and fall mats were not in place. The facility's follow up intervention to prevent further falls was for staff to assist the resident to lay down for 30 minutes after meals. The fall investigation did not include documentation regarding whether the intervention of non-skid strips to the floor by the bed (added to the care plan on 05/09/22) were in place. Observation on 09/28/22 at 3:30 P.M. of Resident #20 revealed resident was sitting in common area in her wheelchair and had a sling on her right arm. Interview on 09/28/22 at 3:30 P.M. with Resident #20 confirmed sometime in the middle of September 2022 she was trying to transfer herself from her wheelchair into bed and she slipped and fell on the floor. Observation on 10/05/22 at 11:35 A.M. of Resident #20's room with the Administrator and the Director of Nursing (DON) revealed the resident was out of the facility-unrelated to the fall on 08/23/22. Observation of Resident #20's room revealed the Resident #20's bed was a high low bed which could be positioned from a standard working height to all the way to the floor. Resident #20 had a thick fall mat which when placed next to the bed in lowest position created a level surface so if the resident rolled out of the bed onto the mat there would be no drop in level. Observation revealed the non-skid strips to resident's bedside were not in place. It appeared that there may have been nonskid strips at one time, but they had been pulled up and there was a dark residue on the floor showing where the strips had once been. Interview on 10/05/22 at 11:35 A.M. with the Administrator and DON confirmed there were no functional non-skid strips by Resident #20's bedside per the plan of care. Interview confirmed Resident #20 had a room move sometime prior to the fall on 09/18/22 and her old room had nonskid strips in place, but they had not been placed in her new room, the room in which she resided at the time of her fall on 09/18/22. Interview on 10/06/22 at 9:43 A.M. with the Administrator confirmed the fall for Resident #20 was not on the facility's incident log and the facility had not completed an investigation of the fall on 08/03/22. Interview on 10/06/22 at 10:10 A.M. with the Administrator confirmed the high low bed and thick fall mat were implemented after the fall on 08/23/22. Administrator confirmed prior to the fall on 08/23/22 in which Resident #20 sustained an arm fracture, the resident had a standard bed and a standard fall mat in place and when the resident rolled out of bed on 08/03/22 there was a change in level which occurred making the potential for injury greater. Review of the facility policy titled Fall Policy dated 07/10/22 revealed all residents will receive adequate supervision, assistance, and assistive devices to prevent falls. Each resident will be evaluated for safety risks, including falls and accidents. Care plans will be created and implemented based on the individual's risk factors to aid in preventing falls. All falls are to be investigated and monitored. The Interdisciplinary Plan of Care (IPOC) team will meet within the same period and discuss the causative factors, interventions to prevent another fall, make therapy referral as necessary, and revise the care plan if necessary This deficiency substantiates Complaint Number OH 128 and Complaint Number OH 814.

Based on observations, interviews, record reviews, and review of Centers for Disease Control and Prevention (CDC) Guidelines, the facility failed to have an effective Infection Prevention and Control Program (IPCP) to properly contain and prevent the transmission of COVID-19. The failure to separate residents who were negative for COVID-19 from roommates who were positive for [MEDICAL CONDITION], place residents who were exposed to COVID-19 on transmission-based precautions, and appropriately wear and use uncontaminated Personal Protective Equipment (PPE) placed 18 of 63 residents at risk of COVID-19 which could result in serious harm or death. 1. The facility failed to separate five residents (Resident (R) 7, R9, R11, R12, and R14), who were confirmed negative for COVID-19, from residing with roommates who were confirmed positive for COVID-19. The facility's failure contributed to a resident's death when R7, who had been negative for COVID-19, subsequently contracted COVID-19 and expired after not being separated from his COVID-positive roommate. 2. Observation on [DATE] of the men's unit revealed that, after the identification of an Immediate Jeopardy on [DATE] for housing negative and COVID-positive residents together, the COVID-positive residents were separated from the negative residents. However, the facility failed to place the negative residents who were exposed to the COVID-positive residents on any type of transmission-based precautions. The facility also failed to identify the need to place the residents who had been exposed to COVID-19 under observation/isolation. The failure to assure that staff were aware of each resident's status and implemented transmission-based precautions when caring for residents who had been exposed to COVID-19 placed 16 of 25 residents on the secured Men's Unit at risk for transmission of COVID-19. 3. Observation on [DATE] revealed Certified Nursing Assistant (CNA) 1 entered the room of a COVID-19 positive resident using personal protective equipment (PPE) which included an improperly worn N95 mask, a face shield, and gloves. The CNA then exited the room of the COVID-19 positive resident, and went directly into the room of R14, who was COVID negative, still wearing the same gloves, placing R14 at risk for transmission of COVID-19. The Immediate Jeopardy began on [DATE] when R6's COVID-19 test result came back as Positive and he was not separated from his roommate, R7, who subsequently contracted the COVID-19 virus and expired. On [DATE] at 4:37 PM, the facility's Administrator was notified and issued an Immediate Jeopardy at F880, Infection Control. Additional concerns at the Immediate Jeopardy level at F880 were identified and issued to the Administrator on [DATE] at 5:12 PM. The removal plan for the Immediate Jeopardy was validated on [DATE] through observations, interviews, and documentation review. The facility was notified that the Immediate Jeopardy was removed on [DATE] at 8:35 PM. After the immediacy removal, the noncompliance remained at a lower scope and severity level of no actual harm with the potential for more than minimal harm that was not Immediate Jeopardy. Findings include: 1. Review of the facility's policy titled, Astoria Place Guidelines for the Coronavirus, revised ,[DATE], revealed .6. For residents that are COVID-19 positive .if possible, residents should be placed in a private room with droplet isolation, or cohort with another resident who is positive for COVID-19. Review of the Centers for Disease Control and Prevention (CDC) website titled, Responding to Coronavirus (COVID-19) in Nursing Homes, revealed: Resident with new-onset suspected or confirmed COVID-19: Ensure the resident is isolated and cared for using all recommended COVID-19 PPE .If the resident is confirmed to have COVID-19, regardless of symptoms, they should be transferred to the designated COVID-19 care unit. https://www.cdc.gov/coronavirus/2019-ncov/hcp/nursing-homes-responding.html a. Observation during initial tour on [DATE] at 10:00 AM revealed that R6 and R7 were listed as roommates. Review of R6's undated Admission Record, located in the Electronic Medical Record (EMR) under the profile tab, revealed R6 was a long-term resident with [DIAGNOSES REDACTED]. On [DATE], the [DIAGNOSES REDACTED]. Review of R6's COVID-19 ([DIAGNOSES REDACTED]-CoV-2) Test Report, dated [DATE], located in the paper medical record, confirmed the results of the COVID test were Positive. Review of R6's medical records revealed no documented evidence R6 was separated from his roommate (R7) after testing positive for COVID-19. Review of R7's undated Admission Record, located in the EMR under the profile tab, revealed R7 was a long-term resident with [DIAGNOSES REDACTED]. Review of R7's COVID-19 ([DIAGNOSES REDACTED]-CoV-2) Test Report, dated [DATE], located in the paper medical record, revealed R7's test results were Negative. Review of R7s medical records revealed no documented evidence that he was separated from his roommate when R6 tested positive for COVID-19 on [DATE]. Review of R7's Immediate Response Report, dated [DATE], located in the paper medical record, revealed Infectious Disease-[MEDICAL CONDITION] .2019 Novel Coronavirus (COVID-19) . Detected (positive) . The positive result indicated R7 tested positive for COVID six days after his roommate, R6, tested