Every finding on record at Azria Health Longview

Based on clinical record review, staff interviews, and policy review the facility failed to provide the needed services in accordance with professional standards by not assessing a resident with a change in condition and failing to notify hospice and/or the provider of the continual refusal of medications. This failure resulted in Resident #48 having increased behaviors resulting in care not received and presenting as a danger to self and others. The resident was hospitalized and treated for sepsis. The facility reported a census of 82 residents. Findings include:The Significant Change Minimum Data Set for Resident #48 dated 6/12/26 provided the Brief Interview of Mental Status was not able to be administered to the resident. The Staff Assessment for Mental Status revealed the resident was normally able to recall the current season, staff, location of room, they were in a facility and were modified independent with daily decision making. The MDS coded the resident required total assistance from staff with oral hygiene, toilet hygiene, dressing, personal hygiene, setup for eating, and total assistance for all mobility (bed, transfers, moving to/from lying and sitting). The document disclosed the resident was always incontinent of bowel and bladder. The document revealed the resident had diagnoses of renal insufficiency/failure, urinary tract infection in past 30 days, diabetes mellitus, anxiety disorder, bipolar disorder, and schizophrenia, The MDS documented the resident received antianxiety, antidepressant, opioid, hypoglycemic and anticonvulsant medications during the last 7 days of the assessment reference period.Resident #48's Care Plan revised 7/22/26 revealed a focus area of terminal prognosis and received hospice services (revised 6/16/26) with interventions of observing the resident closely for signs of pain, administration of medications as ordered and notify the physician immediately of breakthrough pain. A focus area for bowel and bladder incontinence, revised 1/14/26, provided staff interventions of monitor/document/report signs/symptoms of urinary tract infection including foul smelling urine, altered mental status, and change in behavior.Resident #48's Hospice Certificate of Terminal Illness dated 6/5/26 documented the primary care physician agrees the resident would benefit from hospice services to control pain and behaviors. The nursing assessment indicated hospice care can help manage the resident's escalating psychiatric symptoms, agitation and combativeness in the context of her physical decline, focusing on comfort and quality of life. Resident #48's Hospice Care Plan dated 6.5.26 revealed a problem area for pain with interventions of collaboration with primary care physician, titrate medication to control pain, and monitor pain medication for effectiveness; a problem area of psychological/mental/emotional needs with interventions of assessment of agitation, explain to patient all care being given; a problem area related to respiratory with assessment of lung sounds and respiratory status; a problem area for urinary elimination with interventions of incontinence of urine, assessment of patient's bladder pattern and urinary function.Review of Resident #48's 7/26 MAR revealed the following opportunities of medications not administered due to the resident sleeping or resident refusals:Diflucan 100 milligram (mg) 1 tablet by mouth one time a day for yeast infection for 7 days, date ordered 6/27/26 - the resident refused 1/4 opportunities.Duloxetine HCI 60 mg, 1 capsule by mouth daily for bipolar disorder; date ordered 12/9/25 and discontinue (D/C) 7/13/26 - the resident refused 5/13 opportunities.Jariance 10 mg 1 tablet by mouth daily for diabetes; date ordered 1/20/26 and D/C 7/10/26 - the resident refused 2/10 opportunities.Senna 8.6 mg, 2 tablets by mouth daily for constipation; date ordered 6/18/26 and D/C 7/13/26 - the resident refused 5/13 opportunities.Buspirone HCI 10 mg, 1 tablet by mouth twice daily (BID) for anxiety; date ordered 12/9/25 and D/C 7/13/26 - the resident refused 12/25 opportunities.Gabapentin 300 mg, 1 tablet by mouth BID for other chronic pain; date ordered 12/9/25 and D/C 7/13/26 - the resident refused 11/25 opportunities. Lamotrigine100 mg, 1 tablet by mouth BID for schizoaffective disorder; dated ordered 6/26/26 and D/C 7/10/26 - the resident refused 12/ 25 opportunities.Miconazole External Powder 2%, BID for antifungal treatment; date ordered 6/26/26 and D/C 7/10/26 - the resident refused 8/19 opportunities.Propranolol HCI 10 mg, 1.5 tablets BID for high blood pressure; ordered 1/13/26 and D/C 7/10/26 - the resident refused 6/19 opportunities.Lorazepam 2 mg/(milliliter (ml), .25 ml by mouth three times a day (TID) for bipolar disorder, generalized anxiety disorder and schizoaffective disorder; date ordered 6/26/26 and D/C 7/10/26 - the resident refused 7/29 opportunities.Sucralfate 1 gm, 1 tablet TID for gastric protection; date ordered 3/25/26 and D/C 7/10/26 - the resident refused 7/29 opportunities. Haloperidol Lactate 5 mg/ml, inject 5 mg every 6 hours for refusing medications, give injection until resident takes medications by mouth; date ordered 7/11/26 and D/C 7/13/26 - the resident refused 2/7 opportunities.Haloperidol Lactate 5 mg/ml, inject 10 mg every 6 hours for refusing medications, give injection until resident takes medications by mouth; dated ordered 7/13/26 and D/C 7/15/26 - the resident refused 1/8 opportunities.Haloperidol Lactate 2 mg/ml, give .25 ml by mouth every 6 hours for agitation/anxiety; dated ordered 6/29/26 and D/C 7/9/26 - the resident refused 6/35 opportunities.Haloperidol Lactate 2 mg/ml, give .5 ml by mouth every 5 hours for agitation/anxiety; dated ordered 7/9/26 and D/C 7/30/26 - the resident refused 33/84 opportunities.Haloperidol Lactate 2 mg/ml, give .5 ml by mouth every 5 hours for agitation/anxiety; dated ordered 7/9/26 and D/C 7/30/26 - the resident was not provided 3/84 opportunities due to sleeping. Lorazepam 2 mg/ml, give .25 ml by mouth before meals and at bedtime for bipolar, generalized anxiety and schizoaffective disorder; date ordered 7/10/26 and D/C 7/13/26 - the resident refused 9/12 opportunities.Lorazepam 2 mg/ml, give .5 ml by mouth before meals and at bedtime for bipolar, generalized anxiety and schizoaffective disorder; date ordered 7/13/26 and D/C 7/15/26 - the resident refused 6/8 opportunities. Lorazepam 2 mg/ml, give .5 ml by mouth every 5 hours for anxiety; date ordered 7/15/26 and D/C 7/30/26 - the resident refused 20/60 opportunities.Lorazepam 2 mg/ml, give .5 ml by mouth every 5 hours for anxiety; date ordered 7/15/26 and D/C 7/30/26 - the resident was not provided 3/60 opportunities due to sleeping.Morphine Sulfate 20 mg/5 ml, give .5 ml by mouth every 4 hours for pain/shortness of breath; date ordered 6/13/26 and D/C 7/30/26 - the resident refused 67/120 opportunities.Morphine Sulfate 20 mg/5 ml, give .5 ml by mouth every 4 hours for pain/shortness of breath; date ordered 6/13/26 and D/C 7/30/26 - the resident was not provided with 4/120 opportunities due to sleeping. The document lacked documentation for 1/120 opportunities.Review of Resident #48's 8/26 MAR revealed the following opportunities of medications not administered due to the resident refusing:Haloperidol Lactate Concentrate 2 mg/ml, 1 mg by mouth every 4 hours for anxiety/agitation; date ordered 8/1/26, hold from 8/2 - 8/3/26 and D/C 8/3/26 - the resident refused 2/9 opportunities.The electronic medical record's Physician Orders disclosed an order for palliative sedation, do not hold medications even when sleeping, call hospice with concerns every 4 hours for paranoid schizophrenia; ordered 8/1/26, held 8/2-8/3/26 and D/C 8/3/26. The Progress Notes in Resident #48's electronic medical record revealed the following entries:7/2/26 5:13 AM Client refused several doses of medication although complaining of being in pain. The resident did eventually take Haldol/morphine when the medication was put in a small cup of juice and the client drank it. 7/7/26 5:24 AM resident attempting to hit staff and yell at staff during check/change; redirected x3 with eventual ability to change. 