Every finding on record at Avon Health Center

Based on interviews, observations, clinical record review, and review of facility policy for the only sampled resident reviewed for respiratory care (Resident #29), the facility failed to maintain a safe environment for a resident (Resident #29) on continuous oxygen by allowing long-term unsupervised use of petroleum-based jelly on the face and lips without a physician order, staff oversight, or self-administration assessment. Staff were aware of the resident's repeated use of petroleum jelly but did not intervene, despite flammability warning on the oxygen equipment and established contraindications. The facility also failed to monitor and control water temperatures at resident points of use, resulting in widespread temperatures exceeding 120 degrees ( ) Fahrenheit (F) and exposing residents to an immediate risk of scalding. These systemic failures demonstrated a lack of monitoring, a lack of staff awareness, a lack of adherence to policies, and a failure to protect residents from avoidable immediate harm. These failures resulted in the finding of immediate jeopardy. 1.Resident #29's diagnoses included chronic obstructive pulmonary disease (COPD), chronic respiratory failure with hypoxia, and obstructive sleep apnea. Physician orders dated 1/20/26 and currently in effect directed to utilize Oxygen at 3 liters/minute continuously every shift via nasal cannula related to hypoxia for COPD. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #29 had intact cognition and was independent with toileting, transfers, and bed mobility. The MDS further indicated Resident #29 had a diagnosis of COPD and was receiving oxygen therapy. The Resident Care Plan (RCP) dated 2/23/26 identified Resident #29 had an altered respiratory status and difficulty breathing related to oxygen dependence and COPD. Interventions included to monitor Resident #29 for vital signs with oxygen saturations (sats) as ordered and providing oxygen at 3 liters (l) per minute via nasal canula. Observation during the initial tour of the facility on 3/9/26 at 11:00 AM identified Resident #29 was in his/her wheelchair at the bedside, not utilizing oxygen as ordered at 3 liters/minute via nasal cannula with 1 small (1.75 ounce) uncovered tub of petroleum-based jelly which was 3/4 empty located on the nightstand in front of other personal hygiene products such as shampoo. A second observation and an interview with Resident #29 on 3/11/26 at 10:22 AM identified his/her family member had brought in the small (1.75 ounce) tub of petroleum-based jelly (cocoa butter healing jelly) and the resident had been self-administering the jelly on his/her lips (with the oxygen running) several times a day especially at night for years. Resident #29 indicated he/she applied the jelly when his/her lips felt dry. Observation, interview, and review of the clinical record with Nurse Aide (NA) #2 on 3/11/26 at 10:57 AM identified she was aware Resident #29 had 1 small (1.75 ounce) of petroleum-based jelly on the nightstand table that the family had provided. NA #2 indicated she was aware that the resident was self-administering the petroleum-based jelly to his/her face while on continuous oxygen and had been using petroleum-based jelly since admission [DATE]). Observation and interview with Resident #29 on 3/11/26 at 3:09 PM noted Resident #29 wearing oxygen via nasal cannula at 3 l/minute. Resident #29 identified his/her family member provided petroleum-based jelly and she/he liked to apply it to his/her lips frequently throughout the day due to having dry lips. Additionally, Resident #29 noted he/she had a second jar in his/her drawer because the current one was almost empty. Interview on 3/11/26 at 3:10 PM with Licensed Practice Nurse (LPN) #3 identified Resident #29 did not have a physician order to use petroleum-based jelly and the family brought in items at times but did not always check with staff. LPN #3 further identified she had not noticed the petroleum-based jelly on the nightstand table until the NA spoke to her earlier on 3/11/26 subsequent to surveyor's observation. Interview with the Oxygen Company Vendor on 3/11/26 at 3:14 PM identified a resident who was on oxygen should not be using any petroleum-based or oil-based products on their face (including the lip area) because it had the potential to burn or cause other injuries. Interview with the Director of Nurses (DNS) on 3/11/26 at 3:39 PM identified she was not aware Resident #29 applied petroleum-based jelly to his/her lips throughout the day wearing 02 continuously at 3 liters and did not think it was a concern. Subsequent to surveyor inquiry an observation on 3/11/26 at 4:03 PM identified the 1 small (1.75 ounce) of Petroleum-based jelly had been removed from the nightstand table and taken to the medication room by LPN #3 who also identified a second full container (1.75 ounce) petroleum-based jelly (original healing jelly) was found in Resident #29 drawer which was also removed from the resident's room. Interview on 3/11/26 at 4:20 PM with Person #1 noted he/she denied providing petroleum jelly to Resident #29. A second interview on 3/12/26 at 11:00 AM with Person #1 identified she/he did take Resident #29 shopping, and Resident #29 could have purchased the petroleum-based jelly at that time, but she/he did not notice and was unaware it was contraindicated with oxygen. Interview on 3/13/26 at 9:50 AM with LPN #3 identified she was the usual nurse on the unit for the 7:00 AM to 3:00 PM shift, and she noticed the petroleum-based jelly on the front part of the bedside nightstand when it was brought to her attention by the NA on 3/11/26. Interview on 3/13/26 at 1:52 PM with LPN #3 identified that when she enters a resident room to provide medication, treatments, etc. she scans the room but concentrates on the resident when entering a room and doesn't look for hazardous items. Interview with the DNS on 3/16/26 at 10:01 AM identified she would expect the nursing staff to observe general safety of a resident's room. Observation of the portable oxygen label on 3/16/26 at 10:38 AM noted a warning sticker adhered to the side identifying it was flammable and the oxygen concentrator had a label identifying contents vigorously accelerate combustions, keep oil and combustibles away. Review of the facility policy, Oxygen Therapy, identified to maintain proper oxygenation of body tissues and to provide for safety of the environment during oxygen administration. Oxygen therapy was to be administered and monitored by a licensed nurse. The above deficiency resulted in the finding of Immediate Jeopardy (IJ). After observations made on 3/11/26, the facility Administrator was provided with the IJ template on 3/11/26 at 3:43 PM and submitted a removal plan which was approved by the State Agency on 3/11/26. The Removal Plan noted in part, the petroleum-based jelly was immediately removed from Resident #29's room, and all residents utilizing oxygen were checked to ensure no petroleum-based products were present. Additionally, education was provided to all staff, residents and resident representatives regarding the contraindication of using petroleum-based products while using oxygen and if products were found, to immediately remove them. Additionally, the facility will implement weekly audits on each unit to ensure no petroleum-based products were in the room of residents receiving oxygen and laminated signs containing a list of prohibited items to use in the presence of oxygen will be posted in the medication room, supervisor's office and oxygen supply areas. Observations on 3/13/26 identified that the facility implemented the removal plan and the IJ was removed. 2.Observation during initial resident screening on 3/9/26 identified water temperatures in resident bathrooms were above 120.0 degrees F as follows: Unit North (N): Room N11/N12 (a shared bathroom) water temperature was 125.2 degrees F at 10:40 AM, Room N3/N4 water temperature was 127.4 degrees F at 10:46 AM, Room N5/N6 water temperature was 122.8 degrees F at 10:48 AM, Room N11/N12 water temperature was 125.2 degrees F at 10:50 AM, Room N12 (not a shared bathroom) water temperature was 130.1 degrees F at 11:25 AM, and Room N13/N14 water temperature was 129.0 degrees F. A Wing: Room A3 water temperature was 130.8 degrees F at 11:50 AM and Room A5/A7 water temperature was 125.4 degrees F at 11:53 AM. B Wing: Room B2 water temperature was 124 degrees F at 10:52 AM and Room B16/B18 water temperature was 122.5 at 12:30 PM. Unit South: Room S17/S18 water temperature was 135.8 degrees F, Room S21/S22 water temperature was 122.1 degrees F at 11:50 AM, and Room S25/S26 water temperature was 125.7 degrees F at 12:06 PM On 3/9/26 at 12:38 PM, interview and review of the elevated water temperatures taken by the survey team with the Director of Maintenance (DM) identified he was responsible for monitoring water temperatures, and that he monitored water temperatures in the boiler room for the main water supply pipe, mixing valves, holding tanks and water returns (but not in resident rooms/areas) and documented them on the clipboard located next to Mixing Valve #1. He indicated he randomly monitored those same water temperatures multiple times throughout the day but did not document those subsequent water temps on the clip board. Additionally, he identified that he did not monitor water temperatures inside resident bathrooms or shower rooms and only monitored the water temperatures in the boiler room. He identified the water monitoring log binder did identify water temperatures in resident bathrooms and shower rooms, but that was from earlier in the year when he had an assistant who monitored the water temperatures in those areas, but when his assistant left, he (DM) did not continue to monitor water temperatures in the resident bathrooms and showers. Additionally, he identified the facility was in the process of purchasing an electronic mixing valve which would automatically maintain consistent water temperatures at the mixing valves throughout the day. Interview and conducting water temperatures with the DM on 3/9/26 at 12:51 PM identified B2 bathroom had a water temperature of 123.0 degrees F (taken by the surveyor's thermometer and the DM's thermometer). Additionally, N12A bathroom had a water temperature of 122.0 degrees F with the surveyor's thermometer and 123.0 degrees F with the DM's thermometer. While monitoring the water temperatures, in Room N12A, for approximately 30-45 seconds, the water pressure was observed to increase significantly while subsequently increasing in water temperature and then the water pressure would decrease back to the original flow rate with a subsequent drop in water temperature. Room N12A's water temperature taken by the DM ranged from 113.0 degrees F to 123.0 degrees F during the change in water pressure and by the surveyor was 111.0 degrees F to 122.0 degrees F. The DM could not identify the reason the water temperature elevated for a period of time and then dropped more than 10.0 degrees F. Interview with the DM on 3/9/26 at 2:40 PM identified the facility did not have a policy for monitoring water temperatures that he was aware of, and that he was not aware of a regulation which directed to monitor water temperatures in resident bathrooms. He identified if the water temperature for mixing valve #1 was above 120.0 degrees F he would monitor it for a few minutes, if it didn't decrease on its own, he would adjust the mixing valve and then monitor the water temperature at the mixing valve for a while (but not resident rooms). Subsequent to surveyor inquiry, monitoring of water temperatures in resident bathrooms and shower rooms was initiated for off shifts. On 3/10/26 review of the water temperature monitoring noted on 1/28/26 the shared bathroom in N11/N12 identified the water temperature was 130.0 degrees F. The water temperature monitoring log failed to identify what measures were taken in response to the temperature above 120.0 degrees F identified in Room N11/N12. Additionally, the water temperature monitoring log failed to identify the time of day the water temperatures were monitored. Subsequent to surveyor inquiry on 3/10/26, review of the undated Hot Water Temperature Safety policy located in the water monitoring log binder directed water temperatures on all sources accessible to residents would be checked and documented at least monthly. Additionally, the policy directed the water temperature must not exceed 120 degrees (a discrepancy to an interview with the DM on 3/9/26 that stated the facility did not have a policy for monitoring water temperatures on sources accessible to residents). On 3/10/26 at 11:08 AM, noted the shared bathroom of Room N5/N6 had a water temperature of 124.2 degrees F and Room N11/N12 had a water temperature of 122.4 degrees F. Interview with the Administrator on 3/10/26 at 11:15 AM identified the vendor for the company who maintains their Combined Heat and Power ([NAME]) system was in earlier that morning to make adjustments to the system and prior to high water temperatures being identified by the surveyor). Interview and observation on 3/10/26 at 11:30 AM in the shared bathroom for N13/N14 with Licensed Practical Nurse (LPN) #2 identified the water temperature was 129.0 degrees F. LPN #2 tested the water with her finger and stated that it felt very hot and could burn someone. LPN #2 stated that she was to notify the maintenance department that the water was hot so they could determine what needed to be done (but did not instruct staff/resident to not use the faucet until Maintenance could bring water temperatures within acceptable range). Observation on 3/11/26 at 11:27 AM identified the private bathroom in Room B2 had a water temperature of 120.7 degrees F. Review of the water temperature monitoring logs dated 3/9/26 to 3/16/26 (during the re-certification survey) identified water temperatures were monitored in at least 2 resident rooms and/or shower rooms on each unit each day. The logs identified 5 out of the 80 entries indicated that water temperatures were above 120.0 degrees F. On 3/9/26 at 3:44 PM the water temperature in the shared bathroom for A9/A11 was 118.6 degrees F at 1 minute and 122.4 degrees F at 2 minutes; on 3/10/26 at 5:55 PM the water temperature in the only shower on the A wing was 113.7 degrees F at 1 minute and 125.2 degrees F at 2 minutes; on 3/10/26 at 6:00 PM the water temperature in the shared bathroom for B8/B10 was 121.8 degrees F at 1 minute and 130.8 degrees F at 2 minutes; on 3/10/26 at 6:08 PM the water temperature in the shared bathroom for B20/B22 was 129.6 degrees F at 1 minute and 125.1 degrees F at 2 minutes; and on 3/11/26 at 6:47 PM the water temperature in the shared bathroom for B24/B26 was 119.1 degrees F at 1 minute and 122.3 degrees F at 2 minutes. Interview with the Administrator on 3/11/25 at 3:43 PM identified that the Director of Maintenance should be monitoring water temperatures inside resident bathrooms and shower rooms and it was his understanding that this was being done. Interview with the Administrator on 3/13/26 at 1:45 PM identified he had been unaware water temperatures were not being monitored in resident care areas and thought that the DM had been monitoring the water temperatures in resident bathrooms at least regularly if not daily. He identified he had initiated purchasing an electronic mixing valve for the facility at the beginning of the year to help streamline the management of the water temperatures throughout the building but had not completed the process. Interview with Maintenance #1 on 3/13/26 at 2:15 PM identified on 3/10/26 the facility was experiencing water temperature issues. He identified he was checking the water temperatures frequently after 3/10/26 and even though he tried balancing them at the mixing valve, the water temperatures would not remain steady even with putting in 2 refurbished mixing valve cartridges and calling the vendor to order 2 new mixing valves. He identified on 3/11/26 that both mixing valves (Mixing Valve #1 and Mixing Valve #2) were replaced with new mixing valves. He identified that previously Mixing Valve #1 provided water to most of the building and all resident care areas and Mixing Valve #2 provided water to the kitchen. He indicated some changes were made and the facility was operating with just Mixing Valve #1 which was working well and water temps remained steady. Interview with the DM on 3/16/26 at 11:30 AM identified that he followed the contents in the Plant Manager Guide regarding water temperatures and the guide directed to check water temperatures but did not specify the when or where. Review of the Plant Manager guide identified under Part 1 Section D Heating, Venting and Air Conditioning (HVAC) Systems, bullet #3 directed to check water temperature. The guide failed to identify directives to monitor water temperatures in resident care areas or provide a frequency for monitoring of water temperatures. Interview with the Administrator on 3/16/26 at 11:45 AM identified he had located the water temperature monitoring policy and that he made sure it was located in the Maintenance office for use by Director of Maintenance. Review of the Water Temperature Monitoring Policy directed, in part, the facility would monitor and document water temperatures in resident care areas to ensure water delivered to sinks, showers, and tubs (resident-use fixtures) was maintained within a safe range. The policy directed water temperatures would be monitored on a routine schedule of weekly testing of resident sinks, weekly testing of bathing areas and showers, and additional testing after plumbing repairs and/or maintenance and testing sites would rotate weekly to ensure all fixtures are periodically monitored. Additionally, the policy directed when water temperatures fall outside the safe range maintenance staff would immediately adjust the mixing valve, retest the fixture with the out-of-range water temperature, and document the corrective action. The policy directed in the event the immediate correction was not possible the fixture would be removed from resident use until the repairs were completed. The failure to monitor water temperatures in resident bathrooms and shower rooms to identify the potential for water temperatures to exceed 120.0 degrees F to prevent the risk from scalding resulted in a finding of Immediate Jeopardy. On 3/11/26 at 3:43 PM the IJ Template was provided to the Administrator. On 3/11/26 at 6:40 PM the facility submitted the removal plan which was accepted by the State Agency. The Removal Plan noted in part, staff implemented safety measures which included monitoring water temperatures in the affected areas and halting resident showers until water temperatures were to be within proper limits. Additionally, a heating contractor replaced both mixing valves at the source on 3/11/26, water temperatures were re-tested in resident rooms and were within the range of 105.0 degrees F to 120.0 degrees F. The Removal Plan also included education to Maintenance staff on utilizing the temperature log to complete routine water temperature monitoring in resident rooms daily in a rotating sample of 2 resident rooms per unit for 2 weeks and then weekly on a rotating unit basis. Any water temperature reading outside the acceptable range will result in immediate corrective action and re-testing (signage posted over the sink instructing to not use the faucet and notifying staff/resident not to use the faucet). Also, if the staff determine water feels too hot, they will notify maintenance immediately. Observations on 3/17/26 identified that the facility implemented the removal plan and IJ was removed.