positive for COVID-19. Review of R7's Progress Notes, dated [DATE], revealed the resident expired on [DATE] with time of death 5am. R7's death occurred 12 days after being diagnosed with [REDACTED]. During an interview on [DATE] at 11:12 AM, the Administrator confirmed that when R6 first tested positive for COVID-19 on [DATE], he was not separated from R7, who was negative for COVID-19 at that time. Per the Administrator, R6 and R7 remained as roommates until R7's death from COVID-19 that morning ([DATE]). During an interview on [DATE] at 3:10 PM, R7's Attending Physician (AP) 2, stated that once R7 tested positive for COVID-19, he declined quickly. b. Observation during initial tour on [DATE] at 10:00 AM revealed that R8 and R9 were roommates. Review of R8's undated Admission Record, located in the EMR under the profile tab revealed R8 was a long-term resident with [DIAGNOSES REDACTED]. On [DATE] the [DIAGNOSES REDACTED]. Review of 8's COVID-19 ([DIAGNOSES REDACTED]-CoV-2) Test Report, dated [DATE], located in the paper medical record, revealed R8's test results were Positive. Review of R8's medical records revealed no documented evidence R8 was separated from his roommate (R9) after testing positive for COVID-19. Review of R9's undated Admission Record, located in the EMR under the profile tab, revealed R9 was a long-term resident with [DIAGNOSES REDACTED]. Review of R9's COVID-19 ([DIAGNOSES REDACTED]-CoV-2) Test Report, dated [DATE], located in the paper medical record, revealed R9's test results were Negative on the same day that his roommate (R9) tested positive for COVID. Review of R9's medical records revealed no documented evidence that he was separated from his COVID-positive roommate. Further review of test results revealed that R9 had an Immediate Response Report, dated [DATE], located in the paper medical record. This test result revealed Infectious Disease-[MEDICAL CONDITION] .2019 Novel Coronavirus (COVID-19) . Detected (positive) . The positive result indicated R9 tested positive seven days after not being separated from his roommate (R8), when R8 first tested positive for COVID-19. c. Observation during initial tour on [DATE] at 10:00 AM revealed that R10 and R11 were roommates. Review of R10's undated Admission Record, located in the EMR under the profile tab revealed R10 was a long-term resident with [DIAGNOSES REDACTED]. Review of R10's COVID-19 ([DIAGNOSES REDACTED]-CoV-2) Test Report, dated [DATE], located in the paper medical record, revealed R10's test results were Positive. Review of R10's medical records revealed no documented evidence the resident was separated from his roommate (R11) after testing positive for COVID-19. Review of R11's undated Admission Record, located in the EMR under the profile tab revealed R11 was a long-term resident with [DIAGNOSES REDACTED]. Review of R11's most recent COVID-19 test results titled, COVID-19 ([DIAGNOSES REDACTED]-CoV-2) Test Report, dated [DATE], located in the paper medical record, revealed R11's test results were negative for COVID-19. Review of R11's medical records revealed no documented evidence that he was separated from his COVID-positive roommate. d. Observation during initial tour on [DATE] at 10:00 AM revealed that R12 and R13 were roommates. Review of R13's undated Admission Record, located in the EMR under the profile tab, revealed R13 was a long-term resident with [DIAGNOSES REDACTED]. Review of R13's Immediate Response Report, dated [DATE], located in the paper medical record, revealed Infectious Disease-[MEDICAL CONDITION] .2019 Novel Coronavirus (COVID-19) . Detected (positive) . Review of R13's medical records revealed no documented evidence the resident was separated from his roommate (R12) after testing positive for COVID-19. Review of R12's undated Admission Record, located in the EMR under the profile tab, revealed R12 was a long-term resident with [DIAGNOSES REDACTED]. Review of R12's most recent COVID-19 test results titled, COVID-19 ([DIAGNOSES REDACTED]-CoV-2) Test Report, dated [DATE], located in the paper medical record, revealed R12's test results were negative for COVID-19. Review of R12's medical records revealed no documented evidence that he was separated from his COVID-positive roommate. e. Observation during initial tour on [DATE] at 10:00 AM revealed that R14 and R15 were roommates. Review of R15's undated Admission Record, located in the EMR under the profile tab, revealed R15 was a long-term resident with [DIAGNOSES REDACTED]. Review of R15's Immediate Response Report, dated [DATE], located in the resident's paper medical record, revealed Infectious Disease-[MEDICAL CONDITION] .2019 Novel Coronavirus (COVID-19) . Detected (positive) . Review of R15's medical records revealed no documented evidence R15 was separated from his roommate (R14) after testing positive for COVID-19. Review of R14's undated Admission Record, located in the EMR under the profile tab, revealed R14 was a long-term resident with [DIAGNOSES REDACTED]. Review of R14's most recent COVID-19 test results titled, COVID-19 ([DIAGNOSES REDACTED]-CoV-2) Test Report, dated [DATE], located in the paper medical record, revealed the results of negative for COVID-19. Review of R14's medical records revealed no documented evidence that he was separated from his COVID-positive roommate. During an interview on [DATE] at 11:12 AM, the Administrator stated there were currently empty rooms available on the facility's COVID-19 unit and that rooms on the COVID-19 unit were also available at the time that the residents on the men's unit (R6, R8, 10, R13, and R15) tested positive for COVID-19. The Administrator stated the COVID-19 positive residents that resided on the facility's male dementia unit were not moved from the unit after their positive test result due to their confusion. Continued interview with Administrator revealed the Director of Nursing (DON) and corporate leadership discussed it and their belief was that the residents' behaviors would be out of control if they were moved. When asked if the COVID-positive residents could have been roomed with other positive residents while negative residents could have been roomed together, the Administrator stated he would have to find out the answer to that. The Administrator failed to provide an answer to this question prior to exit of the survey on [DATE]. During an interview on [DATE] at 12:58 PM, the Medical Director revealed he would have expected a resident who tested positive for COVID-19 on the men's unit to be moved to the COVID unit if there were open rooms; however, if there were open spaces on the men's unit, this could have also been used to separate the COVID-19 positive resident from their COVID-19 negative roommate. 2. Review of the Centers for Disease Control and Prevention (CDC) website titled, Responding to Coronavirus (COVID-19) in Nursing Homes, revealed: Roommates of residents with COVID-19 should be considered exposed and potentially infected and, if at all possible, should not share rooms with other residents unless they remain asymptomatic and/or have tested negative for [DIAGNOSES REDACTED]-CoV-2 14 days after their last exposure (e.g., date their roommate was moved to the COVID-19 care unit) . HCP (Healthcare personnel) should use all recommended COVID-19 PPE for the care of all residents on affected units. https://www.cdc.gov/coronavirus/2019-ncov/hcp/nursing-homes-responding.html Review of the facility's undated policy titled, Astoria Place-Hibernation Guidelines, revealed .hibernation means droplet precautions .Staff is to wear all PPE equipment, including N95 masks, gowns, gloves, and goggles/face shields for droplet precautions . a. Observation on [DATE] at 8:50 AM of the secured Men's Unit revealed R11, who was previously observed to room with a COVID-positive roommate (R10) on [DATE] at 10:00 AM, was now in a room alone. However, there was no evidence the facility placed R11, who had been exposed to COVID-19, on transmission-based precautions. (TBP). Observation revealed there was no signage on the door to indicate that R11 was on TBP. In addition, there was no PPE outside the door for staff use. b. Continued observation of the secured Men's Unit on [DATE] at 8:50 AM revealed R12, who was previously observed to room with a COVID-positive roommate (R13) on [DATE] at 10:00 AM, was now separated from R13. However, there was no evidence the facility placed R12 on TBP after having been exposed to COVID-19. Observation revealed there was no signage on the door to indicate that R12 was on TBP. In addition, there was no PPE outside the door for staff use. c. Further observations of the secured Men's Unit on [DATE] at 8:50 AM revealed R14, who previously roomed with a COVID-positive roommate (R15), was now in a room alone; however, there was no evidence the facility placed R14 on TBP. Observation revealed there was no signage on the door to indicate that R14 was on TBP. In addition, there was no PPE outside the door for staff use. Interview on [DATE] at 9:02 AM with CNA1, who was working on the secured Men's Unit, revealed she was unaware that R11, R12, and R14 had been exposed to COVID-19 and should be on transmission-based precautions. During an interview on [DATE] at 10:20 AM, the Administrator stated that when moving the COVID positive residents out of the rooms with the confirmed negative residents on [DATE] during their action to remove Immediate Jeopardy, the facility forgot to put the residents who were exposed to COVID-19 on hibernation (the facility's term for droplet/contact precautions). Review of an untitled document provided by the Administrator revealed that as of [DATE], nine of 25 residents on the Men's Unit were positive for COVID-19, leaving 16 residents who were at risk of [MEDICAL CONDITION] if staff failed to observe transmission-based precautions while providing care to residents who had been exposed to [MEDICAL CONDITION]. 