7/9/26 2:33 PM resident refused skin checks x3; hospice notified.7/9/26 2:52 PM resident refused medication administration x2; daughter notified.7/10/26 12:25 PM Resident refused meds. She began yelling and cursing at staff members. She refused care and began throwing her drinks across the room. The unit manager and hospice were made aware. 7/10/26 1:02 PM one time order from Haldol 10 mg injection at 11:45 AM.7/11/26 9:08 AM resident refused medications; resident is stuck in a loop. 7/13/26 4:24 AM attempted to give medications throughout the night with the resident being agitated, swinging at the nurse without contact with the resident refusing medications. 7/14/26 3:11 AM the resident continues on increased dose Haldol injections. The resident refused a second injection at 2:00 AM from this nurse, swinging and screaming at the nurse and staff. 7/14/26 2:52 PM the resident continues on an increased dose of Haldol. She continues to have behaviors, mood swings, yelling, combative with staff and not able to be redirected.7/14/26 9:34 PM the resident continued with injection of Haldol refusing all oral medications and hitting/scratching, biting at staff during care. 7/18/26 2:36 AM refused medications.7/18/26 5:45 AM medication in hot chocolate and only sipped then discarded the rest.7/19/26 11:27 PM refused scheduled medications x2. 7/21/26 8:56 PM medications administered with daughter present.7/24/26 12:20 PM resident continues with increased dose of Haldol and started Asenapine patch. Behaviors and yelling have decreased. The resident still refuses care. 7/25/26 3:21 AM resident continues to refuse care, refused all night meds, yelling in the room telling staff to leave. The resident did finally fall asleep and the nurse did not wake the resident for her medications.7/26/26 2:38 AM resident with decreased behaviors and yelling with patch and increased dose of Haldol.7/27/26 3:19 PM hospice visit with order to increase Asenapine patch to 7.6 mg once a day. 7/28/26 5:08 AM refused all medications throughout the shift, last round of care.7/ 28/26 12:52 PM behaviors and yelling noted throughout the shift.7/28/26 9:17 PM refused night medications x3, but compliant with cares and no adverse behaviors to staff. 7/29/26 1:33 PM provider visit with resident doing better with hospice care but continues to cry out and hallucinate, pain controlled. Plan to adjust the antipsychotic patch. 7/30/26 4:16 AM yelling and crying off and on until 10:30 PM, calmed down and went to sleep with the resident refusing medications at 8:30 PM. The nurse did not wake the resident at other medication times. 7/30/26 12:47 PM orders from hospice to D/C routine morphine, Haldol and Lorazepam, increase Fentanyl to 50 mcg/ hour change every 3 days. 7/31/26 3:12 PM unwitnessed fall from bed, sent to hospital. 7/31/26 6:55 PM returned from hospital where resident received Cetfriaxone 2 g injection (antibiotic to treat severe bacteria injection), Ketamine (fast activating anesthetic valued for treating depression), and Lorazepam. 8/1/26 2:07 PM resident combative, hitting/striking at staff, unable to redirect, refused medication and attempts to give medication from multiple staff members.8/1/26 3:55 PM res. yelling, screaming, lunging at staff, throwing a water cup, unable to console, as needed medication given and ineffective.8/1/26 6:57 PM around 1:35 PM, the resident exhibited acute escalation in behaviors characterized by continuous screaming, striking at staff, swinging fists, and throwing objects toward staff members. The resident was highly agitated, combative, and unable to be redirected despite multiple attempts at verbal de-escalation, reassurance, and environmental modification. The resident was disoriented and unable to participate in redirection or follow simple commands. Scheduled oral/SL Haloperidol and Lorazepam were offered and the resident refused all oral medications. Due to the immediate risk of harm to staff and inability to safely provide care, the on-call provider was notified and a one-time order received for Haloperidol 10 mg injection. Medication administered per order at approximately 1:35 PM. The resident tolerated injection without complication. The resident continued to exhibit severe agitation and combative behaviors following administration of Haloperidol 10 mg injection per provider order. The resident remained verbally disruptive, screaming, attempting to strike staff, swinging fists, and resisting care. Multiple staff members were required to provide care safely. Scheduled doses of Haloperidol 0.5 mL and Lorazepam 0.5 mL were administered as ordered. Due to persistent agitation and continued risk to staff, as needed Haloperidol and Lorazepam were administered at approximately 3:55 PM and again at 4:55 PM per provider orders. The resident monitored closely throughout the shift for response, respiratory status, and level of consciousness. Following medication administration, the resident became somewhat calm and is currently resting in bed. No acute adverse reactions observed. Hospice comfort measures continue. Continued monitoring initiated for response to medication, respiratory status, level of consciousness, and resident safety.Hospice plan of care remains in place. 8/1/26 7:14 PM hospice notified of persistent severe agitation and combative behaviors despite administration of injection of Haloperidol 10 mg, scheduled Haloperidol and Lorazepam, and subsequent as needed doses. Verbal order received to administer Lorazepam injection solution 2 mg/1 mL, give 2 mg injection every 4 hours until resident is palliatively sedated and able to safely take oral medications without combative behaviors. Order entered as received. Will continue close monitoring of respiratory status, level of consciousness, comfort, and response to treatment. 8/2/26 2:16 AM New orders received from hospice to give injections of Haldol and Lorazepam until the resident is compliant with oral medications. Received two doses of Haldol and Lorazepam injections. Compliant with both doses of each. Denies pain/discomfort. The resident stated she didn't want morphine as morphine is killing her. No distress noted. 