Every finding on record at Avir at Longview

Based on interviews and record review, the facility failed to notify the resident's representative when there were changes in the resident's physical, mental, or psychosocial status for 1 of 3 residents (Resident #32) reviewed for notification of changes. The facility failed to notify Resident #32's RP after worsening of the wounds to the left lateral foot and right heel were identified by the facility on 07/28/2026. This failure could place residents at risk of not having their preferred responsible party represent them in care decisions.Findings Included: Record review of an undated facesheet revealed Resident #32 was a [AGE] year-old male readmitted to the facility on [DATE]. Resident #32 had diagnoses of cerebral infarction (stroke; happens when a blood clot or blocked artery stops blood flow to a part of the brain), diabetes type 2 (a long-term condition where your body does not make enough insulin or cannot use it the right way), and cellulitis of the left lower limb (common, potentially serious bacterial skin infection affecting the deep layers of skin and tissues). He was readmitted following an amputation of his left 5th (pinky) toe.Record review of a quarterly MDS assessment dated [DATE] revealed Resident #32 had a BIMS of 07, which indicated moderate memory impairment. Resident #32 required dependent assistance from staff for all ADLs including bed mobility, personal hygiene, dressing, bathing and toileting. The MDS revealed Resident #32 had no unhealed pressure ulcers or injuries, had daily surgical wound care, application of nonsurgical dressings other than feet and application of dressings to feet. The MDS indicated Resident #32 received antibiotics for an infection.Record review of Resident #32's 'Wound Assessment Report' dated 07.14.2026 revealed the following:Wound 1: Left Lateral (running along the side) footMeasurements: 9.5 cm x 0.10 cm x 0,95 cm with no depthTissue type: epithelial (a primary type of body tissue that covers all external body surfaces, lines internal cavities and hollow organs, and forms glands) 100%.Drainage: Light Sutures remain from toe 5th toe amputation on 05/26/2026.Wound 2: Right heelMeasurements: 6.5 cm x 6.0 cm x 0.2 cmTissue- 10% granulation (new, specialized connective tissue and microscopic blood vessels that form on the surface of an open wound during the healing process) 90% eschar.Exposed tissue: Subcutaneous (the deepest layer of the skin) and dermis (the thick middle layer of skin located between the outer epidermis and the inner subcutaneous fat layer). Record review of Resident #32's 'Wound Assessment Report' dated 07.21.2026 revealed the following: Wound 1: Left Lateral (running along the side) Foot Measurements: 9.5 cm x 0.1 cm x 0.0 cmSeverity: full thickness (a severe injury that goes completely through the top two layers of skin (the epidermis and dermis) and into the underlying fat (subcutaneous tissue), muscle, tendon, or bone)Drainage ModerateTreatment: Daily Wound 2: Right heel Measurements:6.5 cm x 6.0 cm x 0.2 cm Severity: Eschar (a thick, dry layer of dead, necrotic tissue that forms over a severe skin wound, burn, or ulcer) Periwound (tissue surrounding wound): red and fragile Treatment: Daily Record review of Resident #32's 'Wound Assessment Report' dated 07/28/2026 revealed the following: Wound 1: Left Lateral (running along the side) Foot Measurements: 9.5 cm x 2.0 cm x 0.3 cm Severity: full thickness Treatment: Daily Wound 2: Right heel Measurements:6.5 cm x 6.0 cm x 0.2 cm Severity: 100% Eschar (a thick, dry layer of dead, necrotic tissue that forms over a severe skin wound, burn, or ulcer) Periwound: (tissue surrounding wound): red and fragile Treatment: Daily During an interview on 08/12/2026 at 10:00 a.m., Resident Representative A stated she had not been informed of the changes in Resident #32's wounds. Resident Representative A stated she was under the impression that his left lateral foot was making slow progress and was completely unaware of the ulcer on his right heel. She stated she was the one that demanded they schedule and MD appointment because she felt the surgeon needed to look at the non-healing surgical wound to his left lateral foot. She stated he went to an MD appointment on 08/05/2026 and the MD took the bandages off Resident #32's feet and stated, this is not good. He was then sent directly to the hospital for treatment. She stated when the Medical NP called her on 07/31/2026 it was to inform her of the appointment and tell her she had ordered labs and x-rays to be sent with him to the appointment. She never mentioned a possible bone infection. She stated 07/31/2026 was the last date she spoke to anyone about his care, before going with him to the MD appointment. During an interview on 08/12/2026 at 12:00 p.m., the treatment nurse stated she did not call family members to update them about the condition of the resident's wounds. She stated the Medical NP called families when she felt like residents were having a decline. She stated she did not think the floor nurses called families unless it was about a physician order they received during their shift or if the resident had a change in condition like a fall. She stated she had not been instructed that she needed to call the family about changes in wounds. She stated Resident #32 wounds were gradually declining. She stated the wound NP had to debride the left lateral foot wound the week prior to the resident being hospitalized because of the amount of dead tissue present. She stated the right heel wound was covered in eschar, and the wound bed could not be visualized but the skin around the wound suggested something was going on underneath because it was very red and fragile. The treatment nurse stated it would be beneficial to the residents and family for the family to be aware of changes in condition, so they could assist in ensuring interventions were carried out and encourage the residents to turn and reposition or keep offloading devices in place. During an interview on 08/12/2026 at 3:30 p.m., the Medical NP stated she was notified on 07/28/2026 of a concern about Resident #32's possibly having osteomyelitis (an infection and swelling of the bone tissue, usually caused by bacteria like Staphylococcus aureus. Germs reach the bone through the bloodstream, nearby open wounds, or surgery. Common signs include bone pain, fever, swelling, and redness. Doctors treat it using strong antibiotics and surgery to clean infected areas) in the left foot. She called that day to make an appointment with the surgeon that amputated his left pinky toe. She stated the MD office called back on 07/31/2026 to inform her that there was an opening on 08/05/2026 and gave orders for labs and new wound care to be done to keep the wounds clean until the appointment. The appointment was made and the family was called and informed of the appointment with the surgeon. She stated on 08/04/2026 the Wound NP informed her the right heel likely had osteomyelitis involvement as well because of the redness and fragility of periwound. The Medical NP stated she did not call the family to inform them of the change in the right heel wound. The DON was unavailable for interview. Attempted to contact Wound NP on 08/12/2026 11:17 a.m. and 08/13/2026 10:06 a.m. with no return call. During an interview on 08/13/2026 at 1:00 p.m., the Administrator stated it was the nursing staff's responsibility to keep both the physician and family up to date on all changes in resident condition. She stated she expected the notification to be made promptly. She stated in the case of Resident #32 the notification should have come from the treatment nurse or the floor nurse. She stated that because the information on the worsening of the wound was conveyed to the Medical NP, she expected the Medical NP to let the treatment nurse know to inform the family or inform the family herself. She stated she was under the impression that notification had occurred. The Administrator stated she could not find any documentation the notification was done. During an interview on 08/13/2026 at 1:30 p.m., Resident #32 was unable to recall if he had daily wound care and he was unable to recall being told about the changes in his wound's conditions. Resident #32 was hospitalized for wound infections and unable to answer all questions but his name and date of birth at the time. Review of a policy dated 2021, titled 'Change in a Resident's Condition', revealed, our facility promptly notifies the resident, his or her attending physician, and the resident representative of changes in the resident's medical/mental condition and/or status (e.g., changes in level of care, billing/payments, resident rights, etc.).

Based on interview and record review the facility failed to ensure an accurate MDS assessment was completed for 1 of 6 residents reviewed for MDS accuracy. (Resident #32) The facility failed to accurately code Resident #32's:Nutrition to manage skin problemsPressure reduction devices This failure could place residents at risk of receiving unneeded care and services. Findings included: Record review of an undated face sheet revealed Resident #32 was a [AGE] year-old male readmitted to the facility on [DATE]. Resident #32 had diagnoses of cerebral infarction (stroke; happens when a blood clot or blocked artery stops blood flow to a part of the brain), diabetes type 2 (a long-term condition where your body does not make enough insulin or cannot use it the right way), and cellulitis of the left lower limb (common, potentially serious bacterial skin infection affecting the deep layers of skin and tissues). He was readmitted following an amputation of his left 5th (pinky) toe. Record review of a quarterly MDS assessment dated [DATE] revealed Resident #32 had a BIMS score of 07, which indicated moderate memory impairment. Resident #32 required dependent assistance from staff for all ADLs including bed mobility, personal hygiene, dressing, bathing and toileting. The MDS revealed Resident #32 had no unhealed pressure ulcers or injuries, had daily surgical wound care, application of nonsurgical dressings other than feet and application of dressings to feet. The MDS indicated Resident #32 received antibiotics for an infection. The MDS for Resident #32 failed to indicate the use of a pressure reduction device or nutritional support for wound care. The MDS dated [DATE] was inaccurately coded that Resident #32 received occupational therapy services in the last 7 days. Record review of Resident #32's care plan dated 07/16/2026 revealed a care plan titled 'Documented Pressure Ulcer' with interventions to offload weight from affected areas and to provide nutrition to support wound healing. Record review of Resident #32's MAR dated August 2026 revealed Resident #32 received Vitamin C 500mg daily and Zinc 220mg per PEG tube for wound healing from 08/01/2026 to 08/05/2026. During an interview on 08/13/2026 at 10:30 a.m., the MDS Coordinator stated she had missed coding the nutritional interventions for Resident #32. She stated she missed coding the pressure reduction devices used for offloading for Resident #32. She stated accuracy of MDS was important because it painted the picture of the resident's care that the care plan was based upon. She stated there was no one that checked her MDSs for accuracy. The DON was unavailable for interview. During an interview on 08/13/2026 at 1:30 p.m., the Administrator stated it was the responsibility of the MDS Coordinator to ensure all information coded on the MDS was as accurate as possible. She stated she was unaware why the MDS Coordinator would have left off nutritional support for wound healing and the use of pressure reduction devices, because both were used on everyone with skin issues. She stated accuracy was important, so the care plan would be accurate and because they affect the QM (quality measure) scores. She stated she did not feel any harm could come to a resident from an inaccurately coded MDS. During a record review of the facility's undated Minimum Data Set Policy for MDS assessment Data Accuracy, revealed the purpose of the MDS policy was to ensure each resident received an accurate assessment by qualified staff to address the needs of the resident who are familiar with his/her physical, mental, and psychosocial well-being. The assessment should accurately reflect the resident's status.

Based on interviews and records reviews, the facility failed to develop and implement a comprehensive person-centered care plan for each resident that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment and described the services that were to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 1(Resident #32) of 6 residents reviewed for care plans. The facility failed to implement a care plan intervention by not administering current wound care orders for Resident #32. These failures could place residents at risk of not having their individualized needs met and a decline in their quality of care and life. Findings included: Record review of an undated face sheet revealed Resident #32 was a [AGE] year-old male readmitted to the facility on [DATE]. Resident #32 had diagnoses of cerebral infarction (stroke; happens when a blood clot or blocked artery stops blood flow to a part of the brain), diabetes type 2 (a long-term condition where your body does not make enough insulin or cannot use it the right way), and cellulitis of the left lower limb (common, potentially serious bacterial skin infection affecting the deep layers of skin and tissues). He was readmitted following an amputation of his left 5th (pinky) toe. Record review of a quarterly MDS assessment dated [DATE] revealed Resident #32 had a BIMS score of 07, which indicated moderate memory impairment. Resident #32 required dependent assistance from staff for all ADLs including bed mobility, personal hygiene, dressing, bathing and toileting. The MDS revealed Resident #32 had no unhealed pressure ulcers or injuries, had daily surgical wound care, application of nonsurgical dressings other than feet and application of dressings to feet. The MDS indicated Resident #32 received antibiotics for an infection. The MDS for Resident #32 failed to indicate the use of a pressure reduction device or nutritional support for wound care. The MDS dated [DATE] was inaccurately coded that Resident #32 received occupational therapy services in the last 7 days. Record review of Resident #32's care plan dated 07/16/2026 revealed a care plan titled 'Documented Pressure Ulcer' with interventions to offload weight from affected areas, to provide nutrition to support wound healing and follow wound care orders as ordered by MD. Record review of Resident #32's MD orders revealed the following: 05/31/2026-08/07/2026Left Lateral Foot; cleanse with wound cleanser, pat dry, apply betadine, apply ABD (abdominal) pad, cover with rolled gauze and secure. Change daily for wound healing. No orders were noted for wet to dry dressings. 05/31/2026-08/07/2026Right heel ulcer: Cleanse with wound cleanser, pat dry, apply betadine, cover with bordered gauze every day for wound healing. No orders for wet to dry dressings. Record review of a progress note dated 07/31/2026 revealed a note from the Medical NP that indicated MD office called with and appointment for 08/05/2026 and ordered wound care to be changed to using a mild, antiseptic solution made from diluted sodium hypochlorite (bleach) and baking soda or boric acid solution or a skin-neutral, biocompatible wound cleanser containing pure hypochlorous acid, whichever the facility had access to keep the wounds as clean as possible until the MD was able to see the resident wet to dry dressings changed daily. During an interview on 08/12/2026 at 12:00 p.m., the Treatment Nurse stated she was unaware of the orders to Resident #32's wound care had been changed on 07/31/2026 to using a mild, antiseptic solution made from diluted sodium hypochlorite (bleach) and baking soda or boric acid solution or a skin-neutral, biocompatible wound cleanser containing pure hypochlorous acid. She stated Resident #32's wounds were gradually declining. She stated the Wound NP had to debride (cut away dead tissue) the left lateral foot wound the week prior to the resident being hospitalized because of the amount of dead tissue present. She stated the right heel wound was covered in eschar and the wound bed could not be visualized but the skin around the wound suggested something was going on underneath because it was very red and fragile. During an interview on 08/12/2026 at 3:30 p.m., the Medical NP stated she was notified on 07/28/2026 of a concern about Resident #32's possibly having osteomyelitis (an infection and swelling of the bone tissue, usually caused by bacteria like Staphylococcus aureus. Germs reach the bone through the bloodstream, nearby open wounds, or surgery. Common signs include bone pain, fever, swelling, and redness. Doctors treat it using strong antibiotics and surgery to clean infected areas) in the left foot. She called that day to make an appointment with the surgeon that amputated his left pink toe. She stated the MD office called back on 07/31/2026 to inform her that there was an opening on 08/05/2026 and gave orders for labs and new wound care to be done to keep the wounds clean until the appointment. The appointment was made and the family was called and informed of the appointment with the surgeon. The new wound care orders were to do wet to dry dressings using a mild, antiseptic solution made from diluted sodium hypochlorite (bleach) and baking soda or boric acid solution or a skin-neutral, biocompatible wound cleanser containing pure hypochlorous acid, whichever the facility had access to keep the wounds as clean as possible until the MD was able to see the resident. She stated she conveyed the orders along with lab orders to the treatment nurse. Record review of the Care Plans, Comprehensive Person-Centered policy, dated March 2022, reflected A comprehensive person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial, and functional needs is developed and implemented for each resident.the interdisciplinary team (IDT), in conjunction with the resident and his/her family or legal representative, develops and implements a comprehensive, person-centered care plan for each resident.the care plan interventions are derived from a thorough analysis of the information gathered as part of the comprehensive assessment.the comprehensive, person-centered care plan includes measurable objectives and timeframes, describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being, including: services that would otherwise be provided for the above, but are not provided due to the resident exercising his or her rights, including the right to refuse treatment;.and which professional services are responsible for each element of care; includes the resident's stated goals upon admission and desired outcomes; builds on the resident's strengths; and reflects currently recognized standards of practice for problem areas and conditions.the interdisciplinary team reviews and updates the care plan. at least quarterly.

Based on observation, interviews and records reviews, the facility failed to develop and implement a comprehensive person-centered care plan for each resident that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment and described the services that were to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 4 (Resident #1, #11, #27, and #35) of 22 residents reviewed for care plans. 1. The facility failed to develop a care plan for Resident #1's diagnosis of schizophrenia (a chronic, severe brain disorder characterized by psychosis, including hallucinations, delusions, and disorganized thinking). 2. The facility failed to ensure Resident #11's comprehensive care plan included contractures, oxygen therapy, and indwelling urinary catheter. 3. The facility failed to develop a person-centered care plan for Resident #27's Hospice Care and code status change. 4. The facility failed to develop a person-centered care plan for Resident #35's medical diagnoses. These failures could place residents at risk of not having their individualized needs met and a decline in their quality of care and life. 1.Record review of Resident #1's undated face sheet indicated Resident #1 was an [AGE] year-old female admitted on [DATE] with the diagnoses of schizophrenia, COPD (a progressive, incurable lung disease that restricts airflow and makes breathing difficult), and anemia (a condition marked by a lack of enough healthy red blood cells or hemoglobin to carry adequate oxygen to your body's tissues). Record review of Resident #1's annual MDS assessment dated [DATE] indicated she had a BIMS score of 11, which indicated she had moderate cognitive impairment. The MDS indicated Resident #1 required maximum assistance with ADLs and she had an active diagnosis of schizophrenia. Record review of the consolidated physician orders dated [DATE] indicated Resident #1 had a diagnosis of schizophrenia dated [DATE]. Record review of a care plan dated [DATE] failed to indicate Resident #1 had a diagnosis of schizophrenia. During an interview on [DATE] at 11:40 a.m., the MDS Coordinator stated the care plans should include all items that were coded on the MDS. She stated the care plan should be reviewed by the nursing staff to know the individual care instructions for each resident. The MDS Coordinator stated items such as falls, high risk medication usage, hospice services, and diagnoses should be care planned for resident safety. She stated not care planning an important item with the interventions could result in the staff not knowing what is needed for the management of the individual resident condition. She stated Resident #1's diagnosis of schizophrenia should have been care planned because it was a major diagnosis and was coded on the MDS. During an interview on [DATE] at 1:00 p.m., the DON stated it was the responsibility of the MDS nurse to create the comprehensive care plan. She stated all major diagnoses, conditions, medications, and falls should be care planned with interventions to alert the staff of the potential of these situations recurring and to give instructions on what to do in those cases. The DON stated she did not feel care planning had a negative impact on the residents. During an interview on [DATE] at 1:30 p.m., the Administrator stated her expectation was for the MDS nurse and administrative nurses to ensure the care plans were complete and accurate for each individual. She stated care plans were meant to be a map to individual resident care and were important to individualized care. 2. Record review of the face sheet, dated [DATE], reflected Resident #11 was an [AGE] year-old female who admitted to the facility on [DATE] with diagnoses of rhabdomyolysis (serious condition characterized by the breakdown of muscle fibers, leading to the release of harmful substances into the bloodstream, which can cause kidney damage), urinary tract infection (bladder infection), pneumonia (infection of the lungs that inflames the air sacs in one or both lungs), pleural effusion (also called water on the lungs, buildup of fluids around the layers of your lungs), contracture of right and left lower leg (condition of shortening and hardening of muscles, tendons, or other tissue leading to restricted joint mobility), and disorder of kidney and ureter (tube that runs from the kidney to the urethra opening), unspecified. Record review of the admission MDS assessment, dated [DATE], reflected Resident #11 had clear speech, was sometimes understood by others, and was usually able to understand others. Resident #11 had a BIMS score of 13, which reflected no cognitive impairment. The MDS reflected Resident #11 had limitations in range of motion to one side of the upper extremity and both sides of her lower extremities that interfered with daily functions or placed her at risk of injury. The MDS reflected Resident #11 had an indwelling catheter and required oxygen therapy while a resident. Record review of Resident #11's comprehensive care plan, undated, did not address her contractures, indwelling catheter, or oxygen therapy. During an observation on [DATE] at 9:32 a.m., Resident #11 was lying in the bed with the head of her bed elevated slightly. Resident #11 was curled up in the fetal position with her knees and hands held tightly beside her face. She had an indwelling catheter drainage bag attached to the side of her bed. She was wearing oxygen at 2 liters per minute by nasal cannula in her nostrils. During an interview on [DATE] at 12:07 p.m., the MDS Coordinator stated the interdisciplinary team was responsible for ensuring the comprehensive care plan was up-to-date and complete. She stated Resident #11's contractures, indwelling catheter, and oxygen therapy should have been included on the care plan. She stated she was not working at the facility at the time Resident #11's comprehensive care plan was due. She stated she had not reviewed Resident #11's comprehensive care plan and had only worked at the facility for 6 weeks. She stated it was important to ensure the comprehensive care plans reflected the resident's status, so it painted a picture of the type of care and services Resident #11 required. During an interview on [DATE] at 12:21 p.m., the DON stated she expected contractures, indwelling catheters, and oxygen therapy to have been included on the comprehensive care plan. She stated the MDS nurse was responsible for monitoring to ensure the comprehensive care plan was complete and provided all the care and services each resident needed. She stated it was important to ensure the comprehensive care plan included contractures, indwelling catheters, and oxygen therapy to the staff knew how to care for each resident and monitor and meet their goals by implementing the required interventions. During an interview on [DATE] at 1:05 p.m., the Administrator stated she expected contractures, indwelling catheters, and oxygen therapy to be included in the comprehensive care plan. She stated the MDS Coordinator was responsible for monitoring to ensure the comprehensive care plan was complete and provided all the care and services each resident needed. She stated it was important to ensure the comprehensive care plan accurately reflected the care and services needed by each resident to ensure the needs were being met. 3.Record review of Resident #27's Face sheet dated [DATE] indicated a [AGE] year-old female who was readmitted to the facility on [DATE]. Resident #27 had diagnoses which included dementia (a syndrome characterized by a decline in cognitive function, affecting memory, thinking, behavior, and the ability to perform everyday activities), depression (a mood disorder that causes a persistent feeling of sadness and loss of interest), anxiety (a common emotion involving fear, tension, or worry in response to real or perceived threats), Type II Diabetes (a chronic condition that occurs when the body cannot properly use blood sugar, leading to high blood sugar levels) and Chronic obstructive pulmonary disease (a progressive lung disease that makes it difficult to breathe, primarily caused by long-term exposure to irritants). Resident #27 was a DNR (Do not resuscitate- instructs medical professionals not to perform CPR (an emergency life-saving procedure consisting of: calling 911, performing chest compressions, and delivering rescue breaths) if breathing or heartbeat stops). Record review of Resident #27's quarterly MDS dated [DATE] indicated she was able to make self-understood and understood others. Resident #27 had a BIMS score of 14 indicating Resident #27 was cognitively intact. Resident #27 was dependent on staff for toileting, dressing upper and lower body and required substantial assistance with bathing. The quarterly MDS also indicated Resident #27 was on Hospice and required oxygen. Record review of Resident #27's Care plan, initiated on [DATE] indicated Resident #27 was a full code with interventions which included: Continue CPR (an emergency life-saving procedure consisting of: calling 911, performing chest compressions, and delivering rescue breaths) until resident responds or EMS (Emergency Medical Services) arrives to take over the code, perform CPR if indicated; cardiac arrest and review periodically with resident/family to ensure wishes were respected. The care plan did not indicate Resident #27 was receiving hospice care. Record review of Resident #27's order summary dated [DATE], indicated Resident #27's code status was DNR (Do not resuscitate) starting on [DATE]. Resident #27 had orders to admit to Hospice care on [DATE]. The order summary also indicated Resident #27 required oxygen continuously via nasal cannula and may titrate between 2-5 liters for shortness of breath or pulse oximetry less than 90% every shift for shortness of breath and to maintain pulse oximetry greater than 90%. The order summary indicated the oxygen tubing and delivery device (nasal cannula) was to be stored in bag when not in use every shift. Record review of an out of hospital do-not- resuscitate order was signed and notarized for Resident #27 on [DATE]. During an interview on [DATE] 12:40 PM, LVN A said the RN/ADON/DON completed the care plans. LVN A said the care plans should be updated quarterly. LVN A said Hospice admission should be care planned immediately. LVN A said the Care plan should be updated/changed if the resident's code status changed from full code to DNR. LVN A said it should be updated as soon as staff became aware and approved of by DON. LVN A said the care plan directs the resident's care. LVN A said if the care plan was not updated according to the Physician order, the residents may not receive the care. LVN A said there could be a miscommunication about care and impact a resident's health. During an interview on [DATE] at 1:14 PM, ADON E said the MDS nurse was responsible for the care plans. ADON E said the care plans should be updated quarterly, annually, and at admission. ADON E said Resident #27's care plan should have been updated when the order was received for Hospice. ADON E said the code status should have been updated when the MDS nurse reviewed the order. ADON E said she updated the crash cart list. ADON E said it was important to update the residents' care plan because the interventions changed. ADON E said a staff member could think the resident was a full code and attempt to resuscitate the resident or not initiate CPR if the resident was a full code. During an interview on [DATE] 1:44 PM, the MDS nurse said she did not see where the MDS was updated indicating Resident #27 was on Hospice and her DNR status was changed to DNR. The MDS nurse said it was an IDT (Interdisciplinary team- a group of healthcare professionals from different clinical and support fields who collaborate to build and execute a residents treatment plan) effort, and anyone could have updated the code status and the Hospice care plan. The MDS nurse said the care plan painted a picture of what the staff do for the residents, so they are all on the same page. The MDS nurse said the care plan should be updated 7 days after the MDS coded 7 days after signed by nurse. She said the care plan should have been updated [DATE]. The MDS nurse said she looked at the orders first before going to the care plan. The MDS nurse said the staff looked at the orders for the documentation for the code status. The MDS nurse said it was the nurse who updated the care plans and the whole team does their parts on the care plan. During an interview on [DATE] at 1:27 PM, the DON said the MDS nurse was responsible for the comprehensive care plan and the ADON and DON were responsible for the acute care plan. The DON said the care plan should be updated at a change of condition such as a fall. The DON said Hospice should be updated on the care plan when residents were placed on Hospice. The DON said the facility staff would not go to the care plan for the out of hospital DNR. She said the staff would not go to the care plan to check the code status. The DON said she would send the DNR with the resident if the resident went to the hospital. She said she would never go to the care plan to look for the DNR. The DON would not say how it could impact a resident. During an interview on [DATE] at 10:50 AM, the ADM said the MDS nurse was responsible for updating the care plan. The ADM said the care plan was updated as needed. The ADM said she expected the care plan to reflect Hospice care and changes in code status for Resident #27. The ADM said the care plan not being updated could cause inadequate care for the residents. 4. Record review of Resident #35's face sheet dated [DATE] indicated Resident #35 was a [AGE] year-old male that admitted [DATE]. Record review of the physician's orders dated [DATE] indicated Resident #35 had diagnoses that included: Hemiplegia and Hemiparesis following Cerebral Infarction [CVA] affecting non-dominant side (weakness and/or paralysis on the non-dominant side after a stroke-blocked or reduced blood flow to the brain), Malignant neoplasm of unspecified part of left bronchus or lung (cancer in the lung), and nightmare disorder (frequent, intensely vivid, and disturbing dreams that typically center on threats to survival or safety). Record review of the admission MDS dated [DATE] indicated Resident #35 had clear speech, understood others, and was understood by others. He had a BIMS score of 15 indicating his cognition was intact. The MDS indicated he had diagnoses that included cancer, hemiplegia or hemiparesis, and Nightmare Disorder. The MDS indicated he had taken and was currently taking anticoagulant (medication that slows down the body's clotting process). Record review of the quarterly MDS dated [DATE] indicated Resident #35 had clear speech, understood others, and was understood by others. He had a BIMS score of 12 indicating moderately impaired cognition. The MDS indicated Resident #35 had diagnoses of cancer, hemiplegia or hemiparesis after a stroke, and Nightmare Disorder. The MDS indicated he had taken and was currently taking an anticoagulant. Record review of the care plan with a revision date of [DATE] did not address his diagnoses for cancer, Hemiplegia/hemiparesis following cerebral infarction, or nightmare disorder. During an interview on [DATE] at 8:12 AM, the MDS nurse said she had been at the facility since the middle of [DATE]. She said Resident #35 was not care planned for his anticoagulant medication, nightmare disorder, CVA with hemiparesis, or cancer. She said all of those things should have been care planned. She said regarding his anticoagulant medication, nurses would want to know he was on that medication to monitor for bleeding and any other signs or symptoms he might have related to taking a blood thinner. His cancer diagnosis should have been care planned so staff could monitor for progression or pain. His hemiparesis/hemiplegia after a CVA would affect his ADL's and overall care, and should have been documented in the care plan. She said staff caring for him needed to know all of that information to provide the care he needed. She said she was responsible for updating the care plan with every new MDS. His last MDS was [DATE], closed [DATE] and she should have it updated by [DATE]. She said anything that was on the MDS when he admitted should already have been care planned. She said she could see that he was on anticoagulant medication when he admitted . She said everything about a resident being care planned was important for staff to know, so they could provide appropriate individualized care. During an interview on [DATE] at 7:54 AM, LVN A said care plans were very important because they were directives for nursing care. She said nurses could add things into a resident's care plan as they needed to, for a change of condition or new orders. She said anything relevant can be added to a care plan by nurses or the MDS nurse. She said if a resident had not been care planned for an anticoagulant, nurses would not know to watch for a clot or side effects of medication. She said if a resident had cancer they would need to know to watch for any new symptoms, monitor whether any signs or symptoms were getting better or worse and monitor medication. She said if things were not on the care plan the nurses would not know to monitor that particular diagnosis, medication, or issue. During an interview on [DATE] at 8:06 AM, ADON D said the care plan was important to know how to care for a resident, and what to do for a resident. She said Resident #35 should have been care planned for his anticoagulant, cancer, hemiplegia, CVA, and Nightmare Disorder and anything else that was relevant. ADON D said it was not acceptable that he was not care planned for all his diagnoses and problems. Staff needed that information on the care plan to provide proper care. Not having an accurate care plan could affect the residents' care negatively. During an interview on [DATE] 9:55 AM, the DON said the importance of a care plan was to know how to care for a resident. She said Resident #35's care plan should have included his anticoagulant. She said he admitted on an anticoagulant so that should have been care planned when he admitted . She said he should have been care planned for his anticoagulant, cancer, hemiparesis/hemiplegia and CVA so staff would know how to care for him, what to monitor, and how to reach the goals. She said, for example his anticoagulant, they would monitor for a clot, any bleeding, and side effects of medication. The DON said they would have had interventions in place to try to reduce the nightmares or monitor them. She said same with his cancer diagnosis, and anything else that was not care planned that should have been. She said with an accurate care plan they would monitor problems, medications, illnesses, try to improve, know what to watch for, and when to call the Nurse Practitioner or Medical Doctor. They know better how to treat a resident with an accurate care plan. During an interview on [DATE] at 10:39 AM, the ADM said the importance of care plans was to present and communicate the full picture of a resident's needs to all departments. The care plans were there so staff could meet the resident's' needs. The risk of not having an accurate care plan, was residents not receiving proper care for their diagnoses. She said the MDS nurse was responsible for making sure the care plans were accurate and the DON should check them for accuracy. During an interview on [DATE] at 11:57 AM, ADON D said she was probably supposed to be checking care plans for accuracy, but she had not. She said she had only been at the facility for a month and was still learning. During an interview on [DATE] at 12:07 PM, the DON said she was ultimately responsible for the accuracy of the care plans. She said she had not looked at Resident #35's care plan. Record review of the Care Plans, Comprehensive Person-Centered policy, dated [DATE], reflected A comprehensive person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial, and functional needs is developed and implemented for each resident.the interdisciplinary team (IDT), in conjunction with the resident and his/her family or legal representative, develops and implements a comprehensive, person-centered care plan for each resident.the care plan interventions are derived from a thorough analysis of the information gathered as part of the comprehensive assessment.the comprehensive, person-centered care plan includes measurable objectives and timeframes, describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being, including: services that would otherwise be provided for the above, but are not provided due to the resident exercising his or her rights, including the right to refuse treatment;.and which professional services are responsible for each element of care; includes the resident's stated goals upon admission and desired outcomes; builds on the resident's strengths; and reflects currently recognized standards of practice for problem areas and conditions.the interdisciplinary team reviews and updates the care plan. at least quarterly.

Based on observation, interview, and record review, the facility failed to provide the necessary services to maintain good nutrition and personal hygiene for 4 of 22 residents reviewed for ADLs. (Resident #30, Resident #52, Resident #58, Resident #73)The facility failed to ensure Resident #30, and Resident #52 received scheduled baths or showersThe facility failed to ensure CNA M provided verbal cuing to Resident #58 while eating her lunch meal on 07/13/26 and her dinner meal on 07/14/26.The facility failed to ensure CNA Q provided adequate incontinent care to Resident #73 on 07/06/26.These failures could place residents who required assistance from staff for ADLs at risk of not receiving care and services to meet their needs, which could result in poor care, feelings of poor self-esteem, and lack of dignity and health.Findings included: 1. Record review of Resident #30's face sheet indicated Resident #30 was an [AGE] year-old female that admitted [DATE] and readmitted [DATE].Record review of the physician's orders dated 7/15/26 indicated Resident #30 had diagnoses that included: Atrial fibrillation (an irregular, often rapid heart rhythm originating in the heart's upper chambers), unspecified fracture of sternum (a broken breastbone caused by high force impact), cardiac arrest (the heart stops beating), and multiple fractures of ribs (cracks or breaks in the rib bones of the rib cage).Record review of the admission MDS indicated Resident #30 had clear speech, understood others, and was understood by others. She had a BIMS score of 15 indicating she was cognitively intact. The MDS indicated Resident #30 required substantial/maximal assistance for toileting hygiene and partial/moderate assistance for shower and bathing.The baseline care plan dated 7/2/26 indicated Resident #30 was dependent on staff for toileting hygiene, showering and bathing.Record review of a Concern/Grievance Form dated 7/6/26 indicated Family Member G had a concern that Resident #30 had no shower since admitted . The ADM signed the grievance on 7/6/26 indicating Resident #30 had a shower on 7/4/26. The plan to resolve the grievance was showers would be monitored and a care plan meeting would be held. Record review of a Multidisciplinary Care Conference meeting dated 7/7/26 indicated: Additional Risks/ConsiderationsAny comments or concerns: If resident refuses shower, offer bed bath.This care conference was attended by several staff including Resident #30, the Ombudsman Family Member G, and the prior DON. Record review of the progress notes dated indicated Resident #30 had gone to the hospital on 7/11/26 and had not returned. During an interview with the Ombudsman on 7/14/26 at 2:30 PM she said Resident #30's family said she did not get a shower the whole time she was in the facility 7/2/26 - 7/11/26. She said they had a meeting on 7/7/26 and showers/baths were addressed in the meeting.During an interview and record review on 07/15/2026 at 3:10 PM, ADON D said that not getting a bath or shower was not good for skin integrity and was not good hygiene. Referring to Resident #30, she said if it had been her family or a friend, she would not be happy if they had not had a bath in 9 days. Record review of the shower sheets for Resident #30 indicated she refused a shower on 7/3/26, refused a shower on 7/6/26, and refused a bed bath on 7/11/26. She said the charge nurse's were responsible for Residents getting their showers, then the ADON after that. She said basically everyone was responsible. During an interview on 07/16/26 at 8:06 AM, ADON D said she could not find any more shower sheets for Resident #30. She said she realized the Multidisciplinary Care Conference meeting on 7/7/26 included concerns about Resident #30's baths/showers. 2. Record review of Resident #52's face sheet dated 07/15/26 revealed Resident #52 was [AGE] years old and admitted to the facility on [DATE] and had diagnoses including parkinsonism (a clinical syndrome characterized by four primary motor symptoms: resting tremors, slowed movement (bradykinesia), rigid muscles, and postural instability), muscle weakness, and anxiety disorder.Record review of an annual MDS assessment dated [DATE] indicated Resident #52 had a BIMS score of 14 which indicated intact cognition. The MDS indicated Resident #52 required partial to moderate assistance with showers or bathing. Record review of Care Plan last revised on 03/30/26 indicated Resident #52 had an ADL self-care performance deficit related to muscle weakness, unsteadiness on feet, reduced mobility, muscle wasting, and lack of coordination. An intervention indicated Resident #52 was totally dependent on one staff member for showers. Record review of a Concern/Grievance Form dated 05/27/26 indicated all east residents had concerned that showers on East need to be given on day assigned. The plan to resolve the grievance was, shower schedule updated, and employees inserviced. The results of action plan indicated, Showers are improving. Issue resolving. The grievance was signed by the Administrator on 06/12/26.Record review of a Report of Employee Education dated 05/28/26 indicated 4 LVNs and 3 CNAs were in-serviced on Showers/Bed Bath (Schedule & Documentation. The in-service indicated, .Showers are to be given daily as indicated without exception.Record review of an ADL Task documentation in the electronic health record for Resident #52 dated 06/17/26 - 06/15/26 indicated no baths or showers documented for 06/19/26, 06/24/26, 06/26/26, 06/29/26, 07/01/26, 07/03/26, 07/06/26, 07/08/26, 07/10/26, and 07/13/26. Record review of Skin Monitoring: Comprehensive CNA Shower Review sheets for Resident #52 indicated she received showers on 07/11/26 and 07/15/26. No other shower sheets were provided by the facility.Record review of Progress Notes dated 06/17/26 - 07/15/26 did not indicate Resident #52 had refused to be bathed or showered.During an interview on 07/13/26 at 12:50 p.m., Resident #52 said she did not receive her showers at least three times a week.During an interview on 07/13/26 at 12:54 p.m., Resident #52's roommate said Resident #52 was not showered three times a week. The roommate said she had gotten on hospice so that she would get her showers three times a week.During an interview on 07/15/26 at 8:28 a.m., Resident #52 said she could not remember the last time she had a shower. She said she never refused her showers. She said not having a shower made her feel dirty. During an interview on 07/15/26 at 9:03 a.m., LVN A said Resident #52 was showered on Mondays, Wednesdays, and Fridays. She said the showers should have been charted in Resident #52's electronic medical record. She said if it was not documented it had not been done. She said she had not known Resident #52 to ever refuse any baths. She said she thought the resident's family member said something last week (the week of 07/06/26 - 07/10/26) about the resident needing to be showered. During an interview on 07/15/26 at 10:27 a.m., Resident #52's family member said they came to the facility on [DATE] after Resident #52 had been released from the hospital. She said on Friday, 07/10/26 the resident was still in the same clothes and had not been bathed. She said the resident had not been bathed in two weeks. The family member said Resident #52 did not receive her showers unless they fought for them. They said it was a constant fight since Resident #52 had been admitted . They said they visit the resident daily. They said they have to make Resident #52's bed and pick up her room. The family member said they do the resident's laundry. The family member said, recently Resident #52 was left in the same dress for three days straight. They said when they visit, they had to ask staff for Resident #52 to be cleaned. The family member said some days the resident smelled like urine. The family member said often the resident's hair was greasy. The family member said it would not be greasy now because they had made sure the resident was showered on Friday, 07/10/26. The family member said they had been told that Resident #52 was to be bathed on Mondays, Wednesdays, and Fridays. The family member said they had taken their concerns to the Administrator multiple times. The family member said on Monday, 07/13/26 they spoke to the admission Coordinator and was told the DON would call them. They said they still had not received a call. The family member said they would have already moved the resident to another facility, but the resident had made friends with her roommate.During an interview on 07/15/26 at 11:55 a.m., CNA B said Resident #52's showers were scheduled for Mondays, Wednesdays, and Fridays. She said the baths and showers were charted in the residents' electronic medical record and they used shower sheets. She said on the days she worked, Resident #52 got her shower. She said she did not know why the resident was missing any showers. She said Resident #52 had been being scheduled to be showered on the evening shift and they were not getting done. She said that was why they had been moved to the day shift. She said Resident #52 was moved to the day shift approximately a month ago. During an interview on 07/15/26 at 12:24 p.m., the DON said she expected residents to be bathed at least three times a week or as needed. She said baths were charted on a shower sheet. She said it was also supposed to be charted in the residents' electronic medical records. She said if Resident #52 missed her baths, it was not acceptable. She said it was a hygiene issue. She said there were good CNAs that work directly with Resident #52 and they give her showers. She said she would look for more shower sheets. She said she had not been told that she needed to call Resident #52's family member.During an interview on 07/15/26 at 12:45 p.m., the Administrator said residents should be bathed three times a week. She said baths should be documented in the shower sheets and in the ADLs section of the residents' electronic medical record. She said she did not know why Resident #52 had not been showered. She said she had just heard a concern yesterday (07/14/26) that the resident had not been getting her showers. She said showers were important so the residents could be clean and for hygiene purposes. 3. Record review of the face sheet, dated 07/15/26, reflected Resident #58 was a [AGE] year-old female who admitted to the facility on [DATE] with diagnoses of unspecified glaucoma (damage to the optic nerve that gradually gets worse and causes blind spots in the vision), both eyes, and unspecified severe protein-calorie malnutrition (life-threatening condition caused by a significant deficiency of both protein and energy, leading to profound weight loss, muscle wasting, and functional impairment).Record review of the admission MDS assessment, dated 07/07/26, reflected Resident #58 had clear speech, was understood by others, and was able to understand others. Resident #58 had moderately impaired vision, which indicated limited vision; not able to see newspaper headlines but can identify objects. She had a BIMS score of 12, which indicated moderately impaired cognition. The MDS reflected Resident #58 usually required substantial/maximum assistance with eating.Record review of the baseline care plan, dated 07/03/26, reflected Resident #58 had impaired vision and required substantial/maximum assistance with eating.During an interview on 07/13/26 at 11:30 a.m., Resident #58's family member stated Resident #58 required assistance with eating because she could not see very well. She stated on 07/09/26 the facility staff placed Resident #58's tray in her room and did not assist her with eating. She stated Resident #58 did not eat that night as reported by Resident #58.During an observation and interview on 07/13/26 at 12:49 p.m., Resident #58 received her meal tray in her room. CNA M placed Resident #58's tray in front of her, lifted the head of the bed to a 90 degree angle, uncovered her tray, and placed a clothing protector over her clothes. Resident #58 asked CNA M what was on her lunch tray and CNA M stated, I'm not sure. She did not explain what each item on her meal tray was or where it was located. CNA M left the room. Resident #58 stated she was unsure what she was eating, but it tasted like mashed potatoes and gravy. She was eating mechanically shredded chicken with white gravy on top. She stated the food was good, but she had to guess what she was eating by tasting. Resident #58 stated she liked to know what she was eating.During an observation and interview on 07/14/26 at 5:53 p.m., Resident #58 received her meal tray in her room. CNA M placed Resident #58's dinner tray in front of her, lifted the head of the bed to a 90 degree angle, uncovered her tray, and placed a clothing protector over her clothing. CNA M did not explain what each item on her meal tray was or where it was located. CNA M left the room. Resident #58 stated she was not told what was on her tray and stated, I don't know what it is, but it's good. The meal ticket reflected it was baked fish.During an interview on 07/16/26 at 10:21 a.m., CNA M stated when she went into a resident's room to set up their meal tray, she made sure they could reach the tray, took all the covers or plastic off, and cut it up as needed. She stated she tried to explain what was on the tray if the residents had questions or if the resident had impaired vision. CNA M stated she was aware Resident #58 had impaired vision but was told she could feed herself. She stated she did not explain what was on her tray because she was able to see the food and Resident #58 did not ask her. CNA M stated it was important to ensure residents with impaired vision were explained what was on their meal tray, so they had an idea of what they were eating. She stated if the residents were unsure what was on their tray, they could eat something they did not like.4. Record review of the face sheet, dated 07/14/26, reflected Resident #73 was an [AGE] year-old female who admitted to the facility on [DATE] and discharged home on [DATE]. She had diagnoses that included hemiplegia, affecting right dominant side (paralysis of right side caused from a stroke) and vascular dementia without behaviors (type of dementia caused by reduced or blocked blood flow to the brain, leading to cognitive impairment that affects memory, thinking, and daily functioning).Record review of the baseline care plan, dated 07/03/26, reflected Resident #73 communicated easily with staff and was able to understand the staff. Her initial discharge goal was to receive respite care (a brief stay (no more than 5 days) for caregiver relief). The baseline care plan reflected Resident #73 usually required partial/moderate assistance with toileting hygiene and toilet transfer. She was frequently incontinent of bowel. During an interview on 07/14/26 at 9:54 a.m., Resident #73's family member stated she admitted on [DATE] for a respite care stay and left on 07/06/26. On 07/06/26, Resident #73's family member stated she called the facility around 4 p.m. to let them know she would be coming to pick up Resident #73 and requested that she was assisted on getting ready to leave. She said when she arrived at the facility at approximately 5:30 p.m., Resident #73 had dried feces all the way up her back and around her perineal area. The family member stated Resident #73 had a clean incontinent pad that was placed on top of the dirty bottom sheet. She stated the bottom sheet had dried feces.During an interview on 07/14/26 at 2:43 p.m., LVN F said on 07/06/26 at about 4 p.m., she asked CNA Q, who was sitting in the lobby area, to ensure Resident #73 was assisted with getting ready to leave the facility. She stated she instructed CNA Q to make sure she was clean and that her family member was going to take her home. LVN F stated her family member arrived at the facility around 5:30 p.m., and she was disgraced by what she observed. LVN F stated Resident #73 had feces half-way up her back. She stated some of the stool was dried and some of it was loose, like she had multiple bowel movements. LVN F stated she asked the family member to step out of the room, so she could assist Resident #73 with incontinent care. She stated Resident #73 had several small, open, blistered areas on her bottom. LVN F stated it looked like the soiled brief had been sitting around that area causing moisture against the skin. LVN F stated it appeared the moisture could have caused some skin damage.During an attempted telephone interview, on 07/16/26 at 8:24 a.m., CNA Q did not answer the telephone. Unable to leave a voice message and there was no return telephone call upon exit of the facility.During an interview on 07/16/26 at 12:21 p.m., the DON stated she expected the nursing staff to ensure ADL assistance was provided as needed by each resident. The DON stated she expected the staff to ensure the residents were aware of what was on their meal tray. She stated if they were unable to see, the staff should have explained what the food items were and where they were located. She stated the CNAs and nurses were responsible for making sure the meal trays were set up and assistance was provided as needed. She said it was important to ensure residents were explained what they were eating to maintain their independence and prevent depression. The DON stated she expected incontinent care to have been performed completely, at least every 2 hours or more if it was needed. She stated the CNAs and the nurses were responsible for monitoring to ensure incontinent care was provided. The DON stated failure to provide incontinent care could have caused skin breakdown.During an interview on 07/16/26 at 1:05 p.m., the Administrator stated she expected the nursing staff to ensure each resident was informed of what they were eating and where everything was located on their meal trays, especially if they had impaired vision. She stated she expected assistance to be provided with eating as it was required. She stated she expected the staff to ensure incontinent care was performed completely. She stated assistance with incontinent care should have been performed at least every 2 hours, and as needed. She stated the nursing department was responsible for monitoring to ensure ADL assistance was provided. She stated it was important to ensure incontinent care was provided adequately and timely to prevent skin breakdown.Record review of the Activities of Daily Living (ADL), supporting policy, dated February 2025, reflected Residents will be provided with care, treatment and services as appropriate to maintain or improve their ability to carry out activities of daily living (ADLs). Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene. Appropriate care and services will be provided for residents who are unable to carry out ADLs independently.including appropriate support and assistance with: elimination. dining (meals and snacks) . Care and services to prevent and/or minimize functional decline will include . treatment for depression and symptoms of depression.Record review of a Bath, Shower/Tub facility police last revised 02/2018 indicated, .The purposes of this procedure are to promote cleanliness, provide comfort to the resident and to observe the condition of the resident's skin.Documentation.The staff member will initial and date the shower/tub bath was performed.If the resident refused the shower/tub bath, the reason(s).Report other information in accordance with facility policy and professional standards of practice.