Based on review of the clinical record, interviews, facility documentation and facility policy for 1 of 2 residents (Resident #76) reviewed for mistreatment, the facility failed to complete a thorough investigation related to an allegation of untimely incontinent care. The findings include: Resident #76 was admitted to the facility in March 2021 with diagnoses that included cerebral infarction (CVA), hypertension, and behavior disturbances.Physician orders dated 7/16/25 directed to provide 2 caregivers for care. The Resident Care Plan (RCP) dated 7/16/25 identified Resident #76 had urinary incontinence with interventions that included providing incontinent care every 2 hours and as needed, utilize an incontinent pad and brief, and preventive skin care with each incontinent episode.The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #76 had a short and long term memory problem, was moderately cognitively impaired in making decisions related to daily care, was always incontinent of urine and totally dependent on staff for incontinent care. A facility Grievance Form completed on 8/2/25 by Registered Nurse (RN) #3 for Person #2 indicated that at 11:30 AM on 8/2/25, Person #2 stated that Resident #76's incontinent brief and draw sheet were saturated with urine when/he/she came to visit. RN #3 spoke to NA #6 (an agency Nurse Aide) that was assigned to Resident #76 and NA #6 indicated that she had not yet provided incontinent care to Resident #76. RN #3 reminded NA #6 that incontinent care should be given at the start of shift. The Grievance Form also indicated that Person #2 activated Resident #76's call bell which was turned off at the nursing station without being answered. The facility follow-up response on the Grievance Form indicated that NA #6 was spoken to and a message was given to the Staff Development Nurse to educate staff not to turn off the call light at the nursing station without answering first. Education was initiated on 8/4/25 regarding call bells however no education was located for agency staff aides regarding timely care and communicating concerns regarding timely care to Nursing Supervisors.Interview with the DNS on 3/11/26 at 10:18 AM indicated that she was made aware of the grievance from Person #2 when she returned from being off but could not recall the exact date. In addition, the ADNS was off on extended leave at that time. The DNS indicated that the supervisors were responsible for investigating grievances or allegations of abuse/neglect when the DNS/ADNS were unavailable as they were aware of the facility's policies. Although the DNS followed up with Person #2 when she returned to work, she was not aware of any statements for the investigation by RN #3 regarding timeliness of incontinent care and the call bell being turned off. The DNS was unaware if the Administrator was made aware of Person #2's concerns regarding the lack of incontinent care and shutting off the call bell at the nurse's station.Interview, review of the Grievance Form dated 8/2/25 and review of documentation in the clinical record with RN #4 on 3/11/26 at 10:52 AM indicated that she was made aware of the grievance that occurred over the weekend on 8/2/25 when she returned to work on Monday on 8/4/25. She indicated that she had spoken to RN #3 and that RN #3 had contacted the nursing staffing agency to inform them that NA #6 was no longer able to come to the facility due to not performing incontinent care timely for a resident. RN #4 indicated that she was not aware of any written statements that were obtained for the investigation and that she would have to contact RN #3 to inquire about the investigation and statements. RN #4 was unable to determine when the last time Resident #76 received incontinent care due to lack of statements obtained by NAs for the investigation. In addition, documentation in Resident #76's nursing notes and behavior monitoring for 8/1/25 and 8/2/25 identified that Resident #76 had not refused any care offered. RN #4 indicated that the facility policy was that incontinent care be provided every 2 to 3 hours and that statements should have been obtained to investigate the concern related to lack of timely incontinent care. Lastly, she was aware that education would be provided to staff regarding the call bell concern, however; she was unaware if any statements were obtained regarding this concern.Interview with RN #3 on 3/11/26 at 2:31 PM indicated that she had not investigated or obtained any written statements from NA #5 and NA #6 or any other staff members that worked on the 11:00 PM to 7:00 AM on 8/1/25 or on the 7:00 AM to 3:00 PM shift on 8/2/25 regarding the timeliness of incontinent care. RN #3 indicated that she did not review the NA flowsheets for documentation regarding the times incontinent care was provided for 8/1/25 on the 11:00 PM to 7:00 AM shift or on 8/2/25 for the 7:00 AM to 3:00 PM shift. RN #3 indicated that she did speak to NA #6 who indicated that she just had not gotten to provide care to Resident #76 yet as it was very busy. RN #3 indicated that NA #6 did not notify her that she was behind in providing timely care until Person #2 had vocalized concerns related to Resident #76 being saturated in urine. RN #3 stated that the facility policy was that residents receive incontinent care every 2 to 3 hours. Lastly, RN #3 indicated that she should have investigated the concern further and obtained statements from the staff.Interview with Person # 2 on 3/13/26 at 10:00 AM indicated that Resident #76 was saturated in urine around 11:00/11:30AM on 8/2/25. Person #2 stated that Resident #76 was upset about being saturated in urine. Person #2 indicated that he/she immediately reported the concern to RN #3, did not wait for NA #6 and provided incontinent care to Resident #76 him/herself. Person #2 indicated that the DNS did contact him/her regarding the concern but he/she has never received a call from the Social Worker (SW)Interview with SW #1 on 3/13/26 at 11:00AM indicated that she was aware of the grievance and signed the Grievance Form on 8/4/26. She indicated that nursing was responsible for investigating the concerns and following up as it was a nursing issue related to care. A second interview with the DNS on 3/13/26 at 11:23 AM indicated based on facility policy the investigation was not complete and RN #3 should have interviewed and obtained statements from staff and reviewed NA documentation.The Abuse Policy dated 7/2021 directed, in part, all allegations will be investigated thoroughly by the facility. Neglect is 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 and emotional distress. A thorough investigation will be conducted by the administrator and/or nursing representative. The investigation will include but is not limited to interviewing the alleged perpetrator, all staff, residents, and visitors who are believed to have knowledge of the event.

Based on interviews, observation, review of the clinical record, and facility policy for 1 resident of 1 resident (Resident #29) reviewed for respiratory therapy, the facility failed to administer oxygen as per physician orders. The findings include: Resident #29's diagnoses included chronic obstructive pulmonary disease (COPD), chronic respiratory failure with hypoxia, and obstructive sleep apnea. Physician orders dated 1/20/26 and currently in effect directed Oxygen at 3 liters/minute via nasal cannula related to hypoxia for COPD and continuous every shift. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #29 had intact cognition and was independent with toileting, transfers, and bed mobility. The MDS further indicated Resident #29 had a diagnosis of COPD and was on oxygen therapy.The Resident Care Plan (RCP) dated 2/23/26 identified Resident #29 had an altered respiratory status and difficulty breathing related to oxygen dependence and COPD. Interventions included to monitor Resident #29 for vital signs with oxygen sats as ordered and providing Oxygen at 3 liters per minute via nasal canula. Observation during the initial tour on 3/9/26 at 11:00 AM identified Resident #29 was in his/her wheelchair at the bedside, not utilizing oxygen despite a physician order for Oxygen at 3 liters/minute continuously every shift.A second observation on 3/10/26 at 10:51 AM noted Resident #29 at the hairdresser without oxygen in place and a portable oxygen tank hanging from the back of the wheelchair.A third observation on 3/11/26 at 10:22 AM noted Resident#29 seated in his/her wheelchair with a portable oxygen tank hanging from the back of the wheelchair, but Resident #29 was not wearing any oxygen.Interview and observation on 3/11/26 at 10:22 AM with Resident #29 identified he/she utilizes oxygen at night only while sleeping.Interview on 3/11/26 at 10:33 AM with the Assistant Director of Nursing Services (ADNS) identified Resident #29 had a current order for Oxygen 3 liter via nasal canula continuously and Resident #29 does not have a care plan for refusals. Additionally, the ADNS identified Resident #29 was not wearing oxygen as per the physician order, the resident should be wearing oxygen and physician orders should be followed.Interview on 3/11/26 at 3:35 PM with Nurse Aide #1(NA) identified Resident #29 used oxygen at night.Subsequent to surveyor inquiry on 3/11/26 at 3:09 PM, Resident #29 was observed in his/her room wearing Oxygen at 3 liters via nasal canula.Review of the facility policy, Oxygen Therapy, oxygen therapy to be provided upon physician's order in following forms, oxygen cylinder, concentrator, liquid oxygen, and portable oxygen tank. Oxygen therapy was to be administered and monitored by a licensed nurse.