8/2/26 9:28 AM resident non-compliant, yelling at staff, refusing care, refusing oral meds; injection medications given until resident compliant to take oral medication.8/2/26 11:25 AM The resident continued to exhibit severe behavioral disturbances throughout this shift, including persistent noncompliance with care, screaming, combative behaviors, attempting to hit and strike staff, and inability to be redirected. The resident struck staff members during care. The resident remained a safety risk to self and others despite medication management and hospice interventions. The resident experienced multiple episodes of loose stool during the shift. Perineal care, brief changes, and complete bed changes were provided as needed. Hospice evaluated the resident at bedside and determined the resident met criteria for transfer to the hospital for general inpatient hospice level of care due to increased behaviors and safety concerns. Law enforcement was present at the facility for standby assistance; however, no intervention by law enforcement was required. The resident remained combative during transfer, requiring multiple-person assistance. The Emergency Department Encounter dated 7/31/26 revealed the resident had a fall from bed and had complaints of bilateral knee pain. The document provided respiratory assessment of breath sounds within normal limits, negative for wheezes, crackles and no accessory muscle use. No acute injuries. Chest CT revealed mild hazy opacities of the left lung may represent developing pneumonia versus pulmonary bruising in the setting of recent trauma. The Emergency Department Encounter dated 8/2/26 revealed the resident arrived via EMS extremely agitated, screaming, cursing. The document disclosed that according to hospice the resident had not been getting her medication at the facility either due to noncompliance or patient sleeping. Resident in acute distress. No active chest disease following chest x-ray and pulmonary effort was normal with normal breath sounds. The document included the following laboratory results: Uurinalysis (UA) was abnormal with the following results: cloudy moderate blood in UA, protein 100 mg/dl, leukocyte moderate, WBC 20-50, yeast UA 5-25, renal epithelial cells 0-2, transitional epithelial cells 0-2, microbiology no growth at 1 day.The complete blood count (CBC): white blood cells (WBC) 24.0 (high) with normal range 4.0-12.0 k/ul signaling an infection, neutrophils abs 18.7 (high) with normal range 1.5-8.0 k/ul indicating bacterial infection/stress/inflammation, monocytes abs 1.4 (high) with normal range 0.1-1.1 k/ul) indicating acute infection.Comprehensive metabolic panel (CMP): glucose 132 (high) with normal range 70-100 mg/dl, Blood Urea Nitrogen (BUN) 33 (high) with normal range 6-24 mg/dl indicating dehydration or decreased blood flow to kidneys, sodium 147 (high) with normal range 135-145 mmol/L indicating dehydration, chloride 11 (high) with normal range 96-110 mmol/L indicating dehydration/kidney dysfunction, globulin 4.6 (high) with normal range (2.5-4.1 gm/dl indicating chronic infection/dehydration/inflammatory condition, osmolality calc 313 (high) with normal range 275-295 mmol/L indicating dehydration , glomerular filtration rate (GRF) Estimate 68 (low) with normal range >=90 mL/min/1.73 m2 indicating kidneys are filtering blood slower than normal.The document disclosed the Medical Decision Making: acutely distressed, agitated, and physically aggressive, vital signs notable for tachycardia; workup revealed leukocytosis (WBD 24.0) and urinalysis consistent with infection. The differential diagnosis included acute delirium secondary to infection (UTI), exacerbation of underlying schizoaffective disorder/psychosis, medication noncompliance or subtherapeutic psychiatric regimen, metabolic derangement (mild hypernatremia, elevated BUN), substance-related or withdrawal state. The emergency department interventions included: chemical sedation for severe agitation, Ketamine 100 mg IV for rapid control of combative behavior, Lorazepam 2 mg IV, IV fluid resuscitation with normal saline (1 L bolus), empiric broad spectrum antibiotics, Cefepime 2 g IV for suspected UTI with systemic response, The independent interpretation and clinical analysis revealed the resident presented with acute agitation in the hospice care requiring rapid stabilization while evaluating for reversible causes. The laboratory findings support an infectious etiology contributing to acute delirium. The hospital record's progress note dated 8/3/26 indicated the resident was admitted with sepsis of unknown source, a life threatening medical emergency when the body has an extreme response to an infection. The document revealed the resident showed a positive response to the antibiotic in the emergency department. The progress note disclosed the resident was alert, cooperative, eating/drinking and asking for assistance with repositioning. The resident denied shortness of breath, chest pain, abdominal pain or nausea. The hospital's Psychiatry Consult dated 8/4/26 revealed the resident was admitted with concerns with medication refusals, combativeness and agitation. The document indicated the resident's WBC was significantly elevated, meeting sepsis criteria with the count trending to appropriate levels with antibiotics. The document disclosed the resident had not received any psychiatric medications since 1:00 PM on 8/3/26 and stated it seemed reasonable to think the agitation and aggression were driven by delirium from some unclear infectious process rather than primary psychiatric illness not unlike our last last visit 2 months ago. Recommendations included: continue Aripiprazole [NAME] 500 mg monthly with next dosage due 8/13/26, not reinitiating Asenapine patch - unclear justification of need for 2 scheduled antipsychotics, as needed Haloperidol 2 mg every 6 hours as needed for oral and IV options titrate to efficacy. The resident did not require a sitter or inpatient psychiatric care. On 8/4/26 at 11:20 AM Staff P, Registered Nurse (RN), stated the resident would refuse medications, care and display behaviors.On 8/4/26 at 12:32 PM Staff Q, hospice RN/Case Manager, stated the resident refusing medications could lead to care refusals, and increased behaviors. Staff Q stated when psychiatric needs were not met, the resident had larger behaviors and cares could not be completed. The staff stated the hospitalization could have been avoided if the medications had been provided. The facility failed to provide medications as ordered and complete assessments preventing a hospital admission.On 8/5/26 at 1:37 PM the DON stated the resident had been admitted to the hospital with a diagnosis of sepsis on 8/2/26. The DON stated it was unclear for the diagnosis of sepsis as the previous hospital document dated 7/31/26 indicated possible pneumonia and the hospital report on 8/2/26 indicated UTI. The DON acknowledged the facility should have been doing assessments to ensure there were not other causes for the resident's increased behaviors and if the resident would not allow assessments notifications and documentation should have been completed. The facility's Medication and Treatment Orders Policy dated July 2016 revealed physician orders shall be followed and if unable to follow the orders the DON/designee and physician will be notified. The facility's Change in a Resident's Condition or Status Policy dated February 2021 disclosed the facility will notify the resident, attending physician, and resident representative of the resident's change in medical/mental condition and/or status.