Based on observations, interviews and record reviews, the facility failed to ensure residents with limited range of motion received appropriate treatment and services to increase range of motion and/or to prevent further decrease in range of motion for 3 of 5 residents with limited range of motion (Resident #1, Resident #6 and Resident #11) Resident #1 had limited range of motion to bilateral ankles with no services to prevent further decrease in range of motion.Resident #6 had limited range of motion to left elbow and bilateral knees with no services to prevent further decrease in range of motion.The facility failed to ensure Resident #11 received treatment or services to prevent worsening of her contractures. These failures could place residents at risk of not having their individualized needs met, decreased range of motion and a decline in their quality of care and life. Findings included: 1. Record review of the undated face sheet indicated Resident #1 was an [AGE] year-old female admitted on [DATE] with the diagnoses of schizophrenia, COPD (a progressive, incurable lung disease that restricts airflow and makes breathing difficult), and anemia (a condition marked by a lack of enough healthy red blood cells or hemoglobin to carry adequate oxygen to your body's tissues). Record review of Resident #1's annual MDS assessment dated [DATE] indicated she had a BIMS score of 11, which indicated she had moderate cognitive impairment. The MDS indicated Resident #1 had limited range of motion to bilateral (both) lower extremities. Record review of an undated form titled 'Residents at Risk for Contractures' indicated Resident #1 had contractures to bilateral ankles. During an interview on 07/13/2026 at 10:00 a.m., Resident #1 stated she had pain daily in her lower extremities. She stated she was stiff and unable to get up for long periods of time because of the pain. Resident #1 stated no one had performed any range of motion exercises with her since the last time she took therapy over 6 months ago. 2.Record review of an undated face sheet revealed Resident #6 was an [AGE] year-old female admitted on [DATE] with the diagnoses of contractures (permanent tightening or shortening of muscles, tendons, skin, or other tissues that cause joints to become stiff and restrict normal movement) of left hand, contracture of left elbow, and vascular dementia (decline in thinking and memory skills caused by restricted or blocked blood flow to the brain). Record review of an annual MDS assessment dated [DATE] revealed Resident #6 had a BIMS score of 03 which indicated severe cognitive impairment. Resident #6 required substantial assistance (helper does more than half of work) for ADLs such as toileting, transfer, and bathing. Resident #6 required supervision/setup for eating. She required partial assist for dressing. Record review of the care plan dated 04/20/2026 revealed Resident #6 had contractures to her left hand and elbow. No interventions of range of motion exercises or brace applications. Record review of an undated form titled 'Residents at Risk for Contractures' indicated Resident #6 had contractures to left hand and elbow and bilateral knees. During an interview on 07/15/2026 at 2:00 p.m., the DOR stated any resident with contractures was screened for worsening of contractures monthly. She stated if worsening was noted, therapy would pick the resident up on case load. The DOR stated when the resident was discharged from therapy it was expected nursing would continue with range of motion exercises, but no documentation existed to prove nursing staff received instruction or performed range of motion exercises. She stated Resident's #1 and #6 had no specific plans for ROM, splint usage or any other contracture management device. 3. Record review of the face sheet, dated 07/15/26, reflected Resident #11 was an [AGE] year-old female who admitted to the facility on [DATE] with a diagnosis of contracture of right and left lower leg (condition of shortening and hardening of muscles, tendons, or other tissue leading to restricted joint mobility). Record review of the admission MDS assessment, dated 04/30/26, reflected Resident #11 had clear speech, was sometimes understood by others, and was usually able to understand others. Resident #11 had a BIMS score of 13, which reflected no cognitive impairment. The MDS reflected Resident #11 had limitations in range of motion to one side of the upper extremity and both sides of her lower extremities that interfered with daily functions or placed her at risk of injury. Record review of Resident #11's comprehensive care plan, undated, did not address her contractures. Record review of the physical therapy notes, dated from 04/25/26 to 05/24/26, reflected Resident #11 received therapy services that included contracture management to her knees. The services ended on 05/24/26. During an observation on 07/13/26 at 9:32 a.m., Resident #11 was lying in the bed with the head of her bed elevated slightly. She was lying on her right side and was curled up in the fetal position with her knees and hands held tightly beside her face. During an observation on 07/15/26 at 8:45 a.m., Resident #11 was lying in the bed with the head of her bed elevated slightly. She was lying on her left side and was curled up in the fetal position with her knees and hands held tightly beside her face. CNA N attempted to hold Resident #11's elbow up slightly, but Resident #11 was stiff and unable to move her elbow. During an interview on 07/15/26 at 12:57 p.m., the DOR stated Resident #11 had been treated with therapy services for her contractures to her lower extremities. She stated Resident #11 did not have true contractures to her upper extremities. She stated Resident #11 had been discharged from therapy services last month. She stated the plan was for Resident #11 to return home initially but she decided last minute to stay for long-term care. She stated CNA staff were taught how to perform passive range of motion for residents with limited range of motion as part of their training. The DOR stated that when residents were discharged from caseload, the nursing staff was responsible for their contracture management. She stated Resident #11 had no splints or braces for her treatment because it placed her at a greater risk for skin breakdown. During an interview on 07/16/26 at 10:21 a.m., CNA M stated she did not perform passive range of motion exercise with Resident #11. She stated she was unsure what Resident #11's range of motion was or what her bone structure was like. She stated she was afraid she could have broken her bones if she performed range of motion exercises. CNA M stated therapy was responsible for performing range of motion exercises with the residents. CNA M stated Resident #11 was on therapy services. During an interview on 07/16/26 at 11:00 a.m., CNA N stated Resident #11 was very contracted. She stated when the staff attempted to move Resident #11, she hollered out in pain. CNA N stated she was afraid to perform range of motion exercises with her because she did not want to hurt her. She stated therapy staff was responsible for performing range of motion exercises. During an interview on 07/16/26 at 11:10 a.m., LVN F stated Resident #11 was on therapy services. She stated therapy staff were responsible for performing range of motion exercise with Resident #11. During an interview on 07/16/26 at 12:21 p.m., the DON stated she expected the CNAs to perform passive range of motion exercise with residents who had contractures, during shower days. She stated therapy was responsible for ensuring range of motion exercises or contracture management was implemented when they were on caseload. She stated she was unsure of the process for residents' not on therapy caseload. She stated it was important to ensure treatment was provided to residents with contractures to prevent worsening or further contractures. During an interview on 07/16/26 at 1:05 p.m., the Administrator stated she expected therapy staff to let nursing staff know when residents with contractures were taken off of caseload. She stated she expected therapy staff to come up with a plan for residents with contractures and expected nursing staff to follow the plan. She stated therapy and nursing staff were responsible for monitoring to ensure residents with contractures received treatment and services. She stated it was important to ensure residents with contractures received care and services to maintain their current level Requested facility policy for limited range of motion from the Administrator on 07/15/2026 at 2:30 p.m. and 07/16/2026 at 11:00 a.m. No contracture policy was provided prior to exit.

Based on observation, interview, and record review, the facility failed to ensure a resident who was incontinent of bladder received appropriate treatment and services to prevent urinary tract infections for 2 of 5 residents (Resident #11 and Resident #70) reviewed for treatment and services related to indwelling catheters. The facility failed to ensure Resident #11 and Resident #70's indwelling catheter drainage bags were kept off the ground on 07/13/26 and 07/15/26. These failures could place residents at risk for urinary tract infections, injuries, and a decreased quality of life.The findings included: 1. Record review of the face sheet, dated 07/15/26, reflected Resident #11 was an [AGE] year-old female who admitted to the facility on [DATE] with diagnoses of rhabdomyolysis (serious condition characterized by the breakdown of muscle fibers, leading to the release of harmful substances into the bloodstream, which can cause kidney damage), urinary tract infection (bladder infection), and disorder of kidney and ureter (tube that runs from the kidney to the urethra opening), unspecified. Record review of the admission MDS assessment, dated 04/30/26, reflected Resident #11 had clear speech, was sometimes understood by others, and was usually able to understand others. Resident #11 had a BIMS score of 13, which reflected no cognitive impairment. The MDS reflected Resident #11 had an indwelling catheter. Record review of Resident #11's comprehensive care plan, undated, did not address her indwelling catheter. During an observation on 07/13/26 at 9:32 a.m., Resident #11 was lying in the bed with the head of her bed elevated slightly. Resident #11 was curled up in the fetal position with her knees and hands held tightly beside her face. She had an indwelling catheter drainage bag attached to the side of her bed, which was lying on the floor. During an observation on 07/13/26 at 3:22 p.m., Resident #11's indwelling catheter drainage bag was attached to the side of her bed. The drainage bag was lying on the floor. During an observation on 07/15/26 at 8:59 a.m., Resident #11's indwelling catheter drainage bag was attached to the side of the bed. The drainage bag was lying on the floor. During an interview on 07/16/26 at 10:21 a.m., CNA M stated the indwelling catheter drainage bags should not have touched the floor. She stated the beds should have been high enough to ensure the drainage bags were not touching the floor. She stated it was a team effort to ensure indwelling catheter drainage bags were kept off the floor. She stated multiple staff members from different departments such as therapy and wound care were in the residents' rooms and did not always remember to keep the indwelling drainage bags off the floor. She stated Resident #11 and Resident #70's indwelling catheter drainage bags could have been overlooked on 07/13/26. She stated it was important to ensure indwelling catheter drainage bags were kept off the floor to prevent cross-contamination and lower the risk of infections. 2. Record review of the face sheet, dated 07/14/26, reflected Resident #70 was an [AGE] year-old female who admitted to the facility on [DATE] with diagnoses of chronic kidney disease, stage 4 (severe kidney function loss) and obstructive and reflux uropathy (condition where urine flow is blocked and simultaneously flows backward toward the kidneys, potentially causing kidney damage). Record review of the MDS list in the electronic charting system, reflected Resident #70's MDS assessment was In Progress. Record review of the baseline care plan, dated 07/06/26, reflected Resident #70 communicated easily with staff and was able to understand the staff. The baseline care plan reflected Resident #70 had an indwelling catheter. During an observation on 07/13/26 at 9:43 a.m., Resident #70 had an indwelling catheter drainage bag that was attached to her bed. The drainage bag was lying on the floor. During an observation on 07/13/26 at 3:20 p.m., Resident #70 had an indwelling catheter drainage bag that was attached to her bed. The drainage bag was lying on the floor. During an observation on 07/15/26 at 9:08 a.m., Resident #70 had an indwelling catheter drainage bag that was attached to her bed. The drainage bag was lying on the floor. During an interview on 07/16/26 at 11:00 a.m., CNA N stated indwelling catheter drainage bags were often found on the floor. She stated she tried to hang the catheter drainage bags so they would not touch the floor. CNA N stated multiple staff members performed care with Resident #11 and Resident #70 so if she noticed the indwelling drainage bags were on the ground, she tried to fix it. She stated it was important to ensure the indwelling catheter drainage bags were kept off the floor to prevent cross-contamination and the spread of infection. During an interview on 07/16/26 at 11:10 a.m., LVN F stated the CNAs were responsible for making sure the indwelling catheter drainage bags were kept off the floor. She stated there was no set schedule for monitoring indwelling catheter drainage bags, but she just glanced at them when she went into their rooms to make sure they were not on the floor. She stated it was important to ensure catheter drainage bags were kept off the floor because of germs and bacteria. She stated it placed the residents at risk for infections. During an interview on 07/16/26 at 11:44 a.m., the Wound Care Nurse stated indwelling catheter drainage bags should not have been kept on the floor. She stated the nurse and CNAs were responsible for making sure the indwelling drainage bags were kept off the floor. She stated it was important to ensure indwelling catheter drainage bags were kept off the floor to prevent cross-contamination and infections. During an interview on 07/16/26 at 12:21 p.m., the DON stated she expected indwelling catheter drainage bags to be kept off the floor. She stated the nursing staff should have been checking that during rounds. The DON stated it was important to ensure the indwelling catheter drainage bags were kept off the ground to prevent cross-contamination. During an interview on 07/16/26 at 1:05 p.m., the Administrator stated she expected the nursing staff to ensure indwelling catheter drainage bags were kept off the ground. She stated nursing staff were responsible for monitoring to ensure the catheter drainage bags were kept off the floor. She stated it was important for infection control purposes. Record review of the Catheter Care, Urinary policy, dated July 2024, reflected The purpose of this procedure is to prevent catheter-associated urinary tract infections. Infection Control. 2. Maintain clean technique when handling or manipulating the catheter, tubing, or drainage bag. be sure the catheter tubing and drainage bag are kept off the floor.

Based on interview and record review, the facility failed to ensure dialysis service were provided consistently with professional standards of practice for 2 of 2 resident reviewed for dialysis services. (Resident #3 and Resident #22) The facility failed to maintain documentation of Resident #3 and Resident #22's dialysis communications. This failure could place residents who received dialysis at risk for complications and not receiving proper care and treatment to meet their needs. 1. Record review of the face sheet dated 7/15/26 indicated Resident #3 was a [AGE] year-old female that admitted [DATE], with a readmission date of 5/31/26. Record review of Resident #3's physician's orders dated 7/15/26 indicated she had diagnoses that included: Diabetes Mellitus Type 2 (a chronic condition where your body either resists the effects of insulin or does not produce enough to maintain normal glucose levels), dependence on renal dialysis (a lifelong treatment required when the kidneys lose 85-95% of their function, replaces lost kidney activity by filtering toxins and excess fluid from the blood), and End Stage Renal Disease (the final, permanent state of chronic kidney disease, occurring when kidney function drops to less than 10% of capacity). Record review of the quarterly MDS dated [DATE] indicated Resident #3 had clear speech, understood others, and was understood by others. The MDS indicated she had a BIM's score of 14 indicating she was cognitively intact. She was on dialysis. Record review of the care plan dated 4/14/26 indicated Resident #3 received Hemodialysis related to renal failure and refused to go to dialysis at times. During an observation and interview on 07/13/26 at 10:20 AM, Resident #3's room had a sign on the door indicating she was on Enhanced Barrier Precautions. Personal Protection Equipment were available outside of her room in a plastic drawer contain. She was sitting in her room in her recliner. Her husband was present. She had glasses on and said she went to dialysis on Tuesday, Thursday, and Saturday. She said staff was good to her and the food was okay, depending on what a person liked. During an interview on 7/15/26 at 9:43 AM Resident #3 said when she went to dialysis, she took a paper with her from the facility that was filled out and brought the same paper back and gave it to the nurse up front. Record review of Dialysis communications received by the DON were: June: 6/9/26, 6/18/26, 6/23/26, and 6/27/26. July: 7/2/26, 7/4/26, 7/7/26, 7/11/26, 7/14/26. Record review of the progress notes for Resident #3 indicated she refused to go to dialysis on 6/20/26 and 6/30/26. 2. Record review of a face sheet dated 07/14/26 indicated Resident #22 was a [AGE] year-old male and admitted on [DATE] with diagnoses including myocardial infarction (heart attack), dependence on renal (related to the kidneys) dialysis, and chronic kidney disease. Record review of a quarterly MDS assessment dated [DATE] indicated Resident #22 had a BIMS score of 14 which indicated intact cognition. The MDS indicated Resident #22 had an active diagnosis of renal insufficiency, renal failure, or end-stage renal disease (kidney disease). The MDS indicated Resident #22 received dialysis while a resident. Record review of a care plan last revised on 07/10/26 indicated Resident #22 needed hemodialysis (a life-sustaining procedure that filters waste, toxins, and excess fluid from the blood when the kidneys fail). There were interventions to monitor vital signs, monitor/document/report as needed any signs or symptoms of infection to access site. The care plan indicated Resident #22 received dialysis on Mondays, Wednesdays, and Fridays. Record review consolidated physician's orders dated 07/14/26 for Resident #22 indicated an order for dialysis on Mondays, Wednesdays, and Fridays with a start date of 10/09/25. Record review of Dialysis Communication Report forms from 05/01/26 – 07/15/26 did not indicate completed forms for 05/01/26, 05/04/26, 05/06/26, 05/08/26, 05/11/26, 05/13/26, 05/15/26, 05/18/26, 05/22/26, 05/25/26, 05/27/26, 06/01/26, 06/03/26, 06/05/26, 06/08/26, 06/10/26, 06/12/26, 06/15/26, 06/17/26, 06/19/26, 06/22/26, 06/24/26, 06/26/26, 06/29/26, 07/01/26, 07/08/26, and 07/10/26. During an interview on 07/14/26 at 10:43 a.m., Resident #22 said he received dialysis every Monday, Wednesday, and Friday. He said he had not had any problems with dialysis. During an interview on 07/15/26 at 10:13 a.m., the DON said what usually happened with Dialysis Communication Forms was once the resident returned back to the facility from dialysis, the residents vitals were charted into the residents' electronic medical record. She said the forms were then placed in a stack at the nurse's station. She said prior to 04/30/26 the forms were uploaded into the residents' electronic medical record, but at that time they did away with a medical records position, and they were no longer uploaded into the system. She said it was important that the vital signs and weights were documented. During an interview on 07/15/26 at 12:00 p.m., LVN C said they send the Dialysis Communication Form with the residents to dialysis. She said before the resident goes to dialysis, they assess the resident and fill out the top portion of the form. She said then dialysis completes the middle portion. She said when the resident returns to the facility they re-assess the resident and complete the bottom portion. She said it was important so they can keep up with the baseline of the resident prior to dialysis, what happened during dialysis, and how the resident was when they returned, in case there was anything out of the ordinary. During an interview on 07/15/26 at 12:24 p.m., the DON said the Dialysis Communication forms were important to make sure there were no issues with the dialysis, to make sure the resident was not bleeding at the dialysis site, and to make sure their vitals were taken pre and post dialysis. During an interview on 07/15/26 at 12:45 p.m., the Administrator said she expected Dialysis Communication Forms to be sent out and to be sent back and for them to be filled out completely. She said the forms were important so the communication between the facility and the dialysis center was effective. Record review of a Hemodialysis Catheters – Access and Care of facility policy last revised on 02/2023 indicated, .Documentation.The Nurse should document in the resident's medical record.Location of catheter.Condition of dressing.if dialysis was done during shift.any part of report from dialysis nurse post-dialysis being given.observations post-dialysis.

Based on observation, interview and record review the facility failed to provide routine and emergency drugs and biologicals to its residents or obtain them under an agreement described in S483.70(f) and provide pharmaceutical services including procedures that assure the accurate acquiring, receiving, and dispensing of routine drugs and biologicals to meet the needs of each resident for 3 of 5 (Resident's #17, #70, and #73) resident reviewed for pharmacy services. 1. The facility failed to ensure Resident #70 received her IV antibiotics as ordered from the hospital. The first dose was given 3 days after Resident #70 was admitted to the facility. 2. The facility failed to ensure Resident #17 received her IV antibiotics as ordered from the hospital. The first dose was given 2 days after Resident #17 returned from the hospital. 3. The facility failed to ensure Resident #73 received her medications as ordered by the physician during her respite care stay between 07/03/26 and 07/06/26. These failures could place residents at risk for exacerbation of their disease process. The findings included: 1. Record review of the face sheet, dated 07/14/26, reflected Resident #70 was an [AGE] year-old female who admitted to the facility on [DATE] with diagnoses of chronic kidney disease, stage 4 (severe kidney function loss) and obstructive and reflux uropathy (condition where urine flow is blocked and simultaneously flows backward toward the kidneys, potentially causing kidney damage). Record review of the MDS list in the electronic charting system, reflected Resident #70's MDS assessment was In Progress. Record review of the baseline care plan, dated 07/06/26, reflected Resident #70 communicated easily with staff and was able to understand the staff. The baseline care plan reflected Resident #70 had an indwelling catheter and received IV medication while a resident. Record review of Resident #70's hospital discharge paperwork, dated 07/04/26, reflected she planned to discharge on [DATE] with a PICC line (central line catheter that is placed into the blood stream to administer medication intravenously) and an IV antibiotic treatment plan. Record review of the Order Recap report, dated 07/01/26 to 07/31/26, reflected Resident #70 had the following orders:1. On 07/07/26 an order for ertapenem 1 gram - Use 500 milligrams intravenously one time a day for two days was placed into the system. The start date was 07/08/26 and the end date was 07/09/26.2. On 07/09/26 an order for ertapenem 1 gram - Use 500 milligrams intravenously one time a day for 2 days was placed into the system. The start date was 07/09/26 and the end date was 07/11/26. Record review of Resident #70's MAR, dated July 2026, reflected the following:1. On 07/08/26, the order for ertapenem 1 gram - Use 500 milligrams intravenously one time a day for 2 days was signed out with a 9, which indicated other/see progress note.2. Resident #70 received ertapenem 1 gram - use 500 milligrams intravenously one time a day for 2 days on 07/09/26 and 07/10/26. This was started 3 days after she was admitted from the hospital. During an observation and interview on 07/13/26 at 9:43 p.m., Resident #70 had an IV pole in her room and a PICC line to her right arm. She had just finished her IV antibiotic therapy a few days ago. She stated she was taking the antibiotic for a urinary tract infection. She said she had no adverse effects or complications from the antibiotics. 2. Record review of the face sheet, dated 07/15/26, reflected Resident #17 was a [AGE] year-old female who readmitted to the facility on [DATE] after a hospital stay with a primary diagnosis of sepsis (life-threatening medical emergency caused by your body's overwhelming response to an infection). Record review of the quarterly MDS assessment, dated 06/05/26, reflected Resident #17 had clear speech, was understood by others, and was able to understand others. She had a BIMS score of 15, which indicated no cognitive impairment. The MDS reflected Resident #17 received an antibiotic medication during the 7 day-look back period. Record review of the comprehensive care plan, dated 01/07/26, reflected Resident #17 was incontinent of bowel and bladder and was at risk for urinary tract infections. The interventions included: monitor for signs or symptoms of urinary tract infections. Record review of Resident #17's hospital discharge paperwork, dated 06/14/26, reflected IV antibiotic treatment plan as follows: daptomycin 650 milligrams intravenously every 24 hours through 06/20/26. Record review of the Order Recap report, dated 06/01/26 to 06/30/26, reflected the following orders:1. On 06/14/26, an order for daptomycin - Use 650 milligrams intravenously in the morning was placed into the system. The start date was 06/15/26 and the end date was 06/15/26.2. On 06/15/26, an order for daptomycin - Use 650 milligrams intravenously in the morning was placed into the system. The start date was 06/16/26 and the end date was 06/20/26. Record review of Resident #17's MAR, dated July 2026, reflected the following:1. On 06/15/26, the order for daptomycin - Use 650 milligrams intravenously in the morning was signed out with a 9, which indicated other/see progress note.2. Resident #70 received daptomycin - use 650 milligrams intravenously in the morning on 06/16/26, 06/17/26, 06/18/26, 06/19/26, and 06/20/26. This was started 2 days after she was admitted from the hospital. Record review of Resident #17's progress notes, dated 06/15/26 at 6:03 p.m., reflected her antibiotic was on order. 3. Record review of the face sheet, dated 07/14/26, reflected Resident #73 was an [AGE] year-old female who admitted to the facility on [DATE] and discharged home on [DATE]. She had diagnoses that included hemiplegia, affecting right dominant side (paralysis of right side caused from a stroke) and vascular dementia without behaviors (type of dementia caused by reduced or blocked blood flow to the brain, leading to cognitive impairment that affects memory, thinking, and daily functioning). Record review of the baseline care plan, dated 07/03/26, reflected Resident #73 communicated easily with staff and was able to understand the staff. Her initial discharge goal was to receive respite care (a brief stay (no more than 5 days) for caregiver relief). The baseline care plan reflected Resident #73 was taking insulin and the medications were reconciled with the representative. Record review of the Order Recap report, dated 07/03/26 to 07/06/26, reflected Resident #73 had the following orders:1. atorvastatin calcium 40 milligrams - give one tablet by mouth in the evening related to hyperlipidemia (high lipids), which started on 07/03/26.2. Cefpodoxime Proxetil 200 milligrams - give one tablet by mouth two times a day related to urinary tract infection (bladder infection), which started on 07/03/26.3. levothyroxine 137 micrograms - give one tablet by mouth one time a day related to hypothyroidism (low thyroid hormone), which started on 07/04/26.4. metoprolol tartrate 25 milligrams - give one tablet by mouth two times a day for hypertension (high blood pressure), which started on 07/03/26.5. Novolog Flex Pen 100 units/milliliter - inject 5 units subcutaneously before meals related to diabetes (high blood sugar). Record review of Resident #73's MAR, dated July 2026, reflected the following:1. One dose of atorvastatin calcium 40 milligrams was missed on 07/05/26 at 7 p.m.2. One dose of Cefpodoxime Proxetil 200 milligrams was missed on 07/05/26 at 7 p.m.3. One dose of metoprolol tartrate 25 milligrams was missed on 07/06/26 at 7 p.m.4. Two doses of levothyroxine 137 micrograms were missed on 07/05/26 and 07/06/26 at 5 a.m.5. One dose of Novolog Flex Pen 5 units was missed on 07/03/26 at 4:30 p.m. During an interview on 07/14/26 at 9:54 a.m., Resident #73's family member stated she admitted on [DATE] for a respite care stay and left on 07/06/26. The family member stated when she dropped Resident #73 off on 07/03/26, she left the exact number of pills that were needed for her stay. The family member stated she left the medication with LVN R and it was in a blue bag. The family member stated when she picked Resident #73 up from the facility on 07/06/26, she had left over medications. She stated Resident #73 had 2 out of 4 levothyroxine left, 4 out of 8 metoprolol tartrate left, 3 out of 4 aspirins left, and 3 out of 4 atorvastatin left. The family member stated she was concerned that Resident #73 did not receive her medications as prescribed. During an interview on 07/15/26 at 2:13 p.m., LVN R stated Resident #73's family member gave her Resident #73's medication before she left the facility. She stated the medication was in a blue bag and she placed it on the medication cart. LVN R stated she did not have to give Resident #73 for the rest of her shift and was told she had already had her morning medications. LVN R stated it was her understanding that Resident #73 did not require any further medication until 8 p.m. During an interview on 07/16/26 at 9:26 a.m., LVN F stated Resident #73 left with pills in each of her medication bottles but was unsure how many because she did not count them. LVN F stated she worked on 07/04/25, 07/05/26, and 07/06/26 and gave all medications that popped up on her to give. She stated that a blank on the MAR would have meant that a medication was not given. She stated if a medication was not available from the pharmacy or at the facility, she used the code 9 other/see progress note. She stated when medications were unavailable from the pharmacy, she called the pharmacy to ask for a status update. She stated usually the pharmacy told her it would be out on the next delivery but that did not always happen. She stated when she placed an order into the charting system, it automatically sent a notification to the pharmacy. LVN F stated it was important to ensure prescribed medications were given as ordered for the residents' health and disease management. She stated as a nurse it was her job to carry out physician orders. She stated if an antibiotic was not given timely or was delayed it could have caused a resident to become septic. During an interview on 07/16/26 at 9:36 a.m., MA O stated she had been working at the facility since June 2026. MA O stated the facility had issues getting medications timely from the pharmacy. She stated some residents have gone without medications because the medications were not available in the emergency kit. She stated when medications were re-ordered, it sent an alert directly to the pharmacy. She stated when she did not receive a medication that was re-ordered, she had to call the pharmacy. MA O stated the pharmacy usually stated, it should be there. She stated it was an inconvenience when residents did not have the medications available and often made other residents' medications late. She stated she had to stop in the middle of her medication pass, find the nurse, and then the nurse had to pull the medications from the emergency kit, if they were available. She stated it was important to ensure medications were given as prescribed by the physician to ensure their disease process was managed. She stated not getting medications timely placed the residents at risk for exacerbation of their disease process, such as high blood pressure. During an interview on 07/16/26 at 12:21 p.m., the DON stated the facility was aware Resident #73 had missed some doses of her medication. She stated an agency nurse had worked on 07/05/26 and was unaware Resident #73's medications were in the cart. She stated if a MAR had a blank, it meant the medication was not signed out as given. The DON stated the facility did have issues getting the medications timely from the pharmacy. She stated the pharmacy completed two deliveries, in the morning and the afternoon. She stated the facility had to make sure they were getting the orders into the system by the cut off time. She stated she was unsure what the breakdown was with the pharmacy. She stated a lot of medications were available in the emergency kit that the nurses could have pulled. She stated she expected the nurses to ensure they were following up with the pharmacy if the medications were unavailable and not delivered even after they were re-ordered. She stated it was important to ensure each resident was receiving medications as prescribed because it treated certain disease process and medical conditions. During an interview on 07/16/26 at 1:05 p.m., the Administrator stated she was not aware of any issues with the pharmacy. She stated she expected medications to be ordered as soon as the resident admitted to the facility. She stated she expected the nursing staff to follow the policy for pharmacy services and follow up with the pharmacy if the medications did not come in. She stated the nursing management was responsible for monitoring to ensure pharmacy services were obtained for each resident. She stated it was important to ensure medications were provided timely as ordered by the physician to ensure adequate care and services were provided to the residents. She stated she was aware Resident #73 had not received several medications during her stay. She stated Resident #73 had no adverse effects. Record review of the Providing Pharmacy Services policy, undated, reflected [Pharmacy] will. provide pharmacy and prescription delivery services as specified by the pharmacy provider contract.provide a continuum of pharmaceutical services to the facility and essential medications and services for customers. Ensure that the facility's staff has access to medications, emergency service for medications, and drug information on a twenty-four (24) hour basis. if orders for medications are received from the physician when the pharmacy is closed, the facility may: remind the physician that the pharmacy is closed and that a delay in medication therapy can be prevented by using a drug that is included in the facility's back-up box.if there is no drug substitution, ask the physician if the drug therapy can be initiated the next morning. If a drug is considered essential and cannot be substituted or delayed, please contact [pharmacy] emergency number. The policy did not address medication administration and/or documentation. No further policy was provided upon exit of the facility.

Based on observation and interview, the facility failed to provide beverages that met resident needs and preferences for 3 (Resident #1, Resident #36, and Resident #50) of 22 residents reviewed for hydration. The facility failed to ensure an adequate supply of ice was available during hydration rounds. Resident #1, Resident #36, and Resident #50 preferred iced beverages and refused to drink tepid water during hydration. This failure places residents at risk for inadequate fluid intake and dehydration.1.Record review of the undated face sheet indicated Resident #1 was an [AGE] year-old female admitted on [DATE] with the diagnoses of schizophrenia, COPD (a progressive, incurable lung disease that restricts airflow and makes breathing difficult), and anemia (a condition marked by a lack of enough healthy red blood cells or hemoglobin to carry adequate oxygen to your body's tissues). Record review of Resident #1's annual MDS assessment dated [DATE] indicated she had a BIMS of 11, which indicated she had moderate cognitive impairment. The MDS indicated Resident #1 required maximum assistance with ADLs and she had an active diagnosis of schizophrenia. Record review of Resident #1's care plan dated 06/10/2026 indicated she had potential for fluid volume deficit. During an observation and interview on 07/13/2026 at 9:40 a.m., Resident #1 had no ice in her water pitcher, only water. She stated there was no ice in the building was the reason she had no ice in her water pitcher and she stated she does not drink warm drinks. She stated there has been no ice in her water pitcher for over a month. During an observation on 07/13/2026 at 10:00 a.m., the ice chest was empty on 100 hall. During an observation on 07/13/2026 at 12:20 p.m., the facility ice machine (100 pound) had 12 cubes of ice in the bottom. During an observation on 07/13/2026 at 2:30 p.m., Resident #1 had no ice in her water pitcher and the level remained at 800 ml. During an observation on 07/14/2026 at 9:00 a.m., Resident #1 had no ice in her water pitcher and the level remained at 800 ml. During an observation on 07/15/2026 at 3:30 p.m., Resident #1 had no ice in her water pitcher and the level remained at 800 ml. 2. Record review of an undated face sheet revealed Resident #36 was an [AGE] year-old female admitted on [DATE] with diagnoses of urinary tract infection, atrial fibrillation (the most common type of irregular heartbeat, characterized by chaotic electrical signals in the heart's upper chambers (atria)), and insomnia. Record review of a quarterly MDS assessment dated [DATE], revealed Resident #36 had a BIMS of 15, which indicated no cognitive impairment. The MDS revealed the use of daily diuretics. Resident #36 was independent with ADLs. Record review of a care plan dated 01/27/2026 indicated Resident #36 was at risk for fluid volume deficit and was on diuretic medication. During an interview and observation on 07/13/2026 at 10:10 a.m., Resident #36 stated she wanted it noted the facility does not have a big enough ice machine to accommodate the facility size. She stated ice had not been passed with water in over a month. She stated the residents were told several months ago that a larger ice machine had been ordered, but it still had not arrived. She stated she does not drink any drink that is not cold, but coffee. She stated she has been surviving off of coffee and the iced tea she is served with lunch and supper. She stated the kitchen uses what ice is available to make drinks for meal trays. There was no ice in her full water pitcher. During an observation on 07/14/2026 at 2:10 p.m., Resident #36 had no ice. During an observation on 07/15/2026 at 10:00 a.m., Resident #36 had no ice. During an interview on 07/15/2026 at 1:00 p.m., the DON stated she was not sure why the facility had such a small ice machine. She stated she had seen the Administrator and maintenance man bring ice in to attempt to assist with the ice shortage. She stated she was told a new larger ice machine had been ordered. The DON stated ice was important for residents that preferred ice, so they would consume fluids. She stated not having ice available to residents that would not drink room temperature beverages could lead to dehydration. During an interview on 07/16/2026 at 1:00 p.m., the Administrator stated it important to ensure resident preferences were followed especially with nutrition and hydration. She stated the residents were already at risk of malnutrition and dehydration and by not providing their preferences could lead to health risks. She stated a new larger ice machine had been ordered and should be in any day. Review of an undated facility policy titled 'Nutrition Services' stated that Each resident is provided with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs, taking into consideration the preferences of each resident.

Based on interview and record review, the facility failed to ensure agreements pertaining to services furnished by outside resources specified in writing that the facility assumes responsibility for obtaining services that meet professional standards and principles that apply to professionals providing services in such a facility for 1 of 1 dialysis facilities reviewed for dialysis services. The facility did not have a written agreement with the dialysis center. This failure could place residents requiring dialysis at risk for failure to receive dialysis services due to lack of coordination of care with a dialysis center and therefore potential physical harm and psychosocial harm. Record review of the Survey Ready Book, behind the tab contracts was a letter. The letter was dated 7/13/26: The Dialysis Center is in the process of working the contract with [facility name and address] and [Name and address] Dialysis Center. The contracts must go through the legal department with [Name] Dialysis.Any questions or concerns please reach out to Dialysis Representative H at [phone number]. During an interview on 07/14/2026 at 3:32 PM, the ADM said the facility had their name since the change of ownership on 3/1/25. She said she had been here since February 2026, and she called the dialysis center on 7/13/26 to see why they did not have a dialysis contract. They told her it was going through legal. ,She said she did not know why they did not have the contract yet. During a telephone interview on 07/15/2026 at 9:27 AM, Dialysis Representative H, with [Name] Dialysis Center said the process to get a dialysis contract was the facility would send the information and dialysis legal department would draw up a contract and they (dialysis) sign the contract, then they would send the contract to the facility for them to sign. She said they had done that, signed the contract, and sent it back to the facility and the facility never signed their part, or sent it back to them. She said she thinks it was about a year ago under the old management and prior administrator. She said nothing had been done since then. No activity in approximately one year. During an interview on 07/16/2026 at 9:55 AM, the DON said she did not know anything about the facility's dialysis contract. She said a contract showed who was liable for what, and what was required to keep the contract valid. She said that was all she knew. During an interview on 07/16/2026 at 8:46 AM, the ADM said she had no policy for 3rd party vendors. During an interview on 07/16/2026 at 10:39 AM, the ADM said the importance of a dialysis contract was to have clear communication of service indicating the responsibility of each entity, meaning who does what. She said she was responsible for making sure they had a dialysis contract, forgot, and did not get it done. She said all residents that needed dialysis were getting dialysis.