3. Review of the facility's policy titled, Astoria Place Guidelines for the Coronavirus, updated ,[DATE], revealed The facility will protect the health and well being of our residents and staff during infectious disease outbreaks .4. Continue to ensure all staff are aware of proper donning of PPE which should include gloves, gown, and the N95 face mask when giving care to residents in isolation or positive COVID . Observation on [DATE] at 8:55 AM revealed CNA1 entered the room of R15, who was a confirmed COVID positive resident. CNA1 was wearing PPE, including an improperly worn N95 mask that exposed both nostrils, a face shield, and gloves on both hands. Continued observation revealed CNA1 exited R15's room with a disposable food tray, wearing the same gloves she had on when she entered the room. Further observation revealed CNA1 then immediately entered the room of R14, who was a confirmed COVID negative resident, wearing the same gloves she had worn while in R15's room. During an interview on [DATE] at 9:00 AM with the Assistant Director of Nursing/Infection Preventionist (ADON/IP) revealed CNA1 possibly exposed R14 to COVID-19 by wearing the same gloves she wore in R15's room, into R14's room. In addition, the ADON/IP stated CNA1 did not wear her N95 mask correctly. Interview on [DATE] at 9:02 AM with CNA1 revealed she did not know R15 was positive for COVID-19. CNA1 confirmed she wore the same gloves from R15's room into R14's room. The facility provided an acceptable plan for removal of the Immediate Jeopardy that was accepted on [DATE]. The surveyor verified that the following actions were implemented to remove the immediacy: Observations were made to confirm COVID positive residents were separated from the negative residents and that the residents who had been exposed to COVID-19 were placed on transmission-based precautions. Interviews with facility staff revealed they had been educated on placing residents on proper precautions and proper PPE usage. The facility's education records were reviewed. The survey team determined the immediacy had been removed on [DATE]. The Administrator was informed on [DATE] at 8:35 PM.

Based on observations, interviews, and record reviews, it was determined the facility failed to ensure that one unsampled resident (Resident (R) 16) received the necessary respiratory care of supplemental oxygen (O2) as ordered by her physician. A housekeeping staff member unplugged R16's oxygen concentrator from the wall, which resulted in R16 being without oxygen for 10 minutes. R16 exhibited signs of distress from being without her supplemental oxygen. The facility's failure placed R16 at likely risk for serious harm or death related to not receiving oxygen as ordered. The Immediate Jeopardy began on 12/22/20 when R16's oxygen was not administered as ordered by her physician. Substandard Quality of Care (SQC) was identified at 42 CFR 483.25 Respiratory Care. On 12/22/20 at 5:12 PM, the facility Administrator was notified and issued an Immediate Jeopardy at F695, Respiratory Care. The removal plan for the Immediate Jeopardy was validated on 12/22/20 through observation, interviews and record reviews. The facility was notified that the Immediate Jeopardy was removed on 12/22/20 at 8:35 PM. After the Immediacy was removed, the noncompliance remained at a lower scope and severity level of no actual harm with the potential for more than minimal harm that was not Immediate Jeopardy. Findings include: Review of the facility's undated policy titled, Astoria Place Oxygen Protocol, revealed .6. Oxygen therapy should only be administered by suitably qualified and trained care staff. Review of R16's undated Admission Record, located in the electronic medical record (EMR) revealed R16 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 12/03/20, R16 was diagnosed with [REDACTED]. Review of R16's Physician Orders, located in the EMR under the orders tab, revealed an order, dated 02/29/20, that R16 was to receive O2 via NC (nasal cannula) up to 4L (liters) continuous, may titrate to maintain sata (sic) above 88%. Observation on 12/22/20 at 9:40 AM revealed R16 was residing on the COVID positive unit. Continued observation revealed Housekeeper (HK) 3 unplugged R16's oxygen concentrator from the wall and removed the nasal cannula from R16's nose. HK3 then gathered items to prepare R16 to move from the COVID-19 unit. During an interview on 12/22/20 at 9:41 AM, R16 revealed she could not go without oxygen very long until she could not breathe. Continuous observation on 12/22/20 from 9:40 AM until 9:47 AM with the Housekeeping Supervisor revealed R16 began to show signs of distress and pant for breath. At 9:47 AM the surveyor intervened and requested the housekeeping supervisor to get a nurse. The 300 Hall nurse immediately responded to the room and put an oxygen oximeter on R16's right index finger. Observation revealed that three minutes elapsed before a reading of 87% was finally obtained at 9:50 AM. Further observation revealed that the nurse failed to reapply R16's oxygen upon arrival to the room, and R16 remained without her physician-ordered oxygen for a period of 10 minutes, until it was finally reapplied at 9:50 AM. During an interview on 12/22/20 at 9:50 AM, the Housekeeping Supervisor stated he noticed R16 appeared to be getting anxious and she was starting to breathe deep and fast (panting), so he started looking for a portable oxygen tank in the area; however, he was unable to locate one. During an interview on 12/22/20 at 9:58 AM, the Administrator stated it was his expectation that nursing would have brought a portable oxygen tank for R16 prior to her concentrator being unplugged. When asked about R16's apparent distress, panting, and oxygen saturation rate, the Administrator stated he would want to know nursing's opinion on this because if this was a resident who removed her oxygen all the time, then it would not be as concerning. During an interview on 12/22/20 at 10:22 AM, the Assistant Director of Nursing/Infection Preventionist (ADON/IP) revealed R16 being without oxygen for 10 minutes was very concerning to her. The ADON/IP stated that for any resident who was severely respiratory compromised and oxygen dependent, the nurse, rather than the housekeeper, should have supervised the resident's move. In addition, the ADON/IP stated that staff should have provided a portable oxygen tank to R16 during the time she was not receiving oxygen via her concentrator. During an interview on 12/22/20 at 11:16 AM with R16's Attending Physician, who was also the facility's Medical Director, he stated it was his expectation a Certified Nursing Assistant (CNA) or a nurse would have managed R16's room transfer. During an additional interview on 12/22/20 at 5:50 PM, R16 indicated she was worried earlier in the day when she was being moved from the COVID-19 unit. R16 stated the reason she was worried was because she was starting to have trouble breathing when she went so long without her oxygen. The surveyor verified that the following actions were implemented to remove the immediacy: Observations and record reviews were completed of residents who were dependent on supplemental oxygen and revealed no concerns. Review of the facility's education provided to staff related to moving residents who were dependent on supplemental oxygen revealed no concerns and was validated by interviewing facility staff.