Based on observations, interviews and review of facility policy for 2 of 3 medication storage rooms, the facility failed to ensure expired heparin syringe flushes for Intravenous (IV) lines and IV 0.45% hydration bags were not expired. The findings include:Observation and interview with Registered Nurse (RN) #5 on 3/13/26 at 6:49 AM identified that there were 52 expired (7/2022) Heparin lock flushes 50 United States Pharmacopeia (USP) (medication meets official standards)/units 5 milliliters (mL) in10 units/mL syringes (for flushing IV line to prevent blood clots) in a drawer in the medication storage room on the North unit. In addition, there were 2 expired (one bag expired April 2025 and one expired November 2025) 1000mL 0.45% Normal Saline (NS) IV hydration bags in the over the counter (OTC) storage room where IV stock supplies were stored. RN #5 indicated there should be no expired IV supplies stored in the medication storage rooms per facility policy. RN #5 indicated that she was not sure of who was responsible for removing the expired IV supplies, but it was not assigned to RN supervisors on the 11:00 PM to 7:00 AM shift. She indicated that she does not check for IV medications and supplies. Interview with the DNS on 3/13/26 at 10:30 AM indicated that there should be no expired IV medications or solutions stored in the medication storage rooms. Although she indicated that there probably had not been an IV on the North unit in a long time since it was not a short-term rehabilitation unit, the policy was that expired medications were to be removed. She indicated that she was not aware of what shift the task of removing expired IV medications and solutions was assigned to but it was nursing who was responsible to ensure that expired medications are removed from the storage rooms. Subsequent to surveyor observations, RN #5 removed the 52 expired heparin flushes and the (2) 0.45% NS hydration bags from the medication storage rooms.The Medication Storage Policy directed, in part, all expired medications will be removed from the active supply and destroyed in facility regardless of amount remaining. The medication will be destroyed in the usual manner

Based on interviews, observation, review of the clinical record, and facility policy for 1 of 1 resident (Resident #6) reviewed for enteral (tube) feedings, the facility failed to adhere to Enhanced Barrier Precautions (EBP) during the initiation of a tube feeding. The findings include:Resident #6 was admitted to the facility on [DATE] with diagnoses that included severe dysphagia with gastric tube (G-tube) dependence, traumatic brain injury, and schizophrenia. The quarterly Minimal Data Set (MDS) assessment dated [DATE] identified Resident #6 was severely cognitively impaired, dependent on activities of daily living, and had a swallowing disorder that required a tube feed. The Resident Care Plan (RCP) dated 1/13/26 identified that Resident #6 was on enhanced barrier precautions related to receiving enteral feeding through a gastric tube, with interventions that included maintaining enhanced barrier precautions as ordered and ensuring that personal protective equipment (PPE) was available to staff on the nursing unit. A physician order dated 1/28/26 directed staff to maintain enhanced barrier precautions secondary to the resident's G tube. A physician order dated 2/10/26 directed G tube feeding via pump using Jevity 1.5 (nutrient) at a rate of 70 milliliters per hour for 21 hours and water flushes 25 milliliters per hour for 21 hours, totaling 1,470 milliliters of nutrient per day and 525 milliliters of water per day. Observation of Resident #6's room on 3/13/26 at 12:30 PM showed signage was posted outside the door for enhanced barrier precautions that directed everyone upon entering and exiting the room must clean their hands. The signage also directed staff to wear gloves and a gown for high contact resident care activities such as dressing, bathing, providing hygiene, wound care, and device care or use involving central lines, urinary catheters, and feeding tubes. Observation on 3/13/26 at 12:40 PM identified that Licensed Practical Nurse (LPN) #3 initiated a tube feeding for Resident #6. LPN #3 performed hand hygiene, donned gloves, prepared the tube feeding with appropriate labels, verified the physician's order, checked tube placement by assessing residuals (which were zero), and confirmed that the resident's head of bed was elevated greater than 30 degrees. However, LPN #3 did not don a gown as indicated by the enhanced barrier precaution signage outside the resident's room. Interview with LPN #3 on 3/13/26 at 12:47 PM identified that Resident #6 was on enhanced barrier precautions related to being on tube feedings, and that these precautions must be maintained during high contact resident care activities such as administering tube feeding nutrition, which includes donning a gown. LPN #3 noted that she should have worn a gown when initiating Resident #6's tube feeding but did not, stating that she forgot. Interview with the DNS on 3/13/26 at 1:15 PM indicated that tube feeding was considered a high contact resident care activity that required enhanced barrier precautions, and that when enhanced barrier precautions were in place, the use of a gown and gloves were required. Review of the undated policy, Enhanced Barrier Precautions, directed that enhanced barrier precautions are required for residents with chronic wounds, multidrug resistant organism colonization or infection, or indwelling medical devices. The policy further defined indwelling medical devices as central lines, urinary catheters, and feeding tubes. The policy identified the required PPE for enhanced barrier precautions as a gown and gloves when providing high risk activities such as care related to activities of daily living, wound care, and device care such as tube feeding.

Based on observation and interviews for 2 of 3 residents (Resident #83 and Resident #102) reviewed for choices and 7 out 7 residents (Resident #12, Resident #37, Resident #52, Resident #67, Resident #70, Resident #75, and Resident #85) that attended the Resident Council meeting, the facility failed to ensure dining rooms were opened for meals. The findings include: 1.Resident #83 was admitted to the facility in March 2025 with diagnoses that included Type 2 diabetes, chronic kidney disease and hypertension.The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified that Resident #83 had intact cognition and was independent with eating. The Resident Care Plan (RCP) dated 12/11/25 Resident #83 had a history of noncompliance with his/her diet with interventions that included providing diet as ordered, monitoring food consumption, providing food preferences, when possible, providing diet education and reinforcement, review labs, and endocrinology as ordered.Physician orders dated 1/20/26 directed to provide a calorie carbohydrate restriction (CCD) and 2-gram sodium diet. Interview and observation on 3/9/26 at 1:30 PM identified Resident #83 was sitting on the side of the bed eating lunch. Resident #83 stated that he/she would eat in a dining room daily unless he/she was not feeling well. Resident #83 stated that he/she did not think a dining room was available for daily for meals. Observation on 3/11/26 at 11:30 AM noted Resident #83 eating lunch in the dining room on the first floor for the weekly pub lunch that was sponsored by recreation only on Wednesdays. 2.Resident #102 was admitted to the facility in March 2024 with diagnoses that included congestive heart failure (CHF), hypertension, and muscle weakness.The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified that Resident #102 was mildly cognitively impaired and was independent with eating. The Resident Care Plan (RCP) dated 12/23/25 identified that Resident #102 leaves greater than 25% of food uneaten for most meals with interventions that included providing diet as ordered, monitoring food consumption and weight, and review labs as ordered. Physician orders dated 2/12/26 directed a dysphagia advanced diet (soft, regular foods) and no added salt (NAS).Observations and interviews with Resident #102 on 3/9/26 and 3/10/26 at 1:30 PM identified that Resident #102 was sitting in his/her chair at his/her bedside eating lunch in his/her room. Resident #102 stated that he/she ate in the room because there was no dining room for meals and if a dining room was opened he/she would eat most meals in the dining room unless he/she did not feel up to it on a certain day. Resident #102 stated that he/she did not believe anyone had ever offered him/her to eat meals in a dining room.3.A Resident Council meeting was held on 3/11/26 at 1:00 PM which identified that all 7 residents that attended the meeting (Resident #12, Resident #37, Resident #52, Resident #67, Resident #70, Resident #75, and Resident #85) stated they would eat in a dining room for meals if a dining room was available. They stated that a dining room was not available for all meals except for the special breakfast and lunches that were held by Recreation. The residents indicated that they do not believe they were ever offered a choice to eat in the dining room daily and that they did not recall discussing the issue at a Resident Council meeting.On 3/11/26 the Recreation Director provided a list of all residents that attended the weekly luncheon in the dining room on 3/11/26. A total of 17 residents attended the luncheon. There were 6 of the 7 residents that attended the resident council meeting on 3/11/26 at the luncheon (Resident #12, Resident #37, Resident #52, Resident #67, Resident #75, and Resident #85). Interview with the Administrator and DNS on 3/16/26 at 10:40 AM identified that dining rooms have not been opened since the COVID-19 pandemic. The Administrator indicated it had been about 3 years, but the facility did have a special dining program once a week for lunch and a special breakfast for some of the residents. He indicated that in December 2025 he had discussed that the facility needed to re-start meals in the dining room and that they would have a Quality Assurance and Performance Improvement (QAPI) plan in the works related to dining room. Also, there was a new Food Service Director in place for about 3 months to work on the QAPI program. He stated that having a high number of agency staff for nursing assistants had posed challenges for the use of the dining room which was on the first floor and that there would be an improvement in nurse aide staffing as the facility has hired many nurse aides. The facility goal was to start with lunch at some point in the spring. Furthermore, he indicated that many equipment items for dining and kitchen have been purchased to improve the dining experience. In addition, the DNS indicated that when she started 3 years ago, she noted that the dining rooms were not in use.Review of the facility daily staffing schedule indicated Dining Room: all units responsible for transporting their residents to the elevator for dining.On 3/16/26 at 11:47 AM the Administrator indicated that the statement on top of the daily nursing schedule, DINING ROOM: All units responsible for transporting their residents to elevator for dining had been in use for a very long time and it had not been updated to reflect the current status of the nonuse of the dining room.A review of the Dining and Food Preferences policy dated 10/2022 directed, in part, the Dining Service Director or designee will interview the resident or resident representative to complete a food preference interview within 72 hours of admission. The purpose of this interview will be to determine individual preferences for dining, location, mealtimes including times outside of the routine schedule.The Resident [NAME] of Rights states that Residents have the right to receive quality care and service with reasonable accommodations of your individual needs and preferences except when your health and safety or others would be endangered by such accommodations.