Based on observation, interview and record review, the facility failed to ensure each resident had the right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences for 2 of 33 residents (Resident #24 and Resident #58) reviewed for reasonable accommodations.The facility failed to ensure Resident #24's, call button was within reach while in bed on 7/13/2026, 7/14/2026 and 7/15/2026. 2. The facility failed to ensure Resident #58's call light was within reach on 07/13/26. These failures could place residents at risk of a delay in assistance and decreased quality of life, self-worth, and dignity. Findings include: 1.Record review of Resident #24's face sheet dated 7/14/2026 indicated she was a [AGE] year-old female readmitted on [DATE] with diagnoses that included metabolic encephalopathy (a brain dysfunction caused by an underlying metabolic or chemical imbalance in the body, leading to altered mental status, confusion, or even coma), Mood disorder (mental health conditions characterized by persistent disturbances in emotional state, including depression and bipolar disorder, which can significantly impact daily life and well-being), Major Depression disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), emphysema (a long-term lung condition that causes shortness of breath), and quadriplegia (a symptom of paralysis that affects all limbs and body from neck down). Record review of Resident #24's significant change in condition MDS assessment, dated 6/9/2026, indicated Resident #24 understood and was understood by others. Resident #24 had a BIMS score of 12 indicating she had moderate cognitive impairment. The MDS indicated Resident #24 was dependent on staff for toileting, bathing, and dressing. Record review of Resident #24's Comprehensive Care Plan revised 1/9/2026 indicated Resident #24 had the potential to be verbally aggressive related to fear, ineffective coping skills, loss of control and poor impulse control. Interventions included administering medications as ordered after attempting non-medicinal approaches, anticipating and remove triggers that cause her to show signs of agitation, anger or aggression, assessing for an understanding of the situation and allow time to express self and feelings towards situation, and document observed behavior and attempted interventions. The care plan also indicated Resident #24 had ADL self-care performance deficits related to muscle weakness, contracture of right and left ankle, reduced mobility, muscle wasting, and lack of coordination. Interventions included Resident #24 utilized a manual wheelchair with 1 person assistance, required assistance by staff with bathing, and bed mobility requiring assist of 1 staff to turn and reposition in bed. During an observation and interview on 07/13/2026 at 10:34 AM, Resident #24 was observed resting in bed with no covers. Resident #24 said everything was going well. Resident #24 said she could not get help when she called for it and was unable to get to her call light. Observed call light wrapped around the handrail and out of resident's reach. Resident #24 said she needed her medication for pain and to be repositioned in bed. The call light was pushed at 10:38 AM and at 10:46 AM, the Social Worker came into the room to see what Resident #24 needed and left the room to get a nurse. Resident #24 started yelling I need help, come help, come help, can I get some help in here? A CNA came to the room to provide assistance. During an interview and observation on 7/14/2026 at 8:21 AM, Resident #24's call light was out of reach. The call light was observed to the left of Resident #24's bed out of reach, wrapped tightly around the handrail making the cord short and tucked between the bed frame and mattress. Resident #24 said she could not reach her call light and said the staff kept it out of her reach. Resident #24 said she had to scream to get someone to come in and then they would tell her to use her call light. During an interview on 7/15/2026 at 8:39 AM, Resident #24 was sitting up in bed with floor mats on both sides of the bed. Resident #24's call light was wrapped around the handrail and tucked between the mattress and the railing. Resident #24 said she could not reach her call light. During an interview on 7/15/2026 at 8:43 AM, ADON E came into the room and asked Resident #24 if she could reach her call light. Resident #24 attempted to reach and could not reach it. ADON E placed the call light closer to Resident #24 then she was able to push the button. ADON E said she made rounds at 8:00 AM and the call light was within reach of Resident #24. She said the CNA who was no longer at the facility must have moved it. ADON E said Resident #24 could have an injury including death if her call light was not within reach and she needed assistance. ADON E said the staff was responsible for ensuring the call light was within reach. During an interview on 7/15/2026 at 9:18 AM, CNA K said the call light should be placed within the resident's reach and ensured the resident can use it. CNA K said she checks placements every time she enters the room. CNA K said a resident could fall, need hydration, or have an incontinence episode and they may not receive timely care. CNA K said call lights should be answered within 5 minutes. During an interview on 7/15/2026 at 1:14 PM, ADON E said all lights should be placed within the reach of residents and ensure the resident could reach. ADON E said Resident #24 could not reach her call light. ADON E said the staff should not be placing residents call lights out of reach. ADON E said Resident #24 had behaviors of screaming out. ADON E said a resident could fall, may need to be changed, have skin breakdown, or need pain medication. It could negatively impact them. During an interview on 07/15/2026 at 1:27 PM, the DON said the call lights should be placed within reach of the residents. The DON said everyone was responsible for placing the call light near the resident before they left the room. The DON said a resident may not receive help they need. The DON said whatever help they need could impact the residents from communicating their needs. The DON said she expected staff to keep the call light within the reach of the resident. During an interview on 7/16/2026 at 10:50 AM, the ADM said the CNAs and nurses were responsible for placing the call light. The ADM said the call lights should be placed within reach of the resident. The residents would not be able to get the help they need. 2. Record review of the face sheet, dated 07/15/26, reflected Resident #58 was a [AGE] year-old female who admitted to the facility on [DATE] with diagnoses of unspecified glaucoma (damage to the optic nerve that gradually gets worse and causes blind spots in the vision), both eyes, and unspecified severe protein-calorie malnutrition (life-threatening condition caused by a significant deficiency of both protein and energy, leading to profound weight loss, muscle wasting, and functional impairment). Record review of the admission MDS assessment, dated 07/07/26, reflected Resident #58 had clear speech, was understood by others, and was able to understand others. Resident #58 had moderately impaired vision, which indicated limited vision; not able to see newspaper headlines but can identify objects. She had a BIMS score of 12, which indicated moderately impaired cognition. Record review of the baseline care plan, dated 07/03/26, reflected Resident #58 had impaired vision. The baseline care plan did not address keeping the call light in reach. During an observation and interview on 07/13/26 at 3:11 p.m., Resident #58 was yelling help me. There were no staff members in the hallway. Resident #58 was sitting up in her wheelchair inside her room. She reported she was left in her wheelchair and wanted to lie down. She was unable to press her call light for assistance because she did not know where it was. The call light was lying on the ground curled up by the head of her bed. Resident #58 requested the facility staff be notified. During an observation and interview on 07/13/26 at 3:14 p.m., the Wound Care Nurse and Administrator were standing at the nurses' station. They were made aware of Resident #58's request for assistance. The Wound Care Nurse entered Resident #58's room to provide assistance. She stated the call light was on the ground. During an interview on 07/16/26 at 11:44 a.m., the Wound Care Nurse stated everyone was responsible for making sure the call light was in reach. She stated on 07/13/26, the therapy staff were the last ones in Resident #58's room and forgot to place the call light in reach. The Wound Care Nurse stated it was important to ensure the call light was in reach so the residents did not fall, or so the residents could have received the help they needed. During an interview on 07/16/26 at 12:21 p.m., the DON stated she expected the residents' call lights to remain in reach, wherever the resident was. She stated everyone was responsible for monitoring to ensure the call lights were in reach. She stated it was important to ensure the call lights were in reach so the residents could have called for assistance and prevented them from having to yell out for help. During an interview on 07/16/26 at 1:05 p.m., the Administrator stated she expected the residents' call lights to remain in reach. She stated the CNAs and nurses were responsible for monitoring to ensure the call lights were in reach. She stated it was important to ensure call lights were in reach so the residents' needs could be met timely. Record review of the Call System, Resident policy, dated January 2025, reflected Residents are provided with a means to call staff for assistance through a communication system that directly calls a staff member or a centralized workstation. each resident is provided with a means to call staff directly for assistance from his/her bed.

Based on observation, interviews, and record review, the facility failed to provide a safe, clean, sanitary, comfortable, and homelike environment for 1 of 33 residents (Resident # 56).The facility failed to ensure Room # 56's bed was made on 7/13/2026, 7/14/2026, 7/15/2026, and 7/16/2026.These failures could place residents at risk of an unsafe, unsanitary, uncomfortable environment, embarrassment due to rooms not appearing homelike, and a decrease in quality of life and self-worth. Findings included: Record review of Resident #56's Face sheet dated 7/16/2026 indicated a [AGE] year-old female who was readmitted to the facility on [DATE]. Resident #56 had diagnoses which included type II diabetes (a chronic condition that occurs when the body cannot properly use blood sugar, leading to high blood sugar levels), Hypertensive heart and chronic kidney disease with heart failure (a complex, interrelated condition in which long-standing, uncontrolled high pressure damages both the heart and kidneys, leading to heart failure and chronic kidney disease), severe protein-calorie malnutrition (a condition that occurs when the body does not receive enough protein and calories to maintain proper health), emphysema (a long-term lung condition that causes shortness of breath), and major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest). Record review of Resident #56's quarterly MDS dated [DATE] indicated she was able to make self-understood and understood others. Resident #56 had a BIMS score of 8 indicating moderate cognitive impairment. Resident #56 required substantial assistance with toileting, bathing, and dressing lower body. The quarterly MDS indicated Resident #56 used a wheelchair. Record review of Resident #56's Care plan, revised on 7/13/2026 indicated Resident #56 had self-care performance deficits related to muscle weakness, unsteadiness on feet, lack of coordination, reduced mobility, and muscle wasting. The care plan indicated following interventions: Resident #56 was able to self-propel in a manual wheelchair. She was able to walk with assist with 1 staff, required assistance by staff with showers, and required assistance by 1 staff to turn and reposition in bed, as necessary. Record review of resident council meeting notes dated 6/9/2026 at unknown time, Resident #56 voiced she would like her bed to be made daily. There was no grievance or report made regarding the request for her bed to be made daily. During an observation and interview on 07/13/2026 at 9:45 AM, Resident #56 stated that her bed was never made and that was something she worried about because when she was able, she made her bed every day. Resident #56 stated because no staff looks at her bed or makes it, she goes about 2-3 weeks without her bed linen being changed. Observation of the bed at this time revealed it was unmade. During an observation on 7/13/2026 at 2:30 PM, Resident #56's bed remained unmade and observed an orange stain noted to fitted sheet just below the pillow. During an observation on 7/14/2026 at 10:10 AM, Resident #56's bed remained unmade and observed an orange stain noted to fitted sheet just below the pillow. During an observation on 7/14/2026 at 3:30 PM, Resident #56's bed remained unmade and observed an orange stain noted to fitted sheet just below the pillow. During an observation on 7/15/2026 at 10:12 AM, Resident #56's bed remained unmade and observed an orange stain noted to fitted sheet just below the pillow. During an observation and interview on 7/15/2026 at 3:45 PM, Resident #56's bed remained unmade and observed an orange stain noted on fitted sheet below the pillow. Resident #56 said her sheets were filthy and she does not want to get into them at night but where else can she sleep. During an interview on 7/16/2026 at 9:00 AM, Resident #56 had reported in resident council meeting that her bed was not being made daily. Observed Resident #56's bed unmade at time of interview. Resident #56 said she was not able to make her own bed every morning and she liked her bed made. Resident #56 said she tried to straighten it up, but it was hard for her to do. Resident #56 said the staff was supposed to make her bed every day. During an interview on 7/16/2026 at 9:25 AM, CNA K said the CNAs were responsible for making residents' beds every day. CNA K said she goes from room to room checking beds to make the beds. CNA K said housekeepers sometimes make the beds when they clean the rooms. CNA K said CNAs were to change sheets on shower days and as needed. She said she usually makes sure all beds were made before lunch. CNA K said she was getting sheets to change Resident #56's bed because she did not have a top blanket. CNA K said a resident may not feel like this is their home if their beds were not made daily. CNA K said the facility was the residents' home and the CNAs and nurses were responsible for ensuring it was homelike. During an interview on 7/16/2026 at 9:37 AM, the Activity Director said she would write up a grievance if a resident had a complaint or concern. The Activity Director said she remembered Resident #56 voiced concerns about her bed not being made. The Activity Director could not recall if she wrote up a grievance and gave it to the Social Worker. The Activity Director said she would not want her loved one to have to make their own bed and she said Resident #56 was in a wheelchair. The Activity Director said the nurses were responsible for ensuring beds were made. During an interview on 7/16/2026 at 9:49 AM, the Social Worker said she did not receive a grievance on Resident #56's bed not being made. The Social Worker said the CNA assigned to the hall was responsible for making the residents' beds. The Social Worker said not making the bed could cause the residents to become anxious, and the staff want to make sure the residents have a clean homelike environment. During an interview on 7/16/2026 at 9:49 AM, ADON E said the CNAs were responsible for making the residents' beds. ADON E said not making a resident's bed could make the resident feel depressed or dirty. ADON E said the facility was the resident's home and should be kept that way. ADON E said the CNAs should be changing the residents' sheets if they were soiled and on shower days. ADON E said she expected the staff to complete the task of changing the residents' sheets. During an interview on 7/16/2026 at 9:52 AM, the DON said she expected the staff to change sheets whenever they need to be. The DON said the sheets needed to be changed on shower days and as needed. The DON said it could cause the residents to feel unclean. The DON said the CNAs were responsible for making the beds daily and she expected it to be completed. During an interview on 7/16/2026 at 10:50 AM, the ADM said the CNAs were responsible for making sure resident beds were made. The ADM said the sheets should be changed on shower days or at least three times a week and as needed. The ADM said she expected the CNAs to make the residents' beds. The ADM said it could make a resident feel unclean. Record review of a facility policy titled Homelike Environment dated February 2021 indicated, .Residents are provided with a safe, clean, and comfortable and homelike environment and encouraged to use their personal belongings to the extent possible. Policy Interpretation and Implementation.1. Staff provides person-centered care that emphasizes the residents' comfort, independence, and personal preferences. 2. The facility staff and management maximize, to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting.a. clean, sanitary and orderly environment.b. comfortable, yet adequate lighting.c. inviting colors and decor.d. personalized furniture and room arrangements.e. clean bed and bath linens that are in good condition.3. The facility staff and management minimize, to the extent possible, the characteristics of the facility that reflect a depersonalized, institutional setting.a. overhead paging.institutional odors.institutional signage.medication carts.chair and bed.4. Comfortable and adequate lighting is provided.

Based on observation, interview, and record review, the facility failed to provide an ongoing program of activities in accordance with the comprehensive assessment to meet the interests and the physical, mental, and psychosocial well-being for 1 of 26 residents reviewed for activities. (Resident #11) The facility failed to ensure Resident #11 was provided with activities, according to her preference and assessment. This failure could place residents at risk of not having activities to meet their interests or needs and a decline in their physical, mental, and psychosocial well-being. The findings included: Record review of the face sheet, dated 07/15/26, reflected Resident #11 was an [AGE] year-old female who admitted to the facility on [DATE] with diagnoses of rhabdomyolysis (serious condition characterized by the breakdown of muscle fibers, leading to the release of harmful substances into the bloodstream, which can cause kidney damage), urinary tract infection (bladder infection), pneumonia (infection of the lungs that inflames the air sacs in one or both lungs), pleural effusion (also called water on the lungs, buildup of fluids around the layers of your lungs), contracture of right and left lower leg (condition of shortening and hardening of muscles, tendons, or other tissue leading to restricted joint mobility), and disorder of kidney and ureter (tube that runs from the kidney to the urethra opening), unspecified. Record review of the admission MDS assessment, dated 04/30/26, reflected Resident #11 had clear speech, was sometimes understood by others, and was usually able to understand others. Resident #11 had a BIMS score of 13, which reflected no cognitive impairment. The MDS reflected Resident #11 believed it was very important to be around animals, keep up with the news, and do her favorite activities. Record review of the comprehensive care plan, dated 04/28/26, reflected Resident #11 expressed enjoyment with independent activities of leisure, such as watching television. The interventions included: interview resident for daily preferences, provide opportunity for resident's expression of individuality, and inform resident of upcoming activities by providing a monthly calendar. Record review of the order summary report, dated 07/14/26, reflected Resident #11 had an order, which started on 04/23/26, for May attend social activities as tolerated. Record review of the Activities - Initial Review, dated 04/24/26, reflected Resident #11 was interested and participated in watching television and reading newspaper. The review reflected Resident #11 wished to participate in activities. The review reflected that she liked independent activities such as reading. During an observation and interview on 07/13/26 at 9:32 a.m., Resident #11 was lying in the bed with the head of her bed elevated slightly. Resident #11 was curled up in the fetal position with her knees and hands held tightly beside her face. Resident #11 was confused during the conversation. She had no reading materials on her table and her television was off. During an observation on 07/13/26 at 3:22 p.m., Resident #11 was lying in the bed. Her knees and hands were drawn up tightly by her face. She had no reading materials on her table and her television was off. During an observation on 07/14/26 at 1:38 p.m., Resident #11 was lying in her bed with her hands and knees drawn up tightly by her face. She had no reading materials on her table and her television was off. During an observation on 07/15/26 at 8:59 a.m., Resident #11 was lying in the bed with the head of the bed slightly elevated. She was facing the door. There were no reading materials on her table and the television was off. During an interview on 07/16/26 at 10:21 a.m., CNA M stated activities were not performed with Resident #11. She was unsure what type of activities Resident #11 liked to do. She was unsure if Resident #11 was provided with reading materials. She stated Resident #11 used to get into her wheelchair and go to therapy, but she was unsure if they were still doing that. She stated she did not think about making sure her television was turned on. She stated it was important to ensure residents were offered activities they preferred for socialization and to maintain their mood. During an interview on 07/16/26 at 11:00 a.m., CNA N stated she was unable to do activities with Resident #11 because Resident #11 was very contracted and could not do much. CNA N stated she loved peanut butter cups and water. CNA N said she sat and talked with Resident #11 whenever she could. She was unsure if the Activity Director visited with Resident #11 in her room. She was unsure if Resident #11 liked to read or watch television. She stated she turned Resident #11's television on sometimes. She stated it was important to ensure residents received activities to increase their mood. During an interview on 07/16/26 at 11:57 a.m., the Activity Director stated residents who required in-room activities were usually dependent on staff and were not able to come out of their room because of their physical or mental health abilities. The Activity Director stated Resident #11's initial discharge goal was to return home. She stated when Resident #11's activity preference and assessment were completed, she was getting up in her wheelchair and working with therapy. She stated she remembered Resident #11 liked to watch television and read. The Activity Director stated in-room activities were not set up for Resident #11 because she was coming out of her room initially. The Activity Director was unsure if Resident #11 was provided reading materials or if her television was turned on. She stated she was unable to remember if she offered activities to Resident #11. The Activity Director stated it was important to ensure each resident was encouraged and provided with activities for their socialization and mood status. During an interview on 07/16/26 at 12:21 p.m., the DON stated she expected each resident to be provided with activities according to their preferences and what they liked. She stated the Activity Director was responsible for monitoring to ensure activities were done. She stated it was important to ensure activities were offered and provided to provide a sense of endearment and socialization. During an interview on 07/16/26 at 1:05 p.m., the Administrator stated she expected the staff to ensure residents were offered activities daily and the care plan was followed. She stated the Activity Director was responsible for monitoring to ensure activities were done. She stated it was important to ensure activities were provided to maintain their socialization. Record review of the Activity Programs policy, dated June 2018, reflected Activity programs are designed to meet the interests of and support the physical, mental, and psychosocial well-being of each resident. Activities offered are based on the comprehensive resident-centered assessment and the preferences of each resident. activities are considered any endeavor, other than routine ADLs, in which the resident participates, that is intended to enhance his or her sense of well-being and to promote or enhance psychical, cognitive, or emotional health. all activities are documented in the resident's medical records.

Based on interview and record review the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice for 1 of 6 (Resident #73) residents reviewed for quality of care. The facility failed to ensure Resident #73's skin was maintained during a respite care stay from 07/03/26 until 07/06/26. This failure could place residents at an increased risk for a decreased quality of care, neglect, and avoidable wound treatment. The finding included: Record review of the face sheet, dated 07/14/26, reflected Resident #73 was an [AGE] year-old female who admitted to the facility on [DATE] and discharged home on [DATE]. She had diagnoses that included hemiplegia, affecting right dominant side (paralysis of right side caused from a stroke) and vascular dementia without behaviors (type of dementia caused by reduced or blocked blood flow to the brain, leading to cognitive impairment that affects memory, thinking, and daily functioning). Record review of the baseline care plan, dated 07/03/26, reflected Resident #73 communicated easily with staff and was able to understand the staff. Her initial discharge goal was to receive respite care (a brief stay (no more than 5 days) for caregiver relief). The baseline care plan reflected Resident #73 usually required partial/moderate assistance with toileting hygiene and toilet transfer. She was frequently incontinent of bowel. She had no documented skin integrity issues. Record review of the admission note, dated 07/03/26, reflected Resident #73 had no skin issues. Record review of the Braden skin evaluation, dated 07/03/26, reflected Resident #73 was at risk for skin breakdown. Record review of the Discharge summary, dated [DATE], reflected Resident #73 had discharged from the facility with her family member. There were no skin issues identified. Record review of a photograph, dated 07/06/26 at 6:29 p.m., reflected Resident #73's buttocks had white scar tissues that had several areas of missing skin. The open areas were superficial with no measurable depth noted. The areas appeared bright red and wet. The areas were not directly over a bony prominence. During an interview on 07/14/26 at 9:54 a.m., Resident #73's family member stated she admitted on [DATE] for a respite care stay and left on 07/06/26. On 07/06/26, Resident #73's family member stated she called the facility around 4 p.m. to let them know she would be coming to pick up Resident #73 and requested that she was assisted on getting ready to leave. She said when she arrived at the facility at approximately 5:30 p.m., Resident #73 had dried bowel movement all the way up her back and around her perineal area. The family member stated Resident #73 had a clean incontinent pad that was placed on top of the dirty bottom sheet. She stated the bottom sheet had dried bowel movement. The family member stated Resident #73 had developed open areas on her bottom that were noticed when Resident #73 was being cleaned on 07/06/26. The family member stated that when Resident #73 was admitted to the facility, she did not have any skin issues. She stated CNA M provided care to Resident #73 on the day she admitted and could have verified she had no skin issues. The family member stated Resident #73 was taken to a wound care doctor and was still receiving treatment. The wound care doctor's notes were requested. During an interview on 07/14/26 at 1:40 p.m., CNA M stated when Resident #73 admitted to the facility on [DATE] her skin was immaculate. She stated Resident #73's skin was smooth and oiled down. CNA M stated she provided incontinent care and she had no open areas on her bottom. CNA M said she saw old scar tissue that appeared white, but nothing that was open. She stated the CNAs were responsible for completing rounds every two hours and when someone was incontinent. She stated she worked on 07/03/26 and on 07/04/26 and did not notice any skin issues on Resident #73. During an interview on 07/14/26 at 2:43 p.m., LVN F said on 07/06/26 at about 4 p.m., she asked CNA Q, who was sitting in the lobby area, to ensure Resident #73 was assisted with getting ready to leave the facility. She stated she instructed CNA Q to make sure she was clean and that her family member was going to take her home. LVN F stated her family member arrived at the facility around 5:30 p.m., and she was disgraced by what she observed. LVN F stated Resident #73 had bowel movement half-way up her back. She stated some of the stool was dried and some of it was loose, like she had multiple bowel movements. LVN F stated she asked the family member to step out of the room, so she could assist Resident #73 with incontinent care. She stated Resident #73 had several small, open, blistered areas on her bottom. LVN F stated it looked like the soiled brief had been sitting around that area causing moisture against the skin. LVN F stated it appeared the moisture could have caused some skin damage. During an interview on 07/15/26 at 2:13 p.m., LVN R stated on 07/03/26 she had been called in by the facility and arrived around 12:15 p.m. She stated she received report from the Wound Care Nurse that Resident #73 had just admitted . LVN R stated she performed Resident #73's skin assessment. She stated Resident #73 had no skin issues on admission. She stated Resident #73's skin was clean, oiled down, and she had no dry skin. LVN R denied working any more while Resident #73 was at the facility. During an attempted telephone interview, on 07/16/26 at 8:24 a.m., CNA Q did not answer the telephone. Unable to leave a voice message and there was no return telephone call upon exit of the facility. During an interview on 07/16/26 at 12:21 p.m., the DON stated Resident #73 had been admitted on [DATE] and discharged from the facility on 07/06/26. The DON stated she was unaware of any problems with Resident #73's stay until 07/07/26. She said on 07/07/26 during staffing meeting, she was informed by Resident #73's family member that Resident #73 was not checked on or changed during her stay. She was told that no one provided care whatsoever. She stated she was told that Resident #73 developed bed sores. The DON said she requested pictures from Resident #73's family member but had not received them. She stated once the family member voiced her concerns the Administrator took over the investigation. The DON stated she did not speak with the nurse who discharged Resident #73 but stated CNA Q had been terminated for failing to show up for her scheduled shift, unrelated. The DON stated she was unaware or unable to verify Resident #73 had any skin issues upon discharge. The DON stated she expected the discharge nurse to perform a skin assessment and report any skin issues identified. She stated skin issues should have been documented in a progress note or change of condition form. She stated the appropriate notifications should have been completed. She stated it was important to prevent the development of skin issues or breakdown for the resident's overall health. During an interview on 07/16/26 at 1:05 p.m., the Administrator stated Resident #73's family member had voiced complaints that Resident #73 had not been changed at any point during her stay. The Administrator stated that was untrue, because during the family members complaints, she stated when my mother was being changed. The Administrator stated she spoke with CNA M who stated she changed Resident #73. She was unable to contact CNA Q and she was terminated. She stated the family member had mentioned something about her skin, but she was unable to verify Resident #73 had developed any skin concerns while at the facility. She stated she spoke with LVN F who discharged Resident #73 and she did not mention any skin concerns. The Administrator stated she expected the nurses to perform a skin assessment upon discharge and document their findings. She stated if new skin issues were identified, she expected the nurses to notify the physician and the family. She stated it was important to ensure residents did not develop skin breakdown for their overall health and quality of care. Record review of Resident #73's discharge from wound care clinical services note dated 07/16/26, reflected there was no open wound present. The notes indicated keep turning her every hour and keep clean of fecal matter to prevent pressure sores and continue to use the zinc to prevent moisture build up.[sic] There was no wound details and the weeks in treatment indicated 0. Record review of the Change in a Resident's Condition or Status policy, dated April 2025, reflected Our facility promptly notifies the resident, his or her attending physician, and the resident repetitive of changes in the resident's medical/mental condition and/or status. The nurse will notify the resident's attending physician or physician on call when there has been a(an): accident or incident involving the resident.significant change in the resident's physical/emotional/mental condition.need to alter the resident's medical treatment significant. Specific instruction to notify the physician of changes in the resident's condition.prior to notifying the physician. the nurse will make detailed observations and gather relevant and pertinent information.

Based on observation, interview and record review the facility failed to ensure each resident received adequate supervision and assistance devices to prevent accidents for 1 of 5 residents (Resident #69) reviewed for adequate supervision. The facility failed to store, supervise, and distribute Resident #69's smoking materials on 7/14/2026. This failure could place residents at risk for injury, harm, and impairment or death. Findings included: Record review of Resident #69's face sheet dated 7/15/2026, indicated she was a [AGE] year-old male admitted to the facility on [DATE]. Her diagnoses included: pyogenic arthritis (a serious condition characterized by inflammation of a joint due to bacterial infection), chronic myeloproliferative disease (a group of rare blood cancers that occur when the bone marrow produces excessive red blood cells, white blood cells, or platelets), chronic obstructive pulmonary disease (a progressive lung disease that makes it difficult to breathe, primarily caused by long-term exposure to irritants), hypertensive heart and chronic kidney disease with heart failure (a combined cardiac-renal condition where long standing high blood pressure damages both the heart and kidneys, increasing risks of hospitalization, fluid overload, and mortality), type II diabetes (a chronic condition that occurs when the body cannot properly use blood sugar, leading to high blood sugar levels) and depression (a mood disorder that causes a persistent feeling of sadness and loss of interest). Record review of Resident #69's Quarterly MDS dated [DATE] indicated resident was able to make self-understood and understood others. Resident #69 had a BIMS score of 15, indicating the resident was cognitively intact. The resident required moderate assistance for bathing and dressing lower body. The resident required supervision for dressing upper body and toileting. Record review of Resident #69's care plan initiated on 3/20/2026, indicated she had Chronic Obstructive Pulmonary Disease related to smoking , interventions included monitor/document/report as needed any signs and symptoms of respiratory infection such as fever, chills, increased sputum (a mixture of saliva and mucus), chest pains, increased difficulty breathing, increased coughing and wheezing. The care plan did not indicate resident currently smoked. Record review of Resident #69's smoking assessment dated [DATE], indicated resident was cognitively capable of making decision to smoke and understood the smoking policy. The smoking assessment indicated Resident #69 had no functional limitations preventing her from smoking without assistance but could not light cigarettes. The smoking assessment indicated Resident #69 required direct supervision while smoking and the facility stored lighters and cigarettes. During an interview on 07/13/26 at 10:12 AM, Resident #69 stated she smoked according to a schedule and staff assigned to take them out to smoke did not always take them out on time. She stated she carried her own cigarettes and lighter on her person and the staff only had to take her outside for supervision. During an observation on 07/14/26 at 5:23 PM, the Housekeeping Director wheeled Resident #69 down the hallway from her room. Resident #69 was holding a package of cigarettes. The Housekeeping Director wheeled Resident #69 into the smoking area. During an observation on 07/14/26 at 5:42 p.m., Resident #69 wheeled herself down the hallway and into her room. She had a package of cigarettes beside her leg on the wheelchair. During an interview on 7/15/2026 at 2:32 PM LVN F said Resident #69's cigarettes were locked on the medication cart. LVN F opened the medication cart and there were several packs of cigarettes stored for Resident #69. LVN F said the residents should not have lighters or cigarettes in their possession. LVN F said Housekeeping and Laundry take the residents out to smoke. LVN F said all staff were responsible for ensuring the cigarettes and lighters were secured on the medication cart. LVN F said it was against facility policy and rules for residents to keep cigarettes and lighters on them. LVN F said if a resident kept their smoking material they could try to smoke in their room, cause a fire or another resident could get the cigarettes and lighter. During an interview on 7/15/2026 at 2:37 PM, Housekeeper L said she takes residents out to smoke at 9:30 AM, and 1:30 PM. Housekeeper L said Resident #69 did not keep her cigarettes on her. Housekeeper L said no one should keep cigarettes or lighters on them. Housekeeper L said the person taking the resident outside to smoke was responsible for making sure cigarettes and lighters were secured. Housekeeper L said the resident could set off the smoke detectors, or the resident could burn themselves. During an interview on 7/15/2026 at 2:42 PM, ADON E said cigarettes, lighters, vapes should be secured on the medication cart. ADON E said the facility should assess residents for smoking materials upon admission and secure them if they were brought to the facility. She said no residents should have their cigarettes or lighters on them. ADON E said the residents were supposed to return their lighters and cigarettes when they return inside. ADON E said she expected the staff to take up the cigarettes and lighters. ADON E said a resident on oxygen could cause a fire or burn self. During an interview on 7/15/2026 at 2:49 PM, the DON said she had seen staff lock up the cigarettes. The DON said she took Resident 69's cigarettes on Monday. The DON said she observed Resident #69 placing her cigarettes in her pants under her shirt. The DON said she re-educated Resident #69 and told her what she needed to do and Resident #69 told her she should give her cigarettes to the nurse. The DON said someone must have brought the cigarettes to the resident. The DON said whoever takes the cigarettes outside should make sure they are taken back up. The DON said she saw the staff with a sandwich bag with the cigarettes in them. The DON said she educated the resident on the facility policy. The DON said the resident could cause a boom (explosion) in the facility if someone kept their lighter or cigarettes. During an interview on 7/16/2026 at 10:50 AM, the ADM said she expected cigarettes to be put back up after residents return from smoking. The ADM said the person taking the residents out was responsible for gathering the cigarettes and lighters. The ADM said vapes, lighters, cigarettes should be placed behind the nurse station or on the medication cart. The ADM said it was not the resident's responsibility to return the items to the nurse. The ADM said a resident could catch their clothes on fire. During record review of facility policy titled Smoking Policy-Residents October 2022 indicated .This facility shall establish and maintain safe resident smoking practices.Policy Interpretation and Implementation.prior to, and upon admission, residents shall be informed of the facility smoking policy.smoking is not allowed inside the facility.smoking is allowed in designated resident smoking areas.oxygen is prohibited in smoking areas.residents will be evaluated on admission to determine if he or she is a smoker or non-smoker.ability to smoke safely with or without supervision.residents may not have or keep any smoking articles, including cigarettes, tobacco, except when they are under direct supervision.the facility maintains the right to confiscate smoking articles found in violation of our smoking policies.

Based on observation, interview, and record review the facility failed to ensure a resident who needed respiratory care was provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, the residents' goals, and preferences for 2 of 7 residents (Resident #27 and Resident #70), reviewed for respiratory care and services. The facility failed to ensure Resident #27's oxygen concentrator filter was without white fuzzy particles on 7/13/2026, 7/14/2026 and 7/15/2026.The facility failed to ensure Resident #70's oxygen settings were set between 2 - 5 liters per minute as prescribed by the physician on 07/13/26.The facility failed to ensure Resident #70 wore her oxygen as prescribed by the physician for approximately 2 hours, on 07/13/26. This failure could place residents at risk for developing respiratory complications. Findings included: 1.Record review of Resident #27's Face sheet dated 7/14/2026 indicated a [AGE] year-old female who was readmitted to the facility on [DATE]. Diagnoses included dementia (a syndrome characterized by a decline in cognitive function, affecting memory, thinking, behavior, and the ability to perform everyday activities), depression (a mood disorder that causes a persistent feeling of sadness and loss of interest), anxiety (a common emotion involving fear, tension, or worry in response to real or perceived threats), Type II Diabetes (a chronic condition that occurs when the body cannot properly use blood sugar, leading to high blood sugar levels) and Chronic obstructive pulmonary disease (a progressive lung disease that makes it difficult to breathe, primarily caused by long-term exposure to irritants). Resident #27 was a DNR. Record review of Resident #27's quarterly MDS dated [DATE] indicated she was able to make self-understood and understood others. Resident #27 had a BIMS score of 14 indicating resident was cognitively intact. Resident #27 was dependent on toileting, dressing upper and lower body and required substantial assistance with bathing. The quarterly MDS also indicated Resident #27 was on Hospice and required oxygen. Record review of Resident #27's Care plan, initiated on 4/7/2026 indicated Resident #27 had potential for altered respiratory status, difficulty breathing related to allergies, wheezing, coughing and congestion. Interventions included administer medication/puffers as ordered, assist resident, caregiver in learning signs and symptoms of respiratory compromise and monitoring signs and symptoms of respiratory distress and report to MD. Resident #27 did not have a care plan for oxygen. Record review of Resident #27's order summary dated 7/14/2026, indicated Resident #27's code status was DNR (Do not resuscitate) starting on 6/10/2026. Resident #27 had orders to admit to Hospice care on 6/23/2026. The order summary also indicated Resident #27 required oxygen continuously via nasal cannula and may titrate between 2-5 liters for shortness of breath or pulse oximetry less than 90% (blood oxygen level means your body was carrying less oxygen than it should resulting in vital organs and tissues may not receive full amount to function properly) every shift for shortness of breath and to maintain pulse oximetry greater than 90%. The order summary indicated the oxygen tubing and delivery device (nasal cannula) was to be stored in bag when not in use every shift. During an interview and observation on 7/13/2026 at 10:54 AM, Resident # 27 was lying in bed with oxygen on 3 liters. Resident #27 said she was on Hospice care and was not feeling good and did not want to talk. Observed oxygen concentrator was covered in a thin layer of white dust. Resident #27 refused additional questions at the time of observation. During an observation and interview on 7/14/2026 at 8:11 AM, Resident #27 was sitting up in bed with oxygen on. Resident #27's oxygen concentrator filter observed to have thin white layer of dust. Resident #27 said she did not know her oxygen concentrator had a filter. Resident #27 said she did not know who changed the filters out. Resident #27 said she received new nasal cannula every Sunday. Resident #27 denied any recent respiratory infections. During an observation on 7/15/2026 at 8:59 AM, Resident #27 was sitting up in bed with oxygen at 3 liters. Observed oxygen concentrator filter was covered with a thin layer of white dust. During an interview on 7/15/2026 at 12:40 PM, LVN A said the nurses were responsible for changing the filters as needed and on Sunday when the nurses changed the oxygen tubing. LVN A said if the filter was not changed and dust built up on the filter, the residents may not breathe good air. LVN A said by not changing the air filter on the concentrator, it could cause a resident to go into respiratory distress. During an interview on 7/15/2026 at 1:14 PM, ADON E said the nurses were responsible for changing the oxygen concentrator filters. She said the filters should be changed every Sunday. ADON E said the facility had extra filters located in the central supply and the facility had just ordered more filters. ADON E said the residents may not have good air quality causing a respiratory infection, respiratory distress, or it could cause lower oxygen saturation levels. During an interview on 7/15/2026 at 1:27 PM, the DON said the night shift nurse was responsible for changing the oxygen concentration filters on Sunday. The DON said the filter could get clogged up and no air would come out. The DON said it could cause a resident to have respiratory issues. During an interview on 7/16/2026 at 10:50 AM, the ADM said she expected the filters to be changed regularly. The ADM said she did not know when the filters needed to be changed. The ADM said the oxygen tubing was changed weekly. The ADM said she could not say what could have happened if the filters were not changed. The ADM said the nurses were responsible for changing the filters. 2. Record review of the face sheet, dated 07/14/26, reflected Resident #70 was an [AGE] year-old female who admitted to the facility on [DATE] with diagnoses of obstructive sleep apnea (sleep-related breathing disorder in which airway becomes partially or completely blocked during sleep), acute and chronic respiratory failure with hypoxia (inability of the lungs to maintain adequate gas exchange, leading to lower oxygen levels), and pneumonia (lung infection that inflames the air sacs in one or both lungs leading to symptoms such as cough or difficulty breathing). Record review of the MDS list in the electronic charting system, reflected Resident #70's MDS assessment was In Progress. Record review of the baseline care plan, dated 07/06/26, reflected Resident #70 communicated easily with staff and was able to understand the staff. The baseline care plan reflected Resident #70 required oxygen therapy while a resident. Record review of the order summary report, dated 07/14/26, reflected Resident #70 had an order, which started on 07/07/26, for oxygen at 2 – 5 liters per minute by nasal cannula continuously for shortness of breath and to maintain oxygen levels greater than 90%. Record review of the MAR, dated July 2026, reflected Resident #70 received oxygen between 2 – 5 liters per minute by nasal cannula continuously starting on 07/07/26. Oxygen levels were documented on the day shift and on the evening shift. All readings were above 92 %. During an observation and interview on 07/13/26 at 9:43 a.m., Resident #70 was lying in her bed with the head of the bed elevated slightly. She was wearing a nasal cannula that was connected to an oxygen machine. The machine was set at 1 liter per minute. Resident #70 stated she normally wore oxygen at 2 liters per minute. She stated she was not having any complications of low oxygen, such as confusion or tiredness. She stated her oxygen machine had been acting up during the night and earlier in the morning. She stated the settings could have messed up. Resident #70 pressed the call light for assistance with her oxygen settings. At 10:07 a.m., ADON D entered Resident #70's room and adjusted the oxygen settings to 2 liters per minute. ADON D stated oxygen settings were checked once per shift or if there were issues. She stated the nurses were responsible for checking the oxygen settings and oxygen levels. During an observation and interview on 07/13/26 at 3:20 p.m., Resident #70's nasal cannula tubing was lying in her recliner. Resident #70 was lying in bed with the head of her bed elevated slightly. She stated it had been about 2 hours since she had her oxygen on and was not aware her oxygen was off. She stated a staff member assisted her back into the bed after lunch and believed they forgot to put it back on her face. She stated she had no symptoms of low oxygen. She said she was not drowsy, short of breath, or confused. Resident #70 grabbed the tubing attached to her oxygen concentrator and pulled the tubing where she was able to grab it and place it on her face. The concentrator was running at 2 liters per minute. During an interview on 07/16/26 at 10:21 a.m., CNA M stated if a resident was on oxygen and needed to be transferred, she would have taken the oxygen off and made sure it was replaced after the transfer. She stated the person performing a transfer was responsible for making sure the oxygen tubing was replaced. She stated she was unsure why Resident #70's oxygen tubing was not replaced on 07/13/26. She said she was unable to recall transferring Resident #70 back to bed after lunch on 07/13/26. She stated it was important to ensure oxygen was worn because the oxygen levels could have dropped and caused medical issues. During an interview on 07/16/26 at 11:44 a.m., the Wound Care Nurse stated she was the nurse caring for Resident #70 on 07/13/26. She stated the nurse was responsible for making sure everyone with oxygen had their oxygen tubing on and set at the correct settings. The Wound Care Nurse stated she was not supposed to have worked the floor on 07/13/26. She stated another nurse had called off and she was the nurse manager on call. She stated she did not arrive at the facility until 8 a.m. and did not remember if she checked Resident #70's oxygen settings. She stated Resident #70's oxygen levels were above 90% and she was not symptomatic of low oxygen levels. She stated it was important to ensure residents received oxygen at the correct levels to maintain good oxygen levels. She stated poor oxygen levels could have caused altered mental status or confusion. During an interview on 07/16/26 at 12:21 p.m., the DON stated she expected the nurses to ensure oxygen was being worn and was set at the settings that were ordered by the physician. She stated the nurses were responsible for monitoring oxygen settings. She stated it was important to ensure oxygen was worn at the appropriate settings to maintain the resident's respiratory status. She stated not wearing oxygen at the prescribed settings could have caused shortness of breath or respiratory distress. During an interview on 07/16/26 at 1:05 p.m., the Administrator stated she expected the staff to follow the physician orders for oxygen settings. She stated she expected the nursing staff to ensure oxygen was worn as prescribed by the physician. She stated the nursing staff were responsible for monitoring to ensure oxygen was worn at the appropriate settings. She stated it was important to ensure oxygen was worn as prescribed by the physician to provide adequate care according to the resident's needs. Record review of the Oxygen Administration policy, dated October 2010, reflected The purpose of this procedure is to provide guidelines for safe oxygen administration. 1. [NAME] there is a physician's order for this procedure. The nasal cannula is a tube that is placed approximately one-half inch into the resident's nose. it is held in place by an elastic band placed around the resident's head. Check the tubing connected to the oxygen cylinder to assure that is free of kinks. turn on the oxygen. Unless otherwise ordered, start the flow of oxygen at 2 to 3 liters per minute. Adjust the oxygen delivery device so that it is comfortable for the resident and the [NAME] flow of oxygen is being administered.

