Every finding on record at Avante at St Cloud Inc

Based on observation, interview, and record review, the facility failed to ensure pain medication was administered to mitigate pain during a stage four pressure wound treatment for 1 of 1 resident reviewed for Pressure Wounds, of a total sample of 52 residents, (#16). Findings:Review of the medical record revealed resident #16, an [AGE] year-old female was admitted to the facility from an acute care hospital on 3/05/20. The resident's active diagnoses included unspecified convulsion, difficulty in walking, unspecified protein/calorie malnutrition, unspecified dementia, anxiety, depression, dysphagia (difficulty swallowing), unspecified feeding difficulties, stage 4 pressure ulcer of the left hip, and unspecified pain.The most recent Quarterly Minimum Data Set (MDS) Assessment with an Assessment Reference Date (ARD) of 5/06/26 documented resident #16 was severely cognitively impaired, dependent on staff to complete all Activities of Daily Living (ADLs), and she received scheduled opiate pain medication. The assessment indicated the facility determined a resident Pain Assessment Interview should be conducted which was marked negative for any pain presence during the look-back period.The Care Plan Report's focus included, hospice care related to terminal illness of end stage dementia with palliative care (revised 3/29/26); chronic stage 4 pressure wound to the left hip with an intervention to administer medications as ordered and monitor/document side effects and effectiveness (revised 5/14/26); and potential for alteration in comfort related to chronic wounds with an intervention to evaluate for non-verbal indications of pain including facial grimaces, moaning, and/or restlessness; and medicate for pain as ordered, (revised 4/12/26).The most recent nursing Quarterly Evaluation of pain dated 4/13/26 documented resident #16 reported rare pain at worst as 3 out of 10, in the previous five days, with daily observed indicators of pain or possible pain to the right foot and left hip wound. The severity verbal faces scale was marked with no hurt. Nonverbal indicators were marked negative with no behavior noted or observed.The July 2026 Medication Administration Record (MAR) included active physician's medication orders for hydrocodone-acetaminophen (narcotic pain medication) 5-325 Milligrams (MG) twice daily at 9:00 AM and 9:00 PM for acute or moderate pain of 4 to 6, out of 10. The Pain Verbal Scale schedule and Behaviors were documented by Licensed Practical Nurse (LPN) A as NA on 7/15/26.The Treatment Administration Record (TAR) included active physician's orders that included, left hip cleanse with wound cleanser, pat dry, skin prep around wound, apply nickel thick Santyl (Collagenase) External Ointment every day shift, and cover with dressing.According to the Centers for Medicare & Medicaid Services (CMS), Stage 4 pressure ulcers include full thickness tissue loss with exposed bone, tendon, or muscle, (retrieved from cms.gov on 7/20/26).Pain is a frequently overlooked aspect of wound care and unresolved pain can have a negative impact on wound healing. The reason and comorbidities associated with chronic wounds can complicate the assessment of the quantity and quality of pain perceived by the patient. Pain is a frequently experienced yet overlooked factor in wound care and wound healing . Pain associated with pressure ulcers is not fully understood. The Agency for Healthcare Research and Quality guidelines stress it should not be assumed that a patient does not have pain solely because he/she does not express it .Body language and non-verbal expressions must be considered and validated . (retrieved on 7/28/26 from www.ncbi.nlm.nih.gov). On 7/15/26 at 10:45 AM, resident #16's pressure wound treatment completed by the Wound Care Nurse and assisted by the MDS Coordinator was observed. The resident was assisted to maintain a right side-lying position in bed. Wound hygiene with wound cleansing spray followed by application of Santyl ointment was performed. During the procedure, resident #16 was observed reaching towards her left hip, and had facial expression changes. The MDS Coordinator and Wound Care Nurse relayed it was the resident's normal behavior pattern/personality to reach out and make various facial expressions and noises during care as she was minimally verbal and pleasantly confused. Upon procedure completion, the wound was covered with a 4-inch by 4-inch bordered dressing.On 7/15/26 at 10:55 AM, the Wound Care Nurse explained she relied upon nurses to administer physician ordered pain medications prior to her pressure ulcer treatments. She said she assumed the nurse had already administered resident #16's morning pain medication but had not verified it was done prior to the wound care treatment.On 7/15/26 at 11:00 AM, the 100 Unit Manager checked resident #16's medical record and stated the resident had physician's medication orders for routine narcotic pain medication twice daily scheduled at 9:00 AM not yet signed off by the nurse. She said the last documented dose was administered at 11:00 PM the prior evening and there was Tylenol for pain available as needed, but none had been administered in the previous 24 hours. The Unit Manager explained she expected nurses to administer medications timely and stated, it's late, referring to the resident's 9:00 AM narcotic pain medication.At 11:04 AM, LPN A said she was the nurse assigned to resident #16 for the day shift. She explained she was behind on her morning medication administrations and resident #16 had not received her 9:00 AM medications. The LPN said she had a very busy morning and fell behind. Review of resident #16's pharmacy Narcotic Medication Log for Hydrocodone-Acetaminophen 5-235 MG noted the resident received pain medication on 7/14/26 at 9:00 PM and not again until 7/15/26 at 11:26 AM, after wound care was completed.In a telephone interview on 7/15/26 at 11:53 AM, Advanced Practice Registered Nurse (APRN) N, the provider explained it was her expectation that all cognitively impaired residents with pressure wounds were pre-medicated for pain. The APRN said she always verified pain medication was administered prior to conducting the weekly assessment/treatment. She stated she knew resident #16 well and recalled she had a chronic stage 4 pressure wound that was sometimes debrided (removal of dead tissue) during assessments/treatments which would be very painful.Review of resident #16's most recent Wound Care Visit Report by APRN N on 7/10/26 revealed the assessment and treatment of a chronic stage 4 Pressure Injury to the left hip that measured 4.5 centimeters (cm) in length by 4 cm in width by 0.3 cm in depth with 100% slough (layer/mass of dead tissue separate from living tissue). After a debridement procedure, the resident's pain level was documented as 1 out of 10 (pain scale). No changes were made to the treatment plan.Review of the facility's standards and guidelines dated 3/02/19 and titled Pain Management outlined that in order to help residents attain or maintain his/her highest practicable level of physical, mental, and psychosocial well-being, and to prevent or manage pain, the facility would recognize when the resident experienced pain and identify circumstances when the pain could be anticipated.

Based on interview, and record review, the facility failed to timely complete 4 of 5 Minimum Data Set (MDS) Discharge Assessments, (#13, #39, #73, #96); and transmit 5 of 5 (#10, #13, #39, #73, #96) MDS Discharge Assessments reviewed for Resident Assessment, of a total sample of 52 residents.Findings:1. Review of the medical record revealed resident #10 was admitted to the facility on [DATE] and discharged on 1/16/26.The Electronic Health Record (EHR) noted resident #10's Discharge Return Anticipated/End of Service MDS Assessment was completed on 4/16/26 and accepted by the Centers for Medicare and Medicaid Services (CMS) on 4/20/26.In a joint interview on 7/16/26 at 10:30 AM, with the Lead MDS Coordinator and MDS Coordinator, the Lead MDS Coordinator checked resident #10's record and conveyed the assessment should have been completed no later than 14 days after the Assessment Reference Date (ARD) of 1/16/26. The Lead MDS Coordinator confirmed the assessment was completed three months late.2. Review of the medical record revealed resident #13 was admitted to the facility on [DATE] and discharged on 3/13/26.On 7/14/26, the EHR noted there was no Discharge Assessment included in the MDS assessments list.On 7/16/26 at 10:32 AM, the Lead MDS Coordinator checked resident #13's record and said the assessment was missed and entered late on 7/14/26, two days prior, and completed on 7/15/26.3. Review of the medical record revealed resident #39 was admitted to the facility on [DATE] and discharged on 2/20/26.On 7/14/26, the EHR noted in red that the MDS Discharge Assessment was 130 days overdue. The list of completed MDS' for resident #39 did not include a Discharge Assessment.On 7/16/26 at 10:35 AM, the Lead MDS Coordinator checked resident #39's record. The Lead MDS Coordinator confirmed the assessment was entered late on 7/14/26 and completed on 7/15/26.4. Review of the medical record revealed resident #73 was admitted to the facility on [DATE] and discharged on 3/17/26.On 7/14/26, the EHR noted in red that the MDS Discharge Assessment was 105 days overdue. The list of completed MDS' for resident #73 did not include a Discharge Assessment.On 7/16/26 at 10:37 AM, the Lead MDS Coordinator checked resident #73's record and said the assessment was entered late on 7/14/26. The Lead MDS Coordinator confirmed the assessment was completed and transmitted on 7/15/26.5. Review of the medical record revealed resident #96 was admitted to the facility on [DATE] and discharged on 3/18/26.On 7/14/26, the EHR noted in red that the MDS Discharge Assessment was 104 days overdue. The list of completed MDS' for resident #96 did not include a Discharge Assessment.On 7/16/26 at 10:40 AM, the Lead MDS Coordinator checked resident #96's record and said the assessment was entered late on 7/14/26 and completed on 7/15/26.Review of the CMS MDS Final Validation Reports for all five residents noted, (assessment completion date) is more than 14 days after A2300 (assessment reference date).In a joint interview on 7/16/26 at 10:44 AM, with the Lead MDS Coordinator and MDS Coordinator, the Lead MDS Coordinator explained all admissions and discharges were discussed every morning amongst the Interdisciplinary Team (IDT) where MDS staff were alerted to enter a discharge assessment. She said they had just reviewed submission reports two days prior and noticed the missing assessments. She stated, they were just missed. The Lead MDS Coordinator relayed it was important for all MDS assessments to be completed and submitted timely, so CMS was aware of the most recent statuses of residents and when they were no longer at the facility.On 7/16/26 at approximately 3:45 PM, the Nursing Home Administrator (NHA) said the MDS staff reported directly to her. The NHA relayed she expected staff to follow the scheduled MDS timeframes, and she had been unaware of lateness issues. She explained assessment timeliness was important to maintain accurate resident and facility statuses for CMS.Review of the facility's standards and guidelines dated 3/02/19, titled Resident Assessment Instrument (RAI), noted it was the facility's policy to adhere to timeliness of regulatory guidelines and the MDS Coordinator maintained Validation Reports in a transmittal notebook organized by month.

Based on observation, interview, and record review, the facility staff failed to follow hygienic practices by not donning hair nets to ensure food served to 119 of 122 residents, was protected from physical contaminants. Findings: On 7/15/26 at 11:45 AM, the lunch tray line in the kitchen was observed. When the Certified Dietary Manager (CDM) checked the hot holding temperatures of the food on the steam table, a kitchen staff member walked behind him but was not wearing a hair net. The staff member had curly blonde hair, put up in a small bun, but the staff member was not wearing a hair restraint to ensure any food being held on the steam table or prepared for lunch nearby, was protected from physical contaminants such as hair. Several minutes later at 11:50 AM, the CDM told the staff member they should leave and don a hairnet. The CDM explained all staff were required to wear a hairnet in the kitchen so that no hair got into the food. On 7/15/26 at 1:06 PM, the Administrator verified the facility's expectation was for all staff in the kitchen to wear hair nets, to ensure sanitary distribution of food with no hair. Review of the Policy/Procedure for Sanitation Inspection revised 3/01/26 revealed the facility conducted inspections to ensure food services areas were clean, sanitary, and in compliance with state and federal regulations.