Based on review of the clinical record, facility policy and interviews for 1 of 1 resident (Resident #37) reviewed for a change in code status, the facility failed to ensure the advance directives CPR/DNR Discussion Form was signed by the resident when the code status was changed by the physician. The findings include: Resident #37's diagnoses included hypertension, anxiety, and encephalopathy.A Cardiopulmonary Resuscitation (CPR) /DNR Discussion Form signed by Resident #37 and a staff member, dated [DATE] and located in the paper chart identified Resident #37 as a full code.Physician orders dated [DATE] directed Resident #37 was a Do Not Resuscitate (DNR).The Resident Care Plan dated [DATE] identified advance directives codes status Do Not Resuscitate (DNR), Do not Intubate (DNI), Registered Nurse May Pronounce (RNP). Interventions included for resident/family wishes to be honored, the DNR/CPR sheet reviewed with resident/family and consent signed.The quarterly Minimum Date Set (MDS) assessment dated [DATE] identified Resident #37 was moderately cognitively impaired and independent with eating, transfers, bathing, toileting and dressing.The electronic medical record (EMR) identified Resident #37 was a Do Not Resuscitate (DNR): DNI, RNP dated [DATE] (a discrepancy with the CPR Discussion Form signed by Resident #37 identifying he/she requested to be a full code). On [DATE] at 10:15 AM interview with Resident #37 identified he/she would want to have CPR and be a full code should he/she become unresponsive (and not have a code status as DNR).Interview on [DATE] at 10:27 AM with Licensed Practice Nurse (LPN) #1 identified Resident #37 was a full code per the signed form in the paper chart dated [DATE]. LPN #1 also identified the EMR identified Resident #37 as a DNR. Further, identifying if Resident #37 was to code during her shift CPR would be provided as per the signed form in the resident's paper chart.Interview on [DATE] at 10:31 AM with the Assistant Director of Nursing Services (ADNS) identified there was a discrepancy with the paper chart and the EMR. The DNS also identified that both the paper chart and the EMR should match.A second interview on [DATE] at11:14 AM with the ADNS identified a physician's progress note dated [DATE] identified a conversation had taken place with Resident #37 by the physician and the order was changed based on the physician identifying Resident #37 wanted to be a DNR but the ADNS was unable to locate a signed CPR/DNR Discussion Form regarding changing of the code status on [DATE]. The ADNS further identified Resident #37 was able to sign the form him/herself, was responsible for him/herself and the nursing staff was responsible for filling out the CPR/DNR Discussion Form with the resident.A second interview with Resident#37 on [DATE] at 11:30 AM with the ADNS present noted Resident #37 stated he/she would like to be a full code.Interview on [DATE] at 12:11 PM with the DNS identified a CPR/DNR Discussion Form was to be filled out and signed by the resident whenever the code status was changed. Also the DNS indicated if there was a conflict with the orders, the facility would follow the physician orders and see if there was a note with a discussion and would not necessarily go by the CPR/DNR discussion form signed by the residents.Review of the facility Advanced Directives Policy directed, in part to establish the residents' wishes regarding medical care. If a decision was made by a resident to change their Advanced Directives status, a new form must be completed.Subsequent to this surveyor's inquiry Resident #37 Advanced Directives were changed to a Full code, the care plan updated, and the CPR/DNR Discussion was completed on [DATE].

Based on review of clinical records, facility documentation, and interviews for one of three residents (Resident #1) reviewed for accidents, the facility failed to ensure the resident was provided care in accordance with physician orders and the plan of care to prevent a fall resulting in a femur fracture that required a closed non-surgical reduction of fractured bone. Resident #1 was admitted to the facility with diagnoses that included Alzheimer's disease, anxiety, and osteoarthritis. An annual Minimum Data Set (MDS) dated [DATE] identified Resident #1 had severe cognitive impairment, required extensive assistance with two (2) staff for bed mobility, and was incontinent. A Resident Care Plan (RCP) dated 6/5/2025 identified Resident #1 was at risk for falls due to impaired mobility, incontinence and cognitive impairment. Interventions directed assist of two (2) staff for Activities of Daily Living (ADLs). A physician order dated 6/5/2025 directed comfort care (CMO) and do not hospitalize (DNH).A physician order dated 6/5/2025 directed assist of two (2) staff for ADLs, Hoyer lift for transfers and Resident #1 was non-ambulatory. A facility reportable event (RE) form dated 6/28/2025 at 5:00 PM identified while Nurse Aide (NA) #1 was providing incontinent care and turning Resident #1 to his/her side, Resident #1 rolled away from NA #1 with his/her arms up and fell from the bed onto the floor. The NA was unable to reach Resident #1, and rushed to the other side of the bed, but was not able to reach Resident #1 before his/her legs went on the floor followed by his/her upper body. An RN assessment was completed, and Resident #1 was assisted back to bed. Resident #1's right knee was noted to be slightly swollen, ice was applied, Tylenol was administered, and new orders were obtained for an x-ray. X-ray results identified an acute distal (away from the torso) femur fracture. The report identified due to Resident #1's CMO and DNH status, the responsible party requested Resident #1 remain at the facility. During a follow-up APRN assessment on 6/30/2025 the responsible party agreed to a hospital transfer. Resident #1 was transferred to the hospital and underwent a closed reduction (non-surgical procedure) with placement of a knee immobilizer. The RE summary dated 6/30/2025 identified Resident #1 required two (2) staff to provide personal care (ADL care) and on 6/28/2025 at approximately 4:45 PM, NA #1 was providing incontinence care alone when Resident #1 became resistive. Resident #1 attempted to move away from NA #1 while on her/his side and facing away from NA #1. Resident #1 rolled off the bed and onto the floor and NA #1 was unable to stop the fall. Resident #1 had a physician order for assist of two (2) staff for ADLs. NA #1 reported that she did not feel she needed a second person and felt she was able to handle turning Resident #1 alone as Resident #1 did not have combative behaviors. Resident #1 remained in the facility after the fracture was identified due to DNH orders and the family decision. An APRN assessment was completed on 6/30/2025 due to increased pain, the responsible party agreed with a hospital transfer, and Resident #1 underwent a closed fracture reduction under sedation 6/30/2025. Record review identified Resident #1 returned to the facility on 7/1/2025 with a knee immobilizer in place, and no additional orthopedic follow up. Interview with the Director of Therapy on 7/22/2025 at 10:30 AM identified Resident #1 required two (2) staff for all care, including turning and positioning. Interview with LPN #1 on 7/22/2025 at 10:26 AM identified she was the charge nurse on 6/28/2025 and indicated all resident care cards contain resident specific information about the resident needs. LPN #1 stated the electronic care card is accessible for all staff electronically on the unit, and she did not remember if she gave any specific directions to NA #1 regarding care for Resident #1 on 6/28/2025. Interview with NA #2 on 7/22/2025 at 11:32AM identified she worked on the same unit with NA #1 on 6/28/2025, and at the start of the shift she told NA #1 that Resident #1 required the assistance of two (2) staff for care. NA #2 stated she told NA #1 that both residents in that room required two (2) staff for care. Interview with NA #1 on 7/22/2025 at 12:32 PM identified she provided incontinent care by herself to Resident #1 on 6/28/2025 at 5:30 PM. NA #1 stated she turned Resident #1 onto his/her left side, facing away from NA #1 and centered in the bed. NA #1 stated the bed was raised to her waist height with the 1/2 side rail raised on the side the resident was turning towards. NA #1 indicated Resident #1 was grabbing her hand as she turned him/her and began to wiggle his/her body, and stated Resident #1 was not fighting to turn but acting more afraid. NA #1 stated she thought it was better to get the care done quickly instead of going to get help when Resident #1 was acting afraid. As Resident #1 turned away from NA #1, he/she rolled towards the edge of the bed and his/her upper body rolled forward. NA #1 indicated she tried to grab Resident #1's legs but was unable to reach them and she ran around the bed but it was too late. Resident #1's legs fell off the bed followed by his/her upper body; Resident #1's knees landed on the floor first, followed by his/her body coming to rest on his/her right side. NA #1 then left the room to get help. NA #1 stated she had provided care for Resident #1 four (4) times prior to the fall, and she thought Resident #1 required two (2) staff for transfers, and one (1) staff for ADL care; NA #1 stated if any resident was an assist of two (2) for Hoyer transfers, they were usually an assist of one (1) for ADLs. NA #1 stated she never had a problem providing care to Resident #1 by herself when Resident #1 had similar behaviors in the past, and she did not think she needed extra help on 6/28/2025. NA #1 stated she was unaware that she needed to check the resident care cards prior to providing care. NA#1 identified after the incident on 6/28/2025, she received education that she was expected to check the resident care cards prior to providing care for any resident, and Resident #1's care card indicated Resident #1 required an assist of two (2) with ADLs. Interview with the DON on 7/22/2025 at 1:15 PM identified Resident #1's physician order directed two (2) staff for ADLs and NA #1 did not follow the physician orders when she provided incontinent care alone on 6/28/2025. The DON indicated staff need to review the NA care card prior to providing care, and Resident #1's card directed two (2) staff assistance for ADLs. The DON indicated the NA care card was easily accessible for the NAs providing care, and she would have expected the staff to stop care and seek assistance if the resident had difficulty or was fearful during care.

Based on clinical record reviews, review of facility documentation and interviews for one (1) of three (3) sampled residents (Resident #1) who were reviewed for an allegation of missing personal property, the facility failed to ensure Resident #1's credit card and cash money were not stolen from the resident's wallet by a staff member. The findings include: Resident #1's diagnoses included acute-on-chronic diastolic heart failure, essential hypertension and Type 2 diabetes. The admission Minimum Data Set assessment dated [DATE] identified Resident #1 was alert and oriented to person, place and time and required assistance from staff with Activities of Daily Living. The Facility Reported Incident form dated 11/12/24 identified the Rehab Director reported that Resident #1 had informed her his/her credit card and cash money were missing from his/her wallet that was stored at the bedside. The investigation identified Resident #1 had last seen the cash money and credit card on 11/9/24 which was in his/her wallet located on the bedside nightstand. The credit card representative informed Resident #1 and a family member numerous charges were made, with the first starting on 11/10/24 for purchases not made by Resident #1. A list of the charges was provided to the facility. Interview and review of the facility incident report with the Director of Nursing (DON) on 11/26/24 at 11:49 AM identified a specific nurse aide had access to the credit card and ninety (90) dollars of cash in Resident #1's wallet which was located on the nightstand when the nurse aide, Nurse Aide (NA) #1, delivered Resident #1's breakfast tray on 11/10/24. The DON identified although a statement was not able to be obtained from NA #1 by the facility, the police investigation determined NA #1 admitted when she delivered the breakfast tray to Resident #1's room, she took the wallet off the bedside nightstand, removed the credit card and ninety (90) dollars of cash from the wallet, and then returned the wallet to the nightstand when she retrieved the breakfast tray from Resident #1's room. The DON indicated NA #1 was an agency nurse aide, had only worked at the facility two (2) other times, and was not permitted to return to the facility. The DON identified in an interview with Resident #1 on 11/15/24, Resident #1 explained that the credit card charges were refunded, he/she was not distressed, and felt the issue was resolved. Review of the facility Abuse Policy dated 7/2021 defined misappropriation of resident property as the deliberate misplacement, exploitation, or wrongful, temporary or permanent, use of a resident's belongings or money without the resident's consent and directed that misappropriation of resident property was prohibited.