Based on observation, document review, interviews, and policy review the facility failed to provide a well balanced diet that meets nutritional and special dietary needs of residents by not following the approved menu for a meal. The facility reported a census of 82 residents.Findings include:Observed on 7/29/26 at 10:00 AM Staff S, Cook, prepare 2 servings of dessert. The staff obtained 2 pre-portioned servings of dessert, placed them in a blender, added apple juice and proceeded to puree the dessert. When the staff obtained the desired consistency, the staff divided the servings back between the 2 dessert cups with one dessert cup having more than the other.Staff S failed to measure and divide the portions according to the menu. During continuous observation on 7/29/26 beginning at 12:55 PM Staff T, Cook, served the main dining room. Staff T dropped the 6 ounce (oz.) scoop into the spaghetti with a meat sauce pan. The staff removed the scoop and obtained a 4 oz. scoop. Staff T stated they did not have another 6 oz. scoop, and would use 4 oz. scoop and then half of the 4 oz. scoop to make 6 oz. Staff completed this process for 25 portions. The Dining Manager Diet Spreadsheet for Day 18 revealed the following: Regular portion size for spaghetti with meat sauce - 6 oz. Puree portion size for pureed fruit crisp - puree #8. On 7/29/26 at 2;35 PM Staff T stated he did the best he could do without an additional 6 oz. scoop when the scoop was dropped. The staff concurred the servings were likely not the same size.On 7/30/26 at 7:30 AM the Dietary Manager stated Staff S should have measured the pureed dessert to ensure the residents received the appropriate serving size. The Dietary Manager stated the facility did not have an additional 6 oz. scoop so the staff improvised to keep the meal service moving. The staff acknowledged the servings may not have been consistent without the use of the 6 oz. scoop.On 7/30/26 at 9:15 AM the Administrator expected staff to provide portions according to the menus. The Administrator stated the facility will be ordering additional utensils. The facility's Kitchen Weights and Measures Policy dated April 2007 revealed staff would be trained in proper use of cooking and serving measurements to maintain portion control. The policy included will be trained in the appropriate measurement and type of serving utensil to use for each food.

Based on observation, interviews, and policy review the facility failed to prepare, serve and distribute food in accordance with professional standards. The facility failed to provide food at a palatable, attractive, and a safe and appetizing temperature to 3 of 20 residents (Residents #10, #54, #66) reviewed. The facility reported a census of 82 residents. Findings Include: 1. Resident #10's Minimum Data Set (MDS) dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 15/15 indicating normal cognition. On 7/27/26 at 11:38 AM Resident #10 revealed the food did not taste good at the facility and it is often cold when it is served.2. Resident #54's MDS dated [DATE] identified a BIMS score of 15/15 indicating normal cognition.On 7/27/26 at 1:30 PM Resident #54 reported she consumed her meals in her room and the meals were not always hot.3. Resident #66's MDS dated [DATE] identified a BIMS score of 15/15 indicating normal cognition.On 7/27/26 at 1:54 PM Resident #66 stated she ate in her room and the room trays were often not warm or hot. Observed on 7/29/26 at 12:30 PM of Staff T, Dietary Aide, and Staff S, Dietary Aide, prepare room trays. Staff T obtained an insulated base, placed a plate on the base, added the menu items, and Staff S placed a domed cover over the plate and placed it in the covered cart for delivery. Observed on 7/29/26 at 12:42 PM the covered cart with the room trays leave the kitchen area for delivery.Observed on 7/29/26 at 12:43 PM a single staff began passing 19 room trays. Staff passed the last room tray at 1:02 PM. Test tray temperatures revealed spaghetti with meat sauce 114 degrees and vegetables 110 degrees. Observed 2 additional staff seated at the nurses station and other staff seated in offices during the passing of room trays. On 7/29/26 at 1:10 PM the Dietary Manager stated the kitchen did not have enough hot plates for all of the room trays. The staff stated that depending on the residents and census sometimes there were more room trays than can fit in the cart, so they have to put them on top of the cart with only a dome cover. On 07/29/26 at 2:35 PM Staff T stated he had been trained to use the heated metal bases for plates delivered to other parts of the building to ensure their food stayed hotter as the residents may not all come out at the same time when delivered to that area or residents preferred their food hotter. On 07/30/26 at 7:30 AM the Dietary Manager stated the drop in temperatures for tray delivery was a concern. The staff stated the kitchen had changed the serving process over the past few years by not serving in multiple areas and preparing food for multiple areas; the change had been to a central serving area, kitchen, with tray delivery to the other areas. The staff stated, however, with the change to more tray deliveries there were challenges that needed to be addressed including not having enough heated metal bases for all areas of the building. On 7/30/26 at 9:15 AM the Administrator acknowledged there had been concerns regarding food temperatures and the facility was working on a plan to correct that problem. The facility's Food Preparation and Service Policy dated April 2019 revealed the danger zone for food temperatures was between 41 degrees Fahrenheit (F) and 135 degrees F. The document stated this temperature range promotes rapid growth of pathogenic microorganisms that cause foodborne illness. The document included foods must be maintained below 41 degrees F or above 135 degrees F.

Based on observations, staff interviews, and policy review the facility failed to prepare, serve and distribute food in accordance with food service safety for general practices of mealtime service. The facility reported a census of 82 residents.Findings include: Observed on 7/29/26 at 11:00 AM Staff T, Cook, pierce the aluminum foil covering 5 pans of food with the food thermometer to obtain temperatures. Continuous observation on 7/29/26 beginning at 11:30 AM in the kitchen revealed the following: Staff U, Cook, presented with facial hair and without a beard net.Staff V, Cook, wore a single pair of gloves and touched cardboard boxes, plastic bags within the boxes, the preparation counter, removed frozen riblets from packaging and placed them on the holding trays, moved the holding trays of frozen riblets, obtained new trays, closed the kitchen door, and returned to unpackaging of the riblets. The staff did not change gloves or complete hand hygiene.Staff U applied gloves without hand hygiene and touched multiple surfaces including food items.Observed on 7/29/26 at 2:35 PM Staff T with facial hair wore a beard net pulled down below his chin exposing the facial hair. On 7/30/26 at 7:30 AM the Dietary Manager stated he had provided education to the men in the kitchen regarding shaving or needing to wear beard nets. The Dietary Manager expected the staff to complete this task. The staff stated he had also provided education to all of the staff on the need for hand hygiene in the kitchen with washing hands after removing gloves, and not to wear gloves and touch multiple surfaces and food. On 7/30/26 at 9:15 AM the Administrator stated some members of management had observed kitchen staff working without beard nets. The Administrator expected hand hygiene tasks and gloves to be used appropriately in the kitchen. The facility's Food Preparation and Service Policy disclosed the expectation for staff to adhere to proper hygiene and sanitary practices to prevent the spread of foodborne illness. The document revealed gloves were to be worn when handling food directly, changed between tasks, were single-use items, and discarded after each use. The document included that kitchen staff must wear beard restraints to prevent hair from contacting food.