Based on observation, interview, and record review, the facility's Quality Assurance and Performance Improvement (QAPI) committee failed to identify repeat deficiencies and area of systemic non-compliance with Accuracy of Assessments, Pain Management, and Respiratory/Tracheostomy Care identified by the survey team. The deficient practice had the potential to affect more than a limited number of residents by not ensuring consistent monitoring and follow-up of identified problems.Findings: Review of the facility's survey history revealed repeat deficiency concerns for accuracy of assessments, pain management, and respiratory/tracheostomy care. The survey history revealed the facility was cited during the 8/15/24 recertification survey for F0641 (Accuracy of Assessments), F0695 (Respiratory/Tracheostomy Care), and F0697 (Pain Management).During the current recertification survey from 07/13/26 to 7/16/26, the facility was again cited for F0641 (Accuracy of Assessments), F0695 (Respiratory/Tracheostomy Care), and F0697 (Pain Management).On 07/17/26 at 4:35 PM, the facility's Administrator discussed the facility's QAPI program. She acknowledged the facility could not show evidence they had a Process Improvement Plan (PIP) or current audits in place for accuracy of assessments, pain management, and respiratory/tracheostomy care. The Administrator was unable to say what processes the facility implemented to ensure the concerns previously identified in the last recertification survey were not repeated.Review of the facility's undated standards and guidelines titled, Quality Assurance & Performance Improvement (QAPI) Plan read, QAPI communicates our organizational wide philosophy, data-driven initiatives, and processes utilized to identify 'opportunities for improvement' as well as to systematically monitor, analyze, and improve our performance thereby increasing resident safety and outcomes. For QAPI is the essential bridge to achieving successful resident outcomes as it directs our proactive approach to quality improvement. The document indicated the facility would develop and monitor performance indicators and track performance for data sources such as certification survey results. The document described the approach to prevent future events and promote sustained improvement would include developing actions to address the identified root cause and/or contributing factors of an issue or event that would affect change at the systemic level.

Based on observation, interview, and record review the facility failed to adhere to infection prevention and control practices related to the use of personal protective equipment (PPE) during the transport and handling of soiled laundry; failed to implement transmission based precautions as ordered by physician for 1 of 4 residents reviewed for transmission based precautions, (#70); and failed to ensure staff performed hand hygiene prior to donning gloves during medication administration in accordance with accepted infection prevention and control practices for 3 of 5 medication passes observed, (#41, #88, and #19) of a total sample of 52 residents. Findings: 1. On 7/14/26 at approximately 3:35 PM, Laundry Attendant K was observed transporting a soiled laundry bin from the East Wing soiled utility room through the hallway toward the laundry room while wearing a glove on her left hand. She opened the laundry room door with her ungloved right hand and used her gloved left hand to pull the soiled laundry bin through the doorway into the soiled-linen area of the laundry room. Laundry Attendant K then pushed the bin to the left side of the room and secured the lid with the same gloved hand. She subsequently removed the glove and performed hand hygiene. On 7/14/26 at 3:48 PM, Laundry Attendant K stated whenever she handled anything dirty, she wore gloves and kept the gloves on while handling dirty items. She indicated she had been trained to wear one glove while transporting soiled laundry bins from the soiled utility rooms to the soiled area of the laundry. Laundry Attendant K confirmed she wore a glove in the hallway while transporting the soiled laundry bin from the East Wing to the laundry room. She stated she did not recall receiving education instructing staff not to wear gloves in the hallways. On 7/15/26 at 3:31 PM, the Regional Director of Clinical Services stated she had served as the interim Infection Preventionist (IP) for approximately two weeks. She stated staff received infection control education during new-hire orientation, annually, and when concerns were identified. The IP indicated staff should not wear gloves in the hallways and identified this practice as a breach in infection control practices. On 7/16/26 at 8:49 AM, the Housekeeping and Laundry Manager stated he previously provided education to his staff regarding PPE and staff were instructed not to wear gloves in hallways. He indicated he had taught staff gloves were not required while transporting the laundry bins because they were not handling chemicals or bodily fluids and could perform hand hygiene after completing the task. The Housekeeping and Laundry Manager stated wearing gloves in the hallways was considered a breach in infection control practices. 2. Resident #70 was admitted to the facility on [DATE] with diagnoses including heart failure, sepsis, urinary tract infection, and chronic kidney disease stage III. Review of a State Agency Medical Certification for Medicaid Long- Term Care Services and Patient Transfer Form completed by the hospital dated 6/29/26 revealed the resident was on contact isolation for extended spectrum beta lactamase (ESBL). Review of resident #70's Electronic Medical Record revealed a physician's order dated 7/01/26, with instructions for contact isolation due to ESBL in urine until 7/20/26. ESBL-producing Enterobacter [NAME] include Klebsiella pneumoniae and Escherichia coli. These bacteria can cause infections in places such as the urinary tract and bloodstream and can cause increased mortality and hospitalization, (retrieved from www.cdc.gov on 7/29/26). Contact isolation is a type of Transmission Based Precaution used as an infection control intervention designed to reduce transmission of multidrug-resistant organisms (MDROs) in nursing homes. Contact isolation involves the use of a gown and gloves during contact with the resident or resident's environment. This means a gown and gloves are needed to enter the resident's room and must be removed before the room is exited to contain the bacteria in order to prevent infections in vulnerable people, (retrieved from www.cdc.gov on 7/29/26). On 7/13/26 at 10:21 AM, resident #70's room was not identified for contact isolation, and no personal protection equipment (PPE) was observed outside his room for use before entering the room. on 7/14/26 at 3:26 PM, Certified Nursing Assistant (CNA) Q said staff should be aware of what residents had infections, the location and how they might be transmitted. She explained having a sign on the door to indicate whether a resident is on isolation including what type of isolation, tells her what to wear to protect other staff and the resident. She said the sign also reminds staff when to do hand hygiene. The CNA said she felt this was important because she wouldn't want to infect residents. On 7/13/26 at 12:44 PM, the Assistant Director of Nursing said she was in training to become the facility's Infection Prevention nurse. She said she checks isolation signage in the facility when she does rounds throughout the building every Monday morning. She did not explain why resident #70's room did not have the correct signage for contact isolation as ordered by the physician almost two weeks prior on 7/01/26. On 7/16/26 at 11:45 AM, the 100 Unit Manager stated her expectation would be that nurses follow physicians' orders. 3. Review of the facility's Infection Prevention and Control Program policy, revised 7/06/26, revealed the facility established an infection prevention and control program designed to help prevent the development and transmission of communicable diseases and infections in accordance with accepted national standards and guidelines. Under Standard Precautions, the policy indicated hand hygiene was to be performed in accordance with the facility's established hand hygiene procedures. On 7/13/26 at 10:40 AM, during observation of medication administration for resident #41, Licensed Practical Nurse (LPN) B prepared the resident's medications and donned gloves without performing hand hygiene prior to donning the gloves. LPN B entered resident #41's room, obtained the resident's blood pressure, and administered one medication. The LPN exited the resident's room, removed the gloves and performed hand hygiene. LPN B crushed the remaining medications and donned a new pair of gloves without first completing hand hygiene. LPN B reentered resident #41's room and administered medications. At 11:05 AM, LPN B explained hand hygiene should be performed before and after medication administration to prevent infection. LPN B acknowledged she did not perform hand hygiene prior to donning gloves. On 7/14/26 at 9:10 AM, during observation of medication administration for resident #88, LPN J entered resident #88's room and donned gloves without performing hand hygiene. LPN J administered eye drops to resident #88, removed gloves, and performed hand hygiene before exiting the resident's room. At 9:15 AM, LPN J stated, I was supposed to perform hand hygiene before putting on gloves and before touching a patient to prevent infection. On 7/14/26 at 9:20 AM, during observation of medication administration for resident #19, LPN A performed hand hygiene and prepared medications. Following medication preparation, LPN A donned gloves without performing hand hygiene and entered the resident's room to administered medications. At 9:25 AM, LPN A stated hand hygiene should be performed to prevent infection and acknowledged hand hygiene should have been performed prior to putting on gloves. On 7/15/26 at 3:30 PM, in a joint interview with the Regional Director of Clinical Services and the acting Infection Preventionist (IP), the Regional Director stated hand hygiene should be performed prior to touching a resident or anything in the resident's environment. She further stated hand hygiene was expected prior to donning gloves and after removal of the gloves to prevent transmission of infection. Review of the facility's Infection Control-Hand Hygiene policy dated 3/2/19, revealed hand hygiene was to be performed prior to caring for a resident, after caring for a resident including after glove removal, and after contact with the resident's environment. The policy further indicated hand hygiene was to be performed upon and after contact with a resident's skin, including when obtaining a blood pressure.

Based on observation, interview, and record review, the facility failed to promote dignity and provide privacy during medication administration for 2 of 3 residents reviewed for dignity, out of a total sample of 52 residents, (#45 and #48).Findings: 1. Review of resident #45's medical record revealed she was admitted to the facility on [DATE] with diagnoses including chronic obstructive pulmonary disease, pleural effusion, pneumonia, anxiety disorder, rheumatoid arthritis, and dysphagia (difficulty swallowing). Review of resident #45's medical record revealed a Brief Interview for Mental Status (BIMS) assessment completed on 7/03/26 showed a score of 15 out of 15, indicating intact cognition. On 7/15/26 at 1:00 PM, resident #45 walked to the nurses' station while coughing and asked Licensed Practical Nurse (LPN) B for cough medicine. LPN B checked the computer and informed the resident she was also scheduled for two other medications at that time. LPN B walked a few feet to the medication cart, which was stationed in the atrium near the nurses' station, removed the medications, placed them in a medication cup, and handed the cup to resident #45. The resident remained standing next to the nurse and swallowed the medications in the atrium, where approximately 10 residents and other staff were present. Resident #45 returned to her room at 1:07 PM. Review of resident #45's Medication Administration Record revealed Benzonatate 200 milligrams (mg), Gabapentin 400 mg, and Lorazepam 0.5 mg were scheduled for administration at 1:00 PM. On 7/15/26 at 1:07 PM, LPN B stated some residents came to the medication cart for their medications and took them there rather than in their rooms. She indicated she did not ask the residents to return to their rooms for administration of the medication. LPN B further stated resident #45 wanted to wait and take her medications at the medication cart, and she complied with the resident's request. She shared she had administered medications to resident #45 and other residents in this manner in the past and had observed other nurses do the same. LPN B stated it was the residents' preference. Review of resident #45's care plan revealed no documented preference to receive or take medications outside her room. 2. Review of resident #48's medical record revealed she was admitted to the facility on [DATE] with diagnoses including encephalopathy (brain dysfunction), type 2 diabetes, unsteadiness on feet, and dysphagia. Review of resident #48's Minimum Data Set annual assessment with an Assessment Reference Date of 5/31/26 revealed a BIMS score of 15 out of 15, indicating intact cognition. On 7/16/26 at 10:36 AM, LPN C was observed handling a medication cup to resident #48 while she sat in her wheelchair in the hallway next to a medication cart between rooms [ROOM NUMBERS]. Resident #48 swallowed the medications while seated in the hallway. LPN C then prepared and administered an injection to resident #48's left upper arm immediately after. The resident then wheeled herself away when the nurse was finished. On 7/16/26 at approximately 10:42 AM, resident #48 stated nurses usually administered her medications in her room. She indicated that earlier today while she was going down the hallway, LPN C told her not to move because he was going to give her medications. Resident #48 stated she had not requested to receive her medications outside her room. On 7/16/26 at 10:40 AM, LPN C stated as long as the residents were in the hallway or atrium area, it was okay to administer their medications outside their rooms. He further stated resident #48 usually wanders around, and it was nearly impossible to find her in her room. Review of resident #48's Medication Administration Audit Report dated 7/16/26 revealed the resident received multiple medications at 10:37 AM, including 10 units of Insulin Glargine by injection. The report also documented a finger-stick blood glucose check was performed at that time. Review of resident #48's care plan revealed no documented preference to receive or take medications outside her room. On 7/16/26 at 9:10 AM, the East Wing Unit Manager stated if an oriented resident expressed a preference to take medications in the atrium, medication administration would occur where the resident preferred. She indicated if a resident requested to receive medications outside the resident's rooms, the preference would be included in the care plan. On 7/16/26 at 12:20 PM, the Regional Director of Clinical Services stated if a resident was not in her room when it was time for medication administration, the resident should be assisted back to her room and the medications administered there. She indicated it would be a dignity issue to administer medications in the hallway because other residents could observe the medication administration. She further stated if a resident requested to receive medications outside their room, the preference should be documented in the resident's care plan. Review of the facility's policy titled Medication Administration, dated 2/25/25, revealed medication administration guidelines included, Provide privacy.Review of the facility's policy titled Promoting/Maintaining Resident Dignity, revised 2/25/26, revealed it was the facility's practice to protect and promote resident rights and treat each resident with respect and dignity. The policy directed staff to report, document and, act upon information regarding resident preferences and to revise care plans, if appropriate, based on information obtained from resident interviews. The policy further directed staff to Maintain resident privacy.