Based on medical record review, observation, interviews with the resident and facility staff, and review of information from Medscape, the facility failed to ensure a resident's pain was adequately managed. This resulted in Actual Harm when the facility failed to administer a scheduled pain medication and/or adequately manage Resident #19's pain resulting in the resident reporting unrelieved severe pain. This affected one (Resident #19) of three residents reviewed for pain. The facility census was 79. Findings include: Review of Resident #19's medical record revealed the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #19's physician orders [REDACTED]. Review of Resident #19's pain assessment dated [DATE] completed by Licensed Practical Nurse (LPN) #55 revealed the resident had pain almost constantly at a pain intensity level of 8, on a scale of one to 10. Review of Resident #19's current comprehensive plan of care dated 02/06/19 revealed a plan of care to address the resident's expressions of pain and discomfort related to [DIAGNOSES REDACTED]. The goal was for the resident to report maximal pain relief/control with minimal interference with activities of daily living. Interventions included, but were not limited to, medications as ordered to manage pain, and to monitor for increased levels of pain and notify physician. Review of Resident #19's (MONTH) 2019 Medication Administration Record [REDACTED]. On 02/18/19, the resident did not receive four of the six ordered doses, and on 02/19/19, the resident did not receive the 1:00 A.M. dose. A total of 11 doses were not given as ordered. Review of Resident #19's nursing progress notes revealed the [MEDICATION NAME] was not administered as ordered as follows: on 02/17/19 at 12:02 A.M., LPN #48 document the medication was not given due to waiting on pharmacy; on 02/17/19 at 6:10 A.M., LPN #48 document the medication was not given due to need script; on 02/17/19 at 9:07 A.M., 1:06 P.M., and 4:46 P.M., LPN #88 documented the medication was not given due to awaiting pharmacy; on 02/17/19 at 11:52 P.M., LPN #48 documented the medication was not given due to need script; on 02/18/19 at 12:00 A.M., and 5:27 A.M., LPN #48 documented the medication was not given due to need script; on 02/19/19 at 3:38 A.M,. LPN #88 documented the medication was not available in the emergency box. Further review of the progress note revealed there was no documentation on (MONTH) 18, 2019 indicating why the resident did not receive his 9:00 A.M., or 9:00 P.M. dose of [MEDICATION NAME]. However, Resident #19 did receive the [MEDICATION NAME] as ordered on [DATE] for the 1:00 P.M. and 5:00 P.M. doses, administered by LPN #19. On 02/19/19 at 5:00 A.M., the resident did receive the pain medication as ordered by LPN #50 for a pain level of 10 and continued to receive the medication ordered after that time. There was no mention in the nursing progress notes on 02/16/19, 02/17/19, 02/18/19 or 02/19/19 of contacting the physician or pharmacy related to the medication, attempting to obtain a refill or new prescription. In addition, there was no documented evidence of monitoring of the resident's pain level on the days and times the medication was not given. Review of Resident #19's nursing progress notes dated 02/19/19 at 8:14 A.M., revealed LPN #95 documented in the resident's nursing progress notes the resident refused his breakfast stating I want water only, I feel so sick. I've vomited all over. She noted the resident has numerous emesis of liquid only. LPN #95 documented the resident's physician was in to see him and ordered laboratory tests and clysis, 0.9% sodium chloride in the right lower quadrant. On 02/19/19 at 10:48 A.M., the Director of Nursing (DON) documented in the nursing progress notes the resident's physician ordered normal saline via clysis at 40 milliliters per hour times two bags for three days, for nausea and vomiting and the resident was agreeable to treatment. Review of a physician's progress note for Resident #19 dated 02/19/19 was reviewed. The physician noted the resident was seen related to nausea, vomiting, a decreased intake by mouth, lethargy and weakness. She noted the resident had a long-standing history of abdominal problems, chronic abdominal pain, and pancreatitis. The physician documented staff reported the resident did not receive his pain medication, he had been on this medication for a long time and developed nausea, vomiting and abdominal pain. He remained afebrile and not able to eat anything because of pain and emesis and reported feeling very bad. The physician documented her assessment for the resident was nausea and vomiting, abdominal pain, lethargy, anorexia, and weakness. The physician noted that clysis would be started. She also documented the resident's opioid medication was restarted, as apparently the pharmacy did not deliver the medications. Review of the resident's Minimum Data Set (MDS) assessment dated [DATE] identified the resident as having moderate cognitive impairment with clear speech, and understands others, and was understood by others. The resident required the physical assistance of one staff person for bed mobility, transfers, toilet use, and personal hygiene. The assessment of the resident's pain on 02/22/19 revealed the resident had pain frequently during the assessment period, that he hurt all over, and the pain made it hard for him to sleep at night and limited his day to day activities. Resident #19's description of his pain was an 8 on a scale of one through 10, with 10 being the worst one could imagine. Interview and observation with Resident #19 on 03/20/19 at 3:35 P.M., revealed the resident was a very thin, frail appearing elderly man. He stated the facility did not give him his pain medications and stated the facility told him someone dropped the ball on ordering his pain medications. Interview on 03/21/19 at 3:42 P.M., with the Director of Nursing (DON) confirmed the resident did not get six ordered doses of [MEDICATION NAME] on 02/17/18, four of the six ordered doses on 02/18/19, and one of the six ordered doses on 02/19/19. Interview on 03/22/19 at 8:42 A.M., the DON reported the medication was received and administered from 01/18/19 through 02/16/19 and confirmed through review of facility controlled drug receipt record/disposition forms. She also provided a copy of the new prescription written by Resident #19's physician which was not written until 02/18/19 after the resident had missed nine doses. Per review of the facsimile dates and times a new prescription appeared to have been received from the physician after 9:00 A.M. on 02/18/19 and sent to the pharmacy on 02/18/19 at 10:14 A.M. The prescription was not filled in a timely manner after the prescription was sent as the first regular dose was not administered until 5:00 A.M. on 02/19/19. She did provide documentation that LPN #19 was able to get remote approval/access to obtain the needed medication for the resident from the emergency medication supply, via an automated dispensing machine on 02/18/19 for the resident's 1:00 P.M. and 5:00 P.M. does of [MEDICATION NAME]. The DON verified there was no documentation in the resident's medical record that the physician was notified to obtain a new prescription prior to, or after, the resident's [MEDICATION NAME] ran out or requests to obtain access to the emergency medication supply for the resident when the medication was first not available. Interview with Resident #19 on 03/25/19 at 8:55 A.M., revealed his pain during the time he did not receive his pain medication as horrible. Interview on 03/25/19 at 11:31 A.M., with LPN #19 revealed on 02/18/19 she called the pharmacy to get the prescription and then got them to release the appropriate dose of [MEDICATION NAME] from the automated medication dispensing machine. She was then able to provide the pain medication to Resident #19 for the 1:00 P.M. and 5:00 P.M. doses. LPN #19 verified Resident #19 stated he was in a lot of pain therefore, she obtained a remote release of the ordered pain medication from the automated medication dispensing machine. Review of information from Medscape revealed [MEDICATION NAME], an opioid [MEDICATION NAME] was indicated to treat pain. Further review revealed precise and systematic pain assessment was required to make the correct [DIAGNOSES REDACTED]. During a pain assessment the resident's pain was assessed on a zero to 10 scale with zero being no pain and 10 being the most severe pain. It also indicated pain medications work best if used at first signs of pain, if delayed, the medication may not work as well. This deficiency substantiates Complaint Number OH 259.