Based on facility record review, staff interview, and policy review the facility failed to have an effective Quality Assurance and Performance Improvement (QAPI) program in place to provide quality care for residents. The facility failed to make good faith attempts to correct quality deficiencies, and maintain and implement a comprehensive QAPI program and plan. The facility identified a census of 82 residents.Findings include:The Department of Health and Human Services/Centers for Medicare and Medicaid Services Provider History Report revealed the facility had repeated deficient practices during standard annual health surveys with current identified deficient practices as exhibited by the following:F550 Resident Rights/Exercise of Rights - 2/4 past surveysF580 Notification of Changes - 1/4 past surveysF656 Develop/Implement Comprehensive Care Plan - 1/4 past surveysF658 Services Provided Meet Professional Standards- 1/4 past surveysF684 Quality of Care - 2/4 past surveysF690 Bowel/Bladder Incontinence, Catheter Urinary Tract Infection - 2/2 past surveysF803 Menus Meet Resident Needs/Preparation in Advance/Followed - 1/4 past surveysF804 Nutritive Value/Appearance, Palatable/Preferred Temperature - 1/4 past surveysF812 Food Procurement, Store/Prepare/Serve-Sanitary - 2/4 past surveysF865 QAPI Program/Plan, Disclosure/Good Faith Attempt - 1/4 past surveysF880 Infection Prevention and Control - 4/4 past surveysReview of the Department of Health and Human Services/Centers for Medicare and Medicaid Services Statement of Deficiencies Form 2567 documents from 6/12/25 - 7/27/26 revealed the facility had repeated deficient practices with current identified deficient practices as exhibited by the following:F804 Nutritive Value/Appearance, Palatable/Preferred Temperature (6/11/26)F812 Food Procurement, Store/Prepare/Serve-Sanitary (6/11/26)F865 QAPI Program/Plan, Disclosure/Good Faith Attempt (11/25/25)On 8/5/26 at 1:58 PM the Administrator stated the QAPI Committee utilized reports generated from the electronic medical record and Plans of Correction to develop Performance Improvement Plans (PIPs). The staff stated the PIPs are interdisciplinary, data driven, and tracked to ensure progress towards the established goals.Review of the facility's Facility Assessment revealed the facility must conduct a facility based and community based risk assessment. The document included gaps and issues should be identified and adapted to QAPI programs. The facility's Quality Assurance and Performance Improvement (QAPI) Program/Policy dated February 2020 revealed the program provided a means to establish and implement PIPs to correct identified negative or problematic indicators. The document identified the program established systems through which to monitor and evaluate corrective actions.

Based on observations, staff interviews, resident interviews, clinical record review and policy review the facility failed to perform proper hand hygiene during intravenous (IV) medication administration for 1 of 1 resident (Resident #91), apply Personal Protective Equipment (PPE) (gown and gloves) during personal hygiene for a resident with a tracheostomy for 1 of 1 residents (Resident #4), and dispose of a medication syringe used for oral liquid medication administration after being dropped on the floor for 1 of 1 residents (Resident #18). The facility failed to provide infection control practices by storing residents' urinals in common areas where hand and oral hygiene tasks were completed for 4/4 residents (Resident #12, #7, #6, #14) reviewed. The facility failed to provide documentation of the Medical Director's annual review and approval of the facility's Infection Control Policy. The facility reported a census of 82 residents.Findings Include: 1. The Minimum Data Set (MDS) dated [DATE] for Resident #91 documented a Brief Interview for Mental Status (BIMS) of 15 indicating no cognitive impairment. The MDS further documented Intravenous (IV) medications through IV access. Observation on 7/29/26 at 11:03 AM revealed Staff I, Assistant Director of Nursing (ADON) entered Resident #91's room, did not perform hand hygiene, identified self, grabbed onto the IV pump and IV medication bag to inspect if the IV medication was completed, applied gown and applied gloves. Staff I unhooked the IV tubing from the lumen, removed a normal saline flush from its packaging, cleansed the lumen with an alcohol swab, flushed the lumen with 5 milliliters of normal saline and applied a green cap to the end of the lumen. Staff I removed the IV tubing and medication bag from the IV pole and threw the contents in the trash. Staff I removed the gown, removed gloves and performed hand hygiene before exiting the room. On 7/30/26 at 1:53 PM the Director Of Nursing (DON) acknowledged concerns with improper hand hygiene before disconnecting the IV line and flushing with NS. 2. A MDS assessment dated [DATE] for Resident #4, included diagnoses of Multidrug-Resistant Organism (microorganisms that are resistant to one or more classes of antibiotics or antifungals), tracheostomy (surgical opening into the neck leading directly into the windpipe), and cancer. The MDS identified the resident had a BIMS score of 8, indicating moderate cognitive impairment for decision-making. Observation and interview on 7/27/26 at 11:24 AM, Resident #4's room door with sign posted for Enhanced Barrier Precautions (EBP). Resident #4 in bathroom in front of sink washing his face and neck with Staff J, Certified Nursing Assistant, wearing gloves only, assisting the resident. Staff J stated the resident had coughed up stuff on himself and she was assisting him to get cleaned up. Resident #4's Care Plan, revised date 1/21/26, revealed a focus of EBP: precautions related to indwelling medical device trach, Methicillin-resistant Staphylococcus aureus positive (a type of staph bacteria resistant to many common antibiotics) on 1/19/26 in skin wound of left neck/clavicle area with interventions to maintain EBP with proper personal protective equipment (PPE) due to wounds, tracheostomy, organism and to use appropriate PPE. Interview on 7/29/26 at 8:30 AM, Staff K, Licensed Practical Nurse (LPN) stated staff should wear PPE with any cares with Resident #4 due to the resident having a tracheostomy. Interview on 7/30/26 at 1 PM, the Director of Nursing (DON) stated her expectation for staff to wear PPE for residents on EBP during any hands-on care with the resident. 3. Observation on 7/30/26 at 9:15 AM, Staff L, LPN standing in front of the medication cart on East Court Hall and dropped a syringe on the floor. Staff L proceeded to cleanse the syringe with an alcohol swab, used the same syringe to draw liquid medication from a bottle and administered the liquid medication orally to Resident #18. Interview on 7/30/26 at 1 PM, the DON stated her expectation for staff to dispose of the dropped syringe and use a new syringe to administer the medication. 4. Observed on 7/30/26 at 1:01 PM Resident #12 and Resident #7's shared room with a urinal in a trash bag hanging from a towel rack just above a toothbrush/toothpaste on the sink counter. Observed on 7/30/26 at 1:02 PM Resident #6 and Resident #14's shared room with a urinal in a trash bag hanging from a towel rack at the shared sink just below and to the right of the soap dispenser. Observe on 7/30/26 at 3:00 PM Resident #12 and Resident #7's shared room with a urinal in a trash bag hanging from the towel rack next to the sink counter with a toothbrush/toothpaste on the counter. Observed on 7/30/26 at 3:02 PM Resident #6 and Resident #14's shared room with a urinal in a trash bag hanging from the sink towel rack next to the soap dispenser. Observed on 8/3/26 at 8:15 AM Resident #12 and Resident #7's shared room with a trash bag containing a urinal hanging from the towel rack next to the sink with toothpaste/toothbrush on the counter just under the bag. Observed on 8/3/26 at 8:17 AM Resident #6 and Resident #14's shared room with a urinal in a trash bag hanging from the towel rack hanging just to the side of the soap dispenser at the sink. On 7/30/26 at 1:24 PM Staff R, Licensed Practical Nurse (LPN)/Infection Preventionist (IP) stated she was unaware if there was a policy/procedure for storage of residents' urinals, but stated they should be kept in a holder or a bag. The staff stated the urinals should not be kept near toothpaste/toothbrush, sink, towel holder or soap dispenser. On 8/3/26 at 4:15 PM Director of Nursing (DON)/Infection Preventionist (IP) stated the urinals should be stored in trash bags or in urinal covers in the bathroom. The staff stated if the residents do not have a bathroom they should be placed somewhere else, but could not provide details. Staff F stated urinals should not be hung from trash cans, towel racks that are near a toothbrush/toothpaste, soap dispenser or towels for drying hands following hand hygiene. 5. During an interview on 7/30/26 at 1:24 PM requested Staff R provide a copy of the facility's Infection Control Policy with the signature of the Medical Director indicating annual review and approval. The staff stated she did not have a copy of the physician's signature on the policy. During an interview on 8/3/26 at 4:15 PM requested the DON/IP provide a copy of the facility's Infection Control Policy with the Medical Director's signature indicating annual review and approval. Staff F stated she would have to locate the policy and signature page. At the time of exit on 8/5/26 at 2:40 PM the facility had not provided a signed copy of the Infection Control Policy indicating the Medical Director's review and approval. The facility's Perineal Care Policy dated February 2018 included basins and reusable supplies should be kept in designated supplies. The facility did not have a specific policy or procedure related to urinal storage.