Based on clinical record reviews, observations, review of policy for 2 of 2 residents ( Resident # 32 and Resident # 52) reviewed for respiratory treatment, the facility failed to ensure the residents nebulizer tubing was changed and stored according to facility policy. The findings included: 1. Resident #32's diagnoses included centrilobular emphysema and presence of a cardiac pacemaker. The annual Minimum Data Set (MDS) assessment dated [DATE] identified Resident #32 was moderately cognitively intact and required one person assist with bed mobility, supervision with transfers, eating and toileting. The Resident Care Plan, (RCP) dated 6/7/24 identified Resident #32 experienced a decline in activities of daily living (ADL) related to dementia and oxygen due to shortness of breath related to emphysema. Interventions directed to provide two caregivers for ADL care and change tubing weekly. The physician's orders dated 6/27/24 directed DuoNeb (medication prescribed to open airways) 0.5mg-3 mg (2. 5mg base/3 ml solution for nebulization for one dose and every (6) hours for (5) days for wheezing. An observation on 7/16/24 at 10:15 AM with Licensed Practical Nurse, LPN #1 identified the tubing on nebulizing mask was dated 7/2/24. An interview with LPN #1 on 7/16/24 at 10:15 AM tubing for respiratory equipment should have been changed weekly while in use. An interview with the Director of Nursing Services, DNS on 7/16/24 at 2:38 PM identified she would expect respiratory equipment to be changed weekly according to policy. A review of the facility policy for Oxygen/ Respiratory Equipment Maintenance and Storage (no date) directed that nebulizer masks be changed weekly and as needed based on wear and tear and be stored in a clear bag when not in use. 2. Resident #51 had diagnoses that included congestive heart failure, (CHF) and a history of acute respiratory failure with hypoxia. The quarterly MDS assessment dated [DATE] identified Resident #51 was cognitively intact and required extensive two person assist with bed mobility, transfers and independent with eating. Physician orders dated 4/17/24 directed DuoNeb 0.5mg-3 mg (2. 5mg base/3 ml solution for nebulization every four hours as needed for shortness of breath. The RCP dated 4/25/24 identified Resident #51 had decreased cardiac output related to CHF. Interventions directed to observe for signs of respiratory distress, shortness of breath and administer medications as ordered. A review of the medication administration record, (MAR) for July 2024 identified Resident #51 last received DuoNeb on 7/10/24. An observation on 7/16/24 at 10:15 AM with LPN #1 identified Resident #51's nebulizer mask was observed directly on h/her bedside table without the benefit of a storage bag. An interview with LPN #1 on 7/16/24 at 10:15 AM identified the nebulizer mask should have been stored in a plastic bag after use. An interview with the Director of Nursing, DNS on 7/16/24 at 2:38 PM identified she would expect respiratory equipment to properly stored in a plastic bag when not in use according to policy. A review of the facility policy for Oxygen/ Respiratory Equipment Maintenance and Storage (no date) directed that nebulizer masks be changed weekly and as needed based on wear and tear and be stored in a clear bag when not in use. 3. Resident #52's diagnoses included chronic obstructive pulmonary disease, (COPD). The quarterly MDS assessment dated [DATE] identified Resident was moderately cognitively intact and required extensive two person assist with bed mobility, transfers, independent with eating. The RCP dated 2/1/24 identified Resident #52 diagnosis of COPD. Interventions directed to notify the physician of a change in condition, administer medications as ordered and monitor for therapeutic/side effects. The physician's orders dated 4/19/24 directed Duoneb 0.5mg-3 mg (2. 5mg base/3 ml solution for nebulization three times daily for (5) days. A review of the Medication Administration Record ( MAR) identified Resident #52 last received Duoneb was on 4/24/24 at 10:51 AM. An observation with LPN #1 on 7/16/24 at 10:55 AM identified the nebulizer mask observed directly on the bedside table without the benefit of bag with a date on tubing of 12/13/23. An interview with LPN #1 on 7/16/24 at 10:55 AM at 10:55 AM identified the nebulizer mask should have been changed weekly and placed in a bag after use. An interview with the Director of Nursing Services, DNS on 7/16/24 at 2:38 PM identified she would expect respiratory equipment to be changed weekly and placed in a bag after use according to policy. A review of the facility policy for Oxygen/ Respiratory Equipment Maintenance and Storage (no date) directed that nebulizer masks be changed weekly and as needed based on wear and tear and be stored in a clear bag when not in use.

Based on clinical record reviews, facility policy and interviews for 2 of 2 residents (Residents # 8 and #405) reviewed for Advanced Directives, the facility failed to ensure the facility advanced directive election form was completed with the resident/responsible party signatures after verbal consent was obtained to change the election and ensure a physician order written. The findings included. 1. Resident #8's diagnoses included atrial fibrillation and a benign neoplasm. A physician's progress note dated [DATE] at 7:02 PM indicated staff spoke with Resident #8's responsible party who indicated the Advanced Directive wishes were to no Cardiopulmonary Resuscitation (CPR). A physician's order dated [DATE] at 1:24 PM directed to provide Advanced directives to include Do Not Resuscitate (DNR,) Do Not Intubate (DNI) and Nurse may pronounce. The care plan labeled advanced directives effective [DATE] indicated Resident #8 Code status interventions included to receive all appropriate medical treatments excluding CPR. The quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #8 was cognitively intact. The care plan labeled Advanced Directives with no change in interventions was reviewed on [DATE]. On [DATE] a review of the clinical record identified an advanced directive election form dated [DATE] in which Resident #8 elected and signed for Cardiopulmonary Resuscitation (CPR) to be provided in the event needed. On [DATE] at 1:20 PM an interview with the Director of Nursing Services (DNS) indicated he/she would attempt to locate the advanced directive sheet signed by the resident reflecting the physician's order for DNR. An interview and facility document review with the DNS on [DATE] at 11:41 AM indicated another staff member was checking in medical records to see if the form was accidentally removed from the chart. A review of facility policy identified the policy did not include information regarding the election form. The DNS further indicated if a resident or responsible party elected a change in their advanced directives, s/he would have expected a new election form be completed and signed by all parties including the type of advanced directive the resident/responsible party had elected. On [DATE] at 1:00 PM an interview and record review with Registered Nurse (RN #3) indicated although a physician progress note was written on [DATE] and a physician order for DNR s/he was unable to explain why a new election form was not signed by the resident indicating the advanced directive wishes. RN #3 further provided a new election form awaiting signature dated [DATE] indicating confirmation via telephone call with the Power of Attorney (POA)for Resident #8 on [DATE] verifying the current order for DNR, DNI, and No Tube feeding reflect Resident #8's wishes, and the form was flagged to be signed. 2. Resident #405 's diagnoses included unspecified dementia, hypothyroidism, and contracture. The care plan dated [DATE] identified Advanced Directives. Interventions included Do not Resuscitate (DNR), Do No Intubate (DNI) and Registered Nurse may pronounce (RNP). The admission Minimum Data Set assessment dated [DATE] identified Resident # 405 as cognitively impaired and required extensive assistance with bed mobility, transfers and eating. A physician's order dated [DATE] directed DNR, DNI and RNP The nursing notes dated [DATE] through [DATE] did not mention the advance directive. Observation of the facility's CPR/DNR Discussion form on [DATE] and 7/ ,d+[DATE] indicated the form should be signed and dated by a representative of the facility. The Advance Directives form for Resident # 405 was observed to have family's/ responsible party signature and date. Interview with DNS on [DATE] at 11:55 AM indicated Advance Directives should be signed upon admission or within 24- 48 hours. The DNS also indicated s/he was unable to provide an explanation of why the form was not signed by the facility representative. The facility policy labeled Admission Procedures; Advanced Directives dated ,d+[DATE] indicated in part the advanced directive status of each resident would be reviewed at the resident's care conference. The policy does not specify if/ when advance directive needs to be signed. 49100

Based on resident interview, clinical record review, review of facility documentation, review of policy and staff interviews for 1 of 3 residents reviewed for abuse (Resident #98), the facility failed to implement the facility's abuse policy for an allegation of abuse. The findings include: Resident #98 was admitted on [DATE] with diagnoses that included heart disease, respiratory failure, and diabetes mellitus. The admission MDS assessment dated [DATE] identified Resident #98 had moderate cognitive impairment and did not exhibit disorganized thinking, altered level of consciousness, or rejection of care. Additionally, Resident #98 required substantial assistance with toileting and personal hygiene. A care plan dated 5/3/2024 indicated Resident #98 did not have a history of dementia but had some short/long-term memory deficit. Interventions included encouraging the resident to participate in activities and providing cues and supervision. A care plan dated 6/28/2024 further indicated Resident #98 received palliative care. Interventions included offering the resident and family support. A review of the internal investigation dated 7/2/2024 identified Person #1 reported to social work that a nursing aide had slapped Resident #98. The internal investigation identified Resident #98 had indicated that s/he wanted to help the aide when getting cleaned up after a bowel movement, but the aide slapped her/his hand away. The internal investigation also indicated that when Resident #98 was asked for a return demonstration by the DNS, Resident #98 indicated NA #7 did not slap her/him hard and indicated NA #7 pushed his/her hand away. A review of the facility nursing schedule from 6/29/2024 through 7/9/2024 identified NA #7 was assigned to care for Resident #98 on Saturday, 7/6/2024. In an interview on 7/16/2024 at 12:12 PM, Resident #98 indicated that a few weeks ago in the evening, Nurse Aide (NA#7) had slapped his/her hand while providing care and indicated NA # 7 said s/he had her/his own way of doing things. Resident #98 indicated NA#7 was by her/himself when providing care. Resident #98 also indicated s/he had not told staff about the incident but told (Person #1) the next day. Person #1 was in the room during the surveyor's interview and further indicated the incident had occurred on the weekend after the July 4 the holiday (7/6 or 7/7/2024). Person #1 also indicated that s/he had spoken to the resident's day nurse the following day but were unsure what the date or the nurse's name was. Additionally, Person #1 indicated s/he had spoken to the Social Worker (SW) about 48 hours after Resident #98 had complained about the incident. Person #1 also indicated that s/he received a phone call from the Director of Nursing Services (DNS) regarding the incident. A review of the medical record, including nursing and social services progress notes from 6/26/2024 through 7/17/2024, did not identify any notes addressing the incident or any allegation of abuse. The facility was unable to provide an Accident/Incident report (A&I) addressing the incident or an allegation of abuse. Additionally, no report of the incident or allegation of abuse was noted in the state agency's online Reportable Event portal. On 7/18/2024 at 11:37 AM, an interview with the Director of Social Services (Social Worker #1) identified that Person #1 had informed her in the morning of 7/8/2024 or 7/9/2024 (Social Worker #1 could not recall the exact date) that a staff member had slapped Resident #98's hand over the weekend. Social Worker #1 further indicated that after being informed of the incident, she immediately notified the DNS. Social Worker #1 was unable to provide any documentation or evidence in the clinical record the date of the allegation of abuse to reported to her and was unable to explain why. On 7/18/2024 at 1:45 PM, an interview with the DNS identified on 7/2/2024, she was notified by Social Worker #1 that Person #1 had told her (Social Worker #1), Resident #98 had complained about being slapped Saturday night (6/29/2024). The DNS indicated s/he initiated an internal investigation and evaluated the resident's hands. After the internal investigation, the DNS determined that NA#7 had not slapped Resident #98. However, the DNS indicated s/he did not interview other staff members or potential witnesses since s/he was able to corroborate the incident with the interviews of NA# 7 and Resident #98. The DNS indicated that the incident was not recorded in the electronic medical record because there was no change to the plan of care. On 7/22/2024 at 10:44 AM, an interview with NA #7 identified s/he had only taken care of Resident #98 once and had not taken care of the resident since the incident secondary to being a floating NA. NA #7 further indicated s/he was currently assigned to another unit. However, NA #7 could not recall what Saturday s/he had taken care of Resident #98. NA #7 indicated s/he did not slap or push Resident #98's hand but was helping Resident #98 wash his/her hands with a washcloth because Resident # 98 had gotten soiled when the resident was trying to help NA# 7 get cleaned. A follow-up interview with Social Worker #1 on 7/22/2024 at 12:22 PM indicated that for any allegation of abuse, the social worker's responsibility is to follow up with the resident for three days to monitor for any emotional or mood changes. Social Worker #1 indicated that s/he followed up with Resident #98 the next day, but the resident was sleeping. However, SW #1 indicated the follow-up was not related to the reported incident but rather regarding the resident's clinical status. A follow-up interview with the DNS on 7/22/2024 at 1:05 PM identified s/he had mistakenly written the wrong date on the internal investigation. The incident had occurred on the night of 7/6/2024, and Person #1 had reported the incident to Social Worker #1 on 7/9/2024 in the morning. A review of the facilities Abuse Policy identified that the facility has trained employees to identify potential and actual occurrences of abuse. The policy also indicated the facility should investigate an allegation and report the allegation by following federal and state guidelines. Additionally, the facilities Abuse Observation and Recording Policy indicated that all allegations and/or reports of any type of abuse toward a resident would be thoroughly investigated, documented, and reported according to procedure. The procedure outlined in the policy included interviewing the alleged perpetrator, all staff, residents and visitors who could have knowledge of the event. The procedure also indicated that a thorough account of the investigation should be documented, all witnesses should sign their individual statements, and all notifications will be noted on the Accident/incident report (A&I) and/or Narrative Nurses Note.