Based on interview, and record review, the facility failed to implement corrective measures to ensure the alleged victim of a resident-to-resident altercation was protected from access by the alleged perpetrator for 1 of 3 residents reviewed for abuse, of a total sample of 52 residents, (#143). Findings: 1. Resident #143 was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses of traumatic subdural hemorrhage without loss of consciousness, laceration without foreign body of scalp, Alzheimer's disease, anxiety disorder, and unspecified psychosis. Review of the Minimum Data Set (MDS) quarterly assessment with assessment reference date (ARD) of 12/06/25 revealed resident #143 had a Brief Interview for Mental Status (BIMS) score of 00/15 which indicated he was severely cognitively impaired. The assessment indicated resident #143 did not exhibit any behavioral symptoms and required assistance for activities of daily living (ADL). 2. Resident #1 was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses of human immunodeficiency virus, other cirrhosis of liver, generalized anxiety disorder, unspecified mood disorder, chronic viral hepatitis C and schizoaffective disorder. Review of the MDS quarterly assessment with ARD of 4/18/26 revealed resident #1 had a BIMS score of 13/15 which indicated he cognitively intact. The assessment indicated resident #1 did not exhibit any behavioral symptoms and was mostly independent for ADL care. A physician progress note dated 9/03/25 read, . Received a call this morning from charge nurse reporting that the patient was very agitated. He was displaying aggressive behaviors throwing objects and cursing at staff. The patient could be heard in the background being verbally aggressive and using swear words. Due to safety risk to others and himself the charge nurse was advised to send patient to hospital for evaluation. Review of the facility's log of reportable incidents revealed resident #1 and resident #143 were involved in a resident-to-resident altercation on 9/03/25. Review of the electronic medical record (EMR) revealed both residents resided in the same room at the time of the incident. On 7/15/26 at 1:10 PM, the Administrator reviewed the incident of 9/03/25. She confirmed that resident #1 and resident #143 were roommates and were in their room together at the time of the altercation. She reported the facility's investigation revealed resident #1 believed resident #143 was messing with the curtains to annoy him and threw an unopened can of soda at resident #143. The Administrator explained the Director of Nursing (DON) and other staff were in the area and responded immediately by separating the two residents. She stated resident #1 continued to exhibit aggressive behaviors yelling out, cursing and stating he was protecting himself from resident #143. She explained resident #1 was sent to the hospital on 9/03/25 where he was transferred to a psychiatric facility for treatment and evaluation. The administrator reported resident #143 was assessed with no skin impairments or bruising noted. The Administrator confirmed resident #1 returned to the facility on [DATE] and was readmitted to the same room as previous where resident #143 still resided. The Administrator was unable to explain why resident #1 returned to the same room as resident #143 and could not identify any interventions initiated to ensure resident #1 (perpetrator) did not have access to resident #143 (victim) for his continued safety and protection. In a phone interview on 7/15/26 at 1:22 PM, the DON stated residents were usually placed on one-on-one supervision when a resident-to-resident altercation occurred. She could not recall exactly what actions were taken to ensure the protection of resident #143 upon resident #1's return to the facility. The DON stated any documentation for one-on-one supervision would be in her office. On 7/15/26 at 1:30 PM, the Social Services Director (SSD) stated resident #1 had been in the room longer than resident #143 and did not want to move. She stated she spoke to resident #143's wife about moving but the wife refused. The SSD acknowledged she did not write a progress note regarding either conversation and could not provide any additional documentation that a room change was offered. On 7/15/26 at 1:34 PM, the Administrator, the Unit Manager for the 200 unit, the Regional [NAME] President (RVP) of Quality Assurance and the [NAME] President of Clinical Services reviewed the files and notebooks in the DON's office. No documentation could be presented to show one-on-one supervision was provided for resident #1 nor resident #143. The Staffing Coordinator brought schedules for 10/11/25 which showed a staff member providing one-on-one supervision. However, the identified room was not the room resident #1 and resident #143 inhabited. The Administrator and RVP of Quality Assurance acknowledged that although no further altercations occurred between resident #1 and resident #143, the facility could not produce any documentation to show where interventions were put in place to ensure the safety of resident #143. The facility's Abuse, Neglect and Exploitation policy and procedure dated 6/06/25 indicated the facility would make efforts to ensure all residents were protected from physical and psychosocial harm, as well as additional abuse, during and after the investigation. Examples of efforts included but were not limited to increased supervision of the alleged victim and residents; and room or staffing changes, if necessary, to protect the resident(s) from the alleged perpetrator.

Based on observation, interview, and record review, the facility failed to ensure the Minimum Data Set (MDS) assessments accurately reflected the resident's documented use of oxygen therapy for 1 of 1 resident reviewed for resident assessments, of a total sample of 52 residents, (#141). Findings:Resident #141 was admitted to the facility on [DATE], and most recently readmitted from an acute care hospital on 7/10/26. admission diagnoses included acute respiratory failure, myocardial infarction, congestive heart failure and chronic kidney disease.Review of resident #141's Five-Day Minimum Data Set (MDS) Assessment with Assessment Reference Date (ARD) 11/24/25, revealed Section O, Special Treatments, Procedures, and Programs did not indicate that resident #141 received oxygen therapy.Review of the Vitals Summary dated 11/20/25 through 11/24/25, revealed resident #141 received oxygen therapy via nasal cannula on 11/21/25 and 11/23/26 during the applicable period.Review of resident #141's admission MDS Assessment with ARD 4/02/26, revealed Section O, Special Treatments, Procedures, and Programs did not indicate that resident #141 received oxygen therapy.Review of the Vitals Summary for resident #141 dated 3/27/26 through 4/02/26, revealed resident #141 received oxygen therapy via nasal cannula on 3/29/26 during the applicable period.Review of resident #141's Quarterly MDS Assessment with ARD 6/16/26, revealed Section O, Special Treatments, Procedures, and Programs did not indicate that resident #141 received oxygen therapy.Review of the Vitals Summary for resident #141 dated 6/10/26 through 6/16/26, revealed the resident received oxygen therapy via nasal cannula on 6/10/26, 6/11/26, 6/12/26, and 6/15/26 during the applicable period.Review of the facility's Resident Assessment Instrument (RAI) policy revised 3/02/19, revealed it was the facility's policy to ensure resident MDS assessments were comprehensive and accurate. The policy identified that the RAI included documentation of Section O, Special Treatments, Procedures, and Programs as a part of the comprehensive assessment. The policy further stated the assessment would accurately reflect the resident's status. The policy identified that Section O, Special Treatments, Procedures, and Programs, was completed by the Nursing Department as part of the interdisciplinary assessment process. The policy further required each individual completing a portion of the assessment to sign and certify the accuracy of the portion of the assessment.On 7/16/26 at 2:00 PM, the MDS Coordinator reviewed resident #141's Five-Day MDS Assessment, dated 11/24/25; admission MDS Assessment, dated 4/2/26; Quarterly MDS Assessment, dated 6/16/26; and the corresponding Vital Summaries with documenting oxygen therapy. The MDS Coordinator acknowledged that Section O, Special Treatments, Procedures, and Programs, of the MDS assessments did not accurately reflect resident #141's documented use of oxygen therapy.

Based on observation, interview, and record review, the facility failed to develop a person-centered Baseline Care Plan addressing smoking for 1 of 2 residents sampled for smoking, out of a total sample of 52 residents, (#45).Findings: Review of resident #45's medical record revealed she was admitted to the facility on [DATE] with diagnoses including chronic obstructive pulmonary disease, pleural effusion, pneumonia, and anxiety disorder. Review of resident #45's medical record revealed a Brief Interview for Mental Status assessment completed on 7/03/26 showed a score of 15 out of 15, indicating intact cognition. On 7/15/26 at 10:44 AM, resident #45 stated she had been coughing at night but missed the physician that morning because she went to smoke at 9:30 AM. Review of resident #45's medical record revealed a Smoking Assessment was completed on 7/03/26 and signed by the resident and a nurse. Resident #45 also signed an Independent Smoker Contract on 7/03/26, which documented the resident would abide by the individualized care plan and all interventions determined by the interdisciplinary team members. Review of resident #45's Baseline Care Plan, effective 7/02/26, revealed the plan did not include a focus or interventions addressing smoking. The plan was signed by Registered Nurse R and dated 7/05/26. On 7/16/26 at 11:06 AM, the Minimum Data Set (MDS) Lead stated she and the MDS Coordinator were responsible for developing the Baseline Care Plan within 48 hours of admission and Comprehensive Care Plan thereafter. She stated the Baseline Care Plan was developed from physician's orders, nursing assessments, and the medical record, and that smoking would be included when applicable. The MDS Lead reviewed resident #45's medical record and confirmed nursing completed a Smoking Assessment on 7/03/26; however, smoking was not included in the resident's Baseline Care Plan. She further confirmed resident #45 did not have a smoking care plan and stated there should have been one.