Based on observation, interview, and record review the facility failed to ensure that laboratory services were obtained to meet the needs of residents for 1 of 22 residents reviewed for laboratory services (Resident #5). The facility did not ensure lab results were obtained for Resident #5 that was exhibiting signs and symptoms of a Urinary Tract Infection. This failure could place residents at risk of not receiving lab services as ordered. Record review of Resident #5's face sheet dated 7/14/26 indicated she was an [AGE] year-old female that admitted [DATE] and readmitted [DATE]. Record review of Resident #5's physician's orders dated 7/14/26 indicated she had diagnoses that included: fracture of right shoulder girdle (break of the bony and muscular ring that attaches the arm to the chest/skeleton), Diabetes Mellitus Type 2 (chronic condition where the body resists insulin or cannot produce enough of it), and Alzheimer's Disease (progressive, irreversible brain disorder that slowly destroys memory, thinking skills, and the ability to carry out simple tasks). The physician's orders indicated: 7/8/26 Urinalysis, UTI Polymerase Chain Reaction Panel Reflex (a rapid molecular urine test that automatically triggers 'reflexes' additional testing such as antibiotic susceptibility testing, only if the initial deoxyribuonucleic acid panel detects specific pathogens or drug-resistance genes). Record review of the quarterly MDS dated [DATE] indicated Resident #5 had clear speech, usually understood others, and was understood by others. She had a BIMS score of 9, indicating moderately impaired cognition. Resident #5 was dependent for toileting hygiene, and required partial to moderate assistance to roll left and right in bed. She was always incontinent of urine and bowel. Record review of Resident #5's care plan dated 1/20/26 indicated she was totally dependent x 1 staff for toileting, had impaired cognition related to Alzheimer's Disease, and Diabetes Mellitus. She had a fractured shoulder. During an observation and interview on 7/13/25 at 9:33 AM, Resident #5 said she took insulin but did not know if she took a blood thinner. Her bed was low and she had enabler bars. She said she had lost some weight because she had stopped eating bread and she was pleased. She had a soda on her bed side table. She had a brace on her left hand and a carrot (a soft rounded device that was placed in the palm to keep the fingers away from the palm) in her right hand. She said staff treated her well and she got help as needed. She denied pain. During an interview on 07/13/2026 at 3:18 PM, the DON said ADON D collected a urine sample for Resident #5 on 7/10/26. She put it in the bucket for the lab to get but somehow it never made it to the lab. They did not follow up until the surveyor asked about it. The DON said the NP ordered an antibiotic for her today. She said the results would have been back today if the sample had not been lost. She said the NP must have ordered an antibiotic today. She said she called the lab a minute ago and they never received the urine. During an interview and record review on 07/13/2026 at 3:45 PM, ADON D said she collected Resident #5's urine sample on 7/10/26. She showed this surveyor a note indicating the urine sample was attempted unsuccessfully on 7/8/26, and was collected 7/9/26 and lab picked it up 7/10/26. LVN C charted the lab picked Resident #5's urine sample up on 7/10/26. The DON said the NP said she had been waiting on the results to come in. She said there was no reason to check on the results before today because it would not have been back until today. The DON said the urinalysis (a diagnostic test that examines the visual, chemical, and microscopic properties of urine) should have been back in 24 hours but not the urine culture (a laboratory test that grows and identifies bacteria or yeast in a urine sample to diagnose a urinary tract infection). She said Resident #5 was being monitored. The NP gave orders for an antibiotic today. The DON said the NP was treating the symptoms. She said the NP did not want another urine sample sent to the lab, it would take time to get back. During an interview on 7/13/24 at 8:04 AM, ADON D said the person responsible for following up on the urine sample/lab would have been the nurse on duty Monday (7/13/26). She said the labs would not have come back until then, but she should have followed up. She said that nurse would have been LVN J. During an interview on 7/14/26 at 8:14 AM, LVN J said she did not follow up on Resident #5's labs. She said she assumed the weekend nurse did because Resident #5 was on an antibiotic yesterday. She said she did not check on the labs Monday (7/13/26) morning. She said she thought the labs should have been back over the weekend. She did not know the urine sample had been lost. During an interview on 07/14/2026 at 10:34 AM, ADON E said Resident #5's urine sample should have been followed up on by the charge nurse the next day (Saturday 11th). She said the charge nurse 7/11/26-7/12/26 was LVN C. If LVN C had called the lab to check on it, she would have found out the sample had been lost. ADON E said she was ultimately responsible for making sure the LVN C had done what she was supposed to. She said she did not follow up on the labs Monday (7/13/26) because state came into the building and she had other things going on. She said she had not gotten to it, yet when state asked about it. She said it was the first thing on her list. Record review of progress notes:7/8/26, LVN J wrote Attempted to collect urine specimen via in and out catheter, unable to get return due to patient just voiding. Will pass on to next shift to try. 7/10/26 LVN C wrote UA sample collected and picked up by lab waiting for results During a telephone interview on 07/14/2026 at 11:35 AM, LVN C said she worked Friday 7/10/26 - Sunday 7/12/26. She said she had written the note on 7/10/26 indicating ADON D had collected the urine sample from Resident #5. She said she saw the lab pick it up. She said she did not call about Resident #5's lab Saturday (7/11/26) or Sunday (7/12/26). Usually once resulted, the Nurse Practitioner or Medical Doctor would look at them in the computer. She said she should have called and checked on the lab result Saturday or Sunday, but it slipped her mind. She did not know the lab never received the urine sample. She saw the lab lady pick up the urine sample. She remembers because she had to rewrite the label before the lab left with it. During an interview on 07/14/2026 at 12:06 PM, ADON D said she collected the urine sample for Resident #5 the night of 7/9/26. The lab picked it up on 7/10/26. She said she put it on the 24-hour report. LVN C knew about it and was there when it was collected. If LVN C had called the lab Saturday (7/11/26) to check on it, and realized they did not have it, they could have collected it again. She said only STAT labs had a 24- hour turn around time. She said Resident #5's labs would not have been back for 48-72 hours. She said if they did not have anything by noon or 2:00 PM on Monday (7/13/26), someone should have called the lab. Sometimes the NP would see the result of the lab before them. The facility and NP get the results at the same time, it flags in the computer system. Record review of the 24-hour reports dated 7/8/26 - 7/12/26 indicated Resident #5's urine sample was collected 7/10/26. There was no other documentation on the 24-hour reports regarding Resident #5's labs or results. During an interview on 07/14/2026 at 2:41 PM, the ADM said she saw on the 24-hour report that Resident #5's UA was collected 7/10/26. That was all she saw in the 24-hour reports dated 7/8/26-7/12/26 regarding anything to do with Resident #5's urine sample going to the lab. During an interview on 7/14/26 at 3:00 PM, the DON said she called the lab today and the lady that picked up the urine sample told her she had delivered it to the lab. No one knows what happened to it. She said when the results of the labs came back it would populate on the Dashboard in PCC (Point Click Care/a computer program) which would be available for staff and the NP to see. During an interview on 07/15/2026 at 8:05 AM, Resident #5 said the burning with urination was so much better now, almost gone. During an interview on 07/15/2026 at 8:55 AM, the Nurse Practitioner said she ordered a Urinary Analysis on Resident #5 when she saw her, she thinks it was 7/8/26. She said knowing [Name of Lab] Lab would not do much on the weekend, she said she checked for the results but did not see them. She said she knew a nurse had collected the urine but did not remember who, because that nurse told her the urine sample was in the cooler to be picked up. She said that particular lab had lost specimens before. She had 3 facilities and all 3 used the same lab. She said Resident #5 was incontinent and had symptoms (burning with urination) of a UTI. Due to her history of Extended-Spectrum beta-Lactamase (a UTI with enzymes produced by certain bacteria that make them resistant to many standard antibiotics), and symptoms she did not want Resident #5 to go septic (a serious condition in which the body responds improperly to an infection. The infection-fighting process turns on the body, causing the organs to work poorly.) Under the circumstances she chose to treat with an antibiotic. During an interview on 07/16/2026 at 7:54 AM, LVN A said for a urine sample sent to the lab, she would check with the lab within 24 hours, or sooner if it was a \ (immediate) lab. She said she would also check the computer to see if the results had uploaded. During an interview on 7/16/26 at 8:06 AM, ADON D said follow up on a lab result was important to keep a resident from getting worse if they were sick. She said a STAT lab would be followed up by a nurse in 24 hours and a non-stat would be followed up on in 72 hours. She said staff would monitor the resident's signs and symptoms and call the NP with any changes. During an interview on 07/16/2026 at 10:39 AM, the ADM said the nurse should follow up on a resident's labs within 24 hours. She did not know if the lab was open on weekends. She said if labs were not followed up on in a timely manner that could mean inadequate care for the residents. The ADM said they were going to follow up on Resident #5's labs Monday (7/13/26) morning, but surveyors came in the building. Record Review of a Lab and Diagnostic Test Results Policy provided by the ADM, with a revision date of November 2018 indicated: Procedure.4.Licenses nurse reviews labs/diagnostic results and notification is made to the physician/physician extender with documentation in the progress notes.9. Provider orders and follow-upa. Implement any new orders from the provider based on resultsb. Document intervention and resident responsec. Schedule repeat labs if indicatedd. Physician's office is to be notified daily until there is a response and document

Based on interviews and record reviews, the facility did not ensure a resident with pressure ulcers received necessary treatment and services, consistent with professional standards of practice, to promote healing for 1 of 3 residents reviewed for pressure injuries (Resident #1). The facility did not ensure Resident #1 received his ordered wound care on the following dates and shifts; 4/24/26 on the pm shift; 5/1/26 on the pm shift; 5/2/26 on the am shift; and 5/3/26 on the pm shift after returning from the hospital for surgical debridement of his Stage IV pressure injury to the right hip. This failure could place Resident's with pressure injuries at risk for infection and wound deterioration.Findings included: Record review of Resident #1's face sheet indicated he was [AGE] years old re-admitted to the facility on [DATE]. The face sheet revealed Resident #1 was originally admitted to the facility on [DATE] on with diagnoses including chronic osteomyelitis with draining sinus (a persistent, long-term infection and inflammation of the bone, often leading to bone destruction, often requiring surgery and prolonged antibiotics- draining sinus is severe complication of chronic bone infection, where a persistent channel forms from infected bone through soft tissue to the skin, releasing pus) of the right femur (thigh bone), chronic osteomyelitis of the left femur, incomplete quadriplegia (spinal cord injury above the thoracic spine who retains partial motor function or sensation below the injury site), and a stage IV pressure injury of the right hip. Record review of the admission MDS assessment dated [DATE] revealed Resident #1 had clear speech, made himself understood and understood others. The MDS indicated Resident #1 was cognitively intact with a BIMS score of 13. The MDS indicated Resident #1 had no behavior of rejecting care. The MDS indicated Resident #1 was dependent on staff for toileting, showering, dressing the lower body, putting on and removing footwear. The MDS indicated Resident #1 required partial/ moderate assistance with personal hygiene. The MDS indicated Resident #1 indicated Resident #1 required substantial/maximal assistance with dressing the upper body, but required setup/clean-up assistance only with eating and oral hygiene. The MDS indicated Resident #1 had an indwelling catheter and ostomy (including ileostomy, colostomy). The MDS identified Resident #1 had 1 unhealed stage III pressure injury present on admission and 1 unhealed Stage IV pressure injury present on admission. The MDS indicated Resident #1 had pressure reducing device for his bed, pressure injury/ulcer care and the application of ointments/medications for pressure injury treatment. Record review of the care plan revised on 3/23/26, detailed that Resident #1 had a stage IV pressure injury to the right hip. Care plan interventions included administer treatments as ordered and monitor for effectiveness. The care plan also detailed Resident #1 had a stage III pressure injury to the coccyx (commonly known as the tailbone). Record review of the physician order with a start date of 4/21/26 and discontinue date of 4/29/26 indicated Resident #1 was to receive wound to the right hip pressure ulcer as follows: Dakins (1/4 strength) external solution 0.125% (Sodium Hypochlorite) Apply to right hip topically two times a day for wound healing right hip pressure ulcer (stage4); cleanse with wound cleanser, pack with dakins moistened, fluffed gauze, apply skin prep to surrounding skin, cover with superabsorbent dressing. Record review of the active physician order with a start date of 4/29/26 indicated Resident #1 was to receive wound care to the right hip pressure ulcer as follows: Cleanse with wound cleanser, pack with vashe moistened, fluffed gauze, apply skin prep to surrounding skin, cover with superabsorbent dressing every shift for wound healing. Record review of the wound care progress note dated 3/10/26 documented Resident #1 Stage III pressure injury to the tail bone measured 0.5 cm in length by 1 cm in width by 0.2 cm in depth. The wound care progress note documented the Stage IV pressure injury to the right hip as measuring 4.5 cm in length by 2.5 cm in width and 0.2 cm in depth. This note was completed by Wound Care provider NP E. Record review of the wound care progress note dated 3/18/26 indicated the Stage III pressure injury to the tailbone had resolved. The note stated Coccyx PU: Resolved. Resident wound has resolved. Resolved wounds do not achieve their original tensile strength. It is possible for wounds to recur despite proper care and interventions. This note was completed by Wound Care provider NP E. Record review of the nursing progress note dated 4/7/26 documented Resident #1's Stage IV pressure injury 4.5 cm in length, 2.5 cm in width, and 2.4 cm in depth. Record review of the nursing progress note dated 4/13/26 documented NP E and NP F were notified Resident #1's Stage IV pressure injury had appearance changes and were in agreement to send Resident #1 to the hospital for further evaluation. Record review of the nursing note progress noted dated 4/20/26 at 9:09 p.m. indicated Resident #1 had returned from the hospital stating Resident arrived via (ambulance) transportation. Record review of the wound assessment report dated 4/21/26 detailed Resident #1's stage IV pressure injury to the right hip measured 5 cm in length by 9 cm in width and 3 cm in depth. The assessment was completed by NP E. During an interview on 5/5/26 at 11:00 a.m., Resident #1 said he received a surgical debridement of his wound at the hospital. He said he had history of pressure wounds and osteomyelitis in both his right and left legs. Resident #1 said he even had to have some bone removed from the right hip in the past. Resident #1 said since he returned from the hospital (on 4/20/26), he had not received wound care twice a day like he was supposed to. He said he could not say exactly how many days he had not received twice a day wound care, but stated it was more than three times. Record review of the Resident #1's April 2026 MAR/TAR reflected he missed wound care on the pm shift of 4/24/26. Record review of the Residents #1's May 2026 MAR/TAR reflected he was not provided wound care on the following dates and shifts;*5/1/26 on the pm shift;*5/2/26 on the am shift; and*5/3/26 on the pm shift. Record review of Resident #1's nursing progress notes dated April - May 2026 indicated Resident #1 was provided care by the following nurses on the following shifts; *4/24/26 on the pm shift - LVN A*5/1/26 on the pm shift- LVN G*5/2/26 on the am shift - LVN H*5/3/26 on the pm shift- LVN I. During an observation on 5/6/25 at 11:30 a.m., RN B performed wound care to Resident #1's Stage IV pressure injury to the right hip. The wound bed was bright red and had scant amount of light yellow slough (soft, moist, stringy, or viscous necrotic tissue, typically pale yellow, tan, or white, that forms on a wound bed as a byproduct of the inflammation phase), no foul odor was noted. The wound measured 6.2 cm in length 8.5 centimeters in width with a depth of 0.5 cm. During an interview on 5/6/26 at 3:00 pm, NP E said Resident #1's pressure wound was unavoidable. NP E said Resident #1 had a long history of osteomyelitis and history of bone removal. NP E said he admitted with the Stage IV wound and also had a Stage III to the sacrum on admission that had been resolved at that time. NP E said it was likely Resident #1 would have incomplete healing and recurrence of wounds. NP E said it was important for nurses to provide ordered wound care for maximum benefit. During an interview on 5/6/26 at 3:47 pm, NP F said Resident #1's pressure wound was unavoidable. NP F said it was unlikely that Resident #1's pressure injury would not heal for any significant length of time, and the possibility of new wounds was likely due to his complex medical diagnoses including chronic osteomyelitis. Record review of the progress note dated 5/1/26 at 5:53 pm documented Resident #1 had just returned from outpatient wound care. During an interview on 5/7/26 at 11:03 am, LVN H said she was a contracted staffing agency nurse that regularly worked at the facility. LVN H said she did remember Resident #1 asking her to look at his wound and change the dressing. LVN H said she asked another nurse to come with her to do the dressing change. LVN H said the nurse was busy and never assisted her and she forgot to return and look at the dressing herself, but said Resident #1 never got back on his call light about it. LVN H said she did not recall having wound care scheduled on her shift. During an interview on 5/7/26 at 4:00 p.m. at 3:50 p.m ., the DON said she expected nurses to perform wound care as ordered. The DON said the ADON J was the wound care nurse and quit without notice on 5/5/26. The DON said, until that [NAME], ADON J was providing wound care Monday through Friday during business hours. The DON said any ordered care on the weekends or night shift was to be performed by the charge nurses. The DON said the facility was working to reduce the use of staffing agency nurses. The DON said the facility was actively hiring and offering incentive bonuses. A follow up interview was attempted on 5/7/26 at 12:00 p.m. with LVN A over the phone but was not completed due to no answer. Record review of the facility's policy and procedures titled, Wound Care, revised October 2010, stated, the purpose of this procedure is to provide guidelines for the care of wounds to promote healing. Verify that there is a physician's order for this procedure. Documentation, The following information should be recorded in the resident's medical record: (1)The date the wound care was given. (2) The initials of the individual performing the wound care. (3) Any change in the resident's condition. (3) Any problems or complaints made by the resident related to the procedure. (4) If the resident refused the treatment and the reason(s) why. (5) The signature and title of the person recording the data.

Based on interviews, record reviews, and observations, the facility did not administer parenteral fluids consistent with professional standards of practice and in accordance with physician orders, the comprehensive person-centered care plan, and the resident's goals and preferences for 1 of 2 residents reviewed for parenteral fluids (Resident #1). The facility failed to ensure Resident #1's PICC (peripherally inserted central catheter, is a long, thin, flexible tube inserted through a vein in the upper arm and guided into a large vein near the heart or just inside the heart) line dressing was changed at least every seven days. This failure could place residents receiving fluids or medications through a PICC line at risk of systemic infection. Findings included;Record review of Resident #1's face sheet indicated he was [AGE] years old re-admitted to the facility on [DATE] (originally admitted to the facility on [DATE]) with diagnoses including chronic osteomyelitis (a persistent, long-term infection and inflammation of the bone, often leading to bone destruction, often requiring surgery and prolonged antibiotics) of the right femur (thigh bone) and chronic osteomyelitis of the left femur. Record review of the care plan revised on 4/30/26 revealed the care plan did not address Resident #1's PICC line access. Record review of the hospital outpatient antibiotic infusion routine orders dated 4/20/26 indicated Resident #1 was to be administered Intravenous (within a vein- refers to the administration of fluids, medications, or nutrients directly into a patient's bloodstream through a needle or tube) piperacillin tazobactam (an antibiotic medication) 4.5 grams every 8 hours through 6/9/2026. The order indicated Resident #1 had a PICC line stating .PICC/midline Care weekly and prn (as needed). Record review of Resident #1's physician order summary report dated 5/5/26 revealed no orders for PICC line dressing changes. Record review of the Resident#1's MAR/TAR for April 2026 revealed no indication there had been any PICC line dressing changes performed. Record review of the Resident#1's MAR/TAR for May 2026 did not indicate there had been any PICC line dressing changes performed from 5/1/26 to 5/6/26. During an observation and interview on 5/5/26 at 11:00 a.m., Resident #1 laid in his bed. Resident #1 had a clear dressing to the anterior portion of the right upper arm dated 4/20/26. Resident #1 said he had the dressing since he went to the hospital. During an observation and interview on 5/5/26 at 1:13 pm, Resident #1 laid in his bed. Resident #1 had a clear dressing to the anterior portion of the right upper arm dated 4/20/26. A line insertion was visible under the clear dressing. Resident #1 said the dressing was placed during his most recent hospital stay. Resident #1 stated the dressing had not been changed since being re-admitted to the facility. During an observation and interview on 5/5/26 at 1:13 pm, Resident #1 laid in his bed. Resident #1 had a clear dressing to the anterior portion of the right upper arm dated 4/20/26. A line insertion was visible under the clear dressing. Resident #1 said the dressing was placed during his most recent hospital stay. Resident #1 stated the dressing had not been changed since being re-admitted to the facility. During an interview on 5/5/26 at 1:17 p.m., LVN A said she was caring for Resident #1. LVN A said she was staffing agency nurse and worked regularly at the facility. LVN A said she did not know if Resident #1's intravenous line was a standard peripheral IV or a PICC line (a standard IV is inserted into a shallow vein and has a short catheter, in contrast a PICC line is peripherally inserted midline catheter, the catheter is much longer and goes all the way up to a vein near the heart or just inside the heart). LVN A said she would have to look at his chart to check. During an observation on 5/6/26 at 9:15 a.m., Resident #1 laid in his bed. Resident #1 had a clear dressing to the anterior portion of the right upper arm dated 4/20/26. Resident #1 said he had the dressing since he went to the hospital. During an observation on 5/6/26 at 1:00 p.m., Resident #1 laid in his bed. Resident #1 had a clear dressing to the anterior portion of the right upper arm dated 4/20/26. Resident #1 said he had the dressing since he went to the hospital. During an interview on 5/6/26 at 1:15 p.m., RN B said PICC line dressing changes should have a sterile dressing change every 7 days as needed. RN B said if an as needed change needed to be performed, that dressing would be dated and the next dressing change would be performed 7 days from that date. RN B said it was important for PICC line dressing changes to be performed every seven days to reduce the risk of infection. RN B said PICC line infections could be very serious because they were central line catheters. RN B said she was not caring for Resident #1 today but had taken care of him since his return from the hospital on 4/20/26. RN B said she had not performed a PICC line dressing change on Resident #1. RN B said it must have not been time for the dressing change when she cared for him. RN B said the PICC line dressing changes would show up on the nursing MAR or TAR for the Resident when it was time for it to be done. During an interview on 5/6/26 at 1:28 pm, LVN C said she had not taken care of Resident #1 since he had been back from the hospital. LVN C said she thought PICC line dressing changes needed to be done every 24 hours but was not sure. LVN C said she had not taken care of a resident with a PICC line since she started working at the facility at the end of January. During an interview on 5/6/26 at 1:40 p.m., LVN D said she was contracted agency nurse and had worked at the facility in the past. LVN D said she was taking care of Resident #1 today, and it was her first shift at the facility in six months. LVN D said PICC line dressing changes needed to be done every 3 days. LVN D said she was not sure if Resident #1 had a PICC line and would have to look in his chart. During an interview on 5/6/26 at 4:00 p.m. the DON said PICC line dressings were to be changed every 7 days. The DON said there was an order set associated with PICC line dressings that the admitting nurse should have entered when Resident #1 was admitted from the hospital with a PICC line. Record review of the facility's policy and procedure dated 11/1/25, titled Medication Administration -Intravenous Therapy, stated .Purpose-to ensure safe, effective, and standardized intravenous (IV) therapy and medication administration via Peripheral IVs, Midline Catheters, and PICC Lines in accordance with facility standards and regulatory requirements. The policy and procedure did not address the frequency or procedure for PICC line dressing changes. During an interview on 5/7/26 at 2:30 p.m., the Administrator said the facility had no additional policy and procedure pertinent to PICC lines. The CDCs Intravascular Catheter-related Infection (BSI) Prevention Guidelines accessed at, https://www.cdc.gov/infection-control/hcp/intravascular-catheter-related-infections/summary-recommendations.html , stated. Replace dressings used on short-term CVC (central vascular catheters[includes PICC lines]) sites at least every 7 days for transparent dressings, . replace dressings used on short-term CVC sites every 2 days for gauze dressings.

Based on observation, interview and record review the facility failed to ensure residents environment remained as free of accident hazards as possible and each resident received adequate supervision and assistance devices to prevent accidents for 4 of 8 residents (Resident #38, Resident #17, Resident #110, and Resident #35) reviewed for accidents and supervision. 1.The facility failed to put interventions in place to keep Resident #38 from all harmful items. *On 02/18/24, LVN E documented Resident #38 was on the floor, face down with the call light cord wrapped around her neck x4. No harmful items were removed after the incident, from Resident #38's room to ensure her safety. *On 03/09/24, CNA S reported Resident #38 was stabbing herself in the abdomen with scissors. CNA S removed the scissors from Resident #38 put no other actions were initiated until later. The facility failed to put interventions in place to keep Resident #38 from harming herself after reported self-harming behaviors. *The facility did not immediately initiate 1:1 monitoring after self-harming incident on 03/09/24. The facility classified Resident #38's incident on 02/18/24 as a fall and shortened her call light and placed a fall mat bedside her bed. *The facility did not ensure Resident #38 was seen after a counseling evaluation and treatment ordered was placed on 02/15/24 and a psych evaluation referral was signed by Resident #38 on 03/04/24. The facility failed to follow their Suicide Threat policy after incidents on 02/18/24 and 03/09/24. Resident #38 was left alone after self-harmful behaviors was witnessed and reported. The facility failed to in-service staff of Suicide Prevention after Resident #38's reported self-harming behavior on 03/09/24. LVN R was the only staff member documented on in-service roster. 2. The facility failed to transfer Resident #17 in safe manner by her care planned needs. Resident #17 was transferred by CNA A without a gait belt which resulted in fall causing back pain requiring x-rays. 3. CNA A transferred Resident #110 without a gait belt resulting in laceration to the back of his head. 4. CNA B transferred Resident #35 with a Hoyer lift by herself resulting in a bruise to her left forearm. An Immediate Jeopardy (IJ) situation was identified on 03/28/24 at 3:45 p.m. While the IJ was removed on 3/29/24 at 12:41 p.m. p.m., the facility remained out of compliance at a scope of a pattern with a potential for with a potential for more than minimal harm, due to the facility's need to evaluate the effectiveness of the corrective systems. These deficient practices could place residents at risk to physical harm and could lead to additional pain and suffering. Findings include: Record review of Resident #38's face sheet printed 03/25/24 indicated Resident #38 was a [AGE] year-old, female and admitted on [DATE] with diagnoses including transient cerebral ischemic attack (is a temporary blockage of blood flow to the brain), hemiplegia (paralysis of one side of the body) and hemiparesis (is a mild or partial weakness or loss of strength on one side of the body) following cerebral infarction (also known as an ischemic stroke, is the pathologic process that results in an area of necrotic tissue in the brain) affecting left non-dominant side, anxiety disorder (a mental health disorder characterized by feelings of worry, anxiety, or fear that are strong enough to interfere with one's daily activities), and depression (is a mood disorder that causes a persistent feeling of sadness and loss of interest). Record review of Resident #38's quarterly MDS assessment dated [DATE] indicated Resident #38 was understood and understood others. The MDS indicated Resident #38 had adequate hearing, clear speech, and adequate vision. The MDS indicated Resident #38 had a BIMS score of 13 which indicated intact cognition. The MDS indicated Resident #38 did not have behaviors such as psychosis or physical or verbal behavioral symptoms. The MDS indicated Resident #38 rated going outside to get fresh air when the weather was good as not very important. The MDS indicated Resident #38 upper extremity limitation in range of motion on one side of the body. The MDS indicated Resident #38 admission performance requirement was maximal assistance for putting on footwear, lower body dressing, and toilet hygiene and moderate assistance for oral hygiene, shower/bathe self, upper body dressing, and personal hygiene. The MDS indicated Resident #38 received antianxiety and antidepressant medication during the last 7 days of the assessment period. Record review of Resident #38's care plan dated 03/09/24, edited on 03/11/24 indicated CNA stated that Resident #38 expressed thoughts of harming self: Resident #38 was in her room with a pair of scissors, and it appears that she was trying to stab herself. Resident #38 stated that she had never thought of anything like that. And she was upset that the CNA even thought that. Interventions created on 03/11/24 included: *Nurse assessed residents' abdomen, and there are no signs of resident trying to stab herself such as redness, discoloration, and marks. *Telemed visit conducted with NP GG- Local Counseling Provider and recommendation made to discontinue 1:1 supervision and suicide precaution on 03/11/24. *Notify MD/RP of suicidal ideations. *Nurse to assess mood and behaviors every shift and document findings. *Provide 1:1 supervision to resident, document every 15 minutes checks during 1:1, Resident to remain on 1:1 until psych provider clears suicidal ideations, discontinued 3/11/24 post psych consult with Local Counseling Provider *Remove all sharp items from room, call light cord, curtains, blinds, phone charger, etc. Provide bell/alternate call light system to resident. Hang sheet over window for privacy. *Resident engages in audiobooks and enjoys listening to Bible app. She enjoys playing on her cell phone and enjoys television. Denies need for activity supplies in room. States she has plenty to do. *Resident #38 was interviewed by the nurse and Resident stated that she would never harm herself that she does not know why the CNA would even say anything like that. Resident #38 was Ax3-4 with a BIMS 15. *Social services to assess mood and behavior and document findings. Record Review of Resident #38's care plan dated 02/14/24, edited on 03/18/24 indicated Resident #38 was at risk for falls due to Hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side. Falls: 02/17/24: Resident #38 had an unwitnessed fall from her bed with no injury. Intervention edited on 03/18/24 included therapy screen, maintenance to shorten call light string, staff to ensure call light is untangled and within reach. Monitor for delayed injuries, may have fall mat at beside while in bed. Record review of Resident #38's progress notes by LVN L dated 02/15/24 at 1:45 p.m., indicated .received psych orders to eval and treat from NP HH . Record review of Resident #38's progress notes by LVN E dated 02/18/24 at 6:29 a.m., indicated .sn [LVN E] noted resident in floor face down in right side of bed with call light wrapped around neck 4 times .sn [LVN E] asked resident what happened resident stated she trying to get call light undone and kept wrapping it around and somehow fell .no injuries noted .no abnormalities/deformities noted .sn [LVN E] and cna assisted resident back to bed via Hoyer lift .prn pain pill administered po .residents son notified .don notified .NP notified by fax .neuros initiated .edited by: LVN E on 02/19/24 10:04 AM Reason: Incorrect data . Record review of Resident #38's progress notes by LVN E dated 02/18/24 at 6:29 a.m., indicated .sn [LVN E] noted resident in floor face down in right side of bed tangled in call light .sn [LVN E] asked resident what happened resident stated she trying to get call light undone and kept wrapping it around and somehow fell .no injuries noted .no abnormalities/deformities noted .sn [LVN E] and cna assisted resident back to bed via Hoyer lift .prn pain pill administered po .residents son notified .don notified .NP notified by fax .neuros initiated . Record review of Resident #38's progress notes by SW dated 03/04/24 at 12:07 p.m., .Resident #38 stated she is having a hard time with her new discharge plan of long-term care but has not desire to leave the facility .SW discussed a referral to local counseling provider .Resident #38 agreed to the referral . Record review of Resident #38's progress notes by DOCR dated 03/09/24 at 9:20 a.m., indicated .this nurse was told by CNA [CNA S] that she caught this resident with a pair of scissors, and that she wanted to commit suicide .this nurse went right away to ask the resident about the scissors .resident stated I [Resident #38] found them in the drawer, and the aide walked in and said you will not commit suicide in this room! .And I [Resident #38] told her why would I ever do something like that, I wouldn't even think about killing myself .I [Resident #38] found these in the drawer and I don't know where they came from .they could have been here before they moved me in this room .the aide took them but I don't what she did with them . Record review of Resident #38's progress notes by Interim DON dated 03/09/24 at 3:20 p.m., indicated .during rounds visited with resident, resident pleasant and no complaints .mentioned she had an issue this morning .she reported that CNA [CNA S] took her scissors and she didn't know why .CNA [CNA S] told resident [Resident #38] that she had a recent suicide in her family and that is why her awareness is heightened .resident reported that she is going to go to the long term care side of the building soon and its going to be an adjustment for her . Record review of Resident #38's progress notes by LVN R dated 03/09/24 at 11:38 a.m., indicated .8:30 am .CNA [CNA S] reported to this nurse [LVN R] that found Resident [Resident #38] in her room with a pair of scissors and it appeared that she was trying to stab herself .CNA [CNA S] stated that she grabbed the scissors from the Resident and asked what are you doing? .and Resident [#38] stated I [Resident #38] was trying to kill myself .CNA [CNA S] gave the pair of scissors to this nurse [LVN R] .the nurse went into Residents [#38] room to interview her to get her side of the story .resident [#38] stated she did not try to stab herself, and that she would never try to kill herself and that she does not have the guts to do that .DOCR went in to get a statement from resident and resident told her the same thing, that she would not ever try to kill herself . Record review of Resident #38's progress notes by LVN R dated 03/10/24 at 9:12 a.m., indicated .no suicidal remarks or attempts made or reported this shift .Resident [Resident #38] appears to be in pleasant mood this shift . Record review of Resident #38's progress notes by LVN JJ dated 03/10/24 at 10:30 p.m., indicated .resident [Resident #38] placed on 1:1 per Interim DON due to self-harm behaviors on 03/10/24 .sitter has been present to ensure resident safety .at this time patient denies any current thoughts or urges to self-harm . Record review of CNA S written statement dated 03/09/24 at 7:56 a.m., indicated .I went in room [ROOM NUMBER] to pick up her [Resident #38] breakfast tray and the resident was stabbing at her stomach with some scissors .I called her name and she threw them in the drawer and put her foot up to it so I couldn't get them, I told her I had to take them because we can't have them up here .she [Resident #38] stated well if it was a knife I could have cut my throat .I said I have to let the nurse know you're talking like this . she stated well if you tell on me I'm going to say you are mean to me .I told her I can't let her hurt herself and I got the scissors out the drawer .took them to the nurse and let her know what happened . Record review of an undated and untimed statement by the Interim DON (provided after entry on 03/27/24) indicated, .On 03/09/24 during rounds visited with resident [Resident #38], resident pleasant and no complaints .mentioned she had an issue this morning .she reported CNA [CNA S] took scissors and she [Resident #38] did not know why . on Sunday 03/10/24 afternoon, I [Interim DON] read in Matrix nurse notes that agency nurse [LVN R] documented that resident attempted suicide with scissors . Record review of Resident #38's local counseling service provider prepared by SW, dated 03/04/24 indicated .reason for referral: depressive symptoms and anxiety .referral/treatment consent form and doctor's order need to be completed PRIOR TO provision of services and COPY OF EACH FAXED to .Corporate Office .along with a current face sheet .please assure there is an order reads similar to: Please refer to .Evaluation and Treatment . During an interview and observation on 03/25/24 at 10:55 a.m. Resident #38's room was dark and quiet. Resident #38 said she had no complaints about the facility, and nothing had happened in her bathroom recently. No fall mat at bedside. During an interview and observation on 03/26/24 at 11:04 a.m., Resident #38's room was dark and quiet. Fall mat noted on left side of the bed. Resident #38 said the facility added it yesterday because she had a little incident and fell out of the bed. She said the fall mat was something soft in case she fell out of the bed again. She said it had been a bad morning that day. She said CNA S had found her in the wheelchair headed out the room not properly dressed. She said she did not attempt suicide with scissors. She said she was reaching for her hairbrush in the nightstand drawer and picked up the scissors instead. She said CNA S asked why she had the scissors and she told her she found them in the drawer. She said she did suffer depression and anxiety but was on medication for it. She said she really missed her dog. She said her dog was a certified support dog and wanted to have at the facility full time. During an interview on 03/26/24 at 4:45 p.m., CNA S said she was picking up lunch trays and looked in Resident #38's room and saw her stabbing at her stomach with scissors. She said she asked her what she was doing, and she threw the scissors in the drawer. She said Resident #38 said If it was a knife, I would have been able to cut my throat with it! She said Resident #38 put her foot up against the drawer so she could not get the scissors. She said she told Resident #38 she had to get the scissors and had to let the nurse know what was going on. She said Resident #38 said If you tell on me, I will say you hurt me! She said Resident #38's foot slipped from the drawer enough for her to get the scissors. She said she took the scissors to LVN R. She said LVN R said she would take care of it. She said she went to finish picking up trays and heard Resident #38 with probably her son telling him I rammed her knee in the bathroom. She said she went back to the nurse's station to ask LVN R to go to Resident 338's room and talk to her. She said LVN R said she would. She said she took the trays to the dining room and wrote her statement about the incident. She said she saw the DOCR and told her about Resident #38 having the scissors. She said the DOCR asked her if someone was sitting 1:1 with Resident #38 and I told her, No. She said the DOCR went to LVN R and asked her why Resident #38 was alone. She said LVN R told the DOCR, she had spoken with Resident #38 and denied trying to stab herself with scissors. She said Resident #38 was probably left alone for 20-30 minutes because she gave a bath and got linen before she saw the DOCR and told her about the scissors. She said Resident #38 had made other comments about hurting herself before. She said on 03/09/24, Resident #38 did not have 1:1 supervision but staff members were going in and checking on her. She said Resident #38 probably should not have been left alone in case she really tried to harm herself. She said she told LVN R so she felt like she should have start everything like 1:1 monitoring immediately. During an interview on 03/27/24 at 10:04 a.m., a family member of Resident #38 said he had been informed of his family members voiced suicide attempts. He said when Resident #38 got out the back door on 03/03/24 without permission, she later texted him saying she wanted to walk into traffic. He said he thought he told the case worker Resident #38 made that statement. He said Resident #38 did not have a history of suicidal ideations. He said his family member wanted to come home, but he could not care for her anymore. During an interview on 03/27/24 at 11:27 a.m., the DOCR said CNA S saw her in the hallway and told her after breakfast, Resident #38 had scissors and would be mad she reported to her what happened. She said she went into Resident #38's room and she denied allegation of harming herself and having scissors. She said LVN R was at the LVN R was at the nurse's station when she got on the hall to talk to Resident #38. She said when she headed towards Resident #38's room, LVN R followed her. She said Resident #38 was alone when she went into her room to talk to her. She said after she finished talking to Resident #38 about the incident with CNA S, she left for the day, called the Interim DON and she showed. She said she did not know the exact time the Interim DON arrived at the facility. She said the Interim DON lived about 3 hours away from the facility. During an interview on 03/27/24 at 11:39 a.m., the SW said Resident #38 was anxious and depressed when she first admitted to the facility. She said she was initial supposed to go back home but changed plan and she was staying for long term care. She said Resident #38 had some adjustment issues but was on medication and psych services. She said Resident #38's family member never reported to her about her texting him she wanted to walk into traffic. She said Resident #38's family had reported attention seeking behaviors like constantly calling and how she had ruined relationships with her behavior. She said Resident #38 family member said Resident #38 would not harm herself, it was just attention seeking and she would not do it. She said she was not notified of the incident on 03/09/24 until Monday, 03/11/24, when she returned for work. She said she assessed Resident #38 on 03/11/24 and she did not make any comments of self-harm. During an interview on 03/27/24 at 12:00 p.m., the Interim DON said she did not know where the 1:1 monitoring documentation paperwork was. During an interview on 03/27/24 at 12:59 p.m., LVN R said she was agency staff but had worked with Resident #38 often. She said Resident #38 had never told her she was depressed. LVN R said she went to speak to Resident #38 after CNA S brought her the scissors and told her Resident #38 tried to harm herself with them. She said CNA S told her she took the scissors from Resident #38 and asked her what she was doing. She said the first time, CNA S said Resident #38 said I don't know or I'm not doing anything. She said she went to speak with Resident #38, and she said CNA S was mad at her because she did not want to assist her to the restroom. She said Resident #38 said she would never harm herself or have the guts to do it. She said she assessed Resident #38's stomach and there were no marks or anything. She said Resident #38 tried to call her family member. She said she tried to call Resident #38's family member also. She said later, her and DOCR went to talk to Resident #38. She said Resident #38 said CNA S may have been frustrated when she took her to the bathroom and did not ram her knees on purpose. She said the Interim DOB showed up and spoke with Resident #38. She said the Interim DON told CNA S to apologize to Resident #38. She said Resident #38 was left alone after the incident, but she was checked on frequently. She said she worked until 6pm on 03/09/24. She said 1:1 monitoring for Resident #38 was started on 03/10/24. During an interview on 03/27/24 at 1:34 p.m., the Interim DON said she went to Resident #38's room on 03/09/24 and she said CNA S took her scissors and accidently bumped her knee. She said she did speak with LVN R, but LVN R never mentioned to her Resident #38's self-harming incident. She said the DOCR did not call her on 03/09/24. During an interview on 03/28/24 at 8:40 a.m., LVN E said on 02/18/24, Resident #38 fell out of her bed. She said Resident #38 said she was trying to get the call light cord and rolled out of the bed. She said Resident #38 did have the cord wrapped around her neck four times when she found her. She said there were no marks on Resident #38 neck after the fall. She said she did not modify her nursing note to state tangled instead of wrapped around neck. She said she believed what Resident #38 said because she was confused, and her room was dark when she arrived. She said she did not think Resident #38 was trying to harm herself. She said she did not know what interventions were put in place after that incident on 02/18/24 because she was agency staff then. She said it was ruled a fall so nothing was taken from her room or 1:1 monitoring done. During an observation on 03/28/24 at 9:00 a.m., Resident #38 was lying down in a dark room asleep. During an interview on 03/28/24 at 4:30 p.m., the SW said the psych treat and evaluation order placed on 02/15/24 was done without a discussion between the morning meeting. She said normally referrals were discussed between her and NP HH. She said then the referral was sent by fax or email to the local counseling provider. She said she preferred doing it by email. She said on 03/04/24, she did a well check and got consent for an evaluation. She said the local counseling provider normally took less than 3 weeks to see residents for services. She said telehealth could be used if needed for some residents. She said medication management was normally done by NP GG. And a Psychologist normally did the evaluations. She said the facility had a licensed counselor that served the facility. She said she did not believe the delay in psych service contributed to Resident #38's self-harming incidents. She said Resident #38 just wants to go home. On 03/29/24 at 9:46 a.m., attempted to contact NP HH by phone and text message. No response before or after exit. During an interview on 03/29/24 at 12:19 p.m., the interim DON said she was not aware of Resident #38's incident on 02/18/24. She said it looked like they tried to cover it up. She said she was also not aware of Resident #38 telling her son she wanted to walk into traffic. She said the Suicide policies should have been followed for Resident #38's incidents. She said the Suicide policies were not new and staff had been re in serviced. She said harmful items should have been removed from Resident #38's room until she was assessed. She said she expected nurses to document every 4 hours and CNAs every 15 mins when the resident is being monitored. She said Resident #38 was able to be seen on Telemed by NP GG who determined she could come off 1:1 monitoring. She said the psych referral process had always been the same and the SW was terminated for not completing them social service duties. She said it was important to take all reports of threats seriously and addressed right way to prevent something from happening. During an interview on 03/29/24 at 12:21 p.m., the Interim ADM said all suicide threats should be taken seriously. He said he expected staff to address the suicide threat or attempt immediately and follow the facility's policies. He said harmful items should be removed from the resident's room and monitoring done. He said it was to keep the resident safe. Record review of an undated facility's in-service Suicide Prevention Program revealed LVN R signature. Record review of a facility's Suicide Threats policy revised 12/07 indicated .resident suicide threats shall be taken seriously and addressed appropriately .staff shall report any resident threats of suicide immediately to the nurse supervisor/charge nurse .the nurse supervisor/charge nurse shall immediately assess the situation and shall notify the Charge nurse/Supervisor and/or Director of Nursing Services of such threats .all staff member shall remain with the resident until the nurse supervisor/charge nurse arrives to evaluate the resident . Record review of a facility's Mandatory Notifications policy revised 02/25/23 indicated .employees must immediately notify the facility Administrator and DON if any of the following events occur .resident with suicidal ideations, suicide attempts . Record review of an undated facility's Suicidal Precaution Management policy indicated .if a resident, who is voicing suicidal thoughts or attempts suicide, is a danger to self or others .physician, psychiatrist/counselor/psychologist, and family are notified immediately .referral is made at this time .suicide precautions are implemented immediately if resident is deemed to be threat to themselves or others .suicide precautions will be implemented immediately for any resident that presents with a significant level of depression or suicidal preoccupation and will be used to address the risk factors .suicide precautions include .one on one supervision .call light removed .if available, a wander device is placed on the patient's wrist or ankle .a licensed nurse will assess the resident at least every four hours and document the assessment .record that the resident as checked every fifteen minutes . Record review of an undated facility's Processing Psych Referrals policy indicated .nurse receives order for psych referral and enters matrix order .nursing to notify social services of needed referral and discuss in daily C.A.R.E meeting to ensure need for referral is communicated .social services will complete referral form/consents as required for psych referral and submit to psych provider in a timely manner .social services to follow up on resident until psych provider visit is made . 2. Record review of Resident #17's face sheet printed 03/25/24 indicated Resident #17 was [AGE] year-old, female and admitted on [DATE] with diagnosis including wedge compression fracture of first lumbar vertebra (this fracture usually occurs in the front of the vertebra, collapsing the bone in the front of the spine and leaving the back of the same bone unchanged, which results in the vertebra taking on a wedge shape). Record review of Resident #17's admission MDS assessment dated [DATE] indicated Resident #17 was understood and understood others. The MDS indicated Resident #17 had a BIMS score of 12 indicated moderate cognitive impairment. The MDS indicated Resident #17 was dependent for putting on footwear, lower body dressing, and toilet hygiene, maximal assistance for shower/bathe self, moderate assistance for oral hygiene and upper body dressing, and supervision for personal hygiene. The MDS indicated Resident #17 was dependent for toilet transfer, chair/bed-to-chair transfer, and sit to stand. Record review of Resident #17's care plan dated 01/31/24, edited on 03/19/24 indicated ADLs Functional Status/Rehabilitation Potential: About Me, My name is [Resident #17], I speak only Spanish and I can understand some English. I require two people to help me transfer. Intervention included Resident #17 needed assist with all transfers related to my diagnosis. Record review of Resident #17's care plan dated 07/28/23, edited on 03/18/24 indicated Falls: 03/11/24: Resident #17 had a fall during transfer. Intervention included in-service CNA [CNA A] to always use a gait belt during transfer and lock the wheelchair prior to transferring the resident. Record review of Resident #17's progress notes by LVN J on 03/11/24 at 8:36 a.m., indicated .patient [Resident #17] fell during transfer from bed to chair with assistance of one when wheelchair moved and patient fell .CNA [CNA A] called this SN to assess patient .on SN arrival patient lying on back on the floor trying to get up .this SN assessed patient, no injury noted .patient motioned that she had hit the back of her head, no bumps or bruising noted .patient also c/o moderate pain to lumbar region .no increased pain on palpation .spoke with admin .and instructed me to have x-rays done here .call to x-ray and paperwork sent for thoracic and lumbar x-ray to be done . Record review of Resident #17's progress notes by LVN J on 03/11/24 at 10:45 a.m., indicated .left shoulder x-ray ordered as well due to pian since fall . Record review of Resident #17's progress notes by LVN J on 03/11/24 at 3:42 p.m., indicated .all x-rays WNL, doctor notified as well as NP . Record review of Resident #17's Safety Event-Fall by LVN J, dated 03/11/24 indicated .fall location was in the resident room .transferring with assistance of 1 .witnessed fall .lumbar back pain .no injury noted .x-rays ordered to rule out back injury . During an interview on 03/29/24 at 11:01 a.m., CNA A said she started at the facility in mid-January 2024. She said CNAs did not receive gait belts until 3 weeks ago. She said the last week the ADON went to PT to figure out if Resident #17 was a 1- or 2-person transfer. She said the charge nurses were never on the same page about the amount of assistance Resident #17 required for transfer. She said the week before last was the first time a gait belt was used on Resident #17. She said when she originally hired on it was somewhere else. She said she was transferred to the floor with 1 week of shadowing another CNA. She said she felt like there was no training on how to properly do things. She said she did not know what resident needed what type of assistance for cares. She said the facility did provide in-services and trainings on transfers and things, but it was verbal and never demonstrated. She said it was important to use a gait belt to transfer for the safety of the resident. She said the resident could fall if transfers were done without gait or right amount of assistance. During an interview on 03/29/24 at 11:45 a.m., LVN J said she assessed Resident #17 after the fall on 03/11/24. She said CNA S transferred Resident #17 alone and with no gait belt. She said after the fall Resident #17 complained of pain and x-ray was done which was all fine. She said Resident #17 was a 2 person transfer assist. She said gait belts were needed to stabilize the resident and a secured hold in case she started to fall. During an interview on 03/29/24 at 12:19 p.m., the Interim DON said she expected staff to use gait belts for one and two person transfers. She said she expected the right amount of assistance to be provided to the resident according to their care plan. She said the gait belt was used for the safety of the resident. 3.Record review of the undated face sheet revealed Resident #110 was a [AGE] year-old male, admitted on [DATE] and discharged [DATE]. Resident #110 had diagnoses that included: wedge compression fracture of the fourth lumbar vertebra with routine healing (the spine weakens and crumbles, loss of bone mass), depression (loss of interest in activities causing significant impairment in daily life), atrial fibrillation (irregular impulses in the heart), and congestive heart failure (accumulation of fluids in the body). Record review of the admission MDS dated [DATE] revealed Resident #110 had a BIMS score of 11 indicating moderate cognitive impairment. The MDS indicated he had no impairment for his upper or lower extremities and used a walker or wheelchair. Chair/bed to chair and toilet transfer indicated he required partial to moderate assistance. Resident #110 had a fall with fracture prior to admission per the MDS. Record review of the care plan dated 3/6/24 revealed Resident #110 had daily weights related to CHF, was in the facility for therapy for a wedge compressi [TRUNCATED]