Based on electronic health record review, resident and staff interviews, and policy review the facility failed to provide care for the resident in a manner that maintained or enhanced dignity by not providing an incontinence system per physician's order or providing timely care to allow the resident to attend activities/functions outside his room without urinating through his clothing for 1 of 3 residents reviewed (Resident #52). The facility reported a census of 82 residents. Findings include:A Minimum Data Set (MDS) assessment dated [DATE] for Resident #52, included diagnoses of End Stage Kidney Disease and heart failure. The MDS identified the resident required supervision or touching assistance with toileting and transfers, was occasionally incontinent of urine and bowel, and was not on a toileting program. The MDS identified the resident had a Brief Interview for Mental Status score of 15, indicating no cognitive impairment.Interview on 7/27/26 at 3:55 PM, Resident #52 stated he leaks urine frequently, that he has no control with his bladder as the urine just comes out, and he frequently soaks through his pull-up to his clothing and bed. The resident stated he is embarrassed when this happens. The resident further stated the physician gave an order for the resident to have a purewick system (system used for urinary incontinence to wick away voided urine from the skin to keep the person dry) and he had not received it as the facility does not use the system.Interview on 7/29/26 at 11:00 AM Resident #52 stated the facility talked to him about the purewick system and felt they were trying to sway him to refuse it. The resident stated he would like to have the system as he used it in the hospital and he felt would save him a lot of embarrassment from wetting through his clothes and his bedding. The resident stated he used pull-ups but soaked through them, as he urinates so much. The resident stated he takes himself to the bathroom sometimes, sometimes staff assist him, and other times staff come in his room when he's on the toilet and they don't stop and help him. The resident further stated he has soaked through his clothing at activities, which is embarrassing and he doesn't always attend activities due to the embarrassment of wetting himself. Interview on 7/29/26 at 12:33 PM, Staff B, Certified Nursing Assistant stated Resident #52 needs assist of 1 staff for cares and transfers, is frequently incontinent of urine, and is a big soaker, frequently wets through his pull up and pants. Staff B stated the resident is usually wet before he is able to call for assistance and the resident expresses his embarrassment and she just tells the resident it is ok, that is what staff are here for. Staff B stated she tries to check on Resident #52 about every 2 hours but he is usually wet before staff get to him so staff just change his pull-up. Resident #52's facility Consultation/Office Visit Form for a primary physician appointment dated 6/24/26, listed new orders for a male purewick #1 with associated materials to use and an appointment with urology for urinary incontinence.Resident #52's facility Consultation/Office Visit Form for a urology appointment dated 7/22/26, listed a new order to start portable purewick.Interview on 7/30/26 at 9AM, Staff I, Assistant Director of Nursing (ADON) stated Resident #52 returned from a physician's appointment with an order for a pure wick system. Staff I stated he spoke with the resident's daughters a few days later and informed the daughters of the corporate policy that the facility does not use the purewick system. Staff I stated a few days later the physician's nurse notified him and inquired why the facility had not started the purewick system for the resident and did not notify the physician that the facility was unable to follow the order.Resident #52's Progress Note, dated 7/2/26 at 10:12 AM, documented by Staff I, revealed: Resident's daughters stopped by my office on the way to see their dad. They inquired about the male purewick system that the doctor had written down for him to get. I explained to them that the system is not something that is usually used in long term care facilities, and in our facility, we do not use them. I let them know we would start a toileting program. This would have the aides taking him to the bathroom every 2 hours. He would be 1 assist for transfers out of bed and to the toilet.Resident #52's Care Plan initiated 6/24/26, lacked documentation of toileting program or toileting care for the resident.Facility's Resident Rights Policy revised February 2021, revealed federal and state laws guarantee certain basic rights to all the residents of this facility including a dignified existence and be treated with respect, kindness, and dignity.Interview on 7/30/26 at 1 PM, the Director of Nursing stated her expectation for a resident to be able to attend activities, go out and about the facility without embarrassment of wetting clothes due to incontinence and for dignity to be maintained for residents.