Based on review of closed and current medical records, interviews with the Hospice nurse, physician, and facility staff and review of the Cardiopulmonary Resuscitation (CPR) policy, the facility failed to initiate CPR or contact Emergency Medical Services (EMS) timely for one resident (#89) who was a Full Code and was found unresponsive without vital signs. Life threatening harm and death occurred when Resident #89 did not receive CPR or EMS and expired at the facility. This resulted in Immediate Jeopardy for one (#89) of four residents reviewed for emergent change in condition and death. The facility identified 65 residents residing in the facility designated with Full Code status. Additionally, two (#73 and #10) of four current residents reviewed were placed at risk for more than minimal harm that is not Immediate Jeopardy for failure of the facility to ensure the residents code status was updated in the electronic medical record, Point Click Care (PCC), to match the code status in the hard-medical record. The facility census was 87 residents. On [DATE] at 3:35 P.M., the Administrator, Director of Nursing (DON), Corporate Nurse #70 and Manager #35 were notified Immediate Jeopardy began on [DATE] at 3:15 A.M. when Resident #89 was found without vital signs. Licensed Practical Nurse (LPN) #10 failed to initiate CPR or provide emergency medical services. LPN #10 left Resident #89's room, located and requested assistance from Registered Nurse (RN) #30. Both LPN #10 and RN #30 failed to initiate CPR or provide emergency medical services. Resident #89 expired at the facility. The Immediate Jeopardy was removed on [DATE] when the facility implemented the following corrective actions: · On [DATE] at 3:18 A.M., RN #30 notified Hospice RN #32 that Resident #89 had expired. · On [DATE] at 6:00 A.M., the previous DON (#65) began in-service training with all nurses regarding the CPR policy, code status and verifying code status. The training was completed on [DATE] at 2:00 P.M. · On [DATE], the Administrator added discussing code status during each resident's care conference. · On [DATE] at 7:00 P.M., DON #65 and Assistant Director of Nursing (ADON) #22 completed medial record audits to ensure correct code status was appropriately identified for all residents residing in the facility. No concerns were identified. · On [DATE], the Administrator implemented reviewing any code status changes during the weekly Risk Management meetings. These meetings will occur indefinitely. · On [DATE], the Administrator implemented for the Social Services department to communicate any code status changes to the charge nurse on duty. Administrative staff is to check the order to ensure accuracy of code status. · On [DATE] between 9:55 A.M. and 10:10 A.M., interviews with LPN #23, LPN #24, LPN #25 and LPN #26 confirmed they received training. The staff correctly verbalized an understanding of the CPR policy, where to locate a residents' code status and their responsibilities regarding the residents' code status. · On [DATE], the Administrator implemented a performance monitoring tool to audit code status of five medical records, three times per week for four weeks to ensure Do Not Resuscitate (DNR) orders are signed by the medical doctor. The audit will include ensuring the code status in the hard-medical record matches PCC. · On [DATE] and [DATE], three (#88, #90, and #91) additional medical records were reviewed for emergent change in condition and death. There were no concerns identified. Although the Immediate Jeopardy was removed, the facility remained out of compliance at a Severity Level 2 (no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) as the facility is still in the process of implementing their corrective action plan and monitoring to ensure on-going compliance. Findings Include: 1. Review of Resident #89's closed medical record revealed the resident was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Further review of Resident #89's medical record revealed a physician's orders [REDACTED]. Review of Resident #89's Care Plan Conference Sheet dated [DATE] documented the resident's advanced directives were a Full Code. Review of Resident #89's significant change Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had moderate cognitive impairment and required extensive assistance with her activities of daily living except for eating. Resident #89 required supervision with eating her meals. The resident was occasionally incontinent and was on continuous oxygen therapy. The resident was receiving Hospice services as of [DATE] with a [DIAGNOSES REDACTED]. Review of Resident #89's Attending physician progress notes [REDACTED]. The resident had a significant functional decline and the family opted for Hospice care. The resident was enrolled in Hospice. Nursing staff did not report any new problems with the resident. She had pain and stiffness at times, but overall remained stable. Review of Resident #89's Attending physician progress notes [REDACTED]. The resident had a significant functional decline and family opted for Hospice. Resident was enrolled in Hospice and remained appropriate. Review of Resident #89's nursing notes revealed an entry dated [DATE] at 3:15 A.M. documented as a Significant Change Note revealed LPN #21 went into the resident's room. The resident was noted without any respirations. Oxygen was on at three liters per minute per nasal canula. LPN #21 notified RN #30 and RN #30 came to the resident's room. Resident #89 was without blood pressure, pulse or respirations. Resident was a Hospice resident. On [DATE] at 2:20 P.M. during a telephone interview with LPN #20, she stated she worked on the night Resident #89 expired. LPN #20 stated State tested Nurse Aide (STNA) #44 asked if she heard Resident #89 had expired. LPN #20 stated she went across the hall and asked LPN #21 and RN #30 if they needed help. One of the nurses was looking through the paperwork and the other nurse was calling Hospice. LPN #20 said these nurses could not find any paperwork that indicated the residents code status. They were calling Hospice to determine the residents code status. At that time, Resident #89 had already expired. On [DATE] at 3:00 P.M. during an interview with the Administrator, she stated staff had previously discussed Resident #89's code status with the son and the son wanted to talk with the rest of the family before changing the resident's code status. The son never changed the code status and Resident #89 remained a Full Code. On [DATE] at 5:38 P.M. during a telephone interview with RN #30, she stated on [DATE] she was assigned to the men's secured unit. She stated LPN #21 ran through the doors and asked her to come over and check on Resident #89. RN #30 went to the resident's room and the resident was not breathing. RN #30 said neither she nor LPN #21 knew what the residents' code status was. On [DATE] at 7:50 P.M. during an interview with LPN #21, she verified she was assigned to provide Resident #89 care and services on [DATE]. LPN #21 stated according to STNA #100, Resident #89 was last seen alive around 1:15 A.M. or 1:30 A.M. when the STNA gave her a drink and changed her. LPN #21 stated around 3:15 A.M., she was charting when she had the urge to check on Resident #89. LPN #21 stated the resident may have been warm when she checked for a pulse. LPN #21 stated Resident #89 was white, ashen and wasn't cold. The resident was not breathing, so she ran to request assistance from RN #30. LPN #21 verified she did not know Resident #89 was a Full Code. LPN #21 stated the resident was receiving Hospice services and Hospice residents usually had a DNR code status. LPN #21 stated when she saw the resident it looked like she was gone. LPN #21 stated if she knew Resident #89 was a Full Code, she would have started CPR. LPN #21 stated she didn't send STNA #100 to get RN #30 because STNA #100 was new and LPN #21 didn't think STNA #100 would know where to find RN #30. LPN #21 stated she thought it would be quicker if she went and asked RN #30 for assistance. LPN #21 stated after the resident had expired, she looked in the chart and noted the resident was a Full Code. On [DATE] at 8:00 P.M. during an interview RN #30, she verified LPN #21 had left Resident #89 to come and get her. RN #30 verified she did not know the code status for Resident #89. RN #30 stated if she knew the resident was a Full Code, she would have initiated CPR. She stated the resident had no vitals, was ashen and white, she was cool to the touch but not cold. RN #30 stated