Based on observation, interview, and record review, the facility failed to provide appropriate urinary catheter care to reduce the risk of urinary tract infection for 1 of 1 resident reviewed for urinary catheter care, of a total sample of 52 residents, (#115).Findings: Resident #115 was admitted to the facility 5/12/26, sent to the hospital on 6/19/26 for difficulty breathing and readmitted on [DATE]. Diagnoses included right femur fracture, Parkinson's Disease, chronic obstructive pulmonary disease, sepsis, and atrial fibrillation.The Minimum Data Set Assessment with Assessment Reference Date 6/30/26 revealed resident #115 had a Brief Interview for Mental Status score of 12/15, which indicated he had moderate cognitive impairment. The assessment detailed the resident required assistance with meal set-up but was dependent for hygiene needs and mobility. The MDS indicated the resident was incontinent of bowel and had a urinary catheter.Medical record review of resident #115's care plan revealed a care plan for an indwelling urinary catheter related to obstructive uropathy dated 5/13/26. Interventions included anchoring catheter tubing to thigh, positioning catheter and tubing below the level of the bladder and checking the tubing for kinks.Review of resident #115's Nursing admission Evaluation record dated 6/26/26 identified resident #115 with chronic urinary retention and an indwelling urinary catheter.Review of the physician orders for resident #115 dated 5/13/26 and 6/29/26 revealed orders to maintain indwelling catheter for obstructive bladder and to irrigate the indwelling urinary catheter every shift as needed for blockage, occlusion, or leakage.On 7/13/26 at 3:20 PM, resident #115 was observed lying in his bed with the head of the bed slightly elevated. Urinary catheter tubing was visible on the left side of the bed, extending to the floor. The urinary drainage bag and catheter tubing was observed under the bed, resting directly on the floor.On 7/14/26 at 11:38 AM, resident #115 was observed lying in his bed with the head of the bed slightly elevated. Urinary catheter tubing was visible on the left side of the bed, extending to the floor. The urinary drainage bag and catheter tubing were observed under the bed with the bed frame on top of the drainage bag. The bag, containing maroon colored drainage, was lying directly on the floor. On 7/14/26 at 3:35 PM, resident #115 was in his bed with the head of the bed slightly elevated. The urinary catheter tubing and bag remained in the same position on the floor, with the bed frame on top of the urinary drainage bag. Maroon-colored drainage was observed in the urinary drainage bag and tubing.On 7/15/26 at 10:15 AM, resident #115 was observed lying in his bed with the head of the bed slightly elevated. Urinary catheter tubing was visible on the left side of the bed extending to the floor. The urinary drainage bag and tubing were observed under the bed with the bed frame on top of the drainage bag, resting directly on the floor. The urinary drainage bag and tubing contained maroon colored drainage.On 7/15/26 at 11:36 AM, Certified Nursing Assistant (CNA) F, stated she was assigned to resident #115 for the 7:00 AM to 3:00 PM shift. CNA F stated the resident had an indwelling urinary catheter and her responsibilities included providing catheter care, emptying the drainage bag, and reporting urine output and color to the nurse. The CNA stated the urinary drainage bag should not be placed on the floor due to risk of infection.On 7/15/26 at 12:05 PM, Registered Nurse (RN) G was at resident #115's bedside. RN G acknowledged the resident's urinary drainage bag should not be on the floor and there was a maroon color drainage in the tubing and bag. RN G stated the provider was aware of the color of the drainage. RN G stated the urinary tubing was flushed prior to the start of her shift. She stated the urinary tubing, and bag should not be on or in contact with the floor due to the risk of infection.On 7/16/26 at 9:05 AM, the 200's Unit Manager stated the expectation for infection prevention for residents with urinary catheters included ensuring the urinary catheter drainage bag did not come in contact with the floor.Review of the facility's policy titled Quality of Care, dated 3/02/19, revealed the facility would ensure residents received treatment and care in accordance with professional standards of practice. The policy indicated a resident with an indwelling catheter would receive treatment to prevent urinary tract infections.

Based on observation, interview, and record review, the facility failed to provide midline intravenous (IV) catheter care and services consistent with professional standards of practice for 1 of 1 resident reviewed for IV catheter care, of a total sample of 52 residents, (#70).Findings:Resident #70 was admitted to the facility on [DATE] with diagnoses including heart failure, sepsis, urinary tract infection, and chronic kidney disease stage III. The admission Minimum Data Set, dated [DATE] indicated the resident had a Brief Interview for Mental Status of 15/15, which meant he was cognitively intact. Review of resident #70's Electronic Medical Record (EMR) revealed a physician's order dated 7/01/26, with instructions to monitor the midline IV catheter in the left arm for signs and symptoms of infection, swelling, color change, pain, drainage, and if present to notify physician. An additional physician's order dated 7/09/26 included instructions to change the dressing to the midline IV insertion site every seven days and as needed, using sterile technique once a day. A midline catheter is a type of IV access comprised of a small thin tube inserted into a vein usually in the upper arm, with the tip ending near the armpit area. Infection is one risk of a midline catheter IV. It is recommended the dressing should be changed at least every seven days, (retrieved on 7/27/26 from ncbi.nlm.nih.com). Resident #70 had a care plan for IV midline for medication administration initiated on 7/01/26. The care plan directed, staff should monitor the midline to resident #70's left arm, alert physician to any changes to insertion site, and administer treatment per physician order. On 7/13/26 at 10:21 AM, resident #70 was in his room and stated he was at the facility to receive IV antibiotics. On his left upper arm was a transparent IV dressing with a label that indicated it was inserted on 6/29, and indicated the dressing was due to be changed on 7/6. Resident #70 stated he got the midline IV at the hospital and confirmed the date the IV dressing was changed was two weeks past. On 7/13/26 at 12:00 PM, Licensed Practical Nurse (LPN) P looked at resident #70's left arm, confirmed the midline IV dressing was dated as inserted on 6/29 and verified the label indicated it should be changed on 7/6. The nurse confirmed the current date was 7/13/26, therefore, the dressing was due to be changed seven days ago. LPN P stated IV dressings should be changed once a week or more often if needed. Review of the Treatment Administration Record (TAR), from 7/01/26 to 7/16/26 revealed documentation resident #70's midline IV dressing was last changed on 7/09/26, in conflict with the date written on the actual midline IV dressing. On 7/14/26 at 9:25 AM, resident #70 stated the midline IV dressing was changed by the nurse yesterday. He confirmed the date on the dressing read now read 7/13. Further review of the July 2026 TAR on 7/16/26 revealed LPN P did not document the dressing change she completed on 7/13/26. LPN P did not document until 7/16/26 that she completed resident #70's midline dressing change she actually completed on 7/13/26. In interviews on 7/16/26 at 11:45 AM, and 4:45 PM, the 100 Unit Manager (UM) reviewed resident #70's July 2026 TAR and confirmed the last IV dressing change was documented as completed on 7/16/26 at 3:21 PM. The UM acknowledged the documentation was incorrect and stated she knew LPN P actually changed resident #70's IV dressing on 7/13/26. She said midline IV dressings should be changed every seven days or as needed, if loose or soiled per facility policy. The 100 Unit Manager stated her expectation was for nurses to follow physicians' orders. On 7/16/26 at 12:16 PM, the Regional Director of Clinical Services stated her expectation was all nurses should follow physicians' orders. Review of the facility's Central Venous Catheter Access and Maintenance Policy revised 3/22/19, revealed dressings that were wet, soiled, or dislodged should be replaced using aseptic technique otherwise transparent IV dressings should be changed every seven days.

Based on observation, interview, and record review, the facility failed to ensure oxygen therapy was provided in accordance with a physician's order, consistent with professional standards of practice, (#141); and failed to ensure changes in a resident's respiratory and swallowing status was timely documented, communicated, and followed up on, (#45), for 2 of 3 residents reviewed for respiratory care, out of a total sample of 52 residents. Findings: 1. Resident #141 was readmitted to the facility on [DATE]. admission diagnoses included acute respiratory failure, myocardial infarction, congestive heart failure and chronic kidney disease. The quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed resident #141 had a Brief Interview for Mental Status (BIMS) score of 12/15, which indicated she had moderate cognitive impairment. The assessment revealed resident #141 required assistance with meal set-up, was dependent for hygiene needs and mobility, and was incontinent of bowel and bladder. Oxygen use was not indicated. Review of resident #141's admission Evaluation dated 7/10/26 at 6:40 PM, revealed the resident's oxygen saturation was 99% on oxygen. The resident's respiratory assessment included oxygen support intermittently or as needed, administration of oxygen as per MD orders, and oxygen saturations as indicated. Review of the Daily Skilled Note, dated 7/11/16 at 2:11 PM, identified resident #141's oxygen saturation was 98% on oxygen via nasal cannula at 12:48 AM, and further documented the resident was not on oxygen. Review of resident #141's Care Plan, dated 5/28/26, revealed the resident had Chronic Obstructive Pulmonary Disease. Interventions included oxygen via nasal cannula as ordered by the physician. The care plan did not identify that the resident independently adjusted her oxygen regulator or include interventions to address if the resident adjusted the oxygen settings. Review of resident #141's Nursing Notes, dated 7/13/26 at 3:49 PM, revealed the resident was receiving oxygen at two liters per minute via nasal cannula for shortness of breath. Review of the vital sign's summary for resident #141, dated 7/11/26 at 12:48 AM, revealed the resident was receiving oxygen at two liters per minute. A review of the Physical Therapy Evaluation and Treatment Plan, dated 7/13/26 at 5:52 PM, reflected that resident #141 used oxygen at night at 2 liters per minute and was dependent on supplemental oxygen. On 7/13/26 at 9:50 AM, resident #141 was in bed with the head of bed slightly elevated with a nasal cannula in place on her head. The oxygen regulator was observed as set to deliver oxygen at five liters per minute. The resident stated she thought her oxygen should be set at three liters per minute. On 7/13/26 at 3:45 PM, resident #141 was in bed with the head of bed slightly elevated and a nasal cannula in place. The oxygen regulator was set to deliver oxygen at five liters per minute. Review of resident #141's Physician Orders on 7/13/26 at 3:55 PM, revealed no physician's order for oxygen therapy. On 7/13/26 at 3:56 PM, Licensed Practical Nurse (LPN) B stated she had cared for resident #141 during previous admissions and recalled the resident used oxygen as needed. LPN B stated the oxygen regulator should be set at two liters per minute. LPN B acknowledged resident #141's oxygen regulator was set at five liters per minute and adjusted it from five liters per minute to two liters per minute. She explained resident #141 sometimes adjusted the oxygen regulator herself. LPN B stated she assessed the resident in the morning, checked the resident's vital signs and oxygen saturation, and matched the oxygen regulator setting with her physician orders. The nurse acknowledged that oxygen is considered a medication and required a physician order. On 7/13/26 at 4:07 PM, the 200 Unit Manager (UM) stated resident #141 arrived at the facility on 7/10/26. The UM stated she knew resident #141 had received oxygen during previous admissions. The UM confirmed resident #141 had no physician's order for oxygen for this current admission and acknowledged the resident was receiving oxygen since admission without a physician order. On 7/15/26 at 4:55 PM, Certified Nursing Assistant (CNA) L stated she was resident #141's CNA when the resident arrived on 7/10/26 and had cared for the resident previously. CNA L stated she had assisted the nurse with the resident's assessment on the night the resident arrived. CNA L stated resident #141 was receiving oxygen when she arrived via transport, and the nurse placed the resident on oxygen after the resident was transferred to bed. CNA L stated the resident never changed her oxygen settings. On 7/15/26 at 5:10 PM, LPN D stated she was resident #141's nurse when the resident arrived on 7/10/26. LPN D stated she had cared for the resident during previous admissions and knew the resident had previously received oxygen. LPN D stated when the resident arrived on 7/10/26, she was receiving oxygen during transport. LPN D stated the resident was transferred to bed, the head of the bed was elevated, and she administered two liters per minute of oxygen to resident #141. The nurse stated she confirmed resident #141's orders with the physician by telephone and recalled the oxygen order but may have forgotten to actually enter the order in the system. LPN D acknowledged that administration of oxygen required a physician order. 2. Review of resident #45's medical record revealed she was admitted to the facility on [DATE] with diagnoses including chronic obstructive pulmonary disease (COPD), pleural effusion, pneumonia, anxiety disorder, rheumatoid arthritis, and dysphagia (difficulty swallowing). Review of resident #45's medical record revealed a BIMS assessment completed on 7/03/26 showed a score of 15 out of 15, indicating intact cognition. On 07/14/26 at 9:45 AM, resident #45 was sitting in bed and reported she felt like she had flu-like symptoms. She further stated she did not want to get up or eat. The resident was coughing during the interview and described the cough as wet but nonproductive. She stated she had vomited during the night because of the cough and indicated the nurse had given her medications. On 7/15/26 at 10:44 AM, resident #45 stated she continued coughing at night and the cough took every piece of energy out of her. She indicated she was receiving an inhaler and medication for the cough and that her chest felt like the bones hurt from the increased coughing. Review of resident #45's care plan with a focus of COPD, revised 7/08/26, revealed a goal to be free of sign and symptoms of respiratory infection through the next review date. On 7/15/26 at 11:08 AM, CNA E stated resident #45 was coughing that morning and requested cough medication, which CNA E reported to the nurse. On 7/15/26 at 12:14 PM, LPN B stated resident #45 was admitted from the hospital with pneumonia, a pleural effusion and had COPD. She indicated the respiratory system was her main issue, including COPD. LPN B stated the resident coughs a lot and was received Tessalon Perles and Guaifenesin for the cough. LPN B stated she was aware of the resident's episode of emesis associated with increased coughing. The nurse indicated the resident coughed frequently in the morning, and she had educated the resident regarding smoking. Review of resident #45's Progress Notes revealed Advanced Practice Registered Nurse (APRN) O note entered on 7/15/26 at 3:23 PM, for a skilled follow-up visit. The note documented the resident was observed sleeping in bed and awakened easily to verbal stimuli, was hemodynamically stable, and denied cough or shortness of breath. The respiratory assessment documented respirations were even and unlabored, and lungs were clear to auscultation. On 7/15/26 at 4:58 PM, CNA L stated resident #45 had been coughing and always requested cough medication. CNA L indicated that during the previous day's 3:00 to 11:00 PM shift, resident #45 reported she was not feeling too good and requested pain and cough medication. CNA L stated she reported the resident's concerns to LPN D. On 7/15/26 at 5:06 PM, LPN D stated resident #45 had been coughing and received Robitussin for the cough. LPN D further stated the resident had difficulty swallowing and needed to be seated while taking her medications. She shared resident #45 almost choke[d] while taking her medications and required assistance. LPN D indicated she reported the resident's coughing and the medication administration incident to the incoming shift nurse but did not document the incident. She stated she had not called the physician regarding the resident's concerns. Review of resident #45's Progress Notes revealed a General Nursing Note entered by LPN D on 7/15/26 at 6:28 PM, after the interview, documenting the resident experienced difficulty swallowing oral medication during medication administration. The note, in late documentation, indicated the resident began choking and had a brief episode of coughing followed by a small amount of emesis. The nurse documented medication administration was stopped, and the resident was assessed. The note documented the resident was alert, breathing without distress, and showed no signs of acute respiratory compromise. The note further indicated the physician was notified. On 7/16/26 at 9:10 AM, the East Wing Unit Manager (UM) stated she was unaware of resident #45's almost chocking incident or increased coughing. The UM stated nurses were expected to contact the physician regarding changes in condition and obtain further direction. Later at 2:45 PM, the UM indicated nurses would assess vital signs, including oxygen saturation, to determine whether a change in condition was occurring. She stated LPN D had not informed her of resident #45 having difficulty swallowing medications and no nurses had reported swallowing concerns to her. The UM further stated swallowing concerns would be reported to the physician and Speech Therapy (ST), so ST could perform a screening. She indicated she expected nursing staff to communicate such a change so appropriate follow-up with therapy could occur. On 7/16/26 at 9:07 AM, during a telephone interview, APRN O stated she assessed resident #45 the previous day. APRN O indicated she expected the nurses to communicate with her if the resident experienced shortness of breath or wheezing. She stated she was aware of the swallowing incident and indicated it would be appropriate for ST to evaluate the resident; however, no one had requested an ST evaluation, and she was unaware whether ST had evaluated the resident. On 7/16/26 at 10:58 AM, the Director of Rehabilitation Services (DOR) stated resident #45 was evaluated by ST on 7/03/26 for swallowing and was determined to be safe at the time and did not require ST services. The DOR indicated he had not received a new ST referral from nursing to reevaluate resident #45 in regard to the recent event. He stated when nurses identified a change in condition, they would typically contact therapy immediately. On 7/16/26 at 2:23 PM, an attempt was made to contact LPN D by telephone to clarify the discrepancy between her interview and subsequent documentation regarding resident #45's swallowing incident and physician notification. LPN D did not answer. A message was left requesting a return call; however, no return call was received prior to the conclusion of the survey. On 7/16/26 at 3:09 PM, the [NAME] President of Clinical Quality Assurance stated nurses were expected to inform the physician of changes in condition and implement any new orders. She explained if a change in condition was documented in resident #45's medical record, it would prompt the interdisciplinary team to review and follow up. Review of the facility's policy titled Respiratory/Tracheostomy Care and Suctioning, revised on 3/26/21, revealed the facility would ensure residents who required respiratory care received care consistent with professional standards of practice, the comprehensive person-centered care plan, and resident goals and preferences.