Based on observation, clinical health record review, resident and staff interviews, and policy review the facility failed to assess a resident for self-administration of medications for 1 (Resident #4) of 1 resident reviewed. The facility reported a census of 82 residents.Findings include:A Minimum Data Set (MDS) assessment dated [DATE] for Resident #4, included diagnoses of Multidrug-Resistant Organism (microorganisms that are resistant to one or more classes of antibiotics or antifungals), tracheostomy (surgical opening into the neck leading directly into the windpipe), and cancer. The MDS identified the resident had a Brief Interview for Mental Status score of 8, indicating moderate cognitive impairment for decision-making.Observation on 7/27/26 at 3:20 PM, with no staff present in the room, Resident #4 got a vial of breathing treatment solution from the end stand, placed the solution in the nebulizer (machine to provide aerosol breathing treatment) mask cup, placed the mask over his nose and mouth, and turned the nebulizer on.The Medication Administration Record dated 7/1/26 - 7/31/26, revealed a physician's order for Ipratroplum-Albuterol Solution (medication to open up the airway) inhale orally 4 times a day and the dose for 7/27/26 for 4 PM - 6PM was signed as completed by Staff O, Licensed Practical Nurse (LPN).Interview on 7/28/26 at 2:00 PM, Resident #4 stated sometimes he administers his breathing treatment and sometimes the staff administer.On 7/28/26 at 2:05 PM, review of Resident #4's electronic health record lacked a self-administration of medications assessment and lacked a physician's order for self-administration of medications.On 7/28/26 at 2:15 PM, review of Resident #4's Care Plan lacked documentation of resident able to self-administer medications.Interview on 7/29/26 at 8:30 AM, Staff K, LPN stated Resident #4's breathing treatments are to be administered by nurses only, the resident is not able to store the medication in his room or administer to himself.Resident #4's Progress Note dated 7/29/26 at 9:04 AM and documented by the Director of Nursing revealed: Self Administration of Medication: assistance required for storing medications in a secure location, assistance required with opening/closing medication containers, resident cannot accurately tell time to know when medications need to be taken, and resident does not understand that skipping/choosing not to take a medication dose is refusal of medication and he/she must notify staff when refusal has occurred.Interview on 7/30/26 at 10:05 AM, the Director of Nursing (DON) stated she completed a Self-Administration of Medication Assessment on 7/29/26 and the resident had no prior self-administration of medication assessments completed. The DON stated after the nurse puts the medication in the nebulizer cup, the resident can be allowed to place the mask on his face and turn off the nebulizer machine when the treatment is completed. The DON further stated the medication for the resident's breathing treatment cannot be stored in the resident's room, the medication needs to be locked up in the medication cart. The DON stated her expectation for a nurse to prepare the nebulizer treatment and then the resident can place the mask on his face, turn off the machine when the treatment is done, and medications are to be stored in a secure location. The DON further stated her expectation for a Self-Administration of Medications assessment to be completed and approved prior to allowing a resident self-administer medications.Facility Self-Administration of Medications Policy revised February 2021, revealed: As part of the evaluation comprehensive assessment the interdisciplinary team (IDT) assesses each resident's cognitive and physical abilities to determine whether self-administering medications is safe and clinically appropriate for the resident. The IDT considers the following factors when determining whether self-administration of medications is safe and appropriate for the resident: the medication is appropriate for self-administration, the resident is able to read and understand medication labels, the resident can follow directions and tell time to know when to take the medication, the resident comprehends the medication's purpose, proper dosage, timing, signs of side effects and when to report these to the staff, the resident has the physical capacity to open medication bottles, and the resident is able to safely and securely store the medication

Based on clinical record reviews, interviews, and policy review the facility failed to notify the physician and resident representative when a change in medical condition and/or treatment occurred for 2 of 20 residents (Residents #48, #52). The facility failed to notify the primary care provider of a resident's refusal of medications, and notification to the provider of the facility's inability to follow an order for a specific treatment. The facility had a census of 82.Findings include: 1. The Significant Change Minimum Data Set (MDS) for Resident #48 dated 6/12/26 provided the Brief Interview for Mental Status (BIMS) was not able to be administered to the resident. The Staff Assessment for Mental Status revealed the resident was normally able to recall the current season, staff, location of room, they were in a facility and were modified independent with daily decision making. The MDS coded the resident required total assistance from staff with toilet hygiene and total assistance for all mobility (bed, transfers, moving to/from lying and sitting). The document disclosed the resident was always incontinent of bowel and bladder. The document revealed the resident had diagnoses of renal insufficiency/failure, urinary tract infection in past 30 days, diabetes mellitus, anxiety disorder, bipolar disorder, and schizophrenia, The MDS documented the resident received antianxiety, antidepressant, opioid, hypoglycemic and anticonvulsant medications during the last 7 days of the assessment reference period. Resident #48's Care Plan revised 7/22/26 revealed a focus area of terminal prognosis and received hospice services (revised 6/16/26) with interventions of observing the resident closely for signs of pain, administration of medications as ordered and notify the physician immediately of breakthrough pain. A focus area for bowel and bladder incontinence, revised 1/14/26, provided staff interventions of monitor/document/report signs/symptoms of urinary tract infection including foul smelling urine, altered mental status, and change in behavior. Resident #48's Hospice Certificate of Terminal Illness dated 6/5/26 documented the primary care physician agrees the resident would benefit from hospice services to control pain and behaviors. The nursing assessment indicated hospice care can help manage the resident's escalating psychiatric symptoms, agitation and combativeness in the context of her physical decline, focusing on comfort and quality of life. Resident #48's Hospice Care Plan dated 6/5/26 revealed a problem area for pain with interventions of collaboration with primary care physician, titrate medication to control pain, and monitor pain medication for effectiveness; a problem area of psychological/mental/emotional needs with interventions of assessment of agitation, explain to patient all care being given; a problem area related to respiratory with assessment of lung sounds and respiratory status; a problem area for urinary elimination with interventions of incontinence of urine, assessment of patient's bladder pattern and urinary function. Review of Resident #48's 7/26 MAR revealed the following opportunities of medications not administered due to the resident sleeping or resident refusals: Diflucan 100 milligram (mg) 1 tablet by mouth one time a day for yeast infection for 7 days, date ordered 6/27/26 - the resident refused 1/4 opportunities. Duloxetine HCI 60 mg, 1 capsule by mouth daily for bipolar disorder; date ordered 12/9/25 and discontinue (D/C) 7/13/26 - the resident refused 5/13 opportunities. Jariance 10 mg 1 tablet by mouth daily for diabetes; date ordered 1/20/26 and D/C 7/10/26 - the resident refused 2/10 opportunities. Senna 8.6 mg, 2 tablets by mouth daily for constipation; date ordered 6/18/26 and D/C 7/13/26 - the resident refused 5/13 opportunities. Buspirone HCI 10 mg, 1 tablet by mouth twice daily (BID) for anxiety; date ordered 12/9/25 and D/C 7/13/26 - the resident refused 12/25 opportunities. Gabapentin 300 mg, 1 tablet by mouth BID for other chronic pain; date ordered 12/9/25 and D/C 