Based on resident interview, clinical record review, review of facility documentation, review of the facility policy and staff interviews for 1 of 3 residents reviewed for abuse (Resident #98), the facility failed to report an allegation of potential abuse to the state agency. The findings include: Resident #98 was admitted on [DATE] with diagnoses that included heart disease, respiratory failure, and diabetes mellitus. The admission MDS assessment dated [DATE] identified Resident #98 had moderate cognitive impairment and did not exhibit disorganized thinking, altered level of consciousness, or rejection of care. Additionally, Resident #98 required substantial assistance with toileting and personal hygiene. A care plan dated 5/3/2024 indicated Resident #98 did not have a history of dementia but had some short/long-term memory deficit. Interventions included encouraging the resident to participate in activities and providing cues and supervision. A care plan dated 6/28/2024 further indicated Resident #98 received palliative care. Interventions included offering the resident and family support. A review of the internal investigation dated 7/2/2024 identified Person #1 reported to social work that a nursing aide had slapped Resident #98. The internal investigation identified Resident #98 had indicated that s/he wanted to help the aide when getting cleaned up after a bowel movement, but the aide slapped her/his hand away. The internal investigation also indicated that when Resident #98 was asked for a return demonstration by the DNS, Resident #98 indicated NA #7 did not slap her/him hard and indicated NA #7 pushed his/her hand away. A review of the facility nursing schedule from 6/29/2024 through 7/9/2024 identified NA #7 was assigned to care for Resident #98 on Saturday, 7/6/2024. In an interview on 7/16/2024 at 12:12 PM, Resident #98 indicated that a few weeks ago in the evening, Nurse Aide (NA#7) had slapped his/her hand while providing care and indicated NA # 7 said s/he had her/his own way of doing things. Resident #98 indicated NA#7 was by her/himself when providing care. Resident #98 also indicated s/he had not told staff about the incident but told (Person #1) the next day. Person #1 was in the room during the surveyor's interview and further indicated the incident had occurred on the weekend after the July 4 the holiday (7/6 or 7/7/2024). Person #1 also indicated that s/he had spoken to the resident's day nurse the following day but were unsure what the date or the nurse's name was. Additionally, Person #1 indicated s/he had spoken to the Social Worker (SW) about 48 hours after Resident #98 had complained about the incident. Person #1 also indicated that s/he received a phone call from the Director of Nursing Services (DNS) regarding the incident. A review of the medical record, including nursing and social services progress notes from 6/26/2024 through 7/17/2024, did not identify any notes addressing the incident or any allegation of abuse. The facility was unable to provide an Accident/Incident report (A&I) addressing the incident or an allegation of abuse. Additionally, no report of the incident or allegation of abuse was noted in the state agency's online Reportable Event portal. On 7/18/2024 at 11:37 AM, an interview with the Director of Social Services (Social Worker #1) identified that Person #1 had informed her in the morning of 7/8/2024 or 7/9/2024 (Social Worker #1 could not recall the exact date) that a staff member had slapped Resident #98's hand over the weekend. Social Worker #1 further indicated that after being informed of the incident, she immediately notified the DNS. Social Worker #1 was unable to provide any documentation or evidence in the clinical record the date of the allegation of abuse to reported to her and was unable to explain why. On 7/18/2024 at 1:45 PM, an interview with the DNS identified on 7/2/2024, she was notified by Social Worker #1 that Person #1 had told her (Social Worker #1), Resident #98 had complained about being slapped Saturday night (6/29/2024). The DNS indicated s/he initiated an internal investigation and evaluated the resident's hands. After the internal investigation, the DNS determined that NA#7 had not slapped Resident #98. However, the DNS indicated s/he did not interview other staff members or potential witnesses since s/he was able to corroborate the incident with the interviews of NA# 7 and Resident #98. The DNS indicated that the incident was not recorded in the electronic medical record because there was no change to the plan of care. Additionally, The DNS indicated the incident was not reported to the state agency because the facility did not consider it an allegation of abuse. A review of the facilities Abuse Policy identified that the facility has trained employees to identify potential and actual occurrences of abuse. The policy also indicated the facility should investigate an allegation and report the allegation by following federal and state guidelines. Additionally, the facilities Abuse Observation and Recording Policy indicated that all allegations and/or reports of any type of abuse toward a resident would be thoroughly investigated, documented, and reported according to procedure.

Based on resident review of the clinical record review, review of facility documentation, review of facility policy for 1 of 3 residents reviewed for abuse (Resident #98), the facility failed to initiate and complete a thorough investigation for an allegation of abuse and failed to maintain documentation that the alleged abuse was thoroughly investigated. The findings include: Resident #98 was admitted on [DATE] with diagnoses that included heart disease, respiratory failure, and diabetes mellitus. The admission MDS assessment dated [DATE] identified Resident #98 had moderate cognitive impairment and did not exhibit disorganized thinking, altered level of consciousness, or rejection of care. Additionally, Resident #98 required substantial assistance with toileting and personal hygiene. A care plan dated 5/3/2024 indicated Resident #98 did not have a history of dementia but had some short/long-term memory deficit. Interventions included encouraging the resident to participate in activities and providing cues and supervision. A care plan dated 6/28/2024 further indicated Resident #98 received palliative care. Interventions included offering the resident and family support. A review of the internal investigation dated 7/2/2024 identified Person #1 reported to social work that a nursing aide had slapped Resident #98. The internal investigation identified Resident #98 had indicated that s/he wanted to help the aide when getting cleaned up after a bowel movement, but the aide slapped her/his hand away. The internal investigation also indicated that when Resident #98 was asked for a return demonstration by the DNS, Resident #98 indicated NA #7 did not slap her/him hard and indicated NA #7 pushed his/her hand away. A review of the facility nursing schedule from 6/29/2024 through 7/9/2024 identified NA #7 was assigned to care for Resident #98 on Saturday, 7/6/2024. In an interview on 7/16/2024 at 12:12 PM, Resident #98 indicated that a few weeks ago in the evening, Nurse Aide (NA#7) had slapped his/her hand while providing care and indicated NA # 7 said s/he had her/his own way of doing things. Resident #98 indicated NA#7 was by her/himself when providing care. Resident #98 also indicated s/he had not told staff about the incident but told (Person #1) the next day. Person #1 was in the room during the surveyor's interview and further indicated the incident had occurred on the weekend after the July 4 the holiday (7/6 or 7/7/2024). Person #1 also indicated that s/he had spoken to the resident's day nurse the following day but were unsure what the date or the nurse's name was. Additionally, Person #1 indicated s/he had spoken to the Social Worker (SW) about 48 hours after Resident #98 had complained about the incident. Person #1 also indicated that s/he received a phone call from the Director of Nursing Services (DNS) regarding the incident. A review of the medical record, including nursing and social services progress notes from 6/26/2024 through 7/17/2024, did not identify any notes addressing the incident or any allegation of abuse. The facility was unable to provide an Accident/Incident Report (A&I) addressing the incident or an allegation of abuse. On 7/18/2024 at 11:37 AM, an interview with the Director of Social Services (Social Worker #1) identified that Person #1 had informed her in the morning of 7/8/2024 or 7/9/2024 (Social Worker #1 could not recall the exact date) that a staff member had slapped Resident #98's hand over the weekend. Social Worker #1 further indicated that after being informed of the incident, she immediately notified the DNS. Social Worker #1 was unable to provide any documentation or evidence in the clinical record the date of the allegation of abuse to reported to her and was unable to explain why. On 7/18/2024 at 1:45 PM, an interview with the DNS identified on 7/2/2024, she was notified by Social Worker #1 that Person #1 had told her (Social Worker #1), Resident #98 had complained about being slapped Saturday night (6/29/2024). The DNS indicated s/he initiated an internal investigation and evaluated the resident's hands. After the internal investigation, the DNS determined that NA#7 had not slapped Resident #98. However, the DNS indicated s/he did not interview other staff members or potential witnesses since s/he was able to corroborate the incident with the interviews of NA# 7 and Resident #98. The DNS indicated that the incident was not recorded in the electronic medical record because there was no change to the plan of care. On 7/22/2024 at 10:44 AM, an interview with NA #7 identified s/he had only taken care of Resident #98 once and had not taken care of the resident since the incident secondary to being a floating NA. NA #7 further indicated s/he was currently assigned to another unit. However, NA #7 could not recall what Saturday s/he had taken care of Resident #98. NA #7 indicated s/he did not slap or push Resident #98's hand but was helping Resident #98 wash his/her hands with a washcloth because Resident # 98 had gotten soiled when the resident was trying to help NA# 7 get cleaned. A follow-up interview with the DNS on 7/22/2024 at 1:05 PM identified s/he had mistakenly written the wrong date on the internal investigation. The incident had occurred on the night of 7/6/2024, and Person #1 had reported the incident to Social Worker #1 on 7/9/2024 in the morning. A review of the facilities Abuse Policy identified that the facility has trained employees to identify potential and actual occurrences of abuse. The policy also indicated the facility should investigate an allegation and report the allegation by following federal and state guidelines. Additionally, the facilities Abuse Observation and Recording Policy indicated that all allegations and/or reports of any type of abuse toward a resident would be thoroughly investigated, documented, and reported according to procedure.