Based on observation, interview, and record review, the facility failed to ensure medications were maintained in a secure manner during medication administration by leaving medications unattended at the residents' bedside for 2 of 5 medication pass observations, of a total sample of 52 residents, (#35, and #41).Findings:On 7/13/26 at 10:40 AM, a medication pass was observed with Licensed Practical Nurse (LPN) B for resident #41. LPN B removed medications from the medication cart and entered the resident's room. LPN B administered one medication, then the resident requested the rest of her pills be crushed. The LPN exited the resident's room to crush the resident's medications, leaving two liquid medications unattended on the resident's bedside table. The medications remained on the resident's bedside table and were no longer under the direct control of LPN B until she returned to the room.On 7/13/26 at 11:05 AM, LPN acknowledged she should not have left the medications unattended at resident #41's bedside. The nurse said she should have taken all the medications with her when she exited the room.On 7/14/26 at 8:45 AM, a medication pass was observed with LPN H for resident #36. LPN H removed the resident's medications from the medication cart and placed the medications on the resident's bedside table. The LPN exited the resident's room to retrieve a blood pressure cuff. The medications remained on the resident's bedside table and were no longer under the direct control of LPN H until she returned to the room.On 7/14/26 at 9:00 AM, LPN H acknowledged she should not have left resident #36's medication unattended on the bedside table when she left the room.Review of the facility's Medication Administration policy, dated 2/25/25, revealed medications were to be administered in accordance with professional standards of practice.On 7/16/26 at 4:30 PM, the Regional Director of Clinical Services stated the facility's expectation was that medications were never to be left unattended at the bedside, not even for a minute, because doing so presented a resident safety risk.

Based on observation, and interview, the facility failed to maintain the refuse storage area in a sanitary condition for 2 of 2 dumpsters to prevent the harborage and feeding of pests, which could adversely affect all 122 residents residing in the facility. Findings: During the initial tour of the facility kitchen on 7/13/26 at 9:45 AM, observation of the exterior refuse area revealed that behind the dumpster there were three discarded plastic gloves on the ground. The Certified Dietary Manager picked them up, opened the lid to the dumpster, and put them in the correct location. He acknowledged they were not supposed to be there, then proceeded to wash his hands with soap and water.

Based on observation, interview, and record review, the facility failed to conduct a medication self-administration assessment to ensure safety for 1 of 1 resident reviewed for self-administration of medications, of a total sample of 53 residents, (#1). Findings: Resident #1 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included Chronic atrial fibrillation, and hypertensive chronic kidney disease with stage 1 through 4. Her most recent Minimum Data Set assessment, dated 8/05/24, revealed a Brief Interview for Mental Status exam score of 13 out of 15, which indicated intact cognition. On 8/12/24 at 11:55 AM, resident #1 was lying on her bed with the overbed table across her. A white plastic bin on the table contained personal items, including Hydrocortisone 1% cream. Resident #1 stated she had applied the cream herself for over one year to her private area. On 8/12/24 at 5:21 PM, the East Wing Unit Manager acknowledged two tubes of Hydrocortisone cream, were present on the resident's bed. The East Wing Unit Manager said the resident's husband had been to visit today, and she thought he must have brought the medications in. She explained the resident had an order for cream because she had a rash between her legs. The East Wing Unit Manager acknowledged the nurse should apply the treatment, as the resident was not approved or assessed to have medications at the bedside. On 8/12/24 at 5:27 PM, the Director of Nursing (DON) stated, A resident must be assessed for self-administration [of medications], and if appropriate, then we get physician orders for the resident to perform the treatment. The DON acknowledged those protocols were not in place for resident #1. A review of the facility's policy and procedure for self-administration of Medication program dated 3/2/19 read, It is the policy of the facility to allow the resident and or legal representative of the resident the right to self-administer medication when it has been deemed by the interdisciplinary team that it is clinically appropriate.

Based on observation, interview and record review, the facility failed to ensure the resident was free from physical restraint for 1 of 1 resident reviewed for restraints, of a total sample of 53 residents, (#65). Findings Resident #65, an [AGE] year-old- female was admitted to the facility on [DATE] and readmitted on [DATE]. The resident was admitted to Hospice Services on 1/17/24. Her diagnoses included convulsions, cerebral atherosclerosis, repeated falls, major depressive disorder, and generalized muscle weakness. Review of the resident's physician orders revealed an order dated 3/12/21 for bilateral upper grab bars to enable positional changes, bed mobility or to determine bed perimeters. The resident's quarterly Minimum Data Set assessment with Assessment Reference Date of 8/02/24 revealed the resident was rarely/never understood and was dependent on staff assistance with activities of daily living, and mobility. A Side Rail Evaluation dated 10/20/22 indicated the recommended type of side rail(s) for resident #65 were left and right upper side rails at all times when the resident was in bed. On 8/12/24 at 12:12 PM, and on 8/13/24 at 9:40 AM, resident #65 was lying in bed with bilateral upper, and bilateral lower bed rails up. On 8/13/24 at 10:48 AM, Registered Nurse (RN) A, confirmed he was the resident's assigned nurse. He stated resident #65 was at risk for falls, and four side rails were implemented approximately four months ago when the resident started on Hospice services. RN A stated the use of the four side rails were implemented because of a request by the resident's family. On 8/14/24 at 9:39 AM, resident # 65 was lying in bed positioned to her left side facing the bathroom. The resident's eyes were open, but there was no response from the resident when spoken to. Bilateral upper and lower side rails were up. On 8/14/24 at 9:59 AM, the [NAME] Wing RN/Unit Manager (UM) stated resident # 65 was on Hospice services, and her bed was provided by Hospice. The UM stated she observed the four side rails on resident #65's bed on 8/13/24. She stated she did not know why the resident had four side rails in place, and recalled she called the Hospice nurse on 8/13/24 to establish the reason for the four side rails. The RN/UM said documentation in the resident's clinical records was for two side rails. On 8/14/24 at 12:18 PM, Certified Nursing Assistant (CNA) C stated that approximately a month ago she noted the resident in bed with four side rails up. The CNA said she was questioning the use of the four side rails, but was told it was a hospice bed, so she did not dig any further. On 8/14/24 at 12:56 PM, the Director of Nursing (DON) stated the [NAME] Wing UM made her aware of the four side rails being used on resident #65's bed. The DON said the bed was a hospice bed, and the [NAME] Wing UM was trying to call Hospice to find out why that bed was sent to the facility. She said four side rails were considered restraints, and if a resident was to have four side rails up, the Interdisciplinary Team (IDT) had to assess, and identify the reason for the four side rails. She stated if use of the side rails falls in the category of restraints, the family would be notified, and asked to sign a consent for the use of the four side rails. The DON stated she knew the hospice bed was delivered for the resident, but she did not know that four side rails were being utilized at the facility. The DON reviewed the resident's clinical records and acknowledged there was no documentation regarding the use of four side rails, or a consent for the use of the four side rails identified. She stated a side rail release consent dated 3/06/20, did not address the use of four side rails. Review of the Side Rails Informed Consent and Release dated 3/06/20 revealed the consent did not address the use of four side rails, and the document read, I understand that the side rails are used as a mobility aid and not as a physical restraint. Documentation on the form revealed verbal consent via telephone was obtained from the family. The DON confirmed no additional consent was obtained when the resident received the bed from Hospice, an assessment for the use of the four side rails was not identified, and there was no documentation in the resident's clinical records regarding the request of the family for the use of four side rails. On 8/14/24 at 1:27 PM, the [NAME] Wing RN/UM stated if family requested four side rails, an assessment for the side rails was required. The RN/UM stated she was aware four side rails were considered restraints, but explained she was not aware resident #65 had four side rails in place until made aware by RN A on 8/13/24. Additional information provided to the field office status post exit from the survey revealed a restraint evaluation was completed for the resident on 8/19/24. The facility's policy Freedom from Physical and Chemical Restraints issued/revised 3/02/19 read, When the use of restraints is indicated, the facility will use the least restrictive alternative for the least amount of time and document ongoing re-evaluation of the need for restraints.