usually the code status was in the front of the chart, but she was unable to locate the code status for Resident #89. RN #30 verified she had not documented her assessment in Resident #89's chart because LPN #21 was assigned the resident. On [DATE] at 8:20 A.M. during an interview with the current DON and Corporate Nurse #70, the DON stated they had spoken to former DON #65 and ADON #22 and were informed LPN #21 and RN #30 reported they did a double check on Resident #89 for signs of life. Corporate Nurse #70 stated LPN #21 and RN #30 were questioning the resident's code status and were surprised she was a Full Code as she was on Hospice. Corporate Nurse #70 stated this was why they implemented the in-service. On [DATE] at 12:50 P.M. during a telephone interview with Hospice RN #32, Hospice Director of Operations #50 and Hospice Clinical Director #75, Hospice RN #32 stated RN #30 called her on [DATE] at 3:18 A.M. and stated Resident #89 had expired at 3:15 P.M. Hospice RN #32 verified Resident #89 was a Full Code. On [DATE] at 1:22 P.M. during a telephone interview with Physician #89, she stated she was aware the nurses did not start CPR. She was told Resident #89 had already expired when the nurses found her. Physician #89 stated the nurses did not start CPR as they used their clinical skills and judgement. 2. Review of Resident #73's medical record revealed the resident was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Review of Resident #73's annual MDS assessment dated [DATE] revealed the resident did not have a cognitive impairment and was independent with eating his meals. Review of the residents hard medical record revealed the resident was listed as a DNR Comfort Care (CC). Further review of the hard medical record revealed a physician order [REDACTED]. Review of the profile page in PCC revealed the resident was listed as a Full Code. On [DATE] at 5:10 P.M. during an interview with the Administrator, she verified the code status in PCC did not match the code status in the hard medical record. The Administrator stated she did not know why the DNR-CC code status was not showing up in PCC. The Administrator stated Resident #73's code status changed from Full Code to DNR-CC on [DATE] and the resident was placed on Hospice on [DATE]. 3. Review of Resident #10's medical record revealed the resident was admitted to the facility on [DATE] with a re-admission date of [DATE]. [DIAGNOSES REDACTED]. Review of the residents hard medical record revealed the resident had a physician order [REDACTED]. On [DATE] at 5:10 P.M. during an interview with the Administrator, she stated she didn't know why the resident's code status was not showing up in PCC. The Administrator stated she was going to check to see if there was a problem linking the physician orders [REDACTED]. The Administrator stated the nurses were instructed to check the physician orders [REDACTED]. Review of the facility's CPR Policy revealed the facility would provide basic life support, including CPR when a resident required such emergency care prior to the arrival of emergency medical services, subject to physician order [REDACTED]. Nurses were educated to initiate CPR, as recommended by the American Heart Association unless the resident presented with obvious signs of clinical death (rigor mortis, dependent lividity, decapitation, transection of decomposition) are present. The objective of the CPR Policy was to provide basic life support until emergency medical services arrives, consistent with the resident's advance directives, in the absence of an advance directive or DNR order and if the resident does not show signs of clinical death. Prompt initiation of CPR is essential as brain death begins four to six minutes following [MEDICAL CONDITION] if CPR is not initiated within that time. This deficiency substantiates Complaint Number OH 163.

Based on record review, facility self-reported incident (SRI) review, abuse policy review and staff interviews, the facility failed to ensure Resident #57 was free from abuse. Actual harm occurred when Resident #57 suffered a nasal fracture after being hit and kicked in the face by Resident #86 who had been exhibiting agitated behavior throughout the day. This affected one (Resident #57) of three sampled residents. The facility census was 85. Findings include: 1. Review of Resident #57's medical record revealed the resident was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Review of Resident #57 quarterly Minimum Data Set Assessment ((MDS) dated [DATE] revealed he was alert, oriented, independent with bed mobility, supervision with transfers, ambulation and eating. He required the limited assistance of one staff with dressing, toilet use and personal hygiene. Review of a facility SRI # 0 dated 01/24/18 revealed an alleged resident to resident abuse allegation was reported with Resident #57 as the resident victim. Review of Resident #57's nursing notes dated 11/24/18 at 7:00 A.M., revealed as the resident was coming out of his room, him and another resident exchanged words and it became physical. The other resident threw the first punch and knocked Resident #57 down and proceeded to kick him in the face. The residents were separated immediately and Resident #57's nose was bleeding. Resident #57 stated he was ok but rated his pain at a six on scale of 10. The resident stated he wanted to go to the hospital to be checked out. Review of hospital documentation dated 01/24/18 revealed Resident #57 presented to the ER after being punched in the nose at the nursing home. There was positive soft tissue swelling to the nose and a small abrasion to the lip. An x-rays revealed a nondisplaced nasal bone fracture. Resident #57 was discharged to the facility and had a follow up appointment. Review of Resident #57's nursing notes dated 01/25/18 at 8:25 P.M., revealed Resident #57 was noted with mild swelling present to the nose. An ice pack was applied for 20 minutes and PRN (as needed) Tylenol was administered for discomfort. 2. Review of Resident #86's medical record revealed the resident was admitted to the facility on [DATE] and discharged [DATE]. [DIAGNOSES REDACTED]. Review of Resident #86's quarterly MDS assessment dated [DATE] revealed he had a mild cognitive impairment. Resident #86 required supervision with his activities of daily living. A review of Resident #86's care plan cover revealed he resided on a secured unit and staff were to involve him with activities as will allow. His behaviors were wandering, agitation and paranoid. He required one on one supervision as needed. Review of Resident #86's nursing notes dated 01/24/18 at 7:04 A.M., revealed Resident# 86 had been agitated during the whole shift. He and another resident exchanged words and Resident #86 punched another resident and knocked him down. Resident #86 then proceeded to kick him several times in the face causing the other residents nose to bleed. Resident #86 was sent out to the hospital emergency department for a psychiatric evaluation. Police arrived to the facility and had to escort the resident out in handcuffs as he was trying to resist. Telephone interview on 02/13/18 at 5:32 P.M., with Licensed Practical Nurse (LPN) #20 revealed she was passing medications, when she heard an altercation. Resident #57 was coming out of his room and Resident #86 was going towards the room. They bumped and Resident #57 told Resident #86 to watch what he was doing. Resident #86 said what are you going to do about it? LPN #20 verified Resident #86 hit Resident #57 in the face, he fell on the floor and Resident #86 started kicking him in the face. His nose and lips were bleeding. LPN #20 called for a male STNA and he came and was able to stop Resident #86 from kicking Resident #57. Resident #57 went to the hospital. Interview on 02/14/18 at 9:18 A.M., with the Administrator, Director Of Nursing and Assistant Director Of Nursing verified an SRI was completed when Resident #86 hit and kicked Resident #57 in the face. The Administrator verified Resident #57 sustained a nasal fracture. Review of the facility's Abuse, Neglect, Exploitation and Misappropriation of Resident Property policy dated 11/21/16 revealed it was the facility's policy to investigate all alleged violations involving abuse, neglect, exploitation, mistreatment of [REDACTED]. Abuse was defined as the willful infliction of injury, pain or mental anguish. Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain or mental anguish which includes physical abuse. This deficiency substantiated Complaint Number OH 963.