Based on clinical record reviews, review of facility policy and staff interviews and for 1 of 1 resident, (Resident #18), reviewed for nutrition, the facility failed to provide supervision with meals according to the plan of care and for 1 of 1 resident reviewed for pain (Resident # 24) the facility failed to ensure the resident's care plan included nonpharmaceutical interventions for pain relief and for 1 of 5 residents (Resident #70) reviewed for unnecessary medications, the facility failed to ensure a resident care plan addressed resident specific behaviors and interventions. The findings included. 1. Resident #18 had diagnoses included Alzheimer's disease, dysphagia (swallowing difficulties), and dyskinesia of esophagus (disorder of esophageal sphincters). On 4/22/24 The Advanced Practicing Registered Nurse (APRN) order directed a dysphagia advanced diet with thin liquids and no straws. An additional order on the same date and time directed aspiration precautions, 90 degrees with anything by mouth and to maintain 90 degrees for 30 minutes after eating, encourage small sips, small bites, slow pace, alternate liquids and solids. An APRN progress note on 5/3/24 at 9:09 A.M. identified a 10.1% weight loss in 6 months. A Speech Therapy Daily Treatment note dated 5/17/24 identified Resident #18's intake amounts increased by 25% - 50% with cueing. An APRN progress note on 5/20/24 at 9:41 A.M. identified Resident #18 required more cueing with meals The quarterly MDS assessment dated [DATE] identified Resident #18 as moderately impaired in cognitive function and requiring supervision or touching assistance with eating. On 7/16/24 at 9:25 A.M. and on 7/16/24 at 12:45 P.M., Resident #18 was observed in his her/room eating a meal independently with no staff present. Interview and clinical record review with LPN #4 on 7/16/24 at 12:52 P.M. identified Resident #18's level of assistance with meals was supervision and Resident #18 should not have been eating unsupervised. Interview and review of the electronic Nurse's Aide (NA) care card with NA #2 on 7/16/24 at 2:15 P.M. identified Resident #18 required supervision with meals. NA #2 stated s/he did not serve Resident #18 his/her meal trays and did not know who did. After surveyor inquiry on 7/16/24, the Speech Therapist (ST #1) reevaluated Resident # 18 for the need for assistance with meals, and the 7/17/24 Treatment Encounter note reflected a change from supervision to assistance as needed with meals. An interview with ST #1 on 7/19/24 at 11:35 AM indicated the meaning of supervision with meals as 100% supervision from the time the resident receives his/her meal tray until the meal tray is removed. ST #1 identified Resident #18 received supervision with meals to monitor and increase meal consumption by providing assistance and verbal cues. She/he further stated the level of assistance is no longer beneficial to Resident #18 or to the staff based on the documented resident meal consumption. ST #1 identified s/he does not have access to review flow sheets where level of assistance is documented but trusts interventions are followed once initiated. Review of the 7/1/24 through 7/22/24 NA flow sheets identified missing documentation for feeding assistance and amount consumed for 36 out of 64 meals. Of the documented meals, the NA's documented set up only assistance for 7 meals and no set up or physical help from staff for 1 meal. Remaining documented meals indicated one-person physical assist and no documentation indicated supervision. An interview with the DNS on 7/19/24 at 12:45 P.M. indicated the NA care card is an extension of the care plan and the instructions on the care card should be followed. The DNS further indicated a resident requiring supervision with meals should not be left unattended with a meal tray, The facility Feeding Policy states, in part, its purpose is to ensure that all residents receive appropriate and safe assistance with feeding promoting their nutritional well-being, dignity, and social engagement. The Feeding Policy further states provide appropriate assistance based on each residents feeding plan and record all assistance provided during mealtimes in the residents' medical record. 2. Resident #24's diagnosis include chronic pain. The physician's orders dated 4/19/2024 at 11:33 PM directed to provide Resident #24 Oxycontin 10 Milligrams (MG), crush resistant, extended-release tablet by mouth every 12 hours and to provide Oxycodone 5 MG tablet by mouth every 6 hours as needed for breakthrough pain. The quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #24 was cognitively intact, received scheduled and as needed (PRN) medication for pain and did not receive non medication interventions for pain. The care plan dated 6/13/2024 indicated in part Resident #24 had alteration in pain. Interventions included: to administer medications as ordered, complete a pain assessment every shift and to notify the provider if pain medication was ineffective. An Advanced Practice Registered Nurse (APRN) progress note dated 7/3/2024 indicated chronic pain and resident complaint of pain all over with opioid use and opioid constipation further indicating to continue the current medication regime and laxative. A follow up APRN progress note dated 7/5/2024 indicated Resident # 24 reported fair effect from current regimen and the PRN Oxycodone was utilized 1-2 x daily with good effect and prescriptions for refills for pain medications were provided. Interview and record review with the DNS on 7/22/2024 at 10:46 AM with the Administrator present indicated Resident #24 had been living at the facility for several years and prior to being admitted to the facility had been on opioid pain medications. The DNS further indicated that although s/he was unable to easy access the exact date, approximately 6 months ago upon return from the hospital Resident #24 returned on no opioid medications but was restarted on the medication several days after readmission due to pain. After surveyor inquiry, the DNS indicated 1:1 visit by recreational staff and diversional activities including watching television were nonpharmaceutical interventions provided to Resident #24. The DNS further indicated s/he was not aware if therapy had been consulted regarding alternative pain relief interventions other than opioid medications or if nursing had requested any other possible alternatives. The DNS further indicated the APRN follows Resident #24 closely for pain as the resident was subject to opioid constipation. During further review of the clinical record, the DNS was unable to locate any non-pharmaceutical interventions utilized in addition to the pain medication in Resident #24's care plan. The facility policy labeled pain management dated 6/2024 indicated in part the facility is committed to assist each resident to attain or maintain the resident's highest practicable mental and psychosocial well-being by assessing pain and using interventions to prevent pain from interfering with the quality of life. 3 Resident #70's diagnoses include traumatic cerebral hemorrhage and anxiety. The quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #70 was cognitively intact and received antianxiety and antidepressant medications and had no behavioral symptoms displayed during the 7-day lookback period. The physician's orders dated 6/13/2024 at 5:58PM directed to monitor and documents target behaviors every shift for use of Klonopin for antianxiety/restlessness and to document outcomes of interventions used for the behaviors and if worsened improved or unchanged every shift. The physician's order also directed to monitor for side effects related to the use of Klonopin every shift and to monitor for target behaviors every shift for use of Melatonin for insomnia/poor sleep. An interview and record review on 7/22/24 at 9:34 AM with MDS Nurse, RN #1 indicated Resident #70 had a diagnosis of anxiety and orders for behavioral monitoring. However, RN #1 was not able to find a care plan addressing the behaviors and interventions utilized to manage the behaviors and s/he further indicated there should be a care plan. An interview and record review with LPN #3 on 7/22/24 at 10:05 AM indicated s/he was speaking with RN #1 and identified the behavioral care plan must have been missed and should have been added to the care plan. After surveyor inquiry, a behavior care plan was added. LPN #3 further indicated without the behavioral care plan interventions used cannot be evaluated for effectiveness. The facility policy labeled Resident Care Plan indicated in part the goal is to achieve optimal physical, psychosocial, and functional status by initiating an interdisciplinary care plan on admission with reviews quarterly and as needed. The policy further indicated the care plan would be maintained in the medical record, updated as needed and reviewed quarterly. 50890

Based on clinical record review, observation, review of facility policy and staff interviews for 1 of 7 residents (Resident #69) reviewed during medication administration, the facility failed to ensure staff disposed of a narcotic medication in an acceptable manner. The findings include. Resident #69's diagnosis included essential hypertension, mood disorder and gastric esophageal reflux. A physician's order dated 3//19/2024 at 11:07 PM directed to provide Propranolol 120 MG, 24 hour extended-release capsule by mouth daily at 9:00 AM for hypertension. A physician's order dated 3//19/2024 at 11:07 AM directed to provide Duloxetine 60 MG capsule, delayed release by mouth daily at 9:00 AM for mood disorder. The care plan dated 4/1/2024 indicated Resident #69 had dysphagia with swallowing difficulty and interventions included in part to provide speech therapy as needed. The quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #69 was severely cognitively impaired. On 7/17/2024 at 8:42 AM observation and interview with LPN #6 during medication administration for Resident #69 LPN#7 indicated the need to dispose of the medications just poured (including a narcotic medication) before repouring the medications for Resident #69. LPN#6 and LPN#7 witnessed the discarded the unused medication for destruction of the crushed medications which included a narcotic. After the disposal was done and LPN #7 left further observations identified the cup of medications in applesauce with the spoon inside was on top of the uncovered small trash receptacle on the side of the medication cart. After surveyor inquiry, LPN #7 indicated the cup of crushed medications was the same cup of medications discarded (including the narcotic) and further indicated s/he did not know what the facility policy was for proper disposal of medications including narcotics but would contact the supervisor. On 7/17/2024 At 9:01 AM RN #2 came to the medication cart and was updated by LPN #6. RN #2 identified the medication should be disposed in a bottle of Drug Buster (usually kept in a drawer of the medication cart and this cart must have run out of the Drug Buster. RN #2 indicated he/she would properly dispose of the medication along with LPN #6 and witness the discard on the narcotic sheet. RN #2 further indicated h/she would talk with LPN #7 regarding the proper procedure as well as inform the Staff Development nurse. The facility policy labeled Controlled Substance Disposal dated 6/2024 indicated in part when a dose of a controlled medication is removed from the container for administration but refused by a resident or not given for any reason the medication will be destroyed in the presence of 2 licensed nurses. Although, the facility policy for the process used to dispose of narcotic medication was requested one was not supplied.

Based on clinical record, observations, facility documentation, and interviews for 1 of 1 resident (Resident #42) reviewed for activities, the facility failed to provide therapeutic recreation activities to meet the psycho-social needs of the resident. The findings include: Resident #42's diagnoses included diabetes mellitus, pain and Alzheimer's disease. The quarterly Minimum Data Set assessment dated [DATE] identified Resident #42 as severely cognitively impaired, non-verbal, and dependent for all aspects of care to include bed mobility, transfers, eating and hygiene. The Resident Care Plan (RCP) last reviewed 7/16/24 identified interventions to inform, invite and escort Resident #42 to appropriate recreation programs, offer music in room, and 1:1 recreation visits to promote socialization. During an observation on 7/16/24 at 11:08 A.M., Resident #42 was sitting in his/her wheelchair at the bedside, sleeping. During further observations at 11:35A.M., 12:15 P.M., 12:40 P.M., 1:04 P.M., 1:30 P.M., 1:53 P.M., 2:10 P.M., and 2:30 P.M., Resident #42 was observed in his/her wheelchair in the same position with no form of stimulation. On 7/19/24 the Recreation Director indicated Resident #42 is brought to activities and is provided sensory forms of stimulation such as stuffed animals and music in his/her room. Review of the Activity Progress Notes dated 7/14/24 through 7/21/24 identified Resident #42 was engaged in activities on 7/15/24. No further activities or 1:1 visits were documented. An interview with Recreation Therapist (RT) #1 on 7/22/24 at 12:22 P.M. identified the week of 7/14/24 through 7/20/24, she was assigned to Resident #42, and she could not recall any further activities aside from the activities documented on 7/15/24. An interview with RT #2 on 7/22/24 at 12:38 P.M. identified there was no further documentation of activities for Resident #42 for the dates of 7/14/24 through 7/21/24. RT #2 further states getting residents to activities is a challenge and describes is between the nursing and recreation departments. RT #2 identified mentioning programs to nursing staff is sometimes effective and other times not. RT #2 further indicated it is particularly challenging for non-verbal residents, like Resident #42, because staff will put him/her back to bed before the opportunity to join an activity. An interview with the Recreation Director on 7/22/24 12:38 P.M. indicated the nursing department doesn't always follow through with getting residents up or bringing them to activities.

Based on clinical record reviews, facility documentation, facility policy and interviews for 2 of 3 sampled residents (Resident # 25 and # 42 ) reviewed for pressure ulcers, the facility failed to ensure a nutritional assessment was completed for a newly identified pressure injury and failed to reposition the resident according to the plan of care. The findings include: 1. Resident # 25's diagnosis include Multiple Sclerosis. The quarterly Minimum Data Set, (MDS) assessment dated [DATE] identified Resident #25 was moderately cognitively impaired, required extensive two person assist with bed mobility/transfers, was at risk for the development of pressure ulcers and had no unhealed pressure ulcers. The Resident care Plan (RCP) dated 2/12/24 identified Resident #25 was at risk for the development of pressure ulcers. Interventions directed to offload heels, check skin condition weekly and apply skin prep to heels twice daily. A Nutritional assessment dated [DATE] identified Resident #52's skin was intact with no pressure ulcers and that the current diet was meeting nutritional needs. An initial Pressure Ulcer assessment dated [DATE] identified a stage II pressure ulcer measuring 3 Centimeter ( CM), width: 2.5 CM, depth: 0 CM, with no exudate. A shallow, intact, red blister to left inner heel, surrounding area was blanchable, and noted to be non-tender with no drainage or odor. A review of the clinical record failed to identify a subsequent nutritional assessment or progress note detailing the newly identified pressure ulcer to determine what, if any nutritional modifications were warranted. An interview and clinical record review with the Dietitian on 7/18/24 at 9:38 AM identified she had been employed by the facility since 6/2024 and worked 20 hours weekly. The Dietitian identified she received a weekly wound report supplied by the wound nurse which was used to monitor the progress of any resident with wounds. For any newly identified wound, the Dietitian would complete a partial assessment including intake, weight and determine if any additional supplementation or protein would be required. The Dietitian identified the limited assessment would be documented in the clinical record. The Dietitian further identified that although she was not employed by the facility when the wound was first known, she was unable to say whether she was aware of Resident #25's pressure ulcer or explain why she had not assessed Resident #25's nutritional status at any time after the receipt of the pressure ulcer report identifying the wound. An interview with the Director of Nursing, DNS on 7/18/24 at 9:47 AM identified she would expect a dietary assessment be conducted for any resident with a newly identified pressure injury. A review of the facility policy for Medical Nutrition Therapy: Assessment and Care Planning identified the Registered Dietitian was responsible for a comprehensive assessment annually, on referral or as indicated by the clinical condition of the resident and that changes would be communicated to nursing staff. 2. Resident #42's diagnoses included diabetes mellitus, pain and Alzheimer's disease. The last nutritional assessment conducted, dated 5/8/24, noted skin is intact. There was no further nutritional assessment conducted with the development of 2 new pressure injuries to the left heel. The quarterly Minimum Data Set assessment dated [DATE] identified Resident #42 as severely cognitively impaired, non-verbal, incontinent, at risk for developing pressure injuries and dependent for all aspects of care to include bed mobility, transfers, eating and hygiene. A progress note dated 5/24/24 identified discoloration to the left heel, an intact blister to the left heel, and supervisor notification. The facility Wound Pressure Ulcer Weekly Record assessment dated [DATE] identified a new facility acquired pressure injury with black eschar to the left heel, which was noted to be located over the site of a previously healed pressure injury. The assessment further noted an adjacent dark purple deep tissue injury. An APRN progress note dated 5/31/24 identified Resident #42 was at high risk for skin impairment due to immobility. The facility Braden Scale assessment dated [DATE] identified Resident #42 as a high risk for developing pressure injuries. The Resident Care Plan (RCP) and Nurse Aide (NA) care card dated 7/16/24 directed Resident #42 to be out of bed and in his/her custom wheelchair for lunch and dinner, not to exceed 2 hours in the wheelchair at a time. The RCP further directs Resident #42 to be transferred back to bed 1 hour after meals and to be turned and repositioned side to side every 2 hours. The RCP did not include interventions for pain or nutrition related to the 2 new pressure injuries. The RCP did not include diabetic foot monitoring and care. During an observation on 7/16/24 at 11:08 A.M., Resident #42 was sitting in his/her wheelchair, sleeping. During further observations at 11:35AM., 12:15 P.M., 12:40 P.M., 1:04 P.M., 1:30 P.M., 1:53 P.M., 2:10 P.M., and 2:30 P.M., Resident #42 was observed in his/her wheelchair in the same position. An interview and review of the NA care card with NA #3 on 7/16/24 at 2:25 PM indicated Resident #42 was out of bed and in his/her wheelchair for breakfast and remained in the wheelchair without any changes in position since transferred out of bed. When reviewing the NA care card, NA #3 indicated the turning and repositioning instructions were for when Resident #42 was in bed and that Resident #42 was not turned or repositioned while in the wheelchair. NA #4 stated we do not reposition him/her in the chair, only in bed. When reviewing the section of the NA care card that directed a 2-hour maximum time in the wheelchair, NA #3 indicated the instructions referred to lunch and dinner, and further indicated Resident #42 should be transferred back to bed after lunch and that she was late transferring him/her back to bed. Interview and review of the clinical record with LPN #4 on 7/16/24 at 2:30 P.M. identified Resident #42 had care planned instructions for a 2-hour maximum time in the wheelchair, had a pressure injury to the left heel and a history of a pressure injury to the coccyx area. LPN #4 indicated any resident who has an active pressure injury or history of a pressure injury should be repositioned every 2 hours. LPN #4 indicated Resident #4 is usually transferred out of bed for lunch and then is transferred back to bed after lunch. LPN #4 indicated after lunch would be by 2:00 P.M. When notified by the surveyor, that Resident #4 was still in his/her wheelchair, LPN #4 indicated he/she should be in bed. After surveyor inquiry of Resident #42's skin integrity identified the plan of care was not followed, LPN #4 performed a skin assessment. An interview with the Director of Nursing Services on 7/19/24 at 12:30 P.M. identified the expectation for repositioning a resident with a pressure injury or at risk of developing a pressure injury is every 2-3 hours unless there is an out of bed schedule. The facility Wound Management Program policy states, in part, in the prevention Protocol section, residents will be turned and repositioned every 2 hours as tolerated while in bed and every 60-90 minutes when in a wheelchair and to improve/maintain nutrition and hydration status as feasible, all residents will have a nutritional consult with condition change. 50890