Based on observation, interview, and record review the facility failed to ensure each resident received necessary behavioral health care services to maintain the highest practicable mental and psychosocial wellbeing for 1 of 3 residents (Resident #38) reviewed for behavioral services. The facility did not ensure Resident #38 was seen after a counseling evaluation and treatment order was placed on 02/15/24 and a psych evaluation referral was signed by Resident #38 on 03/04/24. The facility failed to comprehensively address Resident #38's behaviors and mental distress. The facility failed to update Resident #38's care plan to reflect her increased anxiety medication needs and behaviors. An IJ was identified on 03/28/2024 at 3:45 p.m. While the IJ was removed on 03/29/2024 at 12:41 p.m., the facility remained out of compliance at a scope of a pattern with a potential for with a potential for more than minimal harm, due to the facility's need to evaluate the effectiveness of the corrective systems. These failures could place residents at risk for the lack of behavioral health services with the potential for emotion trauma, mental distress, and adjustment issues. Findings include: Record review of Resident #38's face sheet printed 03/25/24 indicated Resident #38 was a [AGE] year-old, female and admitted on [DATE] with diagnoses including transient cerebral ischemic attack (is a temporary blockage of blood flow to the brain), hemiplegia (paralysis of one side of the body) and hemiparesis (is a mild or partial weakness or loss of strength on one side of the body) following cerebral infarction (also known as an ischemic stroke, is the pathologic process that results in an area of necrotic tissue in the brain) affecting left non-dominant side, anxiety disorder (a mental health disorder characterized by feelings of worry, anxiety, or fear that are strong enough to interfere with one's daily activities), and depression (is a mood disorder that causes a persistent feeling of sadness and loss of interest). Record review of Resident #38's quarterly MDS assessment dated [DATE] indicated Resident #38 was understood and understood others. The MDS indicated Resident #38 had adequate hearing, clear speech, and adequate vision. The MDS indicated Resident #38 had a BIMS score of 13 which indicated intact cognition. The MDS indicated Resident #38 did not have behaviors such as psychosis or physical or verbal behavioral symptoms. The MDS indicated Resident #38 rated going outside to get fresh air when the weather was good as not very important. The MDS indicated Resident #38 upper extremity limitation in range of motion on one side of the body. The MDS indicated Resident #38 admission performance requirement was maximal assistance for putting on footwear, lower body dressing, and toilet hygiene and moderate assistance for oral hygiene, shower/bathe self, upper body dressing, and personal hygiene. The MDS indicated Resident #38 received antianxiety and antidepressant medication during the last 7 days of the assessment period. Record review of Resident #38's care plan dated 03/09/24, edited on 03/11/24 indicated CNA stated that Resident #38 expressed thoughts of harming self: Resident #38 was in her room with a pair of scissors, and it appears that she was trying to stab herself. Resident #38 stated that she had never thought of anything like that. And she was upset that the CNA even thought that. Interventions created on 03/11/24 included: *Nurse to assess mood and behaviors every shift and document findings. *Social services to assess mood and behavior and document findings. Record review of Resident #38's care plan dated 03/03/24, edited on 03/05/24 indicated Resident #38 had the potential for elopement. Intervention included: *Move room closer to nurse's station redirect resident to courtyard area if wanting to go outside. *Attempt to make resident feel secure/safe within facility. Record review of Resident #38's care plan dated 02/14/24, edited on 03/18/24 indicated: *Resident #38 received antidepressant medication for depression. Resident expresses feeling of depression due to long term care transition. Intervention included SW met with resident and referred to Carousel counseling (03/04/24). *Resident #38 received Ativan (antianxiety) for anxiety. On 02/21/24, Resident #38 received Buspirone (antianxiety) tablet for anxiety. The care plan did not indicate several dose changes to the Buspar due to increased anxiety. The care plan did not mention Resident #38's call to 911 due to anxiety. Record review of Resident #38's progress notes by LVN L dated 02/15/24 at 1:45 p.m., indicated .received psych orders to eval and treat from NP HH .increased Buspar (Buspirone) 10 MG BID . Record review of Resident #38's progress notes by LVN L dated 02/15/24 at 2:54 p.m., indicated .Resident #38 called 911 for herself and stated she wanted to go to the ER .Resident #38 has severe anxiety and has complaints of UTI .Notified NP HH and stated patient can go at her request .EMS arrive at 1500 . Record review of Resident #38's progress notes by LVN E dated 02/18/24 at 6:29 a.m., indicated .sn [LVN E] noted resident in floor face down in right side of bed with call light wrapped around neck 4 times .sn[LVN E] asked resident what happened resident stated she trying to get call light undone and kept wrapping it around and somehow fell .no injuries noted .no abnormalities/deformities noted .sn [LVN E] and cna assisted resident back to bed via Hoyer lift .prn pain pill administered po .residents family member notified .DON notified .NP notified by fax .neuros initiated .edited by: LVN E on 02/19/24 10:04 AM Reason: Incorrect data . Record review of Resident #38's progress notes by LVN E dated 02/18/24 at 6:29 a.m., indicated .sn [LVN E] noted resident in floor face down in right side of bed tangled in call light .sn [LVN E] asked resident what happened resident stated she trying to get call light undone and kept wrapping it around and somehow fell .no injuries noted .no abnormalities/deformities noted .sn[LVN E] and cna assisted resident back to bed via Hoyer lift .prn pain pill administered po .residents son notified .don notified .NP notified by fax .neuros initiated . Record review of Resident #38's progress notes by LVN L dated 02/19/24 at 12:02 p.m., .received new orders to increase Buspar to 10 mg 1 PO TID related to increased depression, RP notified, and orders updated . Record review of Resident #38 progress notes by LVN L dated 02/21/24 at 12:03 p.m., .Resident #38 complained of increased anxiety .notified NP HH .received new order for 1 x dose Ativan 0.5mg now for agitation . Record review of Resident #38's progress notes by LVN KK dated 02/23/24 at 3:35 p.m., indicated .Resident #38 had a crying episode and stated it was because she had an upsetting phone call with her son being mean to her . Record review of Resident #38 progress notes by LVN U dated 03/03/24 at 7:25 p.m., indicated .Resident #38 up in wheelchair, sitting inside building at the back door on the long hall .This nurse [LVN U] encouraged resident to stay inside and to notify staff if she wanted to go out .Resident #38 verbalized understanding .Approx 20 mins later, CNAs notified this nurse that they opened the door for a group of family members and noticed Resident #38 sitting outside in the driveway .Resident #38 questioned why she went outside, she stated, well, I just wanted to get a little fresh air. I wasn't going anywhere . Record review of Resident #38's progress notes by SW dated 03/04/24 at 12:07 p.m., .Resident #38 stated she is having a hard time with her new discharge plan of long-term care but has not desire to leave the facility .SW discussed a referral to local counseling provider .Resident #38 agreed to the referral . Record review of Resident #38's progress notes by LVN R dated 03/09/24 at 11:38 a.m., indicated .8:30 am .CNA [CNA S] reported to this nurse [LVN R] that found Resident [Resident #38] in her room with a pair of scissors and it appeared that she was trying to stab herself .CNA[CNA S] stated that she grabbed the scissors from the Resident and asked what are you doing? .and Resident [#38] stated I was trying to kill myself .CNA [CNA S] gave the pair of scissors to this nurse [LVN R] .the nurse went into Residents [#38] room to interview her to get her side of the story .resident [#38] stated she did not try to stab herself, and that she would never try to kill herself and that she does not have the guts to do that .DOCR went in to get a statement from resident and resident told her the same thing, that she would not ever try to kill herself . Record review of Resident #38's progress notes by the SW dated 03/19/24 at 4:55 p.m., indicated .Resident #38 discussed her difficulty with transitioning to long term care .stated she [Resident #38] didn't have anything to live for now that she is here in the facility .stated that she [Resident #38] had no plan to harm herself .she expressed her sadness about being away from her home and dog .she[Resident #38] said that the only thing she has to look forward to is the food . Record review of Resident #38's local counseling service provider prepared by SW, dated 03/04/24 indicated .reason for referral: depressive symptoms and anxiety .referral/treatment consent form and doctor's order need to be completed PRIOR TO provision of services and COPY OF EACH FAXED to .Corporate Office .along with a current face sheet .please assure there is an order reads similar to: Please refer to .Evaluation and Treatment . Record review of Resident #38's General Order dated 03/11/24 at 7:45 p.m., by the Interim DON indicated .Refer to local counseling service provider for evaluation and treatment . Record review of a local counseling service provider NP medication review for Resident #38 dated 03/11/24 at 8:00 p.m., indicated .staff requesting patient [Resident #38] to be seen for services due scissors and statement about death .telemed .anxiety level 5 (1-low 10-high) .mood level (1-poor 10-good) .thought process: other .motor activity: other .affect: other .suicidality: none .insights: fair .impulse control: fair .judgement: fair .discontinue one on one .patient [Resident #38] not suicidal .will monitor any changes . No recommendation chosen (medication change or therapy). Record review of Resident #38's local counseling psychological evaluation dated 03/13/24 indicated .the resident was referred for mental health services due to depressive symptoms and anxiety .mood: depressed mood/apathy, anxiety, loss of interest/withdrawal, helplessness, loss of energy/motivation, hopelessness .affect: restricted .recommend therapy (16-60 min 1x per/wk) . During an interview and observation on 03/25/24 at 10:55 a.m. Resident #38's room was dark and quiet. Resident #38 said she had no complaints about the facility, and nothing had happened in her bathroom recently. No fall mat was at her bedside. During an interview and observation on 03/26/24 at 11:04 a.m., Resident #38's room was dark and quiet. Fall mat noted on left side of the bed. Resident #38 said the facility added it yesterday because she had a little incident and fell out of the bed. She said the fall mat was something soft in case she fell out of the bed again. She said it had been a bad morning that day. She said CNA S had found her the wheelchair headed out the room not properly dressed. She said she did not attempt suicide with scissors. She said she was reaching for her hairbrush in the nightstand drawer and picked up the scissors instead. She said CNA S asked why she had the scissors and she told her she found them in the drawer. She said she did suffer depression and anxiety but was on medication for it. She said she really missed her dog. She said her was a certified support dog and wanted to have at the facility full time. During an interview on 03/26/24 at 4:45 p.m., CNA S said she was picking up lunch trays and looked in Resident #38's room and saw her stabbing at her stomach with scissors. She said she asked her what she was doing, and she threw the scissors in the drawer. She said Resident #38 said If it was a knife, I would have been able to cut my throat with it! She said Resident #38 put her foot up against the drawer so she could not get the scissors. She said she told Resident #38 she had to get the scissors and had to let the nurse know what was going on. She said Resident #38 said If you tell on me, I will say you hurt me! She said Resident #38's foot slipped from the drawer enough for her to get the scissors. She said she took the scissors to LVN R. She said LVN R said she would take care of it. She said Resident #38 had made other comments about hurting herself before. During an interview on 03/27/24 at 10:04 a.m., a family member of Resident #38 said he had been informed of his family members voiced suicide attempts. He said when Resident #38 got out the back door on 03/03/24 without permission, she later texted him saying she wanted to walk into traffic. He said he thought he told the case worker Resident #38 made that statement. He said Resident #38 did not have a history of suicidal ideations. He said his family member wanted to come home, but he could not care for her anymore. During an interview on 03/27/24 at 11:39 a.m., the SW said Resident #38 was anxious and depressed when she first admitted to the facility. She said she was initial supposed to go back home but changed plan and she was staying for long term care. She said Resident #38 had some adjustment issues but was on medication and psych services. She said Resident #38's family member never reported to her about her texting him she wanted to walk into traffic. She said Resident #38's family had reported attention seeking behaviors like constantly calling and how she had ruined relationships with her behavior. She said Resident #38 family member said Resident #38 would not harm herself, it was just attention seeking and she would not do it. She said she was not notified of the incident on 03/09/24 until Monday, 03/11/24, when she returned for work. She said she assessed Resident #38 on 03/11/24 and she did not make any comments of self-harm. During an interview on 03/27/24 at 12:59 p.m., LVN R said she was agency staff but had worked with Resident #38 often. She said Resident #38 had never told her she was depressed. LVN R said she went to speak to Resident #38 after CNA S brought her the scissors and told her Resident #38 tried to harm herself with them. She said CNA S told her she took the scissors from Resident #38 and asked her what she was doing. She said the first time, CNA S said Resident #38 said I don't know or I'm not doing anything. She said she went to speak with Resident #38, and she said CNA S was mad at her because she did not want to assist her to the restroom. She said Resident #38 said she would never harm herself or have the guts to do it. She said she assessed Resident #38's stomach and there were no marks or anything. During an interview on 03/28/24 at 8:40 a.m., LVN E said on 02/18/24, Resident #38 fell out of her bed. She said Resident #38 said she was trying to get the call light cord and rolled out of the bed. She said Resident #38 did have the cord wrapped around her neck four times when she found her. She said there were no marks on Resident #38 neck after the fall. She said she did not modify her nursing note to state tangled instead of wrapped around neck. She said she believed what Resident #38 said because she was confused, and her room was dark when she arrived. She said she did not think Resident #38 was trying to harm herself. She said she did not know what interventions were put in place after that incident on 02/18/24 because she was agency staff then. During an observation on 03/28/24 at 9:00 a.m., Resident #38 was lying down in a dark room asleep. During an interview on 03/28/24 at 9:15 a.m., LVN L said she had taken care of Resident #38. She said when Resident #38 was first admitted , her anxiety and depression seemed to progressively get worse every time she worked. She said she had to contact NP HH several time about Resident #38 anxiety. She said Resident #38 wanted to go to the hospital because her anxiety was so bad. She said Resident #38 was having a hard transition from being at home with her son to now in a nursing home. She said she did stay in her room a lot but was normally in pleasant mood. She said she tried to assess Resident #38 mood and address what may be causing the issue. She said Resident #38's care plan should mention her recent medication changes and behavioral issues. She said the care plan would show what had worked and if Resident #38 was improving or not. During an interview on 03/28/24 at 4:30 p.m., the SW said the psych treat and evaluation order placed on 02/15/24 was done without a discussion between the morning meeting. She said normally referrals were discussed between her and NP HH. She said then the referral was sent by fax or email to the local counseling provider. She said she preferred doing it by email. She said on 03/04/24, she did a well check and got consent for an evaluation. She said the local counseling provider normally took less than 3 weeks to see residents for services. She said telehealth could be used if needed for some residents. She said medication management was normally done by NP GG. And a Psychologist normally did the evaluations. She said the facility had a licensed counselor that served the facility. She said she did not believe the delay in psych service contributed to Resident #38's self-harming incidents. She said Resident #38 just wants to go home. On 03/29/24 at 9:46 a.m., attempted to contact NP HH by phone and text message. No response before or after exit. During an interview on 03/29/24 at 12:19 p.m., the interim DON said she was not aware of Resident #38's incident on 02/18/24. She said it looked like they tried to cover it up. She said she was also not aware of Resident #38 telling her son she wanted to walk into traffic. She said the Suicide policies should have been followed for Resident #38's incidents. She said the Suicide policies were not new and staff had been re in serviced. She said Resident #38 was able to be seen on Telemed by NP GG who determined she could come off 1:1 monitoring. She said the psych referral process had always been the same and the SW was terminated for not completing them social service duties. She said it was important to take all reports of threats seriously and addressed right way to prevent something from happening. Record review of an undated facility's Behavioral Assessment, Intervention and Monitoring policy indicated .behavioral symptoms will be identified using facility-approved behavioral screening tools and the comprehensive assessment .the nurse staff will identify, document, and inform the physician about specifics details .new onset or change in behavior will be documented regardless of the degree of risk to the resident .cause identification .emotional. Psychiatric and/or psychological stressors .functional, social or environmental factors .management .the care plan will incorporate findings from the comprehensive assessment .monitoring . Record review of an undated facility's Processing Psych Referrals policy indicated .nurse receives order for psych referral and enters matrix order .nursing to notify social services of needed referral and discuss in daily C.A.R.E meeting to ensure need for referral is communicated .social services will complete referral form/consents as required for psych referral and submit to psych provider in a timely manner .social services to follow up on resident until psych provider visit is made . The Interim ADM and Interim DON was notified this was determined to be an Immediate Jeopardy (IJ) on 03/28/24 at 3:45 p.m The Interim ADM was provided with the IJ template on 03/28/24 at 3:45 p.m. The POR was accepted on 03/29/24 at 11:07 a.m., and indicated the following: Plan of Removal F740 Immediate Actions: The Medical Director was notified of the immediate jeopardy on 3/28/2024. The resident #38 was seen on 3/09/2024 by Carousal Counseling. An emotional support visit was completed on 3/28/2024 with resident #38 and the resident was assessed for continuing thoughts of self-harm. This visit was completed by the corporate social worker. Abuse Coordinator contact information and Mandatory Notification requirements were confirmed posted at each nursing station for staff use on 3/28/2024. Resident #38's record was reviewed. The care plan was updated for the events on 2/18/24 and 3/3/24. The resident continues on weekly psychotherapy with a licensed psychologist. The provider was notified of these two events by the corporate social worker. Residents, including resident #38, were assessed to ensure no other residents were having suicidal ideations/mental distress on 3/28/2024 and 3/29/2024 by members of the corporate team, including regional nurse consultant, acting administrator and regional reimbursement director. An audit was completed to ensure all orders for psych referrals were completed. Orders for the past 60 days were reviewed. This audit was completed on 3/28/2024 by the corporate social worker. The social worker was terminated on 3/28/2024. The administrator was terminated on 3/26/2024. The previous DON was terminated on 3/08/2024 related to issues leading up to the survey. Education Provided: Direct care staff were educated on Mandatory Notifications to the facility abuse coordinator. Mandatory Notifications include Resident, Environmental and Other extraordinary events that pose a risk to resident safety, among other things. Suicidal Ideations / Attempts are included in this in-service. Direct care staff were educated on Suicide Prevention Management Policy and Procedure, which includes an overview of the steps the facility should enact in the event of suicidal ideations / attempts. These include required notifications, immediate protections and other actions required. Nursing management and social services were in-serviced on the process for managing, communicating, and completing psych referrals timely, including during the daily CARE Meeting. The social worker is responsible for ensuring psych evals are completed timely. The CARE meeting is performed by nurse management and is a review of the previous day(s) activity, including a review of nurse's notes, new orders, any events and the 24-hour report during the period reviewed. Items that require follow-up are noted and tracked until completion, including any ordered psych referrals. The ADONs, with oversight from the corporate social worker, will oversee this process in absence of a social worker. These in-services will be given by the Director of Nursing or designee starting on 3/28/2024 at 5:00PM and completed on 3/29/2024 by 12:00PM. Any staff who haven't been educated by that time will not be allowed to work until education is completed. The DON was educated by the acting administrator and corporate social worker on 3/28/2024. Policies reviewed include the Suicide Management Precaution Policy and Procedure and Abuse Prevention Program. The Psych Referral Process was updated on 3/28/2024. On 03/29/24, Five surveyors confirmed the facility implemented their plan of removal sufficiently to remove the IJ by: Record review of Resident #38's Carousel Counseling note. Resident #38 was seen on 03/11/24, 03/13/24, 03/19/24, and 03/26/24 (Resident #38 cancelled her session due to pain). Record review of Resident #38's Corporate SW note dated 03/28/24. Resident #38 denied feelings of depression or anxiety at the time. Corporate SW spoke with NP GG this evening to request a follow up visit with resident. Record review of Resident #38 care plan dated 03/09/24, edited on 03/29/24 indicated added information of incidents on 02/15/24 (call 911 wanting to go for anxiety), 02/18/24 (Resident noted in floor with call light around neck), and 03/03/24 (found outside in parking lot). Interventions also updated to reflect Carousel Counseling visit and increase Buspar on 02/15/24. Record review of an audit of 60 residents Mood Assessments. Six resident expressed mental distress or depression. Facility has follow up in place for residents. Record review of an audit of 60 resident assessing Carousel Services in place. No issues noted. Record review of the previous SW termination letter dated 03/28/24. Termination of employment due to failed to perform social services duties by failure to complete psych reports as required. Record review of the previous ADM termination letter dated 03/27/24. discharged due to failure to perform Administrator duties. Record review of the previous DON termination letter dated 03/08/24. discharged due to failure to perform Director of Nursing duties. Record review of an In-Service Form indicated for direct care staff dated 03/28/24-03/29/24. The in-service was presented by the [NAME] President of Clinical Operation. The Topics was Abuse Prevention Program. The policy included the seven components: prevention, screening, identification, training, protection, reporting/responding, and investigation. Record review of an In-Service Form indicated for direct care staff dated 03/28/24-03/29/24. The in-service was presented by the [NAME] President of Clinical Operation. The Topics was Suicide Precaution Policy and Procedure. The policy included intervention to start, who to contact, and what to chart. Record review of an In-Service Form indicated for direct care staff dated 03/28/24-03/29/24. The in-service was presented by the [NAME] President of Clinical Operation. The Topics was Mandatory Notifications. The policy included when to notify the facility administrator and DON and what events to report. Record review of an In-Service Form indicated for direct care staff dated 03/28/24-03/29/24. The in-service was presented by the [NAME] President of Clinical Operation. The Topics was Psych Referral Process. This policy included how to initiate a psych referral, step by step process, who was responsible, and the provider the facility used with phone number. During an observation 03/29/24 at 11:22 a.m., posted Abuse Coordinator signs at nurse's station. Abuse Coordinator was the Interim ADM. During interviews conducted on 02/29/24 beginning at 11:20 a.m. through 12:25 p.m., 40 of 69 direct care in-serviced (including staff across all shifts that were upper management, AD, Treatment Nurse, MDS Coordinator, and Maintenance) were interviewed. All staff said they received education on the Abuse Prevention Program, Mandatory Notifications, Suicide Precaution Policy and Procedure, and Psych Referrals (Nurses). All staff said they received education on resident environmental and other extraordinary events that pose a risk to residents' safety, among other things, suicidal ideations/attempts, steps the facility should enact in the event of suicidal ideations/attempts, required notifications, immediate protections and other actions required, processing for managing, communicating, and completing psych referrals timely. All staff reported they would report all reports of suicidal ideation to the charge nurse, DON, and ADM. All staff reported they would not leave the resident alone until another staff member arrived. All staff reported they would remove all harmful items from the resident's room. Nursing staff reported they would document every 4 hours while the resident was on 1:1 monitoring, and the CNA staff said they documented every 15 mins. Nursing staff said when a counseling service order was placed, they would follow the psych referral process. During an interview on 03/29/24 at 12:21 p.m., the Interim DON said she was in-serviced by the Interim ADM on the Abuse Prevention Program. She said the facility was required to report to the State within 2 hours for abuse allegation. She said the facility's policy should be followed to protect the residents. She said suicide policy and procedure should be followed. She said mandatory events should be reported to the facility ADM and DON such as abuse allegation and suicide attempts. She said psych referrals will be followed through and discussed in the C.A.R.E. meetings. She said the facility performed mood assessments on all the residents and would address any signs of mental distress. The Interim ADM, DOCR, Corporate SW, and Regional Nurse were informed the Immediate Jeopardy was removed on 03/29/24 at 12:41 p.m., the facility remained out of compliance at a scope of a pattern with a potential for with a potential for more than minimal harm, due to the facility's need to evaluate the effectiveness of the corrective systems.

Based on observation, interview and record review the facility failed to ensure the resident had the right to be informed of, and participate in, his or her treatment including the right to be fully informed in a language that he or she could understand of his or her total health status, including but not limited to, his or her medical condition for 1 of 12 resident (Resident #17) reviewed for resident rights. The facility failed to ensure Resident #17 was provided care and services in her primary language, which was Spanish. This failure could place residents at risk for not being informed of health status. Findings included: Record review of Resident #17's face sheet, printed 03/25/24, indicated Resident #17 was [AGE] year-old female who was admitted to the facility on [DATE]. Resident #17 had diagnoses which included wedge compression fracture of first lumbar vertebra (this fracture usually occurs in the front of the vertebra, collapsing the bone in the front of the spine and leaving the back of the same bone unchanged, which results in the vertebra taking on a wedge shape), major depressive disorder (is a mood disorder that causes a persistent feeling of sadness and loss of interest), cognitive communication deficit (the person does not recognize everyday social cues, both verbal and non-verbal), vascular dementia (is caused by a range of conditions that disrupt blood flow to the brain and affect memory, thinking, and behavior), mild, with agitation, and generalized anxiety disorder (excessive, ongoing anxiety and worry can interfere with your daily activities). Resident #17's preferred language was Spanish; Castilian and religion was Catholic. Record review of Resident #17's admission MDS assessment, dated 02/06/24, indicated Resident #17's preferred language was Spanish and needed or wanted an interpreter to communicate with a doctor or health care staff. Resident #17 was understood and understood others. Resident #17 had a BIMS score of 12, which indicated moderate cognitive impairment. Resident #17 had a Mood score of 15 (moderately severe depression) out of 27 related to being bothered by certain problems and the frequency of the being bothered. Resident #17 activity preference was somewhat important regarding keeping up with news and participating in religious services or practices. Resident #17 was dependent for putting on footwear, lower body dressing, and toilet hygiene, maximal assistance for shower/bathe self, moderate assistance for oral hygiene and upper body dressing, and supervision for personal hygiene. Resident #17 was dependent for toilet transfer, chair/bed-to-chair transfer, and sit to stand. Record review of Resident #17's care plan, dated 01/31/24, edited 02/16/24, indicated Resident #17 did not speak in the dominant language of the facility. Language Spanish. Interventions included if a family member or friend is present that speaks/understands language, get permission to call them when needed, provide education for safety awareness, provide visual cueing with communication board, interpreter to enhance communication, and redirect resident as needed and reiterate safety awareness using communication board and interpreter. Record review of Resident #17's care plan, dated 01/31/24, edited on 03/19/24, indicated ADLs Functional Status/Rehabilitation Potential: About Me, My name is [Resident #17], I speak only Spanish and I can understand some English. I [Resident #17] do use a communication board to communicate with the staff. But I'm confused due to Dementia and at times and have trouble using the communication board, so I will use an I-Pad for google translate. Record review of Resident #17's progress notes, printed 03/25/24, indicated: On 02/05/24 at 11:44 p.m. by LVN CC, .Resident [#17] sitting up in bed this shift .language barrier continues to inhibit communication this shift .Resident [#17] able to verbalize some needs On 02/09/24 at 10:37 p.m. by LVN CC, .Resident [#17] lying in bed this shift .language barrier continues to disrupt communication between resident and staff On 02/10/24 at 10:21 p.m. by LVN CC, .Resident [#17] lying in bed this shift .language barrier continues to disrupt communication between resident and staff On 02/17/24 at 9:40 p.m. by LVN U, .Resident [#17] is usually very anxious in the evenings .this evening, resident was at the nurses station asking about getting on the bus .communication deficit due to resident [Resident #17] knowing only little English .Unable to understand exactly what resident [Resident #17] is asking .all attempts to calm and redirect unsuccessful until resident's anti-anxiety meds start to work. On 02/19/24 at 1:28 a.m. by LVN U, .all attempts to collect UA have been unsuccessful thus far .resident [Resident #17] refusing in and out cath due to language barrier On 02/19/24 at 10:41 p.m. by LVN CC, .Resident [#17] continues to engage in attention seeking behaviors .continues to self-transfer down onto floor for attention .communication continues to be strained this shift due to resident speaks fluent Spanish only On 02/20/24 at 10:43 p.m. by LVN CC, .Resident [#17] continues to engage in attention seeking behaviors .continues to self-transfer down onto floor for attention .communication continues to be strained this shift due to resident speaks fluent Spanish only On 02/21/24 at 9:50 p.m. by LVN U, .Resident [#17] has been more confused, anxious, and agitated thus far this shift .call placed to resident's daughter so that she could speak Spanish .Resident [#17] is starting to settle down at this time On 03/02/24 at 1:38 p.m. by LVN J, .patient [Resident #17] found lying on stomach on floor next to bed .very difficult to communicate with patient due to her speaking only Spanish On 03/18/24 at 7:41 a.m. by LVN E, .resident [#17] noted with bruising/ swelling to left knee and x2 abrasion .resident unable to tell staff what happened related to language barrier During an interview on 03/26/24 at 8:58 a.m., LVN E said they communicated with Resident #17 with google translator on their phone or the iPad tablet and tried to understand what she tried to say. During an interview and observation on 03/26/24 at 9:00 a.m., the facility's iPad was used to interview Resident #17 When Resident #17 was asked questions that required more than a yes or no response, she could not be understood. The google translator app did not have the capability for Resident #17 to speak Spanish into the microphone and translate to English Resident #17 could not be interviewed without an interpreter. During an observation on 03/27/24 at 11:34 a.m., Resident #17's room had a sign posted that read Call Before You Fall on the wall in English. Attempted an interview on 03/27/24 at 5:01 p.m. and 5:03 p.m., with LVN U by phone, were unsuccessful. Calls were cancelled and messages were left. There was no returned call before or after exit. During an interview on 03/27/24 at 9:59 p.m., Resident #17's family member said this was Resident #17's second time at the facility. She said Resident #17 was currently admitted at a local hospital because she felt like something was not right. She said about a week after Resident #17 was admitted to the facility, the facility provided her with an iPad with google translator. She said she saw some staff using it but there was the problem with staff understanding what Resident #17 said back to them. She said she did not feel like the facility cared to use the communication tools or get to know Resident #17. She said this admission was the worst experience with staff trying to understand Resident #17. She said she never saw the staff use the communication board with Resident #17. She said yesterday (03/26/24) she saw the communication board on Resident #17's closet floor. She said the facility needed a translator machine for the residents whose primarily language was not English. She said there was one staff member in therapy who spoke Spanish, but she had not seen him in a while. She said she expected the same care for her family member even if Resident #17 was a different race. During an interview on 03/28/24 at 8:40 a.m., LVN E said she used the Google translator or whoever spoke Spanish in the building to help her understand Resident #17. She said she did not know about a communication board to use to with Resident #17. During an interview on 03/28/24 at 9:13 a.m., CNA K said most staff spoke to Resident #17 in English. He said Resident #17 replied appropriately to yes and no questions. He said anything else besides yes or no answers, staff had to decipher what she tried to say. He said he had not seen staff use the iPad or communication board to talk to Resident #17. He said it was important to have communication tools to help understand Resident #17's want and needs. He said he never saw Resident #17 watch television or do activities. He said it would be important for the activities to be in Resident #17's preferred language. He said there used to be another resident who spoke Spanish, Resident #17 hung out with, but she was discharged recently. He said Resident #17 normally sat at the table alone with her cell phone. During an interview on 03/28/24 at 9:15 a.m., the Interim DON said staff should be using goggle translator, staff who spoke Spanish, or contacted Resident #17's family members to translate. She said at nighttime when there was less staff available to translate, Resident #17's family did visit at night a lot. She said Resident #17 should have a communication board and staff using it. She said she did not expect the communication board to be in the floor in the closet partially under clothes. She said Resident #17's fall sign should be in Spanish. Attempted interview on 03/29/24 at 9:31 a.m., with LVN CC by phone was unsuccessful. A message was left. During an observation on 03/29/24 at 9:34 a.m., revealed in Resident #17's room was a posted activity calendar and Call Before You Fall sign on the wall in English. In Resident #17's closet floor, partially concealed by a bag of briefs and clothes, was an 8x10 laminate sheet with pictures and words in English was noted (communication board). During an interview on 03/29/24 at 11:01 a.m., CNA A said she worked with Resident #17 often. She said it was hard to communicate with Resident #17 because of the language barrier and mumbling. She said she never saw staff use the iPad or communication board to communicate with Resident #17. During an interview on 03/29/24 at 11:45 a.m., LVN J said communicating with Resident #17 was frustrating for her and the resident. She said Resident #17 answered simple questions that only required yes or no responses. She said Resident #17 had to gesture with her hands where she had pain, when asked. She said she tried to use a translator or got staff to help her talk to Resident #17. During an interview on 03/29/24 at 12:19 p.m., the Interim DON said she expected staff to use the communication tools the facility provided for Resident #17 which were the communication board, iPad with Google translator, or Spanish speaking staff members. She said she expected staff to let her know if the communication tools were not working for Resident #17. She said she expected signs and activities to be in the resident's preferred language. She said she had given the AD an in-service on providing activities in the resident's preferred language. She said it was the facility's responsibility to find ways to effectively communicate with Resident #17. She said Resident #17's needs needed to be met. During an interview on 03/29/24 at 12:21 p.m., the Interim ADM said staff should use the communication tools provided to communicate with Resident #17. He said staff should notify management if the communication tools were not working. He said it was the facility's responsibility to improve or maintain a resident's ADLs. Record review of the facility's Translation and/or Interpretation of Facility Services policy, revised 06/2020, indicated .this facility's language access program will ensure that individuals with limited English proficiency shall have meaningful access to information and services provided by the facility .the types of language access services provided by this facility shall be determined by the following factors .the size of the eligible LEP population served by the facility .the frequency .the nature and/or importance of the information or service .the resources available .all LEP person shall receive a written notice in their primary language of their rights to obtain competent oral translation services free of charge .competent oral translation of vital information that is not available in written translation, and non-vital information shall be provided in a timely manner .a staff member who is trained and competent in the skill of interpreting .a staff interpreter who is trained and competent in the skill of interpreting .contracted interpreter service .voluntary community interpreters who are trained and competent in the skill of interpreting .telephone interpretation service .interpreters and translators must be appropriately trained in medical terminology .family members and friends shall not be relied upon to provide interpretation services for the resident unless explicitly requested by the resident .it is understood that in order to provide meaningful access to services provided by this facility, translation and/or interpretation must be provided in a way that is culturally relevant and appropriate to the LEP individual

Based on observation, interview and record review, the facility failed to ensure the right to be free from abuse was provided for 1 of 12 residents reviewed for abuse. (Resident #19) 3/23/24 Facility failed to prevent LVN BB from verbally abusing Resident #19. LVN BB told Resident #19 that no one liked her causing the resident emotional and mental anguish. This failure could place residents at risk of a diminished quality of life and psychosocial harm. Finding Include: Record review of Resident #19's face sheet indicated she was an [AGE] year-old female initially admitted to the facility on [DATE], with diagnoses that included: Vascular Dementia (brain damage caused by multiple strokes), Senile degeneration of brain (a decrease in cognitive abilities or mental decline) and Depression (a common mental disorder). Record review of the Quarterly MDS assessment dated [DATE] indicated Resident #19 usually understood and usually understood others. The MDS assessment indicated Resident #19 had a BIMS score of 5 which indicated her cognition was severely impaired. The MDS assessment indicated Resident #19 required total assistance with ADL's. Record review of the most recent care plan dated 3/20/2024 indicated Resident #19 did not use her call light at night, but instead she would bang on her bedside table, and it kept her roommate up at night. Staff encouraged Resident #19 to use her call light when she needed assistance. Staff reminded Resident #19 that she disturbed her roommate and others when she banged on the bedside table. During an interview on 03/25/2024 at 10:08 AM Resident #19 said there was a lady staff member that was mean to her 03/23/2024 night about 11:00 PM. Resident #19 said the staff member told her No one likes you. She said she cried all night because of what the staff member had said to her. Resident #19 said she asked the staff member if she could get her a Twinkie out of her drawer because she was hungry. Resident #19 said the staff member told her All you want to do is sit up in bed all night and eat. Resident #19 said after the staff member gave her the Twinkie the staff member said there was nothing else she could do for her. Resident #19 said she did not know the staff member's name that was mean to her. Resident #19 said the staff member worked the night shift and she worked 03/24/2024. Resident #19 said she reported the incident to a family member (Family Member #2 ). During an interview on 03/25/24 at 3:27 PM Resident #19's family member, Family Member #1, said Resident #19 told her today a lady staff member that worked nights was rude to her. Family Member #1 said Resident #19 said the lady staff told her nobody in the facility liked her and when she asked for a Twinkie the lady smashed it before she handed it to her. Family Member #1 said Resident #19 described the lady had mid length loose curled blond hair with a nice built body. Family Member #1 said she really did not know if the incident was real or was a dream, but Resident #19 was very upset about the incident. Family Member said she notified the facility today before she left. During an interview on 03/25/24 at 3:39 PM the ADM was notified of the incident about Resident #19 from the state surveyor. The ADM said she was made aware of the incident earlier that day and was working on the investigation. During an interview and observation on 03/27/24 at 8:50 AM revealed Resident #27 (Resident #19's roommate) was lying in bed. Resident #27 said she remembered that around 11:00 PM or 12:00 AM on 03/23/2024 there was an incident with Resident #19 and an unknown staff. Resident #27 said Resident #19 and the unknown staff were both yelling, and she did not hear anything about a Twinkie. Resident #27 said she heard the unknown staff tell Resident #19 nobody likes you. Resident #27 said she tried to tune Resident #19 and the unknown staff out when they were yelling. Resident #27 said she was not sure what the unknown staff member's name was that said that to Resident #19, but she was a night staff member. Resident #27 said she thought the lady was a nurse because she gave medicine, and she was over the staff at night. During an interview on 03/27/24 at 9:25 AM LVN BB said she answered Resident #19's call light. LVN BB said Resident #19 wanted to be changed and wanted her Twinkie out of her drawer. LVN BB said she asked Resident #19 which one she wanted her to do first. LVN BB said Resident #19 said she wanted the Twinkie first because she had not eaten supper. LVN BB said she told Resident #19 there was no reason for her to be hateful to her. LVN BB said she was just trying to help her. LVN BB said she gave Resident #19 a Twinkie in her hand after she unwrapped it for her. LVN BB said I did not smash the Twinkie. If it was smashed it was because it was smashed in her drawer. LVN BB said she never told Resident #19 she was the most unliked Resident in the facility. LVN BB said a CNA had already given Resident #19 a Twinkie from her drawer earlier. LVN BB said a CNA came in and changed Resident #19 immediately after she left Resident #19 room. LVN BB said she did not know the CNA's name who worked with her Saturday night. During an interview on 03/28/24 at 7:41 AM Resident #19's family member, Family Member #2, said when she got to the facility on [DATE] around 11:30 AM, Resident #19 was crying and very upset. Family Member #2 said Resident #19 said someone told her she was the most unliked resident in the building. Family Member #2 said Resident #19 started crying uncontrollably again. Family Member #2 said Resident #19 said she was hungry, and she could not sleep so she got the nurse to get a Twinkie out of her drawer and smashed it, then handed it to her. Family Member #2 said Resident #19 was so upset and crying uncontrollably. Family Member #2 said Resident #19 said the woman that hurt her feelings usually came in her room at night. Family Member #2 said Resident #19 said after she asked the lady for Twinkie the lady told her all she did was sit up and eat. Family Member #2 said Resident #19 said after the lady had given her the Twinkie, she said there was not much more she could do for her . Family Member #2 did not notify the facility of the incident. During an interview on 03/29/24 at 9:27 AM the Interim DON said the surveyor notified the facility of the incident on Monday 3/25/2024 with Resident #19 by LVN BB. The Interim DON said after she was notified of the incident, a head-to-toe assessment was performed by the treatment nurse. The Interim DON said there were no issues with LVN BB prior to the incident. The Interim DON said the facility terminated LVN BB on 3/27/24 because she felt the nurse was rude during her interview with her. The Interim DON said Social Services met with Resident #19 to assess her. The Interim DON said the facility performed safe rounds with residents that were cared for by LVN BB. The Interim DON said Resident #19 had not reported any issues with LVN BB prior to the incident. The Interim DON said LVN BB was a blunt and to the point type of nurse. The Interim DON said Resident #27 was Resident #19's roommate and she verified the allegations, when interviewed, said she heard the staff member statement, of LVN BB saying nobody liked Resident #19 in the facility. During an interview on 03/29/24 at 10:17 AM the Interim ADM said the following actions were taken after the incident with Resident #19 and LVN BB: LVN BB was suspended during the investigation, then the facility terminated her Wednesday 3/27/2024. The Interim ADM said the facility performed safe rounds with residents to ensure no other residents were affected and terminated LVN BB for verbal abuse. Record review of the Abuse Policy dated 3/26/2024 indicated the following: Verbal abuse includes: Any use of talking inappropriately about a resident when she can hear, such as making jokes about her or calling her names.