Based on medical record review and interviews the facility failed to provide adequate supervision for a resident with disruptive, aggressive, intrusive and maladaptive behaviors. This resulted in actual harm to Resident #4 whom obtained nine staples to the forehead following an altercation with another resident. This affected one Resident (#4) of three residents reviewed for supervision and had the potential to affect ten residents identified with wandering behaviors on the secure male dementia unit. The facility census was 86. Findings include: Medical record review revealed Resident #4 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of annual comprehensive minimum data set (MDS) assessment dated [DATE] revealed a brief interview for mental status (BIMS) was unable to be completed, Resident #4 had moderately impaired cognitive skills for daily decision, limited assistance was required with personal hygiene and supervision was required with all other ADL's. No mobility devices were utilized. Resident #4 was currently hospitalized . Review of Resident #4's alteration in mood and behaviors care plan initiated 03/16/15 and revised on 05/17/16 revealed a [DIAGNOSES REDACTED]. Behaviors included physical and verbal aggression, wanders into other resident rooms, disrobing in front of other residents and in common areas of unit, combative with care, and required frequent redirection. Only one intervention had been added to the care plan since 2015 and included on 05/17/16 to allow resident to smoke when agitated. Review of progress note dated 07/26/16 at 6:43 P.M. revealed Resident #4 attempted to enter the room of Resident #5. Resident #5 attempted to stop Resident #4 from entering his room and when Resident #5 made contact with Resident #4, this resident hit Resident #5 in the face. The residents were separated and interventions were to discourage the residents from physical contact and the residents were placed on every 15 minute checks for 24 hours. Review of the progress note dated 08/09/16 at 2:40 A.M. revealed Resident #4 was found in Resident #13's bedroom attempting to remove Resident #13's pants. Resident #13 was hitting Resident #4 with a water pitcher and Resident #4 was hitting Resident #13 with his hands. Resident #4 was combative and refused to leave Resident #13's room. Both residents were evaluated and Resident #4 was transported to the hospital for a psychiatric evaluation. Resident #4 returned from the hospital at 6:50 A.M. without any orders and walked the hallway without any clothing below the waste. Resident #4 required continuous redirection and was placed on every 15 minute checks for 24 hours. Resident #4 continued to be redirected out of other residents room throughout the shift. Review of care plan conference sheet dated 08/12/16 revealed interdisciplinary team discussed Resident #4's inappropriate sexual behaviors of wandering and invading other residents space. The plan was to continue to monitor the resident closely and refer to the psychiatrist for symptom and medication review. Review of the psychiatric follow up note dated 08/22/16 revealed Resident #4 was in a recent altercation with another resident in which he was the aggressor. Resident #4 was known to wander into other residents rooms and was very intrusive with sexually inappropriate behaviors. Assessment revealed dementia with behavioral disturbances. The plan indicated due to the fact Resident#4's daughter was unwilling to change current medications, there was not much that could be done. Review of the nursing progress note dated 10/08/16 at 7:53 P.M. revealed Resident #4 sat down in the chair of another resident whom was talking and this resident became agitated and punched Resident #4 twice. Resident #4 was assessed and without injuries, placed on every 15 minute checks for 24 hours, and the director of nursing (DON), administrator, family, and medical doctor (MD) were notified. Review of the progress note dated 10/12/16 revealed Resident #4 was observed walking in the hall with blood on his face. Resident #4 was unable to provide any explanation for the injury. Upon assessment, a small cut was noted to the corner of the right eye and discoloration to the cheek. Resident #5 informed staff that Resident #4 wandered in and out of his bedroom all night. Resident #4 wandered into his room one final time and he told Resident #4 to get out. He attempted to redirect Resident #4 out of his room when Resident #4 lost his balance and fell hitting a chair. Treatment was provided to Resident #4's face and the resident was placed on every 15 minute checks for 24 hours. Review of the psychiatric follow up note dated 10/14/16 revealed Resident #4 continued to disrobe and wander with a recent fall. Assessment revealed Alzheimer's dementia with behavioral disturbance. Plan indicated due to the fact Resident #4 combative and sexually inappropriate behaviors were not currently an issue, changes in medications were not recommended as increased medications would not likely stop the wandering behaviors and could increase risk of falls. Review of the nursing progress noted dated 10/16/16 and 10/17/16 revealed Resident #4 continued to wander into other residents rooms and required frequent redirection. Review of the nursing progress note dated 10/22/16 at 12:32 P.M. revealed Resident #4 wandered in and out of other residents rooms and required redirection several times. Resident #4 had an extra large bowel movement on the floor of another residents room. Resident #4 was cleaned up. No other interventions were put into place. At 8:00 P.M. Resident #4 was seated in a chair in another residents room with an eight centimeter (cm) laceration on his forehead above his left eyebrow. Resident #4 was assessed and first aid was administered. The DON, family, and MD were notified and Resident #4 was transported to the hospital for further assessment. A progress note dated 10/22/16 at 11:55 P.M. revealed Resident #4 returned to the facility from the hospital with nine staples to his forehead. Review of the hospital discharge papers dated 10/22/16 revealed [DIAGNOSES REDACTED]. Review of progress note dated 10/23/16 at 11:57 P.M. revealed R #4 had nine staples to the forehead sustained in a resident to resident altercation on 10/22/16. Further review revealed Resident #4 continued to disrobe, walk around naked, wander into other Residents rooms, and refused to be redirected. Review of a note dated 10/25/16 at 12:20 P.M. revealed the physician was notified about incident and Resident #4 was transported to the hospital for evaluation. There wasn't any documentation in the progress notes about the incident. Review of the physician progress notes [REDACTED].#4 assaulted the chaplain and was transferred to the hospital for a psychiatric evaluation. An interview on 11/01/16 at 11:45 A.M. with licensed practical nurse (LPN) #120 reported on 10/22/16 Resident #6 came to the nurses station at shift change and reported staff needed to come check on Resident #4 because he was fighting with his roommate, Resident #5. Resident #6 reported Resident #4 came into his room and hit his roommate, Resident #5. Resident #5 then hit Resident #4 back who then fell and was on the floor bleeding. Staff responded and provided care to Resident #4 who was then transported to the hospital. Interviews with Resident #5 and Resident #6 on 11/01/16 at 2:12 P.M. reported Resident #4 constantly wandered in and out of other residents rooms, seldom wore any clothing, and was aggressive without warning. Stop signs were put up but didn't make any difference. They reported the facility didn't do anything to address Resident #4's inappropriate behaviors until he assaulted the chaplain and then he was immediately sent to the hospital. Resident#5 reported a couple of weeks ago Resident #4 was standing near his bedroom door and as he walked past Resident #4 he punched Resident #5 in the face. Resident #5 reported he turned towards Resident #4 who was standing with his fist up as if he wanted to fight and as Resident #5 lunged towards Resident #4, Resident #4 turned to run and Resident #4 tripped over the table behind him striking his head on the door frame. Resident #6 reported he notified staff of the altercation. An interview on 11/02/16 at 10:09 A.M. with the administrator and Unit Manager (UM) #62 reported after the physical altercation between Resident #4 and Resident #5 on 07/26/16 a stop sign was placed near Resident #5's door and Resident #5 was encouraged to refrain from physical contact with Resident #4. Both residents were placed on 15 minute checks for 24 hours. Resident #4 was transported to the hospital for psychiatric evaluation on 08/09/16 after displaying sexually inappropriate behaviors. After the physical altercation on 10/08/16, both residents were placed on every 15 minute checks for 24 hours and were to receive one to one intervention and redirection during times of confusion. On 10/12/16 and 10/22/16 Resident #4 was to receive increased supervision and he was placed on every 15 minute checks for 24 hours. There wasn't any further investigation into these incidents as they were considered falls. Besides every 15 minute checks for 24 hours following incidents in October 2016, no other interventions were implemented. The administrator and UM #62 reported Resident #4 continued with wandering, intrusive behaviors. The administrator and UM #62 provided a copy of Resident #4's care plan cover and behavior care plan and confirmed this was a complete copy. An interview on 11/02/16 at 4:30 P.M. with psychiatric nurse practitioner (PNP) #700 reported she was not contacted or aware of any incidents or behaviors involving Resident #4 since he was seen on 10/14/16. PNP #700 reported Resident #4 was cognitively impaired with impulsive behaviors. He was non-verbal with progressive dementia. There were residents on the unit that were cognitively intact and they were not going to tolerate his behavior. Medications would not be effective in treating wandering, intrusive behaviors and would increase risk for falls. The facility may not be an appropriate setting for Resident #4 if the staff cannot provide needed supervision. This deficiency substantiates Complaint Number OH 661.