Based on interview and record review, the facility failed to report allegations of abuse to State agencies as required for 2 of 5 residents reviewed for abuse, of a total sample of 53 residents, (#110 and #276). Findings: 1. Review of resident #110's medical record revealed she was admitted to the facility on [DATE] with diagnoses including osteomyelitis (infection in the bone), pressure ulcer of the sacrum and bipolar disorder. Review of resident #110's Admission Minimum Data Set assessment with Assessment Reference Date of 7/17/24 revealed a Brief Interview for Mental Status score of 15 which indicated intact cognition. The assessment showed resident #110 required substantial assistance with toileting and personal hygiene. The assessment indicated resident #110 did not reject evaluation or care needed to achieve her goals for health and well-being. On 8/13/24 at 10:21 AM, resident #110 stated 2 Certified Nursing Assistants (CNAs) flipped out on her because she had diarrhea, and she had to be cleaned multiple times. She explained she apologized to the CNAs and told them she was taking an antibiotic which caused the diarrhea. With tears in her eyes, resident #110 indicated the CNAs were disrespectful to her and added the way they cleaned her was abuse because they were very rough. She shared she told her assigned nurse, but she could not identify the CNAs. She stated her nurse said she was going to report it to upper management. She recalled the nurse even told her they were handling it but did not tell her how. She stated the CNAs seemed to have a chip on their shoulders. On 8/13/24 at 12:20 PM, Registered Nurse (RN) O stated resident #110 needed a lot of support. She recalled resident #110 expressed concerns regarding the diarrhea while taking antibiotics. She explained the diarrhea was ongoing and, sometimes, she had multiple episodes during a shift. She mentioned resident #110 got discouraged and sad when calling the CNAs often because she needed toileting assistance. RN O indicated resident #110 mentioned some CNAs had different attitudes toward her, rolling their eyes or answering disrespectfully. She indicated she told resident #110 she appreciated she told her because there were residents who could not speak for themselves, so she was not only speaking for herself but helping others. She stated she sometimes would address concerns directly with CNAs, but she did not this time and took it, up the chain of command. She indicated she reported resident #110's abuse allegations to her supervisors but did not recall when exactly. RN O mentioned resident #110 told her CNAs were rude to her, stared at her, or made comments we shouldn't say. RN O recalled resident #110 was crying while sharing this with her, because her feelings were hurt. Review of the Abuse Log for July and August 2024 did not show a report for resident #110. On 8/13/24 at 12:34 PM, the Administrator stated she was not aware of any abuse allegations for resident #110. She indicated her expectation was to be notified by staff when they received any abuse allegation from residents. 2. Review of resident #276's medical record revealed she was admitted to the facility on [DATE] with diagnoses including metabolic encephalopathy, anemia and depression. Review of resident #276's medical record revealed Progress Notes dated 8/05/24 and 8/06/24 which showed she was alert and oriented to person, place and time. On 8/12/24 at 12:54 PM, with her husband at bedside, resident #276 said she was physically abused last Wednesday at approximately 3:00 AM. She explained she was not asked if she could go to the bathroom for an urine sample but was told she had to. Resident #276 shared her assigned nurse was, yanking her hands around and told her, If you do not give me a urine sample, I know how to get it. She indicated the nurse collected the urine sample by inserting a catheter into her urethra without her consent, forced it, and it hurt her. They indicated after the incident they spoke with the Social Services Director. Resident #276 repeated she was grabbed by her arm and was told to get up from the bed by the nurse and was taken to the bathroom for a urine sample. She stated when she could not urinate, the nurse told her she would get the urine sample another way. Review of a Resident Concern/Grievance Form dated 8/07/24 revealed it was filed by resident #276's spouse due to a care concern with the CNA and nurse. The follow-up section of the document included a hand-written statement entered by the Assistant Director of Nursing (ADON) which read, ADON and Unit Manager spoke with resident and spouse about care concern, resident request that she don't [sic] want that nurse and CNA to take care her [sic]. ADON removed CNA and nurse to [sic] that assignment and offer to resident to be move to another room or she wants to start a reportable. Resident verbalized NO she is fine. Just to remove that [sic] staff the [sic] assignment. On 8/12/24 at 2:37 PM, the Social Services Director indicated she was the Grievance Officer, and all grievances were discussed in morning or afternoon meetings. She explained resident #276's husband came to her office last week and reported a care issue concern. She mentioned she did not know the extent as it was assigned to nursing and handled by their ADON. On 8/12/24 at 2:54 PM, the ADON joined the interview with the SSD and confirmed she handled the grievance filed by resident #276's husband on 8/07/24. She read the follow-up section she wrote on the grievance form and said she and the Unit Manager (UM) spoke with the resident and her spouse about a care concern that day. She stated resident #276 did not want the nurse and CNA taking care of her. The ADON stated she removed the CNA and nurse from her assignment and offered resident #276 to move into another room or if she wanted to start a reportable. She indicated resident #276 verbalized no, she was going to be fine if the staff was removed from her assignment. When asked why she offered a reportable to resident #276, the ADON stated resident #276 told them the CNA and the nurse were rough when trying to obtain a urine sample. She recalled resident #276 said she felt hurried to get the specimen. She explained after talking to resident #276, she called the nurse who explained she had to collect the urine sample using a straight catheter because the resident could not urinate, but she asked for permission from the resident. The ADON stated she explained the reportable process to the resident which included contacting law enforcement, and the SSD stated based on this, resident #276 did not want a reportable done. The ADON pointed out to resident #276 the way she said the nurse or CNA was rough with her, they would have to investigate deeper. The ADON stated resident #276 told her the CNA grabbed her by her shoulder, to hurry her to pee. The ADON stated she spoke to the assigned CNA who indicated she was never in the room with the nurse during the urine sample collection. The ADON stated the grievance was discussed during their management meeting. The SSD stated the grievance was closed as resolved because the ADON investigated the concern, and the resident was satisfied with the removal of the staff. The ADON stated the resident and her husband, said no all the time, she mentioned reporting, so she did not report it to the Administrator (NHA). The ADON said she did not know they had to do a reportable until today when the Administrator informed her reporting was required. She stated she thought if the resident or family did not want to proceed, they did not have to do it. On 8/12/24 at 3:09 PM, the Administrator stated she met with resident #276 and her husband that day, before she was discharged home. The NHA indicated resident #276 told her she was treated roughly one-night last week while a nurse tried to collect a urine sample. The Administrator stated they initiated an investigation, contacted Law Enforcement and the Department of Children and Families (DCF). She stated both resident #276 and her husband said they did not want to report this incident, but she explained they had to do it. She stated they provided a description of the staff involved and the nurse was suspended pending investigation. She explained if the allegation was substantiated the staff was reported to Board of Nursing. She indicated the resident's safety was most important, but she was not affected as she was discharged today. The NHA read the grievance filed by resident #276's husband on 8/07/24 and stated she had understood it as a customer service issue. She explained if abuse was suspected staff would call her, but she did not receive a phone call last week while she was out of the facility. She stated the Director of Nursing (DON) told her she was not aware of this until today. She explained she had 2 hours to report allegations of abuse to the physician, the resident's representative, Law Enforcement, DCF and to submit an immediate report to the State Survey Agency. On 8/12/24 at 3:39 PM, Registered Nurse (RN) Q in broken English stated resident #276 had a physician order for a urinalysis and culture and the collection needed to follow a sterile procedure. She indicated she explained the procedure and resident #276 agreed. She stated she asked resident #276 if she could go to the bathroom which she did. She mentioned she tried to collect the urine sample in the bathroom, but resident #276 was unable to urinate so she went back to bed. RN Q stated she told resident #276 to relax once back in bed and she waited a few minutes for resident #276 to calm down. She stated she told resident #276, procedure, catheterize urine and cultivo urinary, me catheterize, I can while showing her the equipment she was going to use. She indicated resident #276 responded yes more than once. RN Q stated she, Did not even touch her much, because the urine came out fast. I almost did not touch her. She recalled during morning report she was sitting at the nurse's station when resident #276's husband was upset after his wife stated she was handled roughly, and was catheterized without her consent. She indicated she tried to explain to him what had happened, but he would not listen. She recalled the ADON called her later that day with questions about this resident. On 8/15/24 at 2:03 PM, the East Wing UM recalled the morning of 8/07/24 resident #276's husband brought up a concern to her assigned nurse and the nurse took him to the nurse's station. The UM stated resident #276's husband mentioned the nurse last night, got a foley (catheter) in his wife and she did not need to do that. The UM stated the husband explained his wife was uncomfortable and asked why she was not taken to the bathroom. She indicated she went to resident #276's room with the ADON to speak with her and her husband. She explained she told them there was a physician order for a urine sample and resident #276 could not urinate so the nurse asked if she could collect a sample with a catheter and resident #276 approved. The UM said the husband clarified what his wife told him, she went to the bathroom, and she could not urinate, and the nurse just collected the sample using the catheter even though resident #276 would have been able to urinate. The UM indicated resident #276, could not really understand the nurse, I think it was miscommunication. She recalled resident #276 's husband requested RN Q not be assigned to his wife again. She stated the ADON and SSD were part of the interview, and one of them asked if they wanted the facility to do, a reportable. The UM said this was done, when there is an allegation of abuse or neglect, when the family thinks they were not taken care of, even if they do not want it, they offer that as an option. Review of the facility's Abuse, Neglect, Exploitation and Injuries of Unknown Origin Policy dated 3/01/17 revealed alleged violations involving abuse, Must be immediately reported to the facility administrator and other officials in accordance with state and federal law. The document indicated the facility would thoroughly investigate and document each alleged violation and ensure all alleged violations involving abuse were reported no later than 2 hours to the administrator and other officials (including the State Survey Agency) in accordance with State Law.