Based on observation, interview and record review the facility failed to provide, based on the comprehensive assessment of a resident and consistent with the resident's needs and choices, the necessary care and services to ensure that a resident's abilities in activities of daily living do not diminish unless circumstances of the individual's clinical condition demonstrate that such diminution was unavoidable for 1 of 12 resident (Resident # 17) reviewed for activities of daily living. The facility failed to ensure Resident #17 was provided care and services in her primary language, which was Spanish. This failure could place residents at risk for a decline and diminished quality of life. Findings include: Record review of Resident #17's face sheet, printed 03/25/24, indicated Resident #17 was [AGE] year-old female who was admitted to the facility on [DATE]. Resident #17 had diagnoses which included wedge compression fracture of first lumbar vertebra (this fracture usually occurs in the front of the vertebra, collapsing the bone in the front of the spine and leaving the back of the same bone unchanged, which results in the vertebra taking on a wedge shape), major depressive disorder (is a mood disorder that causes a persistent feeling of sadness and loss of interest), cognitive communication deficit (the person does not recognize everyday social cues, both verbal and non-verbal), vascular dementia (is caused by a range of conditions that disrupt blood flow to the brain and affect memory, thinking, and behavior), mild, with agitation, and generalized anxiety disorder (excessive, ongoing anxiety and worry can interfere with your daily activities). Resident #17's preferred language was Spanish; Castilian and religion was Catholic. Record review of Resident #17's admission MDS assessment, dated 02/06/24, indicated Resident #17's preferred language was Spanish and needed or wanted an interpreter to communicate with a doctor or health care staff. Resident #17 was understood and understood others. Resident #17 had a BIMS score of 12, which indicated moderate cognitive impairment. Resident #17 had a Mood score of 15 (moderately severe depression) out of 27 related to being bothered by certain problems and the frequency of the being bothered. Resident #17 activity preference was somewhat important regarding keeping up with news and participating in religious services or practices. Resident #17 was dependent for putting on footwear, lower body dressing, and toilet hygiene, maximal assistance for shower/bathe self, moderate assistance for oral hygiene and upper body dressing, and supervision for personal hygiene. Resident #17 was dependent for toilet transfer, chair/bed-to-chair transfer, and sit to stand. Record review of Resident #17's care plan, dated 01/31/24, edited 02/16/24, indicated Resident #17 did not speak in the dominant language of the facility. Language Spanish. Interventions included if a family member or friend is present that speaks/understands language, get permission to call them when needed, provide education for safety awareness, provide visual cueing with communication board, interpreter to enhance communication, and redirect resident as needed and reiterate safety awareness using communication board and interpreter. Record review of Resident #17's care plan, dated 01/31/24, edited on 03/19/24, indicated ADLs Functional Status/Rehabilitation Potential: About Me, My name is [Resident #17], I speak only Spanish and I can understand some English. I [Resident #17] do use a communication board to communicate with the staff. But I'm confused due to Dementia and at times and have trouble using the communication board, so I will use an I-Pad for google translate. I do have impaired vision and wear prescription glasses. Sometimes I will crawl out of my bed and sit on the floor to pray. I do require assist with ADLs due to the Dementia and require two people to help me transfer. Interventions included I need assist at times getting up out of the floor when I'm praying or sitting. Record review of Resident #17's care plan, dated 03/01/24, edited on 03/06/24, indicated Behavioral Symptoms: Resident #17 became very combative in the ER and the van, refusing to put seatbelt on, hitting and kicking, grabbing him [Van driver] by the belt. Yelling at ER staff and the van driver. Possible contribution could be the language barrier. Intervention included provided resident with iPad google translator. Record review of Resident #17's progress notes, printed 03/25/24, indicated: On 02/05/24 at 11:44 p.m. by LVN CC, .Resident [#17] sitting up in bed this shift .language barrier continues to inhibit communication this shift .Resident [#17] able to verbalize some needs On 02/09/24 at 10:37 p.m. by LVN CC, .Resident [#17] lying in bed this shift .language barrier continues to disrupt communication between resident and staff On 02/10/24 at 10:21 p.m. by LVN CC, .Resident [#17] lying in bed this shift .language barrier continues to disrupt communication between resident and staff On 02/17/24 at 9:40 p.m. by LVN U, .Resident [#17] is usually very anxious in the evenings .this evening, resident was at the nurses station asking about getting on the bus .communication deficit due to resident [Resident #17] knowing only little English .Unable to understand exactly what resident [Resident #17] is asking .all attempts to calm and redirect unsuccessful until resident's anti-anxiety meds start to work. On 02/19/24 at 1:28 a.m. by LVN U, .all attempts to collect UA have been unsuccessful thus far .resident [Resident #17] refusing in and out cath due to language barrier On 02/19/24 at 10:41 p.m. by LVN CC, .Resident [#17] continues to engage in attention seeking behaviors .continues to self-transfer down onto floor for attention .communication continues to be strained this shift due to resident speaks fluent Spanish only On 02/20/24 at 10:43 p.m. by LVN CC, .Resident [#17] continues to engage in attention seeking behaviors .continues to self-transfer down onto floor for attention .communication continues to be strained this shift due to resident speaks fluent Spanish only On 02/21/24 at 9:50 p.m. by LVN U, .Resident [#17] has been more confused, anxious, and agitated thus far this shift .call placed to resident's daughter so that she could speak Spanish .Resident [#17] is starting to settle down at this time On 03/02/24 at 1:38 p.m. by LVN J, .patient [Resident #17] found lying on stomach on floor next to bed .very difficult to communicate with patient due to her speaking only Spanish On 03/18/24 at 7:41 a.m. by LVN E, .resident [#17] noted with bruising/ swelling to left knee and x2 abrasion .resident unable to tell staff what happened related to language barrier During an observation on 03/25/24 at 10:52 a.m., Resident #17 was sitting in the 400-hall common area at a table alone. During an observation on 03/26/24 at 8:57 a.m., Resident #17 was sitting in the 400-hall common area at a table alone. In Resident #17's room was an iPad tablet on the nightstand and no other forms of communication tools noted in the room. During an interview on 03/26/24 at 8:58 a.m., LVN E said they communicated with Resident #17 with google translator on their phone or the iPad tablet and tried to understand what she tried to say. During an interview and observation on 03/26/24 at 9:00 a.m., the facility's iPad was used to interview Resident #17 When Resident #17 was asked questions that required more than a yes or no response, she could not be understood. The google translator app did not have the capability for Resident #17 to speak Spanish into the microphone and translate to English Resident #17 could not be interviewed without an interpreter. During an observation on 03/27/24 at 11:34 a.m., Resident #17's room had a sign posted that read Call Before You Fall on the wall in English. Attempted an interview on 03/27/24 at 5:01 p.m. and 5:03 p.m., with LVN U by phone, were unsuccessful. Calls were cancelled and messages were left. There was no returned call before or after exit. During an interview on 03/27/24 at 9:59 p.m., Resident #17's family member said this was Resident #17's second time at the facility. She said Resident #17 was currently admitted at a local hospital because she felt like something was not right. She said about a week after Resident #17 was admitted to the facility, the facility provided her with an iPad with google translator. She said she saw some staff using it but there was the problem with staff understanding what Resident #17 said back to them. She said she did not feel like the facility cared to use the communication tools or get to know Resident #17. She said this admission was the worst experience with staff trying to understand Resident #17. She said she never saw the staff use the communication board with Resident #17. She said yesterday (03/26/24) she saw the communication board on Resident #17's closet floor. She said the facility needed a translator machine for the residents whose primarily language was not English. She said there was one staff member in therapy who spoke Spanish, but she had not seen him in a while. She said she expected the same care for her family member even if Resident #17 was a different race. During an interview on 03/28/24 at 8:40 a.m., LVN E said she used the Google translator or whoever spoke Spanish in the building to help her understand Resident #17. She said she did not know about a communication board to use to with Resident #17. She said Resident #17 was offered snacks and crossword puzzles, but they were not in Spanish. During an interview on 03/28/24 at 9:00 a.m., the Regional Nurse said she was making Resident #17 a communication book/binder with basic communication phrases and faces. She said she was also printing out crossword puzzles in Spanish and spiritual based coloring pages. She said she was not aware Resident #17's Call Before You Fall sign posted was in English. She said she would take care of that also. During an interview on 03/28/24 at 9:13 a.m., CNA K said most staff spoke to Resident #17 in English. He said Resident #17 replied appropriately to yes and no questions. He said anything else besides yes or no answers, staff had to decipher what she tried to say. He said he had not seen staff use the iPad or communication board to talk to Resident #17. He said it was important to have communication tools to help understand Resident #17's want and needs. He said he never saw Resident #17 watch television or do activities. He said it would be important for the activities to be in Resident #17's preferred language. He said there used to be another resident who spoke Spanish, Resident #17 hung out with, but she was discharged recently. He said Resident #17 normally sat at the table alone with her cell phone. During an interview on 03/28/24 at 9:15 a.m., the Interim DON said staff should be using goggle translator, staff who spoke Spanish, or contacted Resident #17's family members to translate. She said at nighttime when there was less staff available to translate, Resident #17's family did visit at night a lot. She said Resident #17 should have a communication board and staff using it. She said she did not expect the communication board to be in the floor in the closet partially under clothes. She said Resident #17's fall sign should be in Spanish. Attempted interview on 03/29/24 at 9:31 a.m., with LVN CC by phone was unsuccessful. A message was left. During an observation on 03/29/24 at 9:34 a.m., revealed in Resident #17's room was a posted activity calendar and Call Before You Fall sign on the wall in English. In Resident #17's closet floor, partially concealed by a bag of briefs and clothes, was an 8x10 laminate sheet with pictures and words in English was noted (communication board). During an interview on 03/29/24 at 1:23 p.m., the AD said she had been at the facility for [AGE] years. She said Resident #17 went to activities sometimes but did not stay for long. She said she did bring activities to Resident #17, but they were not in Spanish. She said she mostly brought Resident #17 pictures to color. She said she asked a Deacon from a local Catholic church to come visit with Resident #17. She said she communicated with the Deacon last on 03/06/24, but no one visited with Resident #17 yet. She said Resident #17 also had dementia but had not tried activities like sorting socks with her. She said activities should be in Resident #17's preferred language so she did not feel left out and frustrated. During an interview on 03/29/24 at 11:01 a.m., CNA A said she worked with Resident #17 often. She said it was hard to communicate with Resident #17 because of the language barrier and mumbling. She said she never saw staff use the iPad or communication board to communicate with Resident #17. She said the facility use to have another resident who sat with Resident #17, and they did activities together, but she discharged . She said since the other residents left, Resident #17 had not cared to do activities. During an interview on 03/29/24 at 11:45 a.m., LVN J said communicating with Resident #17 was frustrating for her and the resident. She said Resident #17 answered simple questions that only required yes or no responses. She said Resident #17 had to gesture with her hands where she had pain, when asked. She said she tried to use a translator or got staff to help her talk to Resident #17. During an interview on 03/29/24 at 12:19 p.m., the Interim DON said she expected staff to use the communication tools the facility provided for Resident #17 which were the communication board, iPad with Google translator, or Spanish speaking staff members. She said she expected staff to let her know if the communication tools were not working for Resident #17. She said she expected signs and activities to be in the resident's preferred language. She said she had given the AD an in-service on providing activities in the resident's preferred language. She said it was the facility's responsibility to find ways to effectively communicate with Resident #17. She said Resident #17's needs needed to be met. During an interview on 03/29/24 at 12:21 p.m., the Interim ADM said staff should use the communication tools provided to communicate with Resident #17. He said staff should notify management if the communication tools were not working. He said it was the facility's responsibility to improve or maintain a resident's ADLs. Record review of the facility's Translation and/or Interpretation of Facility Services policy, revised 06/2020, indicated .this facility's language access program will ensure that individuals with limited English proficiency shall have meaningful access to information and services provided by the facility .the types of language access services provided by this facility shall be determined by the following factors .the size of the eligible LEP population served by the facility .the frequency .the nature and/or importance of the information or service .the resources available .all LEP person shall receive a written notice in their primary language of their rights to obtain competent oral translation services free of charge .competent oral translation of vital information that is not available in written translation, and non-vital information shall be provided in a timely manner .a staff member who is trained and competent in the skill of interpreting .a staff interpreter who is trained and competent in the skill of interpreting .contracted interpreter service .voluntary community interpreters who are trained and competent in the skill of interpreting .telephone interpretation service .interpreters and translators must be appropriately trained in medical terminology .family members and friends shall not be relied upon to provide interpretation services for the resident unless explicitly requested by the resident .it is understood that in order to provide meaningful access to services provided by this facility, translation and/or interpretation must be provided in a way that is culturally relevant and appropriate to the LEP individual

Based on observation, interview and record review the facility failed to ensure residents were free from abuse, neglect, misappropriation of resident property, and exploitation for 3 of 7 residents (Resident #2, Resident #5, and Resident #6) reviewed for abuse and neglect. The facility neglected to oversee the implementation of resident care policies and staff responsibilities. Resident #6 was transferred using a bearhug method by a sitter on 12/2/23 and an RN heard a pop during the transfer. Resident #6 had a left hip fracture. Sitters were providing care to residents that had not been trained, facility staff were aware the sitters were providing care and allowed the practice to continue. The facility failed to have a policy and procedure in place for private sitters outlining the care they could provide. The facility failed to ensure sitters were aware of what their duties were and did not perform care to residents to prevent harm. The facility failed to ensure staff did not allow sitters to preform ADL care for their residents. Resident #2 was transferred by a sitter on 2/8/24 and had a fall during the transfer. There were no interventions put into place at that time. Resident #2 had a sitter and on 2/13/24 the sitter said she performed all of Resident #2's care to include, transfers, incontinent care, and assistance with eating. Resident #2 was a 2 person transfer and the resident and the sitter said the sitter transferred her to the chair or bed unassisted. Facility staff were aware sitters were providing care to Resident #2 and Resident #5 and neglected to intervene to prevent possible harm. An Immediate Jeopardy (IJ) situation was identified on 2/14/24 at 4:40 p.m. While the IJ was removed on 2/15/24 at 5:49 p.m., the facility remained out of compliance at a scope of a pattern with the potential for with a potential for more than minimal harm, due to the facility's need to evaluate the effectiveness of the corrective systems. These deficient practices could place residents at risk of physical harm and could lead to additional pain and suffering. Findings include: 1. Record review of Resident # 6's, undated, face sheet reflected a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #6 had diagnoses which included high blood pressure, anxiety disorder, rheumatoid arthritis, and cognitive communication deficit. Record review of Resident #6's hospice visit note, dated 11/26/23, reflected Resident #6 required a total lift or Hoyer for transfer. Record review of Resident #6's significant change MDS, dated [DATE], reflected the resident had moderate cognitive impairment. She required substantial to maximal assist with sit to stand, to move from chair to bed and toilet transfer. She used a manual wheelchair for ambulation. Record review of Resident #6 nursing note dated 12/2/23 at 1:33 p.m. indicated she was transferred from the recliner to the bed using the bear hug transfer technique by Sitter ZZ. As Resident #6 was turned to be repositioned on the bed. A loud noise was heard by the nurse and the sitter. Sitter ZZ carefully seated, the patient on the bed, and Resident #6 was assessed for pain. Resident #6's left knee had no redness, swelling or bruising. The patient expressed that her left knee was hurting, and Tylenol was given for pain. Record review of a provider investigation report dated 12/3/23 indicated on 12/2/23. The weekend RN documented she observed Sitter ZZ transfer Resident #6 from the bed to the recliner using a bear hug transfer technique. As the resident was turned the weekend RN stated she and the sitter heard a noise. Sitter ZZ carefully seated the Resident #6 on the bed. The weekend RN assessed the resident. There was no pain noted. On 12/3/23 at 8:08 p.m. the resident complained of pain in her left knee and hip. The nurse assessed the pain level at a 7 the physician was notified and ordered stat x-ray. The x-ray results indicated left femur fracture. Record review of the Provider Report with an attachment of an in serviced dated 12/3/23 that indicated nursing staff who have sitters are only allowed to sit with the residents. Ensure that our staff ( CNA, Nurses, Therapy) only provide the care and transfers to any resident who has a sitter. Another in service titled transferring indicated Resident #6 was to be transferred via to persons with a Hoyer. If a family refused the Hoyer lift the resident was to be left in bed. Resident #6 had a sitter for companionship and would not provide any care. Another in service indicated Mandatory Notifications that indicated employees must immediately notify the Administrator or DON of events that occur with the Resident or environment that could possibly be abuse, to include injury of unknown origin, fractures, and bruises. Record review of the Provider Report with an attachment dated 12/2/23 attached to the Provider Report indicated on 12/2/23 Resident #6 was transferred by the Sitter ZZ using a bear hug transfer technique to move Resident #6 from the recliner to the bed. The Sitter said she did not require assistance, as she transferred Resident #6 regularly. During the transfer an audible sound was heard. Following this the sitter carefully sat Resident #6 on the bed. Resident #6 said her left knee was hurting and requested a Tylenol. 2. Record review of Resident #2's face sheet with no date indicated she was a [AGE] year-old female admitted to the facility on [DATE]. Some of her diagnoses were high blood pressure, vascular dementia, mood disturbance, anxiety, and Parkinson's. Record review of Resident #2's admission MDS assessment dated [DATE] indicated she had severe cognitive impairment. Resident #2 required substantial to maximum assistance from lying to sit on the side of the bed. She was totally dependent for sit to stand, chair to bed mobility, and transfer to the toilet. Record review of Resident #2's care plan dated 1/18/24 indicated an acute care plan with the resident experiencing self-care deficit related to requiring assist with feeding, bathing, toileting, and self-care. Some of the approaches were staff would assist or supervise with eating at each meal. Staff would assist with transfers, sitting up, transferring to chair, and location in the room and hallways. The resident had a problem of at risk for falls due to weakness to the bilateral lower extremities and safety awareness due to a diagnosis of dementia. Record review of an event report dated 2/8/24 at 8: 00 a.m. indicated Resident #2 had a witness fall. There were no injuries noted. The event indicated, assisted sitter with transfer of resident, advised sitter not to transfer alone, and instructed sitter on proper use of the gate belt. Record review of resident #2 Nurses notes dated 2/8/24 indicated the nurse was called to the room. Upon entrance to the room the resident was noticed sitting on the floor in front of her recliner with a sitter standing at the side. The sitter stated she witnessed the resident slide to the floor. The resident denied pain and discomfort. No injuries were noted at this time. Once level of safety was determined, this nurse and the residence sitter assisted the resident back in the chair. During an observation and interview on 2/13/24 Resident #2 was sitting up in the recliner with covers pulled up to her neck. There were so heel protector boots on the nightstand. She appeared some what confused at that time. During an interview on 2/13/24 at 9:57 a.m. CNA B an agency aide said she worked yesterday. She said Resident#2 was very confused. She said Resident #2 had a sitter from 8:00 a.m. to 5:00 p.m. CNA B said she did not know anything about the boots on the nightstand. She said the sitter was the one that got the resident up and she did not know what the boots were for. CNA B said the sitter was the one that took care of the resident. She said that the sitter got Resident #2 up to the wheelchair for therapy. During an interview on 2/13/24 at 10:05 a.m. LVN G said she was the nurse for Resident # 2. She said Resident #2 had a sitter in the morning and the sitter did everything for the Resident #2. LVN B said sometimes they have different sitters, and some would ask for help when they needed help. During an interview on 2/13/24 at 10:05 a.m. CNA D said she was a full-time staff and did not have any residents with sitter. She said knew some of the sitters provided more care to residents and some did not. During an interview and observation on 2/13/24 at 1:25 p.m. Resident #2 was noted with Sitter BB assisting the resident with eating her lunch. The resident was accepting spoons filled with food when they were presented to her mouth. Sitter BB said she was in the facility it was her job to change, feed, and transfer the resident. She said Resident #2 was her responsibility. Sitter BB said this was her third day working with the resident. She said it was in her job description from the company that she worked for that she was supposed to bath, dress, transfer, feed, and provide incontinent care. She said the resident had been sitting in the chair all day and likely needed to be changed. Sitter BB said she was going to transfer the resident from the recliner to the bed and change her. Resident #2 said she could not bear any weight. The Investigator asked Sitter BB if she got assistance from the staff and she said no, they were too slow. She said by the time they got there she could have the resident changed. She said it was not right for the resident to be left wet so long and the staff did not provide care. Sitter BB was determined about transferring the resident unassisted and the Investigator suggested she wait until staff could be located to assist her. During an interview and observation on 2/13/24 at 1:29 p.m. Corporate RN came to Resident #2's room. She told Sitter BB that Resident #2 was a two person transfer and required two people to safely transfer. The Corporate RN told Sitter BB she should not be transferring Resident #2 alone. The Corporate RN told the sitter the aide and a PTA were coming to transfer Resident #2. During interview and observation on 2/13/24 at 1:31 p.m. CNA B said Resident #2 was a two-person transfer. She said she had used the sit to stand lift to get the resident up and change her about 11:30 a.m. to 11:45 a.m. The CNA said she and CNA D had gotten the resident up. CNA B said and then she brought the food tray to Resident #2. When asked how the regular sitter for Resident #2 changed Resident #2. CNA B said she did not know how she changed her all she knew was that she put the dirty things outside the door to be picked up. During an observation and interview on 2/13/24 at 1:40 p.m. the sitter said she was upset because it was taking the staff so long to come and transfer the resident. She was making comments about transferring Resident #2 herself. The investigator asked her to please wait for the safety of the resident. CNA B brought a sit to sand lift into the room. The sitter said she had not seen one of those in the room and did not know how to use it. She said she was not a CNA, and no one had instructed her on how to transfer or care for Resident #2 Observation at 1:45 p.m. PTA and the CNA B using the sit to stand lift to raise the resident out of her chair. The pulled down her pants and dropped the brief which was saturated and heavy. Her pants and the chair appeared dry. The resident said, y'all are going to stand me up and change me. As if that was new to her. During an interview on 2/13/24 at 1:47 p.m. the PTA said usually when she arrived in the room the morning sitter already had Resident #2 sitting in the wheelchair. She said it should be two people to transfer Resident #2 the resident did bear any weight. During an interview on 2/13/24 at 1:50 p.m. CNA D said she did see the CNA B with the lift but she did not assist her with changing Resident #2 She said she had not been Resident #2's room today. The CNA B confronted CNA D about helping her change Resident #2. CNA D still Resident #2 room and she did not assist with a transfer or her care. During an interview on 2/13/24 at 2:30 p.m. Corporate RN said they did not have a sitter policy and they had two residents with sitters. Resident #2 and Resident #5. During an interview on 2/13/24 at 5:20 p.m. Administrator said they had not taken the sitter issue to QA with the sitter transferring the resident and her falling in December 2023. She said they let the sitters know they were not supposed to be providing care and did an in service with the sitter at that time. Resident #6 had since transferred. The Administrator said she did not know Resident #2 had fallen while a sitter was trying to transfer her. She said they had met with the families in December 2023 when the incident occurred with Resident #6. She said had met with all the families at that time and told them no ADL care was allowed by sitters. The Administrator said she was not aware the sitters had continued to provide care to the Residents. During interview on 2/13/24 at 5:24 p.m. the Corporate RN said staff are supposed to notify the DON and they were [NAME] serviced on today that sitters are for companionship only they are not to provide care. She said the Visitation policy they have said the sitters were for companionship only. The Corporate RN said , they have called the family to let them know the sitters are only for companionship. During interview on 2/14 /24 at 3:31 p.m. DON said no one had notified her that sitters were providing care. She said she had told families before sitters were for companionship only. She said they had conducted an Inservice in December 2023 about sitters. During an interview on 2/14/24 at 3:40 p.m. LVN J said the sitter had been providing care to Resident #2. She said she was very pleasant and appeared to think that it was her job to provide care because the family wanted Resident #2 back at the assisted living. She said on today the sitter had a hard time understanding why she could no longer provide care. During an interview on 2/14/24 at 3:45 p.m. PTA said the sitter was the one that transferred Resident #2 and she knew that she did it by herself because she had told her so. PTA said all the staff knew she was transferring the resident unassisted. She said she had glanced in the room once and saw her transferring the resident. The resident was sitting on the side of the bed and had the gait belt around her. There was no one else in the room the sitter kind of hugged her and placed her in the chair. She said the family said that one person could transfer her safety. She said she told the staff at the assisted living that was not how they transfer, and they required two people for a safe transfer. During an interview on 2/15/24 at 3:00 p.m. Sitter CC said prior to yesterday, she did everything for Resident #5. She said Resident #5 no longer got out of bed, but she felt Resident #5 was her total responsibility. She said now she had been told not to touch her at all. She was to pull the call light if the resident required assistance. She said she got her this morning at 8:30 a.m. and the resident was wet. She pulled the call light at 9:43 a.m. the girl came in and told her she had a shower, and the resident was not changed until 10:48 a.m. She said she had read the policy and signed the form, but it was hard to not do anything for the resident. During an interview on 2/15/24 at 3:31 p.m. DON said she was not aware the sitters were providing care to residents. She said had a conversation with Resident #2 family member. He appeared to encourage the sitters to provide care to Resident #2 he wanted her to go back to the assisted living facility. She had talked to him in the past and talked to him again on yesterday and he agreed the sitter was companionship only. She said they had in service staff, any new staff that comes on that sitters are only here for companionship and not to do any ADL care. The sitters have a siter agreement that they must sign in agreement, and they all work for same company. The company said they are not supposed to provide care, but Resident #2's family had a problem they wanted them to provide care. She said she told the staff that that was a form of neglect, if they did not provide the care the residents required . During an interview on 2/15/24 at 3:59 p.m. CNA E said on yesterday Sitter CC was upset because she said she normally did everything for Resident #5 and she was not allowed to provide care. During an interview on 2/15/24 at 4:30 p.m. LVN J said- said she had two residents with sitters on her hall Resident #2 and Resident #5. She said Resident# 5 was relatively new and was admitted this week. She said Resident #5 had sitters 24 hours a day per the family. She said Resident #2's sitters wanted to take care of her and tried their best to do so. She said one of the sitters had let Resident #2 fall during a transfer about a week ago. Apparently, she put a gait belt on the resident not tight enough and Resident#2 slid out to the floor. Record review of the facility Visitation police dated 4/22/22 indicated the facility permits, residents to receive visitors subject to the residents wishes and the protections of the rights of other residents in the facility. Sitters (no care duties allowed) approved by resident and or family. Record Review of a Safe Lifting and Movement of Residents policy dated 8/17/23 indicated protect the safety and wellbeing of staff and residents and to promote quality of care, this policy is to identify appropriate techniques and devices to live and move residents. Resident safety, dignity, comfort, and medical condition will be incorporated into the goals and decisions regarding the safe lifting and moving of residents. Manual lifting of resident's shell be eliminated when feasible. Staff responsible for direct resident care will be trained in the use of manual (gait/transfers belts, lateral boards) and mechanical lifting devices. Mechanical lifting devices shall be used for heavy lifting, including lifting, and moving residents when necessary. Staff will be observed for competency in using mechanical lifts, and observed periodically for adherence to polices, and procedures regarding the use of equipment and safe lifting techniques. Record review of the Abuse and Neglect Clinical Protocol, dated 4/8/21, reflected Neglect is defined as the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. The Administrator or designee and staff will help identify potential or actual abuse or neglect with the facility for example, problematic family issues, problems related to staff knowledge, skill or performance that might affect how the residents are being cared for. Recurrent failure to provide incontinent care. Upon receiving an allegation of abuse committed against a resident staff must ensure the safety of the resident immediately and notify the supervisor. This was determined to be an Immediate Jeopardy (IJ) on 2/14/24 at 4:40 p.m. The Administrator, Regional Nurse Consultant, VP of Clinical Services and Regional Director of Marketing were notified. The Administrator was provided with the IJ template on 2/14/24 at 4:40 p.m The following Plan of Removal submitted by the facility was accepted on 02/15/24 at 3:29 p.m. Plan of Removal F600 Neglect Failures: o Provide oversight to prevent untrained private sitters from providing ADL care to facility residents. o Oversee the implementation of resident care policies and staff responsibilities. Plan of Removal 1. Immediate actions o Instructed existing sitters (2) on 2/13/24 at 1:30 PM that they are not allowed to provide ADL care. o May not administer Direct Care to the resident. Direct Care includes, but is not limited to, transferring the resident, providing incontinent care, providing assistance with feeding, repositioning, toileting, bathing and dressing, wound care and administering medications, (including over-the-counter medications and supplements). o May monitor patient needs, report issues, ensure patient comfort (e.g., changing bedding, filling water jugs and positioning items within reach) and provide companionship. o Will assist facility to maintain, create and provide a safe environment for the patient. o Must report to the Nurse Supervisor/Charge Nurse when coming on and going off duty. o Must report changes in a resident's condition to the Nurse Supervisor/Charge Nurse immediately. o All residents with sitters (2) were assessed head to toe for any injuries on 2/13/24 at 1:30pm o Notified RP of residents with sitters in place of Facility Sitter Policy. o Family responsible to notify facility of private duty sitter. o Residents/responsible party desiring the use of private duty sitters must first obtain written approval Facility by reviewing and signing the Facility Sitter Agreement. o Private Duty Sitters are required to sign in at nurses station prior to start of shift. Binder at nurses station with sign in sheet for private duty sitters. Charge nurses in-serviced on process of private duty sitters' requirement to sign in and provided Private Duty Sitter Acknowledgement forms to be completed. o Facility staff to monitor private duty sitters as they are rounding to ensure no private duty sitters are providing ADL care. o The Medical Director was notified by the Director of Nursing on 02/14/2024 at 5:00 PM. 2. Education (Administrator/Regional Nurse) o Personal and private sitters in-serviced on Facility Sitter Policy on 2/13/24. Education provided on following: o May not administer Direct Care to the resident. Direct Care includes, but is not limited to, transferring the resident, providing incontinent care, providing assistance with feeding, repositioning, toileting, bathing and dressing, wound care and administering medications, (including over-the-counter medications and supplements). o May monitor patient needs, report issues, ensure patient comfort (e.g., changing bedding, filling water jugs and positioning items within reach) and provide companionship. o Will assist facility to maintain, create and provide a safe environment for the patient. o Must report to the Nurse Supervisor/Charge Nurse when coming on and going off duty. o Must report changes in a resident's condition to the Nurse Supervisor/Charge Nurse immediately. o Nurse Administrative Staff/Direct Care Staff educated on Facility Sitter Policy on 2/13/24. Agency Provider Companies to be notified on 2/14/24 of need for all agency staff to review Private Duty Sitter Policy prior to start of shift at Summer Meadows. To be completed by 2/14/24 at 5:00 PM. All future facility staff will be in-serviced upon hire. o Private Duty Sitter Acknowledgement to be signed for residents with current sitters by 2/14/24 and reviewed with future sitters as they are assigned to residents. o Facility Administrative Staff/Nurses/CNA/Agency staff were in-serviced on 2/13/24 by ADON and Regional Nurse on their job duties related to residents with private duty sitters present on providing all ADL care by (facility) staff only, private duty sitter policy and agreement o All facility staff in-serviced by Administrator/DON/ADON's on Abuse and Neglect, covering prevention, screening, identification, training, protection, reporting/responding and investigation, including all ADL care to be provided by (facility) staff regardless of sitter on 2/14/24 at 5:00 PM. Staff who are out on vacation, FMLA, or PRN will be in-serviced prior to next scheduled work shift. 3. Medical Director - The Medical Director has been notified of the Immediate Jeopardy. 4. QAPI Committee Review - An interim QAPI committee meeting was completed on 02/14/2024. 5. Plan of removal date: 02/14/2024] Monitoring of the POR on 02/15/24 included the following: Record review of the Private Duty Sitter Agreement with no date indicated: by signing below we agree to the following. The sitter is an employee of the family, failure to meet the guidelines or interference in the care of other patients could result I the sitter not being allowed to work in the facility. The sitter will be required to adhere to the responsibilities listed below. Th sitter May Not administer direct care to the resident. Direct care includes, transferring, providing incontinent care, assistance with eating, reposition, toileting, bathing and dressing, wound care administering medications including over the counter. They must report when coming on and going off duty, monitor the patient needs and report issues. Record review of Resident #5's nursing notes dated 2/13/24 at 2;50 p.m. p.m. indicated the RN spoke with the POA. He as reminded sitters for Resident #2 need to always call for assistance when performing any care for the resident. He was informed he needed to alert the sitters that sit with her daily. Record review of Resident #2's nursing notes dated 2/13/24 at 6:31 p.m. indicated the RN spoke with the POA. He as reminded sitters for Resident #2 need to always call for assistance when performing any care for the resident. He was informed he needed to alert the sitters that sit with her daily. Interviews with facility staff: At 3:35 p.m. LVN A- agency work all shifts At 3:59 p.m. CNA E said she worked all shifts At 4:10 p.m. CNA F worked 2p to 10 p At 4:15 p.m. CNA H worked 6a to 6p and sometimes 6p to 10 p. At 4:22 LVN I worked 6a to 6p At 4:30 p.m. LVN J worked 6a to 6p At 4:40 p.m. CNA K worked 2p to 10 p At 4:49 p.m. CNA L agency worked 6a to 6p and all shifts At 4:45 p.m. CNA M worked 6a to 6p At 5:01 p.m. MA worked 6:30 a.m. to 6:30 p.m. Interviews with staff indicated they were knowledgeable about the in-services provided. They were able to voice their knowledge of the sitter policy, the sitter books located at the nurse's station. They voiced if they saw a sitter providing ADL care to a resident, they would intervene to ensure the resident safety. Then they would inform the charge nurse, and or DON. They also indicated staff not providing care to residents could be a form of neglect, and allowing sitter to perform care they were not trained to provide could be neglect. During an interview on 2/15/24 at 5:05 p.m. the family member of Resident #5 said they were informed that sitters were no longer to provide personal care to the residents. The family member said she understood but was concerned Resident #6 would not receive timely care. During an interview on 2/15/24 at 5:10 p.m. Sitter DD the evening sitter f for Resident #5 said she was made aware today that she could no longer provide care to the resident. She said this was her first day back this week. The sitter said in the past she had provided ADL care to Resident #5 but would comply with the new rules. During an interview on 2/15/24 at 5:15 p.m. the DON said she had been out sick and not aware they had a new resident, Resident #6. She said she had just gotten back from sick leave yesterday and was not aware the new admissions. The census indicated the resident was admitted on Monday. The DON said she was not aware there was an incident on 2/8/24 when the sitter was transferring Resident #2 fall and she fell . She said they had the sitter books at the nurse's station and sitters were to sign in and out so they knew who was in the building. The DON said if the sitter was new the Charge nurse would have them read and sign the sitter policy. If there were any problems the staff were aware they could contact her for assistance. The aides and nurses were also aware if they saw any sitter breaking the policy by providing care they were to intervene and let the charge nurse, and DON know. During an interview on 2/15/24 at 5:20 p.m. Sitter EE said she was providing care to Resident #2 before and did not understand why she could not continue. She said had been a CNA for 5 years. She had provided all care, assistance with eating, transfers, and incontinent care the staff were aware and just left them alone. She said on yesterday, LVN J and the DON explained to her she was not supposed to provide any care and she signed the form stating she understood. During an interview on 2/15/24 at 5:25 p.m. the two sitters with Resident #6 Sitter GG said she was going home, and Sitter HH said she was coming on. They said they were aware they were not to provide any care Resident #6 they were there for companionship only. They said they understood their duties and had not proved care to the resident while she was at the facility. They were informed by the facility staff and had signed the form. During an observation on 2/15/24 at 5:30 p.m. of the north wing nurses' station had a sitter book with the sitter policy, and the signatures of the sitters and a sign in and out sheet. During an observation on 2/15/24 at 5:32 p.m. of the East wing nurses' station had a sitter book with the sitter policy, and the signatures of the sitters and a sign in and out sheet. During an interview on 2/15/24 at 5:35 p.m. the Administrator said they had met with the Director of the company all the sitters worked for today and told them they did not want the sitters providing ADL care to the residents. The Director of the sitter company had agreed. They had spoken to the families via telephone and one family in person and they said they understood. She said they had taken the concerns with sitters and neglect to the QA meeting. The Medical Director was involved via phone. The administrator said they had placed the sitter books at the nurse's station and all sitters were to sign in and out. if it was a new sitter the charge nurse would go over the policy with them and have them to sign. The Administrator said that staff were aware they were to notify the DON or Administrator if they noticed any sitter breaking the policy. She said staff were aware that not providing care to residents could be a form of neglect. The Administrator, DON, Regional Nurse Consultant and VP of Clinical Services were informed the Immediate Jeopardy was removed on 2/15/24 at 5:49 p.m. The facility remained out of compliance at a severity level of potential harm with a scope of a pattern due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place.