Based on review of the clinical record, observations, facility policy and interviews for 1 of 7 residents (Resident #69) reviewed during medication administration, the facility failed to ensure staff appropriately prepared Extended release/delayed release medications for administration to a resident. The findings include. Resident #69's diagnoses included essential hypertension, mood disorder and gastric esophageal reflux. A physician's order dated 3//19/2024 at 11:07 PM directed to provide Propranolol 120 MG, 24 hour extended-release capsule by mouth daily at 9:00 AM for hypertension. A physician's order dated 3//19/2024 at 11:07 AM directed to provide Duloxetine 60 MG capsule, delayed release by mouth daily at 9:00 AM for mood disorder. The care plan dated 4/1/2024 indicated Resident #69 had dysphagia with swallowing difficulty and interventions included in part to provide speech therapy as needed. The quarterly Minimum Data Set (MDS) dated [DATE] indicated Resident #69 as severely cognitively impaired. On 7/17/2024 at 8:42 AM observation and interview with LPN #6 during medication administration for Resident #69 identified Resident #69 requires medications to be crushed therefore s/he would be opening the capsules and crushing the other medications to put into applesauce. Further observation included LPN #7 preparing all medications as ordered for the time opening the capsule of Duloxetine Delayed Release and the capsule of Propranolol Extended-Release place in applesauce with the other medications mix and entered Resident #69's room again, LPN #1 scoop the medication onto spoon and start to administer to Resident #69. The surveyor intervened and asked LPN #7 to step out of the room with the surveyor for a moment. Once at the medication cart after surveyor inquiry, LPN#7 reviewed the medication orders and indicated the Propanol, and the Duloxetine capsules should not have opened, and s/he would need to repour the medications and provide whole in applesauce. On 7/17/24 at 9:07 AM LPN #7 repoured all medications crushed in applesauce with the Duloxetine and Propranolol capsules intake in the applesauce. Medications were administered via spoon of in applesauce to Resident #69 who at which time spit out the capsules but took all the other crushed medication. LPN #7 indicated s/he would call the supervisor to and provide an update and inform the APRN regarding refusal for further orders. After surveyor inquiry, a physician's order dated 7/17/2024 at 9:55 AM directed to provide Propranolol 60 mg tablet by mouth twice daily at 9:00 AM and 9:00 PM for hypertension. After surveyor inquiry, a physician's order dated 7/17/2024 at 10:42 AM directed to provide Duloxetine 60 mg delayed release capsule by mouth and not to open capsule. An interview and medication review for Resident #69 with Pharmacist #1 on 7/19/2024 at 11:26 AM indicated Propranolol 120 MG Extended release and the Duloxetine 60 mg delayed release should not be opened and the Propranolol information provided no option at all for opening the capsule. The facility policy labeled Medication Crushing Guidelines dated 6/2024, indicated in part time released capsules are designed to release medication over a sustained period usually 8-24 hours in which the contents are designed to dissolve at different times, utilized to reduce stomach irritation, in some cases and to achieve a prolonged medication action in other cases. Before opening a capsule to administer in food a reference or pharmacist should be consulted before administering in this manner.

Based on observation, review of facilities policy and interview for 1 out of 2 medication rooms, the facility failed to label medications appropriately once opened. The finding include: Observation of the A/B Wing medication room on 7/19/24 at 10:53 AM identified Morphine Sulfate 100 MG every 4 hours as needed prescribed to Resident # 98; was opened, however, a date open sticker was not on the medication. Interview with LPN #2 on 7/19/24 at 10:53 AM identified the date was documented somewhere else. The Medication Book indicated the Morphine was opened 7/7/24. After inquiry, RN#2 prompted LPN #2 to place the open date on the container. The facility's Storage of Medications Policy notes when the original seal of a manufacturer's container or vial is initially broken, the container or vial will be dated. The nurse shall place a date open/ sticker on the medication.

Based on clinical record reviews, interviews and review of facility documentation for two of six sampled residents (Resident #119 and Resident #181) reviewed for accidents, the facility failed to provide adequate supervision resulting in an injury and/or the facility failed to transfer the resident in accordance with the facility policy and the care plan resulting in an injury. The findings include: 1. Resident #119 [DIAGNOSES REDACTED]. The fall assessment dated [DATE] identified a score of 15 indicating a high risk for falls. An admission Minimum Data Set assessment ((MDS) dated [DATE] identified intact cognition, assistance of two for transfers, extensive assistance of two for toilet use, was not steady moving on and off the toilet and moving from seated to standing position, and only able to stabilize with staff assistance. The care plan dated [DATE] identified a risk for falls due to cognitive impairment and impaired balance. Interventions included PT, OT as ordered, personal care items in reach, transfer and ambulation with assistance as ordered. The physician orders [REDACTED]. Review of a reportable event dated [DATE] at 9:20AM identified the resident was assisted to the bathroom by NA#1 and was later found on the floor. A review of the nursing notes dated [DATE] at 9:20AM identified that Resident #119 was assessed subsequent to the fall and was noted as alert and with baseline confusion. The nurse's note further identified that at 10:15 AM Resident #119 began to complain of left wrist and hand pain and swelling. The APRN was notified and directed to obtain an X-ray of the left wrist and hand which revealed a non-displaced fracture of the left wrist. Resident #119 was transferred to the emergency roiagnom on [DATE] at 6:00PM for evaluation and treatment of [REDACTED]. Resident #119 returned to the facility on [DATE] with a splint in place and orders for an orthopedic consultation. Interview with NA#1 on [DATE] at 9:45AM identified he/she recalled assisting Resident#119 to the bathroom on [DATE] and giving the resident the call light to ring when assistance was needed. NA #1 left the resident unattended on the toilet and continued with his/her assignment. NA #1 further identified that he/she was not aware the resident should not be left alone in the bathroom. Interview with the Director of Nurses (DNS) on [DATE] at 10:00AM identified it was the responsibility of the licensed staff to instruct the nurse aide to stay with the resident when toileting. The DNS indicated that the RCP and nurse aide care card failed to reflect the needs and interventions appropriate for the resident which included not leaving the resident unattended on the toilet. Interview and review of the clinical record with the Director of Rehabilitation(DOR) on [DATE] at 2:00PM identified Resident#119 had a history of [REDACTED]. The DOR further identified Resident#119 required the assistance of 1 for toileting, therefore the staff was expected to remain with the resident when toileting was provided. Interview with RN#2 on [DATE] at 2:00PM identified Resident#119 was confused prior to the fall and per the facility ' s policy/practice, residents are not to be left unattended in the bathroom. 2. Resident # 181 [DIAGNOSES REDACTED]. A Quarterly Minimum Data Set assessment dated [DATE] identified severely impaired cognition and total dependence on staff with ADL ' s including the assistance of two for bed mobility and transfers. The care plan and the NA assignment dated [DATE] directed the staff to transfer the resident with a mechanical lift with the use of a large green sling (the color sling is based on the weight of the resident). The nurse's note dated [DATE] identified at 3:30 PM, Resident#181 fell out of the mechanical lift during a transfer. The physician was notified and the resident was sent to the ED for evaluation and returned to the facility at 10:50 PM. The Emergency Department documentation dated [DATE] identified [DIAGNOSES REDACTED]. Additionally, a mildly comminuted displaced fracture of the left occipital condyle (bony surface at the base of the skull) was identified and a laceration over the right eye that required sutures to approximate. Resident #181 returned to the facility on comfort care. Nurse notes dated [DATE] identified Resident #181 expired at 6:00 AM. (six days after the fall) Interview and review of facility policy and procedures on [DATE] at 10:30 AM with the Staff Development Nurse identified that during a mechanical lift transfer the wheelchair should be placed next to the bed. One staff member stands behind the wheelchair to guide and position the resident as the second staff member operates the mechanical lift. Interview, review of the clinical record and facility documentation on [DATE] at 11:30 AM with the DNS identified that due to the height of the resident's head rest on the custom wheelchair the NA could not stand behind the wheelchair to appropriately guide and position the resident. Additionally, during the transfer on [DATE] the wheelchair was positioned 18 inches away from the bed. During the transfer on [DATE] the NA's were guiding the resident from the sides of the wheelchair instead of guiding the mechanical lift from behind the wheelchair. Additionally, an extra-large sling (blue) was used during the transfer instead of the large size (green) as directed in the plan of care. Interview and review of facility documentation on [DATE] at 2:10 PM with NA #3 identified that NA #3 and NA #4 checked to ensure the sling was appropriately attached to the mechanical lift before lifting the resident off the bed with the mechanical lift. While lifting Resident #181 off the bed, the NA's attempted to readjust the resident into a sitting position while guiding the resident to the wheelchair. The NA's indicated they heard a snap and the upper right sling clip detached from the mechanical lift and the resident fell forward landing face down on the floor. Interview with a representative from the company that manufactures the mechanical lift on [DATE] at 2:15 PM identified the mechanical lift and the sling used during the incident were in good condition and functioning appropriately. Additionally, the representative indicated that when the mechanical lift sling clips are latched appropriately it is highly unlikely they will spontaneously detach. A review of the facility mechanical lift policy directed to place the chair bedside with the second staff member behind the chair. Lock the chair and bed wheels. Elevate the resident according to the manufacturer's recommendation. When you are sure that the resident cannot slip out of the mechanical lift, wheel the lift from under the bed and position the lift so that the resident is over the chair, Lower the resident slowly as the second staff member guides the resident into the chair. Subsequent to the incident in-service training was provided to all staff who conducts mechanical lift transfers.