Based on interview and record review, the facility failed to provide written Notification of Transfer or Discharge forms to the residents or their representative for 2 of 2 residents reviewed for hospitalization s, of a total sample of 53 residents, (#121 and #123). Findings: 1. Resident #121 was admitted to the facility on [DATE] with diagnoses including atrial fibrillation, type 2 diabetes, angina, secondary malignant neoplasm of bone, malignant neoplasm of bladder, acute kidney failure and benign prostatic hyperplasia with lower urinary tract symptoms. Review of resident #121's medical record revealed he was scheduled to be discharged home on 6/08/24. Review of progress notes revealed resident #121 was admitted with an indwelling catheter on 6/02/24. The catheter was removed on 6/04/24. On 6/07/24, staff observed a urinal in resident #121's bathroom which contained bloody urine. Resident reported he started to see blood in his urine the day before but did not report it as he was not in pain. Nursing contacted resident #121's physician who ordered the resident be sent to the hospital immediately for evaluation and treatment. The facility provided a copy of the Notification of Transfer or Discharge form for the hospitalization . The form was not signed by resident #121 or his representative. The resident discharged home from the hospital and did not return to the facility. 2. Resident #123 was admitted to the facility on [DATE] with diagnoses including pancreatic cancer, spinal stenosis, chronic obstructive pulmonary disease, congestive heart failure, sleep apnea, and anxiety. Review of resident #123's medical record revealed she was hospitalized on [DATE]. A progress note dated 5/20/24 indicated the resident was noted to be very sleepy with non-reactive pupils and responded only to touch stimulus. The facility received an order for STAT (immediate) labs. Another progress note dated later on 5/20/24 noted the resident to have a blood pressure of 88/60, pulse 57 beats per minute and oxygen saturation level at 93%. The facility received a new order to transfer resident #123 immediately to the hospital for altered mental status and abnormal vital signs. The resident's representatives came in shortly after the transfer and removed her belongings from the facility. The facility provided a copy of the Notification of Transfer or Discharge form for the hospitalization . The form was not signed by resident #123 nor her representative. On 8/15/24 at 1:07 PM, the Social Services Director stated nursing completed the notice of Transfer or Discharge forms for residents who discharged to the hospital. The forms were then given to social services and they sent them to the Ombudsman's office. The Social Services Director clarified she only sent them to the Ombudsman office. She explained she was not responsible for sending the notification to residents or their representatives. On 8/15/24 at 2:50 PM, the Assistant Director of Nursing (ADON) acknowledged her signature was on each of the Notice of Transfer or Discharge forms. She explained nursing completed the forms, sent a copy in the hospital paperwork and gave the form to social services. The Director of Nursing was present and stated she did not know who provided a copy of the form to the resident or resident's representative. The facility was unable to provide proof the resident or resident's representative were notified in writing of the reason for transfer. On 8/15/24 at 2:10 PM, the Executive Director stated she thought social services sent a copy of the Notice of Transfer or Discharge form to the resident's representative if no one was here to sign the form. She explained she was not aware the forms were not being mailed out. The Executive Director clarified the expectation was the resident or resident's representative was provided a copy of the Notice of Transfer or Discharge form.

Based on interview and record review, the facility failed to ensure the Minimum Data Set (MDS) assessments were accurate for tracheostomy care for 1 of 1 resident, (#86), failed to accurately assess for insulin administration for 1 of 1 resident, (#15), and failed to ensure assessment accurately reflected oxygen (O2) therapy for 2 of 2 residents reviewed for O2 therapy, (#64, and #95), of a total sample of 53 residents. Findings: 1. Resident #86 was admitted to the facility on [DATE] with diagnoses that included nontraumatic brain bleed, respiratory failure, and partial paralysis. Review of the MDS Admission modification assessment with an assessment reference date (ARD) of 8/05/24 revealed resident #86 was, rarely or never understood. The assessment indicated the resident did not have tracheostomy care. A review of resident #86's medical record revealed a physician order dated 7/29/24 to obtain oxygen saturation every shift and, as needed, notify the physician. The order continued for staff to cap the tracheostomy, uncuffed as tolerated. Another order dated 8/01/24 read, tracheostomy-provide tracheostomy care every day and as needed. Change tracheostomy ties daily and as needed. On 8/15/24 at 1:35 PM, MDS Coordinator 1 reviewed resident #86's MDS assessment dated [DATE] and acknowledged she incorrectly coded section O for tracheostomy care. She acknowledged the MDS assessment should reflect the resident's status at the time of the assessment. The MDS Coordinator explained the assessment should include a chart review of the orders, all progress notes, and resident observation/interview during the assessment look-back period. 2. Resident #15 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including multiple sclerosis, pulmonary embolism, and cardiomegaly. A review of the MDS Quarterly assessment with ARD 5/23/24 revealed resident #15 had a Brief Interview for Mental Status (BIMS) score of 0/15, which indicated the resident was severely cognitively impaired. The assessment showed the resident received insulin injections on three days during the last seven days or since admission or reentry if less than seven days. A review of resident #15's medical record revealed no physician orders or medication administration for insulin administration. On 8/15/24 at 1:35 PM, MDS Coordinator 1 reviewed resident #15's MDS and acknowledged she incorrectly coded section N. She again indicated the MDS assessment should reflect a picture of the resident at the time of the assessment. The MDS Coordinator stated the assessment should include a chart review of the orders, all progress notes, and resident observation/interview during the assessment look-back period. Review of the facility's policies and procedures Resident Assessment (RAI) dated 3/02/19 read, It is the policy of the facility to adhere to the following procedures related to the proper documentation and utilization of a resident's Minimum Data Set (MDS) to ensure a comprehensive and accurate assessment of residents will be completed in the format and in accordance with time frames stipulated by the Department of Health and Human Services Center for Medicare and Medicaid Services. 49840 Cross Reference F695 3. Resident #64 was admitted to the facility on [DATE] with diagnoses that included dysphagia, obstructive sleep apnea, acute respiratory failure, shortness of breath, and encounter for palliative care. On 8/12/24 at 11:47 AM, resident #64 was observed in bed wearing a nasal cannula connected to an O2 concentrator set at 2 liters per minute (LPM). He stated that he used oxygen all the time and was received hospice care. The Quarterly MDS assessment dated [DATE], revealed resident #64 was cognitively intact, was dependent on staff for all activities of daily living (ADLs), had several respiratory diagnoses, and received hospice services. The assessment incorrectly reflected O2 therapy was not provided. A review of resident #64's medical record revealed no physician's order for O2. Review of resident #64's medical record revealed a hospital record dated 4/25/24 showed the resident had a diagnosis of O2 dependence, and used 2 LPM of O2 via nasal cannula. Resident #64 had a care plan for O2 therapy initiated on 6/09/23. Interventions included the use of O2 via nasal cannula at bedtime per resident request as ordered. On 8/15/24 at 11:03 AM, MDS coordinator #1 and MDS coordinator #2, both Licensed Practical Nurses (LPNs) stated they were both responsible for completing the MDS assessments. They confirmed resident #64 had been on O2 since he was admitted to the facility, nor was there an order in the medical record for O2 therapy. They explained it was therefore missed during the last Quarterly MDS assessment. 32131 4. Resident # 95 was admitted to the facility on [DATE], with diagnoses that included chronic obstructive pulmonary disease (COPD) with acute exacerbation, asthma, malignant neoplasm bronchus or lung, cough, and dependence on supplemental oxygen. A physician order dated 7/10/24 was for continuous O2 at 3 LPM via nasal cannula for shortness of breath. The resident's Admission MDS assessment with ARD of 7/16/24 revealed the resident's cognition was intact with a BIMS score of 15 out of 15. Section O for O2 therapy while a resident was not assessed. On 8/15/24 at 1:33 PM, MDS Coordinator 1 stated MDS assessments were completed by doing a seven day look back of the resident's clinical records, observation of the resident, interview of the resident if the resident's cognition was intact, if not the family would be interviewed, interview of nurses, and Certified Nursing Assistants (CNAs). MDS Coordinator 1 reviewed the resident's Admission MDS assessment with ARD of 7/16/24 and confirmed O2 therapy was not assessed. She reviewed the resident's physician orders, which revealed an order dated 7/10/24 for O2 therapy at 3 LPM. The LPN MDS Coordinator confirmed the MDS assessment dated [DATE] was not accurate. On 8/15/24 at 1:35 PM, the Regional MDS Specialist stated the facility did not have a policy regarding accuracy of assessment. She said they followed the guidelines outlined in the RAI Manual. The Centers for Medicare & Medicaid Services Long term Care Facility Resident Assessment Instrument effective October 2019 on page 2-41 read The RAI process, which includes the Federally mandated MDS, is the basis for an accurate assessment of nursing home residents. The MDS information and the CAA (Care Area Assessment) process provide the foundation upon which the care plan is formulated.

Based on interview and record review, the facility failed to refer residents with a newly evident mental disorder for Level II Preadmission Screening and Resident Review (PASARR) evaluation and determination for 1 of 4 residents reviewed for PASARR, of a total sample of 53 residents, (#97). Findings: Resident #97 was admitted to the facility on [DATE] with diagnoses including metabolic encephalopathy, diabetes mellitus, unspecified psychosis, and depression. A review of the Minimum Data Set Admission assessment with assessment reference date of 6/12/24 revealed resident #97 had a Brief Interview for Mental Status score of 13, which indicated she was cognitively intact. The document stated her active diagnoses included depression (other than bipolar) and psychotic disorder (other than schizophrenia). Review of resident #97 's electronic medical record revealed the diagnoses of unspecified psychosis with an onset date of 6/05/24 and major depressive disorder also with an onset date of 6/05/24 The record contained a Level I PASARR screening form dated 6/03/24 which did not indicate resident #97 had a mental illness (MI) or suspected MI. The record did not contain a Level II PASARR screening form. On 8/15/24 at 1:05 PM, the Director of Nursing (DON) stated that new admissions from the hospital should have a level l PASARR Screening completed by the hospital before admission to the facility. She explained when psychiatry services made a new diagnosis, the PASARR should be updated. The DON reviewed the Level I PASARR and current diagnoses for resident #97. The DON acknowledged the PASARR did not reflect the resident 's current MI diagnoses of unspecified psychosis and major depressive disorder. The DON stated she did not know why the diagnoses were not listed.