Based on observation, interview and record review the facility failed to ensure residents environment remained as free of accident hazards as possible and each resident received adequate supervision and assistance devices to prevent accidents for 3 of 7 residents ( Resident #2, Resident #5 and Resident #6) and 5 of 7 sitters (Sitters BB, CC, EE, DD and ZZ ) reviewed for accidents and supervision. 1. The facility failed to ensure Resident #6 was appropriately transferred. The resident was transferred using a bearhug method by Sitter ZZ on 12/2/23 and an RN heard a pop during the transfer. Resident #6 had a left hip fracture. 2. The facility failed to have a policy and procedure in place for private sitters outlining the care they could provide. 3. The facility failed to ensure sitters were aware of what their duties were and did not perform care to residents to prevent harm. 4. The facility failed to ensure staff did not allow sitters (Sitters, BB, CC, EE, DD, and ZZ) to preform ADL care for their residents. 5. The facility failed to ensure interventions were put into place after Resident #2 was transferred by a sitter (unknown) on 2/8/24 and had a fall during the transfer. 6. The facility failed to ensure Sitter BB did not perform care to include, transfers, incontinent care, and assistance with eating for Resident #2. 7. The facility failed to ensure Resident #2 was appropriately transferred by a two person transfer. Resident #2 was transferred by the sitter to the chair or bed unassisted. An Immediate Jeopardy (IJ) situation was identified on 2/13/24 at 5:26 p.m. While the IJ was removed on 2/15/24 at 5:49 p.m. p.m., the facility remained out of compliance at a scope of a pattern with a potential for with a potential for more than minimal harm, due to the facility's need to evaluate the effectiveness of the corrective systems. These deficient practices could place residents at risk to physical harm and could lead to additional pain and suffering. Findings include: 1. Record review of Resident # 6's, undated, face sheet reflected a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #6 had diagnoses which included high blood pressure, anxiety disorder, rheumatoid arthritis and cognitive communication deficit. Record review of Resident #6's hospice visit note, dated 11/26/23, reflected Resident #6 required total lift or Hoyer for transfer. Record review of Resident #6's significant change MDS, dated [DATE], indicated the resident had moderate cognitive impairment. She required substantial to maximal assist with sit to stand, to move from chair to bed and toilet transfer. She used a manual wheelchair for ambulation. Record review of Resident #6's nursing note, dated 12/2/23 at 1:33 p.m., reflected she was transferred from the recliner to the bed using the bear hug transfer technique by Sitter ZZ. As Resident #6 was turned to be repositioned on the bed. A loud noise was heard by the nurse and the sitter. Sitter ZZ carefully seated, the patient on the bed, and Resident #6 was assessed for pain. Resident #6's left knee had no redness, swelling or bruising. The patient expressed that her left knee was hurting, and Tylenol was given for pain. Record review of a provider investigation report, dated 12/3/23, reflected on 12/2/23 the weekend RN documented she observed Sitter ZZ transfer Resident #6 from the bed to the recliner using a bear hug transfer technique. As the resident was turned the weekend RN stated she and the sitter heard a noise. Sitter ZZ carefully seated Resident #6 on the bed. The weekend RN assessed the resident. There was no pain noted. On 12/3/23 at 8:08 p.m. the resident complained of pain in her left knee and hip. The nurse assessed the pain level at a 7 the physician was notified and ordered stat x-ray. The x-ray results indicated a left femur fracture. Record review of the Provider Report with an attachment of an in-serviced, dated 12/3/23, reflected nursing staff who have sitters are only allowed to sit with the residents. Ensure that our staff (CNA, Nurses, Therapy) only provide the care and transfers to any resident who has a sitter. Another in-service titled transferring indicated Resident #6 was to be transferred via two persons with a Hoyer. If a family refused the Hoyer lift the resident was to be left in bed. Resident #6 had a sitter for companionship and would not provide any care. Another in-service indicated Mandatory Notifications which indicated employees must immediately notify the Administrator or DON of events that occur with the resident or environment that could possibly be abuse, to include injury of unknown origin, fractures, and bruises. Record review of the Provider Report, with an attachment of a statement, written by RN Supervisor, dated 12/2/23, reflected on 12/2/23 Resident #6 was transferred by Sitter ZZ using a bear hug transfer technique to move Resident #6 from the recliner to the bed. The Sitter said she did not require assistance, as she transferred Resident #6 regularly. During the transfer an audible sound was heard. Following this the sitter carefully sat Resident #6 on the bed. Resident #6 said her left knee was hurting and requested a Tylenol. 2. Record review of Resident #2's, undated, face sheet reflected a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #2 had diagnoses which included high blood pressure, vascular dementia, mood disturbance, anxiety and Parkinson's. Record review of Resident #2's admission MDS assessment, dated 1/23/24, reflected she had severe cognitive impairment. Resident #2 required substantial to maximum assistance from lying to sit on the side of the bed. She was totally dependent for sit to stand, chair to bed mobility and transfer to the toilet. Record review of Resident #2's care plan, dated 1/18/24, indicated an acute care plan with the resident experiencing self-care deficit related to requiring assist with feeding, bathing, toileting, and self-care. Some of the approaches included staff would assist or supervise with eating at each meal. Staff would assist with transfers, sitting up, transferring to chair, and location in the room and hallways. The resident had a problem of at risk for falls due to weakness to the bilateral lower extremities and safety awareness due to a diagnosis of dementia. Record review of an event report, dated 2/8/24 at 8: 00 a.m., reflected Resident #2 had a witnessed fall. There were no injuries noted. The event indicated, assisted sitter with transfer of resident, advised sitter not to transfer alone, and instructed sitter on proper use of the gait belt. Record review of Resident #2 Nurses notes, dated 2/8/24, reflected the nurse was called to the room. Upon entrance to the room the resident was noticed sitting on the floor in front of her recliner with a sitter standing at the side. The sitter stated she witnessed the resident slide to the floor. The resident denied pain and discomfort. No injuries were noted at this time. Once level of safety was determined, this nurse and the residence sitter assisted the resident back in the chair. During an observation on 2/13/24 revealed Resident #2 was sitting up in the recliner with covers pulled up to her neck. She appeared somewhat confused at that time. During an interview on 2/13/24 at 9:57 a.m., CNA B, an agency aide, said she worked yesterday. She said Resident #2 was very confused. She said Resident #2 had a sitter from 8:00 a.m. to 5:00 p.m. CNA B said she did not know anything about the boots on the nightstand. She said the sitter was the one who got the resident up and she did not know what the boots were for. CNA B said the sitter was the one that took care of the resident. She said the sitter got Resident #2 up to the wheelchair for therapy. During an interview on 2/13/24 at 10:05 a.m., LVN G said she was the nurse for Resident # 2. She said Resident #2 had a sitter in the morning and the sitter did everything for the Resident #2. LVN B said sometimes they had different sitters, and some would ask for help when they needed help. During an interview on 2/13/24 at 10:05 a.m., CNA D said she was a full-time staff and did not have any residents with sitters. She said she knew some of the sitters provided more care to residents and some did not. During an interview and observation on 2/13/24 at 1:25 p.m., Resident #2 was noted with Sitter BB assisting the resident with eating her lunch. The resident was accepting spoons filled with food when they were presented to her mouth. Sitter BB said she was in the facility it was her job to change, feed and transfer the resident. She said Resident #2 was her responsibility. Sitter BB said this was her third day working with the resident. She said it was in her job description from the company that she worked for that she was supposed to bath, dress, transfer, feed and provide incontinent care. She said the resident had been sitting in the chair all day and likely needed to be changed. Sitter BB said she was going to transfer the resident from the recliner to the bed and change her. Resident #2 said she could not bear any weight. Sitter BB stated she didn't receive assistance from the staff and stated they were too slow. She said by the time they got there she could have the resident changed. She said it was not right for the resident to be left wet so long and the staff did not provide care. Sitter BB was determined about transferring the resident unassisted and the State Surveyor suggested she wait until staff could be located to assist her. During an observation on 2/13/24 at 1:29 p.m., the Corporate RN came to Resident #2's room. She told Sitter BB Resident #2 was a two person transfer and required two people to safely transfer. The Corporate RN told Sitter BB she should not be transferring Resident #2 alone. The Corporate RN told the sitter the aide and a PTA were coming to transfer Resident #2. During interview and observation on 2/13/24 at 1:31 p.m., CNA B said Resident #2 was a two-person transfer. She said she used the sit to stand lift to get the resident up and change her about 11:30 a.m. to 11:45 a.m. The CNA said she and CNA D had gotten the resident up. CNA B said then she brought the food tray to Resident #2. When asked how the regular sitter for Resident #2 changed the resident, CNA B said she did not know how she changed her all she knew was she put the dirty things outside the door to be picked up. During an observation and interview on 2/13/24 at 1:40 p.m., the Sitter said she was upset because it was taking the staff too long to come and transfer the resident. She made comments about transferring Resident #2 herself. The State Surveyor asked her to please wait for the safety of the resident. CNA B brought a sit to sand lift into the room. The sitter said she had not seen one of those in the room and did not know how to use it. She said she was not a CNA, and no one had instructed her on how to transfer or care for Resident #2. Observation at 1:45 p.m. revealed the PTA and CNA B used the sit to stand lift to raise the resident out of her chair. They pulled down her pants and dropped the brief which was saturated and heavy. Her pants and the chair appeared dry. The resident said, y'all are going to stand me up and change me? As if that was new to her. During an interview on 2/13/24 at 1:47 p.m., the PTA said usually when she arrived in the room the morning sitter already had Resident #2 sitting in the wheelchair. She said it should be two people transferring Resident #2, the resident did bear any weight. During an interview on 2/13/24 at 1:50 p.m., CNA D said she saw CNA B with the lift, but she did not assist her with changing Resident #2. She said she had not been in Resident #2's room today. CNA B confronted CNA D about helping her change Resident #2. CNA D still Resident #2 room and she did not assist with a transfer or her care. During an interview on 2/13/24 at 2:30 p.m., Corporate RN said they did not have a sitter policy and they had two residents with sitters, Resident #2 and Resident #5. During an interview on 2/13/24 at 5:20 p.m., the Administrator said they had not taken the sitter issue to QA with the sitter transferring the resident and her falling in December 2023. She said they let the sitters know they were not supposed to be providing care and did an in service with the sitter at that time. Resident #6 had since transferred. The Administrator said she did not know Resident #2 had fallen while a sitter was trying to transfer her. She said they had met with the families in December 2023 when the incident occurred with Resident #6. She said she met with all the families at that time and told them no ADL care was allowed by sitters. The Administrator said she was not aware the sitters continued to provide care to the residents. During an interview on 2/13/24 at 5:24 p.m., the Corporate RN said staff were supposed to notify the DON and they were [NAME]-serviced today (02/13/24) that sitters were for companionship only and they were not to provide care. She said the Visitation policy they had said the sitters were for companionship only. The Corporate RN said they called the families to let them know the sitters were only for companionship. During interview on 2/14/24 at 3:31 p.m., the DON said no one notified her that sitters were providing care. She said she told families before sitters were for companionship only. She said they conducted an In-service in December 2023 about sitters. During an interview on 2/14/24 at 3:40 p.m., LVN J said the sitter was providing care to Resident #2. She said she was very pleasant and appeared to think that it was her job to provide care because the family wanted Resident #2 back at the assisted living. She said today the sitter had a hard time understanding why she could no longer provide care. During an interview on 2/14/24 at 3:45 p.m., PTA said the sitter was the one who transferred Resident #2 and she knew she did it by herself because she had told her. PTA said all the staff knew she was transferring the resident unassisted. She said she had glanced in the room once and saw her transferring the resident. The resident was sitting on the side of the bed and had the gait belt around her. There was no one else in the room the sitter kind of hugged her and placed her in the chair. She said the family said one person could transfer her safety. She said she told the staff at the assisted living that was not how they transferred, and they required two people for a safe transfer. During an interview on 2/15/24 at 3:00 p.m. Sitter CC said prior to yesterday, she did everything for Resident #5. She said Resident #5 no longer got out of bed, but she felt Resident #5 was her total responsibility. She said now she was told not to touch her at all. She was to pull the call light if the resident required assistance. She said she got her this morning at 8:30 a.m. and the resident was wet. She pulled the call light at 9:43 a.m. the girl came in and told her she had a shower, and the resident was not changed until 10:48 a.m. She said she read the policy and signed the form, but it was hard to not do anything for the resident. During an interview on 2/15/24 at 3:31 p.m., the DON said she was not aware the sitters were providing care to residents. She said she had a conversation with Resident #2's family member. He appeared to encourage the sitters to provide care to Resident #2 he wanted her to go back to the assisted living facility. She talked to him in the past and talked to him again on yesterday and he agreed the sitter was companionship only. She said they had in-serviced staff, any new staff that came on, that sitters were only there for companionship and not to do any ADL care. The sitters had a sitter agreement that they must sign in agreement, and they all worked for same company. The company said they were not supposed to provide care, but Resident #2's family had a problem they wanted them to provide care. She said she told the staff that was a form of neglect, if they did not provide the care the residents required. During an interview on 2/15/24 at 3:59 p.m., CNA E said yesterday Sitter CC was upset because she said she normally did everything for Resident #5, and she was not allowed to provide care. During an interview on 2/15/24 at 4:30 p.m., LVN J said she had two residents with sitters on her hall Resident #2 and Resident #5. She said Resident #5 was relatively new and was admitted this week. She said Resident #5 had sitters 24 hours a day per the family. She said Resident #2's sitters wanted to take care of her and tried their best to do so. She said one of the sitters had let Resident #2 fall during a transfer about a week ago. LVN J stated the sitter put a gait belt on the resident not tight enough and Resident #2 slid out to the floor. Record review of the facility Visitation policy, dated 4/22/22, reflected the facility permits, residents to receive visitors subject to the residents wishes and the protections of the rights of other residents in the facility. Sitters (no care duties allowed) approved by resident and or family. Record review of a Safe Lifting and Movement of Residents policy, dated 8/17/23, reflected protect the safety and well-being of staff and residents and to promote quality of care, this policy is to identify appropriate techniques and devices to live and move residents. Resident safety, dignity, comfort, and medical condition will be incorporated into the goals and decisions regarding the safe lifting and moving of residents. Manual lifting of resident's shall be eliminated when feasible. Staff responsible for direct resident care will be trained in the use of manual (gait/transfers belts, lateral boards) and mechanical lifting devices. Mechanical lifting devices shall be used for heavy lifting, including lifting, and moving residents when necessary. Staff will be observed for competency in using mechanical lifts, and observed periodically for adherence to polices, and procedures regarding the use of equipment and safe lifting techniques. This was determined to be an Immediate Jeopardy (IJ) on 2/13/24 at 5:26 p.m. The Administrator, Regional Nurse Consultant, VP of Clinical Services and Regional Director of Marketing were notified. The Administrator was provided with the IJ template on 2/13/24 at 5:26 p.m. The following Plan of Removal submitted by the facility was accepted on 02/14/24 at 2:45 p.m.: Plan of Removal F689 Supervision to Prevent Accidents Failures: o Ensure Resident #6 received ADL care and was transferred in the correct way by facility staff. o Ensure Resident #2 received ADL care from facility staff. o Ensure the facility had policy and procedures in place for private sitters outlining the care they can provide. o Ensure personal/private sitters were aware of what their duties were and did not perform care to residents to prevent harm. o Ensure facility staff were aware they were to provide care to Resident #2 when the sitters were at the facility. Plan of Removal 1. Immediate actions o Instructed existing sitters (2) on 2/13/24 at 1:30 PM that they are not allowed to provide ADL care. o May not administer Direct Care to the resident. Direct Care includes, but is not limited to, transferring the resident, providing incontinent care, providing assistance with feeding, repositioning, toileting, bathing and dressing, wound care and administering medications, (including over-the-counter medications and supplements). o May monitor patient needs, report issues, ensure patient comfort (e.g., changing bedding, filling water jugs and positioning items within reach) and provide companionship. o Will assist facility to maintain, create and provide a safe environment for the patient. o Must report to the Nurse Supervisor/Charge Nurse when coming on and going off duty. o Must report changes in a resident's condition to the Nurse Supervisor/Charge Nurse immediately. o Notified RP of residents with sitters in place of Facility Sitter Policy. o Family responsible to notify facility of private duty sitter. o Residents/responsible party desiring the use of private duty sitters must first obtain written approval Facility by reviewing and signing the Facility Sitter Agreement. o Private Duty Sitters required to sign in at nurses station prior to start of shift. Binder at nurses station with sign in sheet for private duty sitters. Charge nurses in-serviced on process of private duty sitters requirement to sign in and provided Private Duty Sitter Acknowledgement forms to be completed. o Facility staff to monitor private duty sitters as they are rounding to ensure no private duty sitters are providing ADL care. o The Medical Director was notified by the Director of Nursing on 02/13/2024 at 6:05 PM. o Resident #2 was assessed with head-to-toe assessment on 2/13/24 at 1:30 PM by facility ADON. 2. Education (Administrator/Regional Nurse) o Personal and private sitters in-serviced on Facility Sitter Policy on 2/13/24. Education provided on following: o May not administer Direct Care to the resident. Direct Care includes, but is not limited to, transferring the resident, providing incontinent care, providing assistance with feeding, repositioning, toileting, bathing and dressing, wound care and administering medications, (including over-the-counter medications and supplements). o May monitor patient needs, report issues, ensure patient comfort (e.g., changing bedding, filling water jugs and positioning items within reach) and provide companionship. o Will assist facility to maintain, create and provide a safe environment for the patient. o Must report to the Nurse Supervisor/Charge Nurse when coming on and going off duty. o Must report changes in a resident's condition to the Nurse Supervisor/Charge Nurse immediately. o Nurse Administrative Staff/Direct Care Staff educated on Facility Sitter Policy on 2/13/24. Agency Provider Companies to be notified on 2/14/24 of need for all agency staff to review Private Duty Sitter Policy prior to start of shift at [the facility]. To be completed by 2/14/24 at 5:00 PM. All future facility staff will be in-serviced upon hire. o Private Duty Sitter Acknowledgement to be signed for residents with current sitters by 2/14/24 and reviewed with future sitters as they are assigned to residents. o Facility Nurses/CNA/Agency staff were in-serviced on 2/13/24 by ADON and Regional Nurse on their job duties related to residents with private duty sitters present. 3. Medical Director - The Medical Director has been notified of the Immediate Jeopardy. 4. QAPI Committee Review - An interim QAPI committee meeting was completed on 02/13/2024. 5. Plan of removal date: 02/13/2024 Monitoring of the POR on 02/15/24 included the following: During an observation on 2/15/24 at 5:30 p.m. of the north wing nurses' station revealed a sitter book with the sitter policy, and the signatures of the sitters and a sign in and out sheet. During an observation on 2/15/24 at 5:32 p.m. of the East wing nurses' station revealed a sitter book with the sitter policy, and the signatures of the sitters and a sign in and out sheet. At 3:35 p.m. LVN A- agency work all shifts At 3:59 p.m. CNA E said she worked all shifts At 4:10 p.m. CNA F worked 2p to 10 p At 4:15 p.m. CNA H worked 6a to 6p and sometimes 6p to 10 p. At 4:22 LVN I worked 6a to 6p At 4:30 p.m. LVN J worked 6a to 6p At 4:40 p.m. CNA K worked 2p to 10 p At 4:49 p.m. CNA L agency worked 6a to 6p and all shifts At 4:45 p.m. CNA M worked 6a to 6p At 5:01 p.m. MA worked 6:30 a.m. to 6:30 p.m. Interviews with staff indicated they were knowledgeable about the in-services provided. They were able to voice their knowledge of the sitter policy and the sitter books located at the nurse's station. They voiced if they saw a sitter providing ADL care to a resident, they would intervene to ensure the resident's safety. They would inform the charge nurse and/or the DON. They also indicated staff not providing care to residents could be a form of neglect, and allowing sitters to perform care they were not trained to provide could be neglect. During an interview on 2/15/24 at 5:05 p.m. the family member of Resident #5 said they were informed sitters were no longer to provide personal care to the residents. The family member said she understood but was concerned Resident #6 would not receive timely care. During an interview on 2/15/24 at 5:10 p.m., Sitter DD the evening sitter for Resident #5, said she was made aware today that she could no longer provide care to the resident. She said this was her first day back this week. The sitter said in the past she had provided ADL care to Resident #5 but would comply with the new rules. During an interview on 2/15/24 at 5:15 p.m., the DON said she was out sick and not aware they had a new resident, Resident #6. She said she had just gotten back from sick leave yesterday and was not aware of the new admissions. The census indicated the resident was admitted on Monday. The DON said she was not aware there was an incident on 2/8/24 when the sitter was transferring Resident #2 and she fell . She said they had the sitter books at the nurse's station and sitters were to sign in and out so they knew who was in the building. The DON said if they were new the Charge nurse would have them read and sign the sitter policy. If there were any problems the staff were aware they could contact her for assistance. The aides and nurses were also aware if they saw any sitter breaking the policy by providing care they were to intervene and let the charge nurse and the DON know. During an interview on 2/15/24 at 5:20 p.m., Sitter EE said she was providing care to Resident #2 before and did not understand why she could not continue. She said was a CNA for 5 years. She provided all care, assistance with eating, transfers, and incontinent care the staff were aware and just left them alone. She said yesterday, LVN J and the DON explained to her she was not supposed to provide any care and she signed the form stating she understood. During an interview on 2/15/24 at 5:25 p.m. the two sitters with Resident #6, Sitter GG said she was going home, and Sitter HH said she was coming on. They said they were aware they were not to provide any care for Resident #6 they were there for companionship only. They said they understood their duties and had not provided care to the resident while she was at the facility. They were informed by the facility staff and had signed the form. During an interview on 2/15/24 at 5:35 p.m., the Administrator said they met with the Director of the company and all the sitters worked for today and told them they did not want the sitters providing ADL care to the residents. The Director of the sitter company agreed. They spoke to the families via telephone and one family in person and they said they understood. She said they took the concerns with sitters and neglect to the QA meeting. The Medical Director was involved via phone. The Administrator said they placed the sitter books at the nurse's station and all sitters were to sign in and out. If it was a new sitter, the charge nurse would go over the policy with them and have them sign. The Administrator said staff were aware they were to notify the DON or Administrator if they noticed any sitter breaking the policy. Record review of the, undated, Private Duty Sitter Agreement with reflected: by signing below we agree to the following. The sitter is an employee of the family, failure to meet the guidelines or interference in the care of other patients could result I the sitter not being allowed to work in the facility. The sitter will be required to adhere to the responsibilities listed below. The sitter May Not administer direct care to the resident. Direct care includes, transferring, providing incontinent care, assistance with eating, reposition, toileting, bathing and dressing, wound care administering medications including over the counter. They must report when coming on and going off duty, monitor the patient needs and report issues. Record review of Resident #5's nursing notes, dated 2/13/24 at 2:50 p.m., reflected the RN spoke with the POA. He was reminded sitters for Resident #5 need to always call for assistance when performing any care for the resident. He was informed he needed to alert the sitters that sit with her daily. Record review of Resident #2's nursing notes, dated 2/13/24 at 6:31 p.m., indicated the RN spoke with the POA. He as reminded sitters for Resident #2 need to always call for assistance when performing any care for the resident. He was informed he needed to alert the sitters that sit with her daily. The Administrator, DON, Regional Nurse Consultant and VP of Clinical Services were informed the Immediate Jeopardy was removed on 2/15/24 at 5:49 p.m. The facility remained out of compliance at a severity level of no actual harm with the potential for more than minimal harm that is not immediate jeopardy with a scope of a pattern due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place.

Based on observation, interview, and record review, the facility failed to provide the necessary behavioral health care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being 1 of 1 residents (Resident #170) reviewed for behavioral health. 1.The facility failed to assess, provide safety intervention and immediate psychological services, per their policy, for Resident #170 who made a verbalization of suicidal ideation to the facilities on 02/09/23. 2. The facility failed to in-service staff on behavioral healthcare and services as a part of the person-centered environment. 3. The facility failed to train on and implement suicidal precautions per policy, (for example: assigned a one-to-one staff member who will remain within 6 feet of resident and maintain visual contact and document the observation every 15 minutes) for Resident #170. 4. The facility failed to have the Nurses document every 4 hours the assessment of the resident in the medical records per policy for Resident #170. 5. The facility failed to revise Resident #170's mood state care plan with interventions for suicidal ideations. 6. The facility failed to inform staff of Resident #170 suicidal ideation. These failures resulted in an Immediate Jeopardy (IJ) situation. The Administrator was notified on 02/13/23 at 3:40 PM. While the IJ was removed on 02/14/23 at 3:49 PM and the Administrator was notified, the facility remained out of compliance at a severity level of no actual harm at a scope of isolated due to the need to complete in-service training and evaluate the effectiveness of the corrective systems. These failures placed residents at risk for a decline in quality of life related to suicidal ideations. Findings include: Record review of Resident #170's electronic face sheet, dated 02/14/23, revealed an [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses which included depression, PVD (a systemic disorder that involves the narrowing of peripheral blood vessels), anxiety (Feelings of being worried, tense, or afraid that are triggered by certain traumatic situations), and high blood pressure. Record review of Resident #170's admission MDS assessment, with an ARD of 02/02/23, revealed under Section B, Hearing, Speech, and Vision, under sections B0300 was coded a 0 indication her speech was clear, under section B0700 was coded as a 0 indicating she understands and was usually understood by others. Section C, Cognitive Patterns, under section C0500 Brief Interview for Mental Status, was scored a 15 indicating she had cognitive intact cognition. Section D, Mood, under section D0200 was coded a15 indicating she was moderately severely depressed. Section E, Behavior, under section E0200 was coded a 0 indicating she had no behaviors. Section G, Function Status, under section G0110 indicated he needed extensive assistance with bathing, personal hygiene, toileting limited assist with dressing, bed mobility, and supervision with eating. Record review of Resident #170's comprehensive person-centered care plan, dated 02/02/23, indicated, Problem: mood state, Resident #170 had signs and symptoms of mood distress as evidence by feeling down and depressed and hopeless. Approach: Administer medication as ordered, encourage resident to verbalize feelings, observe for signs and symptoms of depression, obtain a psychologist consult and work with resident to identify effective coping skills. The care plan was not revised to indicate anything about suicidal ideations. Record review for Resident #170's progress note dated 02/02/23 at 4:23 p.m., revealed, the social worker was in room visiting with Resident #170, when she expressed some feelings of depression. SW sent a referral to Carousel clinical services for counseling. Record review for Resident #170's counseling clinical nurse practitioner (NP) medication review note dated 02/06/23 at 11:27 a.m., revealed, facility requested service. Resident #170's mood was coded a 4. The NP wrote order for Remeron 15mg by mouth every night for mood and to increase appetite. Record review for Resident #170's progress note dated 02/07/23 at 3:00 p.m., revealed, the facility received a new order for Remeron 15 mg, give 1 tablet by mouth every night for mood and to increase appetite. Review of Resident #170's physician's orders dated 02/08/23 indicated: Remeron 15 mg, give 1 by mouth every night for mood and appetite. Record review for Resident #170's MAR (medication administration records) dated 02/01/23 until 02/14/23 revealed Remeron 15 mg was initially given on 02/08/23 at 8:00pm. Record review for Resident #170's progress note dated 02/09/23 at 1:13 p.m., revealed hospice nurse in facility with new orders for Citalopram (Celexa) 10 mg, give 1 tablet by mouth every day for depression. Review of Resident #170's physician's orders dated 02/09/23 indicated: Celexa 10mg, give 1 tablet by mouth daily for depression. Record review for Resident #170's MAR revealed Celexa10mg was initially given on 02/10/23 at 8:00am. Record review for Resident #170's progress note dated 02/09/23 at 2:36 p.m., revealed facility called the resident's family member to talk about new medication when he said a family friend called him and said Resident #170 told the friend she wanted to die, and if she could, she would kill herself. The son said Resident #170 said if she could get ahold of some razors, this was how she would do it. Record review for Resident #170's hospice progress note dated 02/09/23, revealed blood pressure at 174/68, pulse at 101, heart rate at 18, temperature at 98.8 and oxygen saturation at 90%. Resident #170 was tearful with no eye contact, soft spoken voice. No complaints of pain or distress. Resident #170 was moved to room [ROOM NUMBER] and placed on suicidal watch. Record review for Resident #170's progress noted written on 02/10/23 by a licensed psychologist revealed diagnosis of major depression, generalized anxiety, and unspecified neurocognitive disorder. His treatment plan indicated: medication and counseling are the most common treatment for depression. It was recommended that the client see a physician and a counselor for treatment. He indicated the physician often prescribed an antidepressant, and the counselor could monitor for efficiency and compliance. The counselor can also help the client learn effective coping mechanism for this disorder. Resident #170 was unlikely to follow through with suicide attempt. However, counseling and medication were recommended immediately to relieve symptoms. Note: It can take weeks or a month for many of the antidepressants to have a significant effect. Resident #170 had started medications already, but he indicated counseling could provide quicker symptoms relief. Counseling can help her adjust to the nursing home as well. Record review for Resident #170's 24-hour report dated 02/09/23 indicated she wanted to kill herself, moved to room [ROOM NUMBER], all sharp objects removed from room and dietary aware to send plastic ware with meals. Record review for Resident #170's 24-hour report dated 02/10/23 did not indicate anything about suicide or ideations. Record review for Resident #170's 15-minute surveillance log dated 02/09/23 indicated facility started monitoring at 2:30pm. Record review for Resident #170's 15-minute surveillance log dated 02/10/23 indicated facility started monitoring at 6:00pm. Record review for Resident #170's 15-minute surveillance log dated 02/11/23 indicated facility started monitoring at 10:15pm. Record review for Resident #170's 15-minute surveillance log dated 02/12/23 indicated facility started monitoring at 6:15 am and completed at 11:45 am. Re-started at 4:30 pm and completed at 6:00 am on 2/13/23. Record review for Resident #170's 15-minute surveillance log dated 02/13/23 indicated facility started monitoring at 6:15 am and completed at 12:00 noon. Record review for Resident #170's MAR (medication administration records) indicated no depressed mood documented under target behavior from 02/02/23 thru 02/13/23. Record review for Resident #170's progress noted written on 02/13/23 by a psychologist indicated mood was a 3. His comment stated: Some previous ideals and verbalization, dealt with in therapy. Resident #170 said she will try to let go of the thought. During an observation and interview on 02/12/23 at 9:59 a.m., Resident #170 was in her bed alert with eyes open. Resident #170 said she was moved to room [ROOM NUMBER] about a week ago because of suicide statement. Resident #170 said she wanted to kill herself because she was depressed. Resident # 170 said she did not feel like harming herself at that time but it was still present in her mind. Resident # 170 became tearful when talking about her suicidal thoughts. Resident # 170 said she felt like she was dumped in the nursing home, had no independence, no friends and did not see the need to live. Resident #170 said she did not have a plan at that time. Resident #170 had her call light attached to her sheets, remote control to her bed and blinds still in room during interview. During an interview on 02/13/23 at 11:32 a.m., the SW said she went to do an assessment on Resident #170 and felt she was depressed based off the PHQ (Quick Depression Assessment) scale score of 15 indicating moderately severely depressed and the way she was answering the questions to her. The SW said she referred Resident #170 to counseling clinical services. During an interview on 02/12/23 at 12:00 p.m., LVN N said Resident #170 was moved to room [ROOM NUMBER] because she said she wanted to kill herself with a razor. LVN N said on Friday (02/10/23) a psychologist doctor came to visit Resident #170 and he let someone in management know upfront she was not a threat to herself or anyone else. LVN N said management staff wanted us to keep her on every 15-minute suicided watch for the next 72 hours. LVN N presented the 15-minute monitoring sheets for Resident #170, but they were incomplete on days for 2/10/23, and 2/11/23. LVN N said she should have filled out the forms on 2/10/23, and 2/11/23 but did not. LVN N said she had not started the 15-minute monitoring sheets for that day but had seen Resident #170 every 15-minutes and would fill out the sheet. During an interview on 02/12/23 at 12:21 p.m., the SW said during a visit and assessment on 02/02/23, Resident #170 made a statement she was ready to die but it was not a suicidal statement. The SW said she talked with a family member about the statement and they both agreed to have counseling to see her. The SW said she made the referral to counseling. The SW said Resident #170 was currently on every 15-minute checks because on 02/09/23, she had a plan to cut her throat, if she was able. The SW said Carousel counseling talked to Resident #170 on Friday 02/10/23 and felt she was not suicidal but gave her a diagnosis of major depression. The SW said she had not typed up her note from Friday's (02/10/23) visit with the psychologist but would. During an interview on 02/12/23 at 1:04 p.m., CNA E said she was the aide providing care to Resident # 170. CNA E said she was not aware of any suicidal threats on Resident #170. CNA E said LVN N gave her report on Resident #170 but failed to mention anything about suicidal thoughts. During an interview on 02/12/23 at 2:28 p.m., LVN O said she had worked since Friday (02/10/23) in the facility but was not aware of any resident with suicidal thought until 02/12/23 when they did an in-service. During an interview on 02/12/23 at 2:31 p.m., LVN Y said she worked Friday (02/10/22), Saturday (02/11/23), and 02/12/23 and was aware a resident said something but was not quite sure what was said or who the resident was. LVN Y said LVN N and LVN G sat at the front nurse's station during the 6am-6pm shift for the last three days but neither voiced anything about suicidal thoughts to her. LVN Y said she sometimes reliefs LVN N for breaks. LVN Y said prior to 02/12/23 they had not had an in-service on suicide. During an interview on 02/12/23 at 2:38 p.m., CNA W said she was the primary aide for Resident #170 since Friday (02/10/23) but was not aware of any residents with suicidal thoughts. CNA W said she thought Resident #170 moved rooms because she was complaining about her mattress. During an interview on 02/12/23 at 2:43 p.m., LVN G said she worked since Friday (02/10/23), but was not aware they had a resident with suicidal ideation and she often walks hall 100 where Resident #170 resides and reliefs LVN N for breaks at times. During an interview on 02/12/23 at 2:51 p.m., LVN N said she was Resident #170 day nurse. LVN N said Resident #170 kept her call light and remote control to her bed during suicidal watch. LVN N said no staff member sat with Resident #170 during her shift. LVN N said they just walked by Resident #170's room and checked on her every 15 minutes. LVN N said Resident #170 required assist x 1 with ADL's and usually sat up in her wheel chair throughout the day. During an interview on 02/13/23 at 8:21 a.m., LVN A said she was Resident #170 primary day nurse. LVN A said she was the nurse who called the family member on 02/09/23 to get consent for Celexa and during the call the family member informed her a friend had stopped by and told him his mother was having suicidal thoughts of killing herself and if she had a razor, she would end it now. The family member stated he called hospice and informed them. LVN A said when she hung up, the hospice nurse called her. LVN A said she informed the ADON, and they searched Resident #170's room and removed some scissors and a fork. LVN A said they moved Resident #170 to room [ROOM NUMBER] and did every 15 minutes checks. This nurse stated the resident kept her call light and bed control. During an interview on 02/13/23 at 9:49 a.m., CNA B said on Thursday (02/09/23) Resident #170 told the hospice nurse she wanted some medicine for depression and the nurse told her she would see what she could do. CNA B said when she came back to work on Saturday (02/11/23) they had moved Resident #170 to room [ROOM NUMBER]. CNA B said she was not aware why Resident #170 was moved and she thought she could not sleep in the other room because her roommate was loud at times. CNA B said she was Resident #170 primary day aide since Saturday and still not aware why she moved rooms. During an interview on 02/12/23 at 12:37 p.m., the DON said on Thursday (02/09/23) Resident # 170 told an unidentified nurse she wanted to kill herself and had a plan. The DON said she was not in the building at the time but was aware they swept Resident #170's room, moved her to another room, notified the family member and was on every 15-minute checks. During an interview on 02/12/23 at 1:12 p.m., the ADON said she was in charge Thursday (02/09/23) when LVN A reported Resident #170's family member called and said Resident #170 was having suicidal thoughts with a plan. The ADON said she notified the SW and they went down to talk to Resident #170. The ADON said they did a sweep of Resident #170's room and moved her to room [ROOM NUMBER]. The ADON said they initiated every 15-minute monitoring of Resident #170. Record review of Suicidal Precautions policy given by DON on 02/13/23 indicated, Management policy: #1. Resident suicide threats shall be taken seriously and addressed appropriately, #2 the facility will provide and or arrange for transfer to the safest, practical living environment for all patients slash residents who voice suicidal thoughts, attempt suicide, or cause self the injury. Procedures: #1 if a resident who was voicing suicidal thoughts or attempts suicide was a danger to self or others. A. additional interventions will be initiated including physician, psychiatrist, counselor, and family are notified immediately. If the patient doesn't have a psychiatrist, then a referral was made at this time, B. suicidal precautions are implemented immediately if a resident was deemed to be a threat to themselves or others to preserve the well-being of patient resident. The physician should be notified immediately of suicide ideations and for further orders, C. if it was determined that the facility cannot provide a safe environment due to suicide ideations of the resident the resident will be transported to an acute care setting for evaluation and treatment. #2 suicide precautions will be implemented immediately for any resident that presents with a significant level of depression or suicidal preoccupation and will be used to address the risk factors presented by the resident. #3 suicidal precautions include the following: A. one-on-one supervision be the resident will eat on the unit without sharp utensils sing until evaluation or transfer current can occur third item such as belts, drawstring pants, shoes with laces, sheets etc. May be prohibited if they present a potential danger for the resident. D. call light cord was removed from residence room. If available a bell or other signal device was given to replace the call light E. medication nurses observe resident swallowing all medications and checks or cavity to ensure resident has swallowed, I. a licensed nurse will assess the resident at least every four hours and document the assessment in the medical record. #4 family member or responsible party will be notified of suicide precautions. # 5 a physician order was required to discontinue suicide precaution. # 7 documentation guidelines: A. when a position order suicide precaution documentation was completed at least every 15 minutes and more often if needed, B. Documentation includes date, time, one-on-one continue, the reason the patient was placed on suicide precautions, resident responses and behaviors, additional safeguard and supervision of resident, the search for and removal of items that may be used in suicide attempts and time family was contacted, C. date, time and reason suicidal precautions were discontinued and signature. #8 record the resident was checked every 15 minutes or suicide precaution. Staff documents this by signing their initials in the column for their shift. This was determined to be an Immediate Jeopardy (IJ) situation on 02/13/23 at 3:43 p.m. The Administrator was notified of the IJ and he needed to send us his plan of removal. The Administrator was provided with the IJ template on 02/13/23 at 3:49 p.m. The following Plan of Removal submitted by the facility was accepted on 02/14/23 at 3:49 p.m. and included the following: Plan of Removal 1. Immediate actions o The Medical Director was notified by the Director of Nursing on 02/13/2023 at 4:25 PM. o Resident #170 care plan was updated immediately on 02/13/2023 at 5:00 PM to include interventions related to suicidal ideation which include Carousel Counseling discontinuing suicidal precautions and continuing psychology services, nurse to monitor for 72 hours after suicide precautions discontinued, social services available as needed, and notification to hospice to provide spiritual and social services. o Resident #170 will continue Psychiatric visits from 02/13/2023 ongoing. The QAPI Team will monitor continued care based on the results of the consult to include potential placing resident in a behavioral health setting. Resident #170 will continue Psychiatric Services to monitor any recurrence of suicidal ideation. 2. Education (provided by DON or ADON) o All staff were in-serviced on behavioral healthcare and services available to include Carousel Counseling should a resident's mood and behavior warrant them. In-patient facilities are available, such as Oceans Behavioral, etc. This in-service will be completed by 02/14/2023 at 10:00 PM. Staff will not be allowed to return to shift without this in-service. This in-service was completed by the Director of Nursing and the Social Services Consultant. o SW/DON/Activity Director/MDS/ADON were in-serviced on implementing person-centered care plans to include interventions for behavioral healthcare and the importance of updating care plan to reflect current interventions related to suicidal ideations, current behaviors, and mood. Care plan to be updated as situation changes, and suicide precautions are discontinued. This in-service will be completed by 2/14/23 at 10:00 PM. Staff will not be allowed to return to work without this in-service. o In-service Social Worker/DON/All Charge Nurses on 2/13/23 at 5:00 PM on need to visit with resident after resident expresses feelings of depression to build coping skills until Carousel Counseling/psychology service arrives. This in-service will be completed on 2/14/23 at 10:00 PM. Staff will not be allowed to return to shift without this in-service. o In-service Social Worker/DON/Charge Nurse on need to notify hospice when resident was experiencing depression/mood changes to have hospice agency send chaplain/social worker for resident visit. This in-service will be completed on 2/14/23 at 10:00 PM. Social Service Consultant to complete in-service, staff will not be allowed to return to shift without this in-service. o All staff were in-serviced on implementing suicidal precautions per current facility policy, resident will be assigned a one-to-one staff member who will remain within 6 feet of resident and maintain visual contact and document the observation every 15 minutes on 02/13/2023. Each staff member will be in-serviced prior to returning to shift. This will be completed by 02/14/2023 at 10:00 PM. Staff will not return to shift without the in-service. This in-service includes the removal of potentially harmful objects. Staff will follow the current policy. In-service completed by Director of Clinical Services and DON. o All staff were informed of [Resident #170's] suicidal ideation on 02/12/2023 at 5:00 PM by the Director of Nursing. o All nurses were in-serviced on documenting every 4 hours the assessment of the resident's mood and behavior in the medical record on 02/12/2023. This in-service will be completed by 02/12/2023 at 10:00 PM. This in-service was completed by the Director of Nursing and the Regional Nurse Consultant. The Director of Nursing will review the 24-hour report as well as the documentation to ensure all staff are documenting appropriately and monitoring for further suicidal ideation during the morning meeting. 3. Medical Director - The Medical Director has been notified of the Immediate Jeopardy. 4. QAPI Committee Review - An interim QAPI committee meeting was completed on 02/13/2023. 5. Plan of removal date: 02/13/2023 Monitoring included: Interviews on 02/14/2022 from 1:30 p.m. until 4:00 p.m., the surveyors confirmed the facility implemented their plan of removal sufficiently to remove the IJ by: Interviews with 4 (6am-6pm) nurses LVN A, LVN G, LVN F, and LVN N,1 (6pm-6am) nurses LVN K who indicated they had received a written in-service regarding suicidal precautions and things they needed to do such as put them on 1 on 1, chart every 15 minutes on form provided, and assess on condition and document in chart every 4 hours. They also indicated they learned how to notify outside services such as carousel counseling or hospice for spiritual services if needed. SW or designee are supposed to chart every day until resident seen by carousel counseling. Interviews with 4 CNAs (6am-2pm) CNA B, CNA C, CNA M, and CNA T, 4 CNAs (2pm-10am) CNA H, CNA W, CNA Z and CNA X and 1 CNA (10-6) CNA R who all indicated they were in-serviced on suicidal precautions and if they heard a resident voice any concerns over killing themselves or even if they are feeling down, they were to stay with the resident and notify the nurse, so they could assess them. Interviews with the MDS nurse, the social worker, the dietary manager, the activity director, the ADON, the DON and the ADM who all indicated they were in serviced on behavior health support, person centered care plans, depression, coordinating spiritual services with hospice, care plans for suicidal residents and residents with mood changes or depression and suicide precautions. They said they all played a part in the residents' overall care. The Administrator was informed the Immediate Jeopardy was removed on 02/14/2023 at 3:49 p.m. The facility remained out of compliance at a severity level of no actual harm that was not immediate jeopardy and a scope of isolated due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place.