Based on record review, staff interviews, and policy review the facility failed to ensure the residents were free from injury and had adequate supervision to prevent accidents. This involved one (#67) of the 15 sampled residents when the resident was transferred per a Hoyer lift by one person and sustained a fractured femur. Findings include: Review of the medical record of Resident #67 revealed the [DIAGNOSES REDACTED]. Review of renal consult notes revealed the resident had a [DIAGNOSES REDACTED]. According to the resident's plan of care dated 08/04/09, she was to have all transfers with a Hoyer with two staff for safety. Nurse's notes dated 01/03/10 stated the nurse aide reported the resident's leg did not look right and upon assessment by the nurse, the resident's left femur was noted to be deformed and appeared to be fractured or broken. The physician was notified and gave an order to send the resident to the hospital. Review of the medication administration record (MAR) for 01/10 revealed the resident was given a narcotic pain medication, Vicodin 5-500 milligram (mg) for pain. The resident's orthopedic surgery consultation dated 01/04/10 stated the impression of the clinical situation was an extraordinary serious fracture that required fixation but operative intervention would most likely result in death secondary to intraoperative and/or post operative complications. The resident's Durable Power of Attorney (DPOA) was spoken with and was in agreement to withhold surgery. Review of the facility Incident Investigation Record dated 01/03/10 revealed Resident #67's left leg was deformed and swollen. The record stated state tested nurse aide (STNA) #98 had transferred the resident to bed from the wheelchair prior to the incident. The resident was identified to require a Hoyer lift for all transfers and was nonverbal. Due to the outcome from statements it was concluded STNA #98 transferred the resident improperly according to the resident's plan of care. The resident sustained [REDACTED]. Review of a written statement dated 01/03/10 by STNA #98 revealed he went in to care for Resident #67 about 1:10 P.M. to 1:15 P.M. and put her to bed. STNA #98 stated he took care of the resident's roommate and went back to check Resident #67 and he noticed her leg did not look right. He then reported that the resident's leg did not look right to the supervisor. Review of the Administrator's telephone interview with STNA #98 dated 01/04/10 revealed STNA #98 stated he transferred Resident #67 to bed with the Hoyer lift. He stated he put the Hoyer pad behind the resident's back with the straps around her legs, hooked the pad to the Hoyer and lifted the resident. STNA #98 stated he pushed the resident over so she would not get caught on her bed. He stated he laid her in bed and she yelled out. STNA #98 stated he checked on the resident again and noticed the injury and reported it to the supervisor. STNA #98 stated he knew he should have had two people whenever he did a Hoyer lift. He stated he transfers with the Hoyer with one person all the time. Review of a written statement by STNA #98 dated 01/05/10 revealed he stated he put the Hoyer pad on Resident #67, got the lift, and hooked her on the lift. He stated he lifted the resident up, moved her legs over, to center her in the bed, and put her in the bed. STNA #98 stated he checked and changed the resident. He then provided care for the resident's roommate and went back to check Resident #67 and noticed her leg did not look right. He stated he reported it to the supervisor. Nurse's notes dated 01/05/10 stated the resident returned from the hospital with medication orders which included Vicodin 5-500 milligrams (mg) every six hours and as needed every four hours for pain. On 01/06/10 the physician ordered a narcotic analgesic (Roxinal 5 mg) sublingual (SL) every four hours for pain and to premedicate one half hour before personal care. On 01/06/10 at 6:30 P.M., 01/07/10 at 6:00 A.M. and 6:30 A.M. the resident was documented as grimacing with pain with Vicodin 5-500 mg given. Review of the resident's pain assessment dated [DATE], revealed the resident showed evidence of pain/discomfort with the site of the pain/discomfort the fractured femur. Review of the residents' care plan dated 01/18/10 revealed the resident had complaints/evidence of pain /discomfort due to the recent inoperatable femur fracture. The resident's psychosocial plan of care dated 01/18/10, stated she experienced a health decline due to a fracture and could be uncooperative, tearful, and may yell out, grimace moan related to pain due to the fracture. Nurse's notes dated 01/23/10 at 6:45 P.M. stated the resident was grimacing, moaning and teary eyed with Roxinal given. Nurse's notes dated 01/24/10 at 6:30 P.M. stated the resident grimaced and moaned with pain earlier with Roxinal given. Nurse's notes dated 01/25/10 at 6:50 P.M. stated the resident was grimacing and moaning due to left leg fracture with Roxinal given. Nurse's notes dated 01/26/10 at 6:00 A.M. and 3:00 P.M. stated medications were given for pain. Nurse's notes dated 01/27/10 at 11:00 P.M. stated the resident was given Roxanol at 9:00 P.M. for moaning at intervals. Further review of the MAR for 01/10 revealed the resident received Roxinal 5 mg SL twice daily routinely prior to personal care. During interview on 05/26/10 at 12:48 P.M., licensed practical nurse (LPN) #96 affirmed Resident #67 was transferred with a Hoyer lift with one person from the wheelchair to the bed and was found to have a left femur fracture. LPN #96 stated STNA #98 was inserviced on 01/02/10 on the requirement for two staff members with mechanical lifts. Review of a facility inservice sign-in sheet for Transfers dated 01/02/10, revealed the signature of STNA #98.