Based on record review and interview, the facility failed to honor a resident's advance directives, and did not follow physician's order to provide basic life support and initiate Cardiopulmonary Resuscitation (CPR) for 1 of 4 sampled resident in a total sample of 5 residents reviewed for code status, (#1). Resident #1 had advance directives and physician's order that did not include withholding of cardio-pulmonary resuscitation (CPR). On [DATE] at approximately 2:30 AM, resident #1 was found unresponsive in bed with the absence of vital signs. The resident's primary nurse, Licensed Practical Nurse (LPN) A failed to verify the resident's code status which included Cardiopulmonary Resuscitation to be initiated. LPN A did not initiate CPR as per the resident's wishes or call 911 per facility policy after finding the resident unresponsive. The resident died . The facility's failure to provide CPR per the resident's advance directives, and physician orders, resulted in Immediate Jeopardy beginning on [DATE]. The Immediate Jeopardy was removed on [DATE]. Findings: Resident #1 was a long-term care resident admitted to the facility on [DATE]. He was hospitalized on [DATE] and readmitted to the facility on [DATE]. His [DIAGNOSES REDACTED]. The resident was placed in the facility's COVID-19 unit when he was readmitted . The facility's policies and procedure for Cardiopulmonary Resuscitation (CPR) dated [DATE] and revised on [DATE] included the following: The facility will follow current American Heart Association (AHA) guidelines regarding CPR. If a resident experiences a [MEDICAL CONDITION], facility staff will provide basic life support, including CPR, prior to the arrival of emergency medical services, and a. in accordance with the resident's advance directives, or b. in the absence of advance directives or a Do Not resuscitate order or c. if the resident does not show obvious signs of clinical death (e.g., rigor mortis, dependent lividity, decapitation, transection, or decomposition). CPR sequence- check patient for responsiveness. If unresponsive, call for help and activate EMS, or direct others to do so .check for breathing and pulse. If no pulse and not breathing, begin CPR cycle .CPR will be continued: until EMS arrives or until resident regains spontaneous circulation or Until medical provider is called, resident condition is discussed/described, and provider gives order to discontinue resuscitative efforts. The CPR During COVID-19 Pandemic- Interim Policy dated [DATE] read, If a resident experiences a [MEDICAL CONDITION], facility staff will provide basic life support, including CPR, prior to the arrival of emergency medical services, and a. in accordance with the resident's advance directives, or b. in the absence of advance directives or a Do Not resuscitate order or c. if the resident does not show obvious signs of clinical death (e.g., rigor mortis, dependent lividity, decapitation, transection, or decomposition) .Staff will don appropriate PPE prior to initiation of CPR: eye protection, N95 respirators (preferred), gloves, and gowns. Four sets of PPE will be placed on all crash carts. An appropriate bag-mask device with tight seal will be on all crash carts and immediately obtained for rescue breathing .The number of people in the room will be limited to essential personnel (i.e. those with active duties such as compressions and airway management). Each person in the room must wear appropriate PPE. All other essential staff (i.e. runners, scribe) shall remain in the hall at the doorway. The facility's policy and procedure: Advance Directives dated ,[DATE] included: In the event that a resident experiences cardiopulmonary arrest the nurse on duty shall immediately determine the resident's status as a code or no code. If the person is a full code, the nurse or designee shall begin Cardiopulmonary Resuscitation and direct someone to call 911. Review of the medical record revealed resident #1's physician orders dated [DATE] read, Full code. LPN A's progress note on [DATE] at 3:49 AM read, [DATE] 0115 (1:15 AM) Resident resting in bed comfortably with eyes closed alert and responsive, no s/s (signs and symptoms) of distress. [DATE] 0230 (2:30 AM) check on him see if he is okay, if needed to be reposition (repositioned). Found him unresponsive, not breathing, no pulse, could not get a BP. There was no documented evidence that a Code Blue had been called when the resident was found unresponsive. There was no documented evidence that CPR had been initiated or that 911 had been called. Code Blue: An emergency situation announced in a hospital or institution in which a patient is in cardiopulmonary arrest, requiring a team of providers (sometimes called a code team) to rush to the specific location and begin immediate resuscitative efforts. (MedicineNet.com website at https://www.medicinenet.com/meaning_of_code_black_and_code_blue/views.htm accessed on [DATE] at 2:15 PM). On [DATE] at 7:12 AM, LPN C walked toward her medication cart. At that time, an interview was conducted with her. She stated that she received in-service regarding CPR and Advance Directives about 2 to 3 months ago and had not received any in-service or re-education recently on CPR or Advance Directives since [DATE]. Review of the facility's Education In-service Attendance Record did not find LPN C's name identified. On [DATE] at 8:51 AM, the Executive Director (ED) stated that the facility's investigation revealed that the nurse caring for resident #1 (LPN A), identified no pulse, or blood pressure, and because of the condition he was in- showing signs of dependent lividity, CPR was not initiated. Dependent lividity is hypostasis of the blood following death that causes a purplish red discoloration of the skin. (Merriam-Webster Medical Dictionary at https://www.merriam-webster.com/medical.) On [DATE] at 9:19 AM, an interview was conducted with the ED and the Director of Nursing (DON). The DON stated that the facility's process for an unresponsive resident included checking the code status. If the resident is a full code, staff should initiate CPR, and call 911. The DON stated that a different staff member would be designated to call the physician, family, and 911. The DON said that CPR by the facility staff would be stopped on arrival of the Emergency Medical services (EMS), or if the resident shows signs of life, or if directed by the physician. The DON stated that she received notification regarding resident #1 on [DATE] at 5 AM. She said that a voice message was left by LPN B, stating resident #1 had expired. The DON stated she reviewed the resident's clinical records remotely, and had some questions regarding the actions LPN A took. The DON said she called LPN A for additional information and an explanation of her actions. She asked LPN A who she notified, and if she activated a Code Blue. The DON said that LPN A described bruising to the (body) area the resident was lying on and there was some blood from his nose and his [MEDICAL TREATMENT] fistula. She also reported, that the resident had no heart rate, no respiratory rate, and that CPR was not warranted according to the facility's CPR policy. The ED stated that the facility initiated an investigation on [DATE]. They needed to verify why CPR was not initiated. The ED said that the timeframes documented by LPN A were questionable as they were too precise. The ED stated that LPN A explained, that at the beginning of her shift, resident #1's vital signs were within normal limits. He was responsive at 1 AM, with no sign or symptom of distress. At approximately 2:30 AM, the nurse reported she went in to further monitor the resident and found him unresponsive. He had bruising where his back met the bed. Code Blue was not called and CPR was not initiated. The DON stated a Code Blue was not called by LPN A to alert staff to come to resident #1's room. The DON said LPN A made an independent decision not to initiate CPR based on the facility's CPR during COVID-19 Pandemic policy and procedure. A further interview with the DON on [DATE] at 10:51 AM revealed that she was not sure why the night supervisor did not investigate, or go to resident #1's room when she was informed of his death. The DON verbalized that she educated LPN B on her responsibilities. The DON stated that Registered Nurses (RN) in the facility at the time of the incident were not made aware of the resident's condition/expiration, since a Code Blue was not called. On [DATE] at 11:40 AM, LPN A stated that on [DATE], around midnight, she monitored resident #1's vital signs and they were stable. She found him in bed leaning towards one side and asked the certified nursing assistant (CNA) for assistance to reposition the resident. LPN A stated that at approximately 1 AM, resident #1 had his face covered with his blanket. She uncovered his face, opened his eyes and said he was okay. At 2:30 AM, LPN A said the resident's face was again covered with his blanket. She uncovered him, and he did not respond. He did not open his eyes, he did not have a pulse, no respiration, and no blood pressure. The resident had bluish-reddish bruises on his left side. LPN A did not explain why she checked the resident's back while monitoring the resident's response. LPN A stated, that due to the data she collected at that time, she decided not to start CPR. LPN A stated she had seen residents like that before, and her CPR educational classes said one reason not to do CPR, was if the resident showed signs and symptoms of clinical death. LPN A stated she called the night supervisor, LPN B approximately half an hour after observing the resident and explained her findings. LPN A did not explain why she waited half a half hour before notifying the night supervisor, LPN B. She verbalized that LPN B asked her what the resident's code status was, and she responded, I don't know. LPN B directed her to call the physician, family, and the funeral home. LPN A stated that the night supervisor did not come to the COVID unit to observe resident #1. LPN A did not explain why she did not call any of the three RNs who were working in the facility at the time. LPN A stated, that since she was on the COVID unit, and knew her clinical data, she felt it was not necessary for a nurse to come into the COVID unit and then return to the non-COVID units. LPN A stated that she did not document her observations, the clinical signs and symptoms of death, and her reason for not initiating CPR for resident #1 as she was in a rush, thinking of something else. The witness statement from CNA D dated [DATE] revealed that resident #1 was repositioned multiple times during the shift. Documentation read, around 2:30 am, the nurse on shift notified me that the patient (name) was unresponsive, so we checked the pulse which was absent. Then she notified the supervisor. At this point I was notified by the nurse to 'clean the patient'. I followed orders and provided the patient care. On [DATE] at 1:29 PM an interview was conducted with the ED, the DON and LPN B. LPN B stated she was the night supervisor on the 11:00 PM-7:00 AM shift on [DATE] to [DATE]. She stated that on [DATE] at approximately 3 AM, she received a call from LPN A who informed her that resident #1 had expired. LPN B stated that LPN A mentioned that the resident was found unresponsive with no pulse or heart rate. LPN A reported that there was bruising to the left side of the resident's body and the resident was showing no signs of life. LPN B stated that she did not observe the resident as LPN A was competent. She said she directed LPN A to call the physician and notify the resident's family. LPN B stated that she did not go to resident #1's room to assess him as she was worried about going into the COVID unit and then returning to other units with healthy residents. LPN B stated that prior to COVID 19, she would have checked on the resident and followed the facility's policy. LPN B stated that she did not document her interaction with LPN A. On [DATE] at 9:15 AM, the DON stated that LPNs monitor and observe residents, while RNs assess residents. She said the expectation was that LPN A should have called the RN to assess the resident prior to her decision to withhold CPR. She added that it would have been best practice for LPN B to consult with the RNs on duty to assess the resident. On [DATE] at 10:15 AM, the Medical Director (MD) stated she saw resident #1 the day before he expired. The MD stated that LPN A should have called the registered nurse (RN) to assess the resident prior to making the final decision to withhold CPR. The MD said there was a need to re-educate the staff. She added that LPN A should have called the RN on duty when resident #1 was found unresponsive. The MD stated she did not know why this was not done. The Facility Assessment completed on [DATE] and last reviewed on [DATE] indicated that training topics would include, Resident's rights and facility responsibilities-ensure that staff members are educated on the rights of the resident and the responsibilities of a facility to properly care for its residents. Review of the Job description for Licensed Practical Nurse showed that LPN charge nurses should, Ensure that nursing services personnel are giving proper resident care and performing their respective duties in accordance with written policies, procedures and manuals .Know and comply with and ensure that all nursing services personnel know and comply with Residents' Rights rules; Monitor nursing services to ensure that residents' rights and needs are met Review of the corrective measures implemented by the facility starting on [DATE] revealed the following: -An Ad Hoc Quality Assurance and Performance Improvement (QAPI) was conducted on [DATE], and a Four-point Action plan was developed. -The Agency for Healthcare Administration (AHCA-state survey agency) Immediate report was submitted on [DATE]. -LPN A was suspended pending investigation, and witness statements were obtained from LPN A, and LPN B on [DATE]. -Nursing administration team initiated staff education on the CPR Policy, Advance Directive Policy, and conducted Code Blue Quality Assurance Drills, detailed documentation, two nurse's verification of clinical findings initiated on all licensed nurses starting on [DATE]. -As of [DATE] thirty-three of forty licensed nurses had been educated, and post tests conducted. The remaining staff will not be permitted to work until all in-service education on resident code status was complete. -CNAs assigned to resident #1 were interviewed on [DATE] and [DATE]. -[DATE] full house Advance Directive audit was conducted by the ED and DON -[DATE] CPR certification audit completed by the ED and Human Resource (HR) -[DATE] Code Blue drills/competencies were conducted every shift starting with the ,[DATE]PM shift. Previously, the drills were monthly. -On [DATE] department heads, therapy, housekeeping, and dietary staff educated regarding CPR and AD policies. -On [DATE], a second ad hoc QAPI was held including record review with the Medical director. Plan of care was deemed appropriate by MD and IDT determined POC was carried out. CPR would not be performed when obvious signs of clinical death are present per CPR policy and AHA guidelines. Verification by two clinical nurses and documentation noted as areas for improvement. -On [DATE] Code Blue drills/competencies continued. On [DATE] Code Blue drills/competencies continued. New Hire Orientation conducted, included extra training on CPR policy and AD, post-test completed by new hires. The Code Blue drills/competencies were reviewed, and showed they were conducted every shift. -On [DATE] at 1:29 PM the Executive Director and DON revealed, that based on their investigation, the facility determined the root cause analysis was that LPN A made an independent decision not to initiate CPR for resident #1 when he was found unresponsive, based on her clinical judgement. The ED stated that there should have been verification by another nurse, of what LPN A saw. -Staff interviews conducted with 18 staff members on [DATE] between 6:30 AM to 3:35 PM (4 RNs, 4 LPNs, and 10 CNAs) revealed the facility had provided education on CPR/code status and that mock code Blue Drills were being conducted. The nurses confirmed that the code status of each resident was on the profile section of the electronic health record, and the first page of the paper medical chart. The nurses stated that they received CPR/DNRO/Code status training upon hire and re-education since [DATE]. -The sample was expanded to include all resident deaths in the facility for the period [DATE] to current. Clinical record reviews showed the resident rights regarding CPR/code status was honored, except in the case of resident #1. -Medical record review was conducted for one current resident. The resident's code status was quickly found in the health record.