Based on observation and interview, the facility failed to ensure an effective infection prevention and control program to prevent the development and transmission of communicable diseases was provided for 10 of 11 residents reviewed for infection control regarding COVID 19 (a respiratory disease which can cause mild to severe illness with most severe illness in adults 65 and older). (Resident #s 1, 2, 3, 4, 5, 6, 7, 8, 9 and 10) The facility did not follow guidelines making sure the appropriate PPE was worn in resident rooms and properly disposed of by OT D, housekeeper B, CNA A and LVN C on the quarantine unit. OT D did not doff her PPE before exiting a resident room and wore it through the quarantine hallway. Housekeeper A did not change her eye protection and gown between cleaning resident rooms. CNA A did not wear a gown, gloves or goggles into Resident #1's room. CNA A doffed her gown and left it on a table other staff used for donning. LVN C did not wear gloves during medication administration and did not change her gown or sanitize her eye protection between residents. The facility had 4 COVID-19 positive residents residing on the COVID-19 unit, and all those residents had previously lived on the quarantine unit. This failure could place residents at risk of COVID-19 transmission or death. An Immediate Jeopardy (IJ) situation was identified on 9/16/20. While the IJ was removed on 9/17/20, the facility remained out of compliance at a potential for more than minimal harm with a scope identified as a pattern due to the facility's need to evaluate the effectiveness of the corrective systems. Findings included: The daily census dated 9/17/20, indicated Resident #'s 7, 8, 9 and 10 lived on the COVID-19 unit and all had previously lived on the quarantine unit that was located between rooms [ROOM NUMBERS]. During an interview on 9/15/20 at 11:48 a.m., the MDS nurse said staff on the COVID 19 quarantine units did not change gowns, hair coverings, and sanitize their goggles between resident care. She said no residents on the quarantine unit were showing signs or symptoms of COVID-19, and that was why staff were not changing PPE. She said the residents who were on the quarantine unit had roommates that tested positive for COVID-19. During an observation on 9/15/20 at 2:41 p.m., multiple gowns were seen hanging in the quarantine hallway on a clothes line for reuse. During an observation on 9/15/20 at 2:43 p.m., CNA A on the quarantine unit entered Resident #1's room wearing an N-95 mask and no other PPE. She used hand sanitizer, and then shut the resident's door. During an observation on 9/15/20 at 2:49 p.m., CNA A exited Resident #1's room, removed her gloves and discarded them. She doffed her gown and placed it on top of a clean table used by staff members for hand sanitization and donning of PPE. The table top contained hand sanitizer, bleach wipes and boxes of clean gloves. A face sheet with a print date of 9/17/20, indicated Resident #1 was [AGE] years old, admitted [DATE] and had [DIAGNOSES REDACTED]. A September 2020 physician order [REDACTED]. The most recent MDS, dated [DATE], indicated Resident #1 had adequate hearing, clear speech and intact cognition. She required extensive assistance with bed mobility, transfers, dressing and toilet use. During an observation of the quarantine unit on 9/15/20 at 2:45 p.m., Housekeeper B entered Resident #2's room wearing an N-95 mask, gown, gloves and goggles. She cleaned Resident #2's room, exited into the hallway, and changed her gloves, but did not change her gown or eye protection. She then entered Resident #3's room and began cleaning. CNA A exited Resident #1's room, donned a gown and gloves, then reentered Resident #1's room. A face sheet with a print date of 9/17/20, indicated Resident #2 was [AGE] years old, admitted [DATE] and had [DIAGNOSES REDACTED]. The most recent MDS, dated ,[DATE], indicated Resident #2 had minimal difficulty hearing, clear speech and moderately impaired cognition. She required extensive assistance with bed mobility and toilet use and was totally dependent with dressing. A face sheet with a print date of 9/17/20, indicated Resident #3 was [AGE] years old, admitted [DATE] and had [DIAGNOSES REDACTED]. A September 2020 physician order [REDACTED]. The most recent MDS, dated [DATE], indicated Resident #3 had minimal difficulty hearing, clear speech and intact cognition. She required limited assistance with bed mobility, transfers, dressing and toilet use. During an observation on 9/15/20 at 3:00 p.m., LVN C entered Resident #4's room for medication administration wearing an N-95 mask, gown, and goggles, she was not wearing gloves. She exited the room, sanitized her hands, and began preparing medications for Resident #5 without doffing her PPE or sanitizing her goggles. A face sheet with a print date of 9/17/20, indicated Resident #4 was [AGE] years old, admitted [DATE] and had [DIAGNOSES REDACTED]. A September 2020 physician order [REDACTED]. The most recent MDS dated [DATE] indicated Resident #4 had adequate hearing, clear speech and intact cognition. She required supervision with bed mobility, transfers, dressing and toilet use. During an observation on 9/15/20 at 3:05 p.m., the LVN C entered Resident #5's room for medication administration wearing the same N-95 mask, gown and goggles, with no gloves. LVN C exited the room, sanitized her hands and began preparing medications for Resident #6 without doffing her PPE or sanitizing her goggles. A face sheet with a print date of 9/17/20, indicated Resident #5 was [AGE] years old, admitted [DATE] and had [DIAGNOSES REDACTED]. A September 2020 physician order [REDACTED]. The most recent MDS dated [DATE] indicated Resident #5 had adequate hearing, clear speech and intact cognition. She required extensive assistance with bed mobility, transfers, dressing and toilet use. During an observation on 9/15/20 at 3:10 p.m., LVN C entered Resident #6's room for medication administration wearing the same N-95 mask, gown and goggles, and no gloves. A face sheet with a print date of 9/17/20, indicated Resident #6 was [AGE] years old, admitted [DATE] and had [DIAGNOSES REDACTED]. A September 2020 physician order [REDACTED]. The most recent MDS dated [DATE] indicated Resident #6 had minimal difficulty hearing, clear speech and intact cognition. She required supervision with bed mobility, transfers, dressing and toilet use. During an interview on 9/15/20 at 3:11 p.m., LVN C said she only worked on the quarantine unit but shared the nurse's station with the non-quarantine nurse. She said she wore the same PPE throughout her shift. During an observation on 9/15/20 at 3:14 p.m., OT D exited a resident's room wearing a gown, goggles, N-95 mask, and gloves into the hallway. She walked down the hallway and left the COVID unit without doffing her PPE. During an interview on 9/15/20 at 3:15 p.m., LVN E said staff donned PPE for the day and changed gloves between residents. During an observation on 9/15/20 at 3:21 p.m., a sign hanging at the entrance of the quarantine unit indicated one gown would be dispensed to staff members for the day. The gowns would be hung on hooks when not in use and were not to be thrown away until the end of shift. During an interview on 9/16/20 at 10:09 a.m., the MDS nurse said the four cases of COVID-19 came from the quarantine unit. She said the facility converted the hall into a quarantine unit due to all the cases of COVID-19 coming from that hall. She said staff had cleaned as much as possible and they aired out the rooms by opening the windows. She said the residents on the quarantine unit were the same residents who lived there before it became quarantined. She said she did not know what else the facility could do to rid that hall of COVID-19, because they had tried everything. During an interview on 9/16/20 at 11:20 a.m., the DON said the quarantine guidance did not state to change PPE between residents and that the expectation of staff was to dispose of PPE at the end of every shift. An undated Droplet Isolation handout indicated before making direct contact with residents, the staff member must don an N-95 mask, head covering, goggles, gown, shoe covers, gloves, and face shield. Staff members would only be issued 2 N-95 masks and must be reused. Head coverings, gowns, and shoe covers were to be removed after use, and clipped on a hook for reuse. Goggles and face shields were to be disinfected and reused. Gloves were to be disposed after use. The sign also indicated isolation supplies were not to be thrown away and re-used throughout the shift. An Isolation - Categories of Transmission-Based Precautions policy, with a revision date of October 2018, indicated: .6. When transmission-based precautions are in effect, non-critical resident-care equipment items such as a stethoscope, sphygmomanometer, or digital thermometer will be dedicated to a single resident (or cohort of residents) when possible. a. If re-use of items is necessary, then the items will be cleaned and disinfected according to current guidelines before use with another resident. Contact Precautions .4. Staff and visitors will wear gloves (clean, non-sterile) when entering the room. .b. Gloves will be removed, and hand hygiene performed before leaving the room. .5. Staff and visitors will wear a disposable gown upon entering the room and remove before leaving the room and avoid touching potentially contaminated surfaces with clothing after gown is removed. The website https://www.cdc.gov/coronavirus/2019-ncov/hcp/ppe-strategy/isolation-gowns.html, updated by the CDC on 3/17/20 and accessed 9/21/20 indicated the following: .Extended use of isolation gowns. Consideration can be made to extend the use of isolation gowns (disposable or cloth) such that the same gown is worn by the same HCP when interacting with more than one patient known to be infected with the same infectious disease when these patients housed in the same location (i.e., COVID-19 patients residing in an isolation cohort). This can be considered only if there are no additional co-infectious [DIAGNOSES REDACTED]. If the gown becomes visibly soiled, it must be removed and discarded as per usual practices. The administrator and DON were notified on 9/16/20 at 11:20 a.m., an IJ situation was identified due to the above failures and the IJ template was provided. The facility's Plan of Removal was accepted on 9/17/20 at 4:49 p.m. and included: .The facility is immediately implementing the following: Facility staff recognizes that residents residing in the facility have the potential to be affected by the deficient practice related to Infection Control. Residents on the designated Quarantine Unit/Warm Zone will be assessed on this day 9/16/20 by the end of the day 9/16/20 by charge nurses and nursing administration nurses to ensure no adverse effects from the deficient practice. These assessments will be continued on each shift by the nurse assigned to the resident and the documentation will be reviewed and verified by a member of nursing administration periodically for validation. Charge nurses will immediately notify the physician/extender and the DON/designee if a resident displays symptom of COVID-19, this practice has been in effect and will remain in effect. Nursing Administration will begin in-service and competency check off for nurses on the following topics: - Glove Use During Medication Administration - Use of Gown PPE for Resident Care on a Quarantine Unit/Warm Zone - Use of Gown PPE for Resident Care on a Non-Isolation Unit Nursing Administration will begin in-service and competency check off for all staff (therapy, housekeeping, laundry, maintenance, activity, social work) on the following topics: - Use of Gown PPE for Resident Care on a Quarantine Unit/Warm Zone - Use of Gown PPE for Resident Care on a Non-Isolation Unit The in-services listed above began immediately upon notification of the IJ today 9/16/20 and will be completed by 09/18/20. Compliance with infection control measures will be monitored by members of Nursing Administration through the following: - Care rounds daily on each shift by a member of the nursing administrative team: - Condition of the residents on each unit - Compliance with wearing gloves during medication administration when indicated - Compliance with PPE usage on each designated unit (Cold Zone, Warm Zone/Quarantine Unit, Hot Zone/Isolation Unit) - Daily monitoring of residents for signs and symptoms of COVID-19 by assigned nurses with periodic review and sign off of documentation by nursing administration. - Nurses immediately reporting of any signs and symptoms of COVID-19 to the physician/extender and the DON/designee - Infection Control tracking and trending through record review and physician order [REDACTED]. The residents who reside in the section of rooms on East Wing, room [ROOM NUMBER]-130, will be monitored per guidelines for signs and symptoms of COVID-19. Residents exhibiting signs and symptoms will be tested with the facilities Clia-Waived POC testing device. If the resident tests negative, the resident's symptoms will be addressed by the primary care physician orders. If the resident tests positive, the guidelines for transfer to the Isolation Unit will be followed. Otherwise the previous designation for East Wing rooms 117-130 in a warm zone will be re-designated back to a Cold Zone. This designation will remove the requirement for a separately designated nurses' station. The staff caring for the residents who meet the criteria to be admitted to the facility on the Quarantine Unit/Warm Zone area of North Wing, rooms 401-422 or through 425 when needed, will follow the Infection Control best practice guidelines to change gowns between each resident encounter and re-using and de-contamination guidelines for PPE beginning 09/16/2020. This unit has a designated nurses' station that is not shared by any other unit. Compliance related to this best practice will be monitored by Administration (Administrator, Nursing Administration Nurses and trained charge nurses, and Director of Therapy) daily through care rounds and observation on each shift for each unit. Effectiveness of these practices will be monitored weekly by the Quality Assurance Team members through observation, review of the care round documentation, and infection control tracking and trending with adjustments made as needed. Re-in-servicing will occur when the need is identified by the QA Team. Please accept the above as Summer(NAME)official Plan of Removal for cited IJ for Infection Control on 9/16/2020. On 9/17/20 the surveyor confirmed the facility implemented their plan of removal sufficiently to remove the IJ by: A gown with non-isolation unit in-service dated 9/16/20 indicated: the rationale for gown wearing was for protecting the health care professional and resident. The soiled gown should always be removed as soon as possible and perform hand hygiene. Providers and staff should wear gloves and a gown for high contact resident care activities such as transfers, linen changes, providing hygiene, brief changes or toileting, and dressing changes. Do not wear the same gown and gloves for the care of more than one person. A gowns in quarantine in-service dated 9/16/20 indicated: the rationale for gown wearing was for protecting the health care professional and resident. The soiled gown should always be removed as soon as possible and perform hand hygiene. Providers and staff must wear gloves and a gown for high contact resident care including contact and droplet precautions for suspected or confirmed case of COVID-19, requires hand hygiene, surgical mask, gown, goggles, gloves; airborne precautions for suspected or confirmed case of COVID-19 requiring healthcare facility admission requires: hand hygiene, respirator mask, gown, goggles, gloves. A gloves and medication administration in quarantine/warm area in-service dated 9/17/20 indicated: the rationale for medical gloves are recommended to be worn for two main reasons: 1. To reduce the risk of contamination of health-care workers hands with blood and other bodily fluids. 2. To reduce the risk of germ dissemination to the environment and of transmission from the health care worker to the resident and vice versa, as well as from one patient to another. An undated Summer Meadow Action Plan for a Positive COVID19 handout indicated: A resident will be transferred to the hospital for unstable or worsening medical condition or to the designated unit (isolation/hot zone) if suspect/confirmed and medical condition is stable immediately upon receiving the positive result. Follow standard orders for symptom management and deep clean the room the resident is moved out of. Follow the guide for symptomatic residents and nursing administration will compile a list of all staff assigned to provide direct care to the resident within the past 7-14 days. Keep family up to date on the resident's status and staff will follow droplet precautions-N95 mask, head covering, goggles/face shield, gown and gloves. Designated staff will care for residents in isolation/hot zone and these staff members cannot leave the unit, provide care to residents on other units, or be floated. Residents will be monitored for symptoms via standing orders and NP/physician consults for symptom management. During an interview on 9/17/20 at 9:45 a.m., the MDS nurse said in-services were started on 9/16/20 and would continue through 9/18/20. She said staff were still being in-serviced on the morning of 9/17/20. During an interview on 9/17/20 at 10:11 a.m., LVN F said she was in-serviced yesterday (9-16-20) about PPE on the isolation and non-isolation unit. She said on the isolation wing, PPE should be changed between rooms and residents. The PPE should be changed, hands washed and change gloves. During an interview on 9/17/20 at 10:13 a.m., LVN G said the facility assesses vital signs on every resident for COVID-19. She said they check temperatures, blood pressures, pulses, respirations and oxygen saturations. She said they check lung sounds and for cough, sore throat, and pain. She said she was recently in-serviced about PPE and she only works on the non-isolation unit. During an observation on 9/17/20 at 10:19 a.m., cold zone signs posted on the 200 hall indicated using standard precautions, wearing a mask and hand hygiene. Another cold zone sign posted at the outside door to the hall indicated a cold zone was about to be entered. During an interview on 9/17/20 at 10:28 a.m., LVN H said she was in-serviced yesterday (9-16-20) on PPE and how to don and doff. She said she was instructed on when to use PPE and what PPE she should use on the quarantine and COVID-19 units. She said she was also checked off on donning and doffing of PPE. During an interview on 9/17/20 at 10:32 a.m., housekeeper J said she was in-serviced this morning on PPE and how to put it on and take it off. She said she was checked off on PPE usage and donning and doffing. During an observation on 9/17/20 at 10:36 a.m., the previous quarantine unit, rooms 117 through 130, were no longer used as quarantine. A sign was posted at the entry to the hall and indicated when to wear PPE and why, as well as to not wear PPE with more than one resident. During an observation on 9/17/20 at 10:40 a.m., a sign was posted at the entry door to the warm unit, the sign indicated an N-95 mask and eye wear were needed to enter the hall. A gown and gloves must be donned for entry into rooms and to change PPE and disinfect eyewear between residents. During an observation and interview at 10:51 a.m., OT K said she was in-serviced on PPE and that she much change PPE in between each resident on the quarantine unit. She said she must don a new gown and gloves for each resident. She said she should wash her hands between each resident and disinfect her goggles. She was donning a new gown to enter a resident room and had disinfecting wipes on her cart for her goggles. During an interview on 9/17/20 at 10:58 a.m., the RN said she works only on the quarantine unit. She said she documents daily on COVID-19 signs and symptoms and the MDS nurse checks the documentation. She said she was checked off on PPE yesterday and was in-serviced on changing PPE between each resident. She said she has a gown for each resident that she dons before she enters the room. On 9/17/20 at 5:00 p.m., the administrator and DON were informed the IJ was removed; however, the facility remained out of compliance at a potential for more than minimal harm with a scope identified as a pattern due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems.

Based on interview and record review, the facility failed to ensure adequate supervision was provided to prevent accidents for 1 of 2 residents reviewed for accidents. (Resident #1) The facility did not provide adequate assistance to prevent Resident #1 from sustaining a fractured left hip during incontinent care. This failure could place residents who require staff assistance with transfers at risk of severe injury or decreased quality of life. Findings included: 1. Physician orders [REDACTED].#1 was [AGE] years old, was admitted on [DATE], and had [DIAGNOSES REDACTED]. A care plan initiated 12/19/17, and last reviewed on 8/26/19, indicated Resident #1 had poor bed mobility, was bedfast most of the time, and was incontinent of bowel and bladder. The care plan did not indicate whether a pad should be used during repositioning or how many staff were required to provide incontinent care or reposition Resident #1. The most recent MDS dated [DATE] indicated Resident #1's cognition was intact. Resident #1 had no behaviors. Resident #1 required extensive assistance of two staff with bed mobility and toileting. The MDS indicated no transfers occurred during the lookback period. She was always incontinent of bowel and bladder. During a telephone interview on 11/13/19 at 9:05 a.m., the DON said Resident #1 had been bedbound for over [AGE] years due to her disease process. The DON said Resident #1 was completely alert. The DON said on 11/1/19, while CNA A was performing incontinent care for Resident #1, she turned Resident #1 using the incontinent pad, and both the resident and CNA A heard a popping noise. The resident complained of pain in her left lower extremity. The DON said CNA A reported the incident to RN C, and CNA B assisted CNA A to finish providing care for Resident #1. The DON said RN C assessed Resident #1 and reported the incident to the physician. The DON said Resident #1 had some pain which was treated with medication. The DON said Resident #1 refused to go to the emergency room and refused an x-ray until the following night (on 11/2/19) when her pain became more persistent. The DON said the facility received the results of Resident #1's x-ray during the early morning hours of 11/3/19, indicating Resident #1 sustained a fractured left hip. The DON said Resident #1 continued to refuse to go to the emergency room . The DON said Resident #1's physician saw Resident #1 in the facility and ruled the resident's fracture as spontaneous. The DON said prior to Resident #1's fracture, one or two staff could safely reposition the resident to provide incontinent care. The DON said since the incident, she in-serviced staff to ensure two staff should provide care for Resident #1. The DON said Resident #1 finally agreed to go to the emergency roiagnom on [DATE], where it was determined she was not a surgical candidate and because of her lower extremity contractures and deterioration, no immobilization was needed. The DON said the hospital records indicated the resident's fracture was caused by a transfer from the resident's wheelchair. The DON said Resident #1's transfer to the ambulance gurney was her first transfer in a long time, and the resident's fracture did not occur from a transfer. The DON said in her investigation, there was no wrong-doing by the staff. She said Resident #1 had not accused anyone of doing anything wrong. A nursing note dated 11/1/19 at 8:30 p.m. indicated Resident#1 complained the CNA may have turned me wrong and reported pain in her upper left leg. Resident #1 refused to be sent to the emergency room and refused an x-ray. The resident was assessed with [REDACTED]. During an interview on 11/13/19 at 10:03 a.m., Resident #1 said she had a fractured left hip which she received when CNA A used the palm of her hand to roll Resident #1 in the bed during incontinent care instead of using the pad to turn her. Resident #1 said her bones were very thin and because of CNA A not using the pad, Resident #1's left hip just broke. Resident #1 said she heard the pop and it hurt very bad. Resident #1 said CNA A then got the nurse, who wanted to get an x-ray for it. Resident #1 said she refused the x-ray because it hurt too bad and she did not want anyone to touch it. Resident #1 said CNA A usually used a pad to reposition her, but did not know why she did not that time. Resident #1 said usually 1 person repositioned her, but since she had the fracture, 2 people repositioned her. Resident #1 said in the past, she could hold the assist rails and assist the staff with turning her, but she could no longer do that because it hurt too bad. During a telephone interview on 11/13/19 at 2:48 p.m., CNA A said when she was in the process of changing Resident #1 on 11/1/19, CNA A pulled the pad up to reposition the resident, and then heard a crack. CNA A said Resident #1 hollered out oh my leg, oh my leg. CNA A said she could not finish changing Resident #1 because the resident was in pain. CNA A said she stopped changing the resident and told RN C Resident #1's leg was hurting. CNA A said she then got CNA B to assist her with Resident #1. CNA A said she pulled off Resident #1's brief and cleaned her. CNA A said CNA B pulled Resident #1's dirty pad from underneath Resident #1, and then CNA A put a new pad underneath Resident #1. CNA A said Resident #1 complained her leg hurt, but the CNAs were gentle with Resident #1 and were able to get Resident #1 changed and pulled up in the bed. CNA A insisted she did use the pad to reposition Resident #1 as she always had. CNA A said before that incident, she had always been able to change Resident #1 by herself. CNA A said since that incident, she always got help with changing or repositioning Resident #1, and the resident was no longer able to assist with repositioning. During a telephone interview on 11/13/19 at 2:15 p.m., CNA B said on 11/1/19, CNA A called her into Resident #1's room to help pull Resident #1 up in bed because she was hollering from being in pain. CNA B said Resident #1 was hollering in pain before she and CNA A touched her or tried to move her. CNA B said she and CNA A had to put a pad beneath Resident #1 in order to try to pull the resident up in bed. CNA B said she did not recall if Resident #1 had a pad beneath her before they put a new one under her. CNA B said Resident #1 complained of leg pain and begged and pleaded with the CNAs to stop trying to move her, so CNA A and CNA B were not able to pull Resident #1 up in bed. CNA B said they did not provide incontinent care to Resident #1, but she said there appeared to be a bag of clothes on the floor, so CNA B suspected Resident #1 had been changed prior to CNA B entering the room. CNA B said that was the only time she had ever worked with Resident #1. A nursing note dated 11/2/19 at 8:30 p.m. indicated Resident #1 continued to complain of left hip pain. Her left hip was tender to the touch, with no discoloration or bruising noted. However, swelling was noted. The physician was notified and ordered an x-ray. An incident/accident assessment dated [DATE] completed by the DON indicated the CNA may have turned Resident #1 without assistance of the bed pad in a log roll. A nursing note dated 11/3/19 at 1:00 a.m. indicated an x-ray was completed at the facility for Resident #1. An x-ray report dated 11/3/19 indicated Resident #1 had an acute impacted nondisplaced subcapital [MEDICAL CONDITION] hip. The x-ray indicated Resident #1's bones were osteopenic. A nursing assistant care plan updated 11/4/19 indicated Resident #1 was incontinent of bowel and bladder and required assistance with positioning. The nursing assistant care plan did not specify how many staff were required to provide incontinent care or reposition Resident #1. The nursing assistant care plan indicated the positioning equipment to be used for Resident #1 were pillows and a cushion between the resident's legs and feet, but it did not indicate whether a pad should be used during repositioning. A physician progress notes [REDACTED].#1 felt a pop in her left hip on 11/1/19 when she was turned to provide incontinent care. She refused to go to the emergency room for evaluation. The x-ray results on 11/2/19 indicated a fractured left femur. She again refused to go to the emergency room . The physician's progress note indicated Resident #1 had been bedbound for about [AGE] years. Her pain was controlled with over the counter [MEDICATION NAME] and [MEDICATION NAME] as needed. The physician noted Resident #1 had to be repositioned routinely from side to side for incontinent care, which she was refusing because of the pain. The physician's note indicated Resident #1 had a spontaneous fracture. During a telephone interview on 11/13/19 at 3:06 p.m., Resident #1's physician said he had no knowledge of Resident #1 ever being improperly turned or repositioned and did not know if being improperly repositioned could have contributed to the resident's fracture. Resident #1's physician said he ruled Resident #1's fracture as spontaneous, and the resident would be at risk for a fracture even if she was turned and repositioned properly. A nursing note dated 11/6/19 at 11 a.m. indicated Resident #1 agreed to go to the emergency room for evaluation of her left femur fracture. Staff called 911 and Resident #1 was transferred to the emergency room . Hospital records dated 11/6/19 indicated Resident #1 was attempting to transfer from her wheelchair to her bed at the nursing facility when she had a twisting injury to her left leg. She initially declined transport to the emergency room . However, Resident #1 was convinced after 3 days to come to the emergency department. In the emergency department, imaging revealed a left subcapital nondisplaced fracture. Ortho was consulted and their recommendation was pain control since this was considered a nonsurgical case. During an interview on 11/13/19 at 10:45 a.m., LVN D said Resident #1 was bedbound, had not gotten up in the 4 years. LVN D said she had worked at the facility, and the resident seemed cognitively intact. LVN D said before Resident #1's fracture, at least two staff would turn her and Resident #1 would help the staff turn her. She said Resident #1 could not assist staff with turning as she previously could. LVN D said during repositioning, staff would use the sheet underneath her or an incontinent pad to turn Resident #1. She said it would not be appropriate to roll the resident without using a sheet or pad because Resident #1's bones were fragile due to being bedridden. During an interview on 11/13/19 at 11:00 a.m., CNA [NAME] said Resident #1 required total assistance with turning and repositioning. CNA [NAME] said Resident #1 reported the fracture was CNA A's fault but she did not report how it was CNA A's fault. CNA [NAME] said before the fracture, one or two staff would turn Resident #1 and would use a draw sheet every time. CNA [NAME] said she did not know if Resident #1's nursing assistant care plan specified how many staff should reposition the resident or if a pad or sheet was needed for turning and repositioning the resident. CNA [NAME] said I know I should look at her care plan, but I haven't. CNA [NAME] said other aides told her Resident #1 required a sheet for turning and repositioning. CNA [NAME] said before Resident #1's fracture, Resident #1 could assist with turning by holding on to the grab bars. CNA [NAME] said Resident #1 does not do that now and constantly hollers when being repositioned. CNA [NAME] said now it takes 2 staff to turn and reposition Resident #1. During a telephone interview on 11/13/19 at 3:46 p.m., the DON said the number of staff required for assistance with transfers or incontinent care would be dependent on who was providing care for the resident, how experienced they were, and their strength. The DON said prior to Resident #1's fracture, it would have been appropriate for her care plan to say Resident #1 required the assistance of 1 or 2 staff for repositioning or incontinent care. The DON said now with Resident #1's fracture, it would be safer to use two people for repositioning or incontinent care. An undated Care Plans - Comprehensive policy indicated a comprehensive care plan that includes measurable objectives and timetables to meet the resident's medical, nursing, mental and psychological needs shall be developed for each resident. A Safe Handling of Resident to Minimize Resident/Staff Injuries policy dated 5/19/06 indicated a plan of care is initiated with measures to implement to prevent falls, injuries and accidents. During an interview on 11/13/19 at 4:07 p.m., the facility was asked for additional information at exit, no additional information was provided.

Based on observation, interview and record review, the facility failed to provide adequate supervision and assistance to prevent an accident for 1 of 26 residents reviewed for accidents. (Resident #35) The facility did not prevent Resident #35 from falling during toileting. Resident #35 was at risk for falls and was identified to require 2-person maximum extensive assistance during toileting and transfers. Resident #35 was left alone on the toilet and was found some time later on the floor, unresponsive. She was admitted to the hospital with [REDACTED]. Interventions were not implemented, and the resident fell again 2 more times, with one of the times requiring another hospital stay. This failure could place residents who were dependent on staff for toileting at risk for injury. Findings included: An undated face sheet indicated Resident #1 was an [AGE] year old female admitted on [DATE]. Physician orders [REDACTED].#35's [DIAGNOSES REDACTED]. Physician orders [REDACTED].#35's [DIAGNOSES REDACTED]. The most current Nursing Assistant Care Plan dated 7/11/18 indicated Resident #35 had right sided weakness and required two staff to transfer. No fall interventions or bed/chair alarms were listed. A nursing note completed by LVN D, dated 7/13/18 at 9:45 a.m. indicated Resident #35 was found on the floor, no injuries. Resident #35 said she was trying to get into bed. The MDS dated [DATE] indicated Resident #35 had moderately impaired cognition. She required extensive two-person assistance for bed mobility, transfers, and toileting. She was frequently incontinent of bowel and bladder but had at least one episode of continent voiding and bowel movement. The MDS indicated Resident #35's balance moving on and off the toilet was not steady and she was only able to stabilize with staff assistance. The MDS further indicated no bed or chair alarms were used, and she had a fall since her admission. A care plan dated 7/24/18, re-evaluation date 10/18/18, indicated Resident #35 had decreased cognition and history of a stroke with [MEDICAL CONDITION] affecting her right side. The care plans indicated the resident had a history of [REDACTED]. An intervention was added on 9/16/18 which indicated to use a bed/chair alarm if appropriate and to keep items within the resident's reach. Telephone physician orders [REDACTED]. An Alleged Incident/Accident Report dated 9/10/18 at 8:20 a.m. indicated Resident #35 was found on the floor beside her commode in a fetal position, with her head tucked underneath her body. The resident was unable to explain how the fall happened. EMS was called, and the resident was transported to a local hospital. As of 12/11/18 the report was not signed by the DON or administrator to indicate a review of the incident was conducted. Nursing notes, completed by LVN B, dated 9/10/18 at 8:20 a.m., indicated Resident #35 was found lying on the floor in a fetal position with her head tucked down. The note indicated the resident was, unresponsive to verbal stimuli, labored breathing noted EMS initiated. During an interview on 12/12/18 at 08:16 a.m., CNA C said Resident #35 leaned to her right side when she was up. She said she transferred Resident #35 to the commode on 9/10/18 while passing breakfast trays. She said she left the resident on the commode alone and went to pass 2 or 3 more meal trays to other residents. CNA C said when she returned, she found the resident lying between the commode and the wall, in a fetal position with her head tucked underneath her body. She said she left the resident as she was and went to get help. She said they could not tell if Resident #35 was breathing because of the way her head was tucked under her body. She said they did not want to move her because they thought her neck was broken, so they pulled her forward a little to see if she was breathing and she took a big gasp. CNA C said the resident was unresponsive. During an interview on 12/12/18 at 8:35 a.m., LVN B said she was the nurse taking care of Resident #35 when she was found on the floor in her bathroom (on 9/10/18). She said she was in the dining room monitoring breakfast when someone came to get her because Resident #35 was on the floor. She said when she walked in Resident #35's bathroom, the resident was on the floor in a fetal position between the commode and the wall. LVN B said she was unsure of the extent of her injuries and the resident was unable to tell her what happened. She said when EMS arrived they placed a C-Collar on her neck and placed her on a back board to transfer her to the hospital. She said Resident #35 leaned to her right side when she was up and should not have been left alone on the commode. The hospital Department of Medical Imaging CAT/CSpine (CAT scan of the cervical spine) report dated 9/10/18 indicated Resident #35 had two fractures of C7 (neck fracture). [MEDICAL CONDITION] facet of C7 on the left and a displaced fracture of right pedicle of C7. There was a mild anterior wedge [MEDICAL CONDITION] plate of T1. (The 7 bones in the neck are called vertebra. The vertebra are numbered C1 through C7. C1 is closest to the skull, T 7 is in the middle of the chest between the seventh and eighth pair of ribs. It plays important roles in the support of the spinal cord, ribcage, and muscles of the chest) Admission physician orders [REDACTED].#35 returned to the nursing facility from the hospital (six days later) with a C7 neck fracture and [MEDICAL CONDITION] embolism (blood clot). Nursing notes, completed by LVN D, dated 9/26/18 at 1:30 p.m. indicated Resident #35 was found in the floor in front of her wheelchair. Resident #35 said she slid out her chair and she complained of neck pain. EMS was called, and the resident was transported to a local hospital. An Alleged incident/accident Report dated 9/26/18 at 1:30 p.m. indicated Resident #35 was found on the floor in front of her wheelchair with her head and neck under the seat of the wheelchair. She complained of pain, 911 was called, and she was transported to a local hospital. The report indicated measures to be implemented were for the resident to have alarms on at-all-times. Hospital History and Physical dated 9/26/18 indicated Resident #35 was admitted to the hospital on this day after she fell and hit her neck. She had intense pain and was admitted to hospital. The report further indicated a CAT scan was performed and indicated C7 fracture with subluxation (misalignment of the spinal column) from C7 to T1. Admission physician orders [REDACTED].#35 returned from the hospital (two days later) with [DIAGNOSES REDACTED]. Telephone physician orders [REDACTED]. The MDS dated [DATE] (after incident) indicated Resident #35 had moderately impaired cognition. She required extensive two-person assistance for transfers. The MDS also indicated no bed or chair alarms were used. An Alleged Incident/Accident Report dated 10/28/18 at 5:45 p.m., indicated Resident #35 was sitting in her recliner and fell out while she attempted to reposition herself. There was no indication of an alarm being used at this time. The report indicated measures to be implemented were for staff to properly sit the resident up and reposition her before her tray was given to her. Nursing Notes, completed by LVN B, dated 10/28/18 at 5:45 p.m. indicated Resident #35 was found in the floor beside her recliner. Resident #35 reported she slid out of the recliner while she attempted to reposition herself. During an interview on 12/12/18 at 10:41 a.m., LVN B said she could not recall Resident #35 ever having a chair or bed alarm. She said if a resident had a bed or chair alarm the nurses should write an order so it would print on the next month orders, and it would print off on the resident's Flow Sheet. Flow sheets dated (MONTH) (YEAR) through (MONTH) (YEAR) did not address if Resident #35 had a bed/chair alarm. During an observation and interview on 12/11/18 4:24 p.m., Resident #35's bathroom had a grab bar on the wall on the right side of the commode. Resident #35 said I remember I didn't remember I think I fell in the bathroom, the best I can recall I just knew something happened to me and they took me to the hospital. Evidently, I blacked out. I must have hit my head or something that's the best I can recall. I was in the ambulance when I came to. I spent a few days in the hospital. She further said when she needed to use the bathroom now, they bring the potty-chair out of the bathroom for her to use. She said they sat her on the chair and left her alone to give her privacy and they came back later, she said if her husband was there he sat in the room with her. When the resident was asked if she could hold onto the grab bar in her bathroom she took her left hand and held up her right arm to show she could not use her right arm. Resident #35 said she had never had an alarm in her chair or bed. During an observation on 12/11/18 at 4:24 p.m., the emergency call light and cord in Resident #35's bathroom was on the wall to the left of the commode approximately 2-3 feet from the commode. The Physical Therapy Discharge Summary dated 9/7/18 indicated Resident #35 required moderate assistance to stand from a sitting position. The resident's fall recovery ability was dependent. During an interview on 12/11/18 4:50 p.m., PT J said when Resident #35 first came into the facility (admission 7/11/18) she received therapy for a stroke. PT J said the resident was not motivated and there no sign of progress. She said Resident #35 sitting balance was fair and she was discharged to nursing restorative care program because she was not motivated. An Occupational Therapy Daily Note dated 8/29/18 indicated Resident #35 required verbal/tactile cues for posture alignment while sitting upright. During an interview on 12/11/18 at 4:50 p.m., COTA E said she transferred Resident #35 alone using maximum assist to help the resident get on the toilet; however, she would not leave her sitting alone. She said it took a lot of cueing the resident to get her to do any tasks. She said she would not have recommended leaving Resident #35 alone on the toilet because she leaned to the right and was at risk for falling. She said when Resident #35 returned from the hospital after falling off the toilet, she would no longer take steps to get to recliner. She said prior to that fall, the resident would take steps with assistance. During an observation on 12/12/18 at 1:00 p.m., CNA C and CNA I transferred Resident #35 from her wheelchair to her bed. The resident did not bear any weight on her feet. During an interview on 12/12/18 at 11:59 a.m., CNA C said Resident #35 was incontinent but sometimes she would tell them when she wanted to get on the commode. She said she placed the resident on the bed side commode and would then leave the room to give her privacy During an interview on 12/11/18 at 4:41 p.m., CNA L and CNA M said they had not seen a bed or chair alarm in Resident #35's room. They said they were not aware of any fall interventions for her. During an interview on 12/12/18 at 10:15 a.m., the DON said after Resident #35's fall on 7/13/18, if the resident had an alarm and it should be on the resident's care plan. The DON reviewed the records and said there was no documentation of a bed/chair alarm in the resident's record. During an interview on 12/13/18 at 3:44 p.m., the DON said she expected the care plan to be updated with new fall interventions after a fall. An undated Accident and Incident Investigating and Reporting policy indicated the investigation report form must be submitted to the DON no later than 12 hours after the occurrence, and to the administrator no later than 24 hours after the occurrence of the accident or incident.

Based on observation, interview, and record review, the facility failed to ensure residents were free of significant medication errors for 1 of 6 residents reviewed for medication administration. (Resident #1) Resident #1 did not receive [MEDICATION NAME] (antiarrhythmic) for 7 days. (12 missed doses) After complaints of chest pains and elevated heart rate Resident #1 was admitted to the hospital. This failure contributed to the hospitalization of Resident #1 for [MEDICAL CONDITION]. This failure could place 22 residents who resided on the skilled unit at risk for not receiving the intended therapeutic benefits of their medications. Findings included: Physician orders [REDACTED].#1, admitted [DATE], was [AGE] years old with [DIAGNOSES REDACTED]. An admission order dated 12/02/16 indicated Resident # 1 was to receive [MEDICATION NAME] 80 milligrams (mg) (160mg) two times a day for high blood pressure. There was an X marked through the order. According to the website, www.drugs.com, accessed 02/13/17, .[MEDICATION NAME] ([MEDICATION NAME]) is used for maintaining a normal heartbeat in patients who have [MEDICAL CONDITION] or [MEDICAL CONDITION] flutter (certain types of abnormal heartbeat). [MEDICATION NAME] is an antiarrhythmic medicine. It works by helping the heart beat regularly for a longer period of time. Do not suddenly stop taking [MEDICATION NAME]. Sharp chest pain, irregular heartbeat, and, sometimes, [MEDICAL CONDITION] may occur if you suddenly stop [MEDICATION NAME] . An initial care plan printed 12/02/16 indicated Resident #1 was admitted for left total knee replacement. The plan documented the resident had [DIAGNOSES REDACTED]. The plan did not include interventions for medications. A physician clarification order dated 12/05/16 at 9:30 a.m., indicated Resident #1 was to receive [MEDICATION NAME] 120 mg two times a day and hold if systolic blood pressure <100 diastolic blood pressure <60. A MDS dated [DATE] indicated Resident #1 understood others and made his needs known. The MDS indicated Resident #1 did not exhibit behaviors and did not reject care. He required one person assist with bed mobility, dressing, bathing, toilet use, and personal hygiene. A handwritten MAR indicated [REDACTED] A computer generated MAR indicated [REDACTED]. A skilled nursing note dated 12/11/16 at 4:15 p.m., indicated Resident #1 was sitting in his recliner in his room and complained of chest pains and said, my heart is racing. The note indicated Resident #1 was transferred to the hospital and admitted with a [DIAGNOSES REDACTED]. An undated facility discharge summary indicated Resident #1's admitted was 12/02/16 and discharge date was 12/11/16. Final disposition on discharge indicated Resident #1 had complaints of chest pain and [MEDICAL CONDITION] was sent to the emergency room via ambulance with a [DIAGNOSES REDACTED]. A nursing note dated 12/12/16 completed by the DON indicated she was notified of a potential transcription error. The note indicated the [MEDICATION NAME] was not listed on the printed MAR for December 2016. The note indicated Resident #1 did not receive [MEDICATION NAME] for 2 days. (4 missed doses) During an interview on 01/31/17 at 2:50 p.m., the DON said the [MEDICATION NAME] medication was marked out on the admission orders [REDACTED]. She said a clarification order was written on 12/05/16 and the medication did not get put on the printed MAR. She said she investigated and did not know what happened. During a phone interview on 1/31/17 at 9:45 a.m., Resident #1 said he did not receive his heart medication, [MEDICATION NAME], and ended up in the hospital with [MEDICAL CONDITION]. The policy and procedure Administration of Drugs revised 01/17/17 indicated .2. medications must be administered in accordance with the written orders of the attending physician.( Note: If a does seems excessive considering the resident's age and condition, or a drug order seems to be unrelated to the resident's current [DIAGNOSES REDACTED]. 3. All current drugs and dosage schedules must be recorded on the resident's Medication Administration Record [REDACTED] .8. Unless otherwise specified by the resident's attending physician, routine medications should be administered as scheduled . .12. Should a drug be withheld, refused, or given other than the scheduled time, the nurse must initial and circle the MAR indicated [REDACTED] 13. The nurse must enter and explanatory note on the reverse side of the MAR indicated [REDACTED]. The resident roster dated 01/31/17 indicated 22 residents resided on the skilled unit.