7/13/26 - the resident refused 11/25 opportunities. Lamotrigine100 mg, 1 tablet by mouth BID for schizoaffective disorder; dated ordered 6/26/26 and D/C 7/10/26 - the resident refused 12/ 25 opportunities. Miconazole External Powder 2%, BID for antifungal treatment; date ordered 6/26/26 and D/C 7/10/26 - the resident refused 8/19 opportunities. Propranolol HCI 10 mg, 1.5 tablets BID for high blood pressure; ordered 1/13/26 and D/C 7/10/26 - the resident refused 6/19 opportunities. Lorazepam 2 mg/(milliliter (ml), .25 ml by mouth three times a day (TID) for bipolar disorder, generalized anxiety disorder and schizoaffective disorder; date ordered 6/26/26 and D/C 7/10/26 - the resident refused 7/29 opportunities. Sucralfate 1 gm, 1 tablet TID for gastric protection; date ordered 3/25/26 and D/C 7/10/26 - the resident refused 7/29 opportunities. Haloperidol Lactate 5 mg/ml, inject 5 mg every 6 hours for refusing medications, give injection until resident takes medications by mouth; date ordered 7/11/26 and D/C 7/13/26 - the resident refused 2/7 opportunities. Haloperidol Lactate 5 mg/ml, inject 10 mg every 6 hours for refusing medications, give injection until resident takes medications by mouth; dated ordered 7/13/26 and D/C 7/15/26 - the resident refused 1/8 opportunities. Haloperidol Lactate 2 mg/ml, give .25 ml by mouth every 6 hours for agitation/anxiety; dated ordered 6/29/26 and D/C 7/9/26 - the resident refused 6/35 opportunities. Haloperidol Lactate 2 mg/ml, give .5 ml by mouth every 5 hours for agitation/anxiety; dated ordered 7/9/26 and D/C 7/30/26 - the resident refused 33/84 opportunities. Haloperidol Lactate 2 mg/ml, give .5 ml by mouth every 5 hours for agitation/anxiety; dated ordered 7/9/26 and D/C 7/30/26 - the resident was not provided 3/84 opportunities due to sleeping. Lorazepam 2 mg/ml, give .25 ml by mouth before meals and at bedtime for bipolar, generalized anxiety and schizoaffective disorder; date ordered 7/10/26 and D/C 7/13/26 - the resident refused 9/12 opportunities. Lorazepam 2 mg/ml, give .5 ml by mouth before meals and at bedtime for bipolar, generalized anxiety and schizoaffective disorder; date ordered 7/13/26 and D/C 7/15/26 - the resident refused 6/8 opportunities. Lorazepam 2 mg/ml, give .5 ml by mouth every 5 hours for anxiety; date ordered 7/15/26 and D/C 7/30/26 - the resident refused 20/60 opportunities. Lorazepam 2 mg/ml, give .5 ml by mouth every 5 hours for anxiety; date ordered 7/15/26 and D/C 7/30/26 - the resident was not provided 3/60 opportunities due to sleeping. Morphine Sulfate 20 mg/5 ml, give .5 ml by mouth every 4 hours for pain/shortness of breath; date ordered 6/13/26 and D/C 7/30/26 - the resident refused 67/120 opportunities. Morphine Sulfate 20 mg/5 ml, give .5 ml by mouth every 4 hours for pain/shortness of breath; date ordered 6/13/26 and D/C 7/30/26 - the resident was not provided with 4/120 opportunities due to sleeping. The document lacked documentation for 1/120 opportunities. Review of Resident #48's 8/26 MAR revealed the following opportunities of medications not administered due to the resident refusing: Haloperidol Lactate Concentrate 2 mg/ml, 1 mg by mouth every 4 hours for anxiety/agitation; date ordered 8/1/26, hold from 8/2 - 8/3/26 and D/C 8/3/26 - the resident refused 2/9 opportunities. Review of the Resident #48's Progress Notes in electronic medical record from 7/1 - 8/2/26 revealed 19 entries indicating the resident refused medications or medications not provided due to the resident sleeping. The Progress Notes disclosed of those entries only included documentation of the provider being notified. On 8/4/26 at 11:20 AM Staff P, Registered Nurse (RN), stated the resident would refuse medications. When asked about the process for medication refusal, the staff responded she would use multiple attempts or use another nurse or Certified Medication Aide (CMA) prior to accepting the refusal. The staff failed to indicate primary care provider notification. On 8/4/26 at 12:32 PM Staff Q, RN/Case Manager for hospice, stated hospice had not been made aware of all of the resident's medication refusals. The staff stated when made aware of the increased behaviors with medication refusals, changes were made to the medications with the inclusion of change of routes, dosages and types of medications. On 8/5/26 at 1:37 PM the Director of Nursing (DON) when asked the process for resident refusal of medications responded the nurse/CMA needed to try again, the CMA would notify the charge nurse, the charge nurse should attempt medication dispensing, and if continued refusal the family and doctor should be notified. When asked about residents with hospice services, the DON stated notification should be made to hospice and sometimes the primary and family. The DON stated it should be documented who was notified of the refusals. The DON stated she was under the understanding that hospice was being made aware of the resident's refusals. The DON concurred if notifications were not documented then they didn't occur. The facility's Medication and Treatment Orders Policy revealed physician orders should be followed and if unable to follow the orders notification should be made to the DON/designee and physician. 2. A Minimum Data Set (MDS) assessment dated [DATE] for Resident #52, included diagnoses of End Stage Kidney Disease and heart failure. The MDS identified the resident required supervision or touching assistance with toileting and transfers, was occasionally incontinent of urine and bowel, and was not on a toileting program. The MDS identified the resident had a BIMS score of 15, indicating no cognitive impairment. Interview on 7/27/26 at 3:55 PM, Resident #52 stated he leaks urine frequently, that he has no control with his bladder as the urine just comes out, and he frequently soaks through his pull-up to his clothing and bed. The resident further stated the physician gave an order for the resident to have a purewick system (system used for urinary incontinence to wick away voided urine from the skin to keep the person dry) and he had not received it as the facility does not use the system. Resident #52's facility Consultation/Office Visit Form for a primary physician appointment dated 6/24/26, listed new orders for a male purewick #1 with associated materials to use and an appointment with urology for urinary incontinence. Resident #52's facility Consultation/Office Visit Form for a urology appointment dated 7/22/26, listed a new order to start portable purewick. Interview on 7/29/2026 at 12:33 PM, Staff B, Certified Nursing Assistant stated Resident #52 needed assistance of 1 staff for all cares and transfers. Staff B stated the resident is frequently incontinent of urine and is a big soaker, frequently wets through his pull-up and pants, and is usually wet before he is able to call for assistance. Staff B stated try to check on the resident about every 2 hours but he is usually wet before staff get to him, so the staff just change his pull-up. Interview on 7/30/26 at 9AM, Staff I, Assistant Director of Nursing (ADON) stated Resident #52 came back from a physician's appointment with an order for a pure wick system. Staff I stated he spoke with the resident's daughters a few days later as it is a corporate policy that the facility does not use the pure wick system. Staff I stated a few days later the physician's nurse called and asked why the facility had not started the pure wick system for the resident and not notified the physician that the facility was unable to provide the system and did not follow the order. Staff I stated he dropped the ball as he should have followed up and communicated back with the physician the facility was not able to follow the order. Staff I stated when residents return from appointments, the initial nurse notes the orders and then the new orders go to the ADON for a second check to ensure the orders are completed and correct. Facility Change in a Resident's Condition or Status Policy revised February 2021, revealed the nurse will notify the resident's attending physician or physician on call when there has been a need to alter the resident's medical treatment. Interview on 7/30/26 at 1:00 PM, the Director of Nursing stated her expectation for the physician to be notified if unable to follow a physician orders.

Based on observations, resident and staff interviews, and policy review the facility failed to provide a clean and homelike environment when the facility staff failed to cleanse a bedside commode (Resident #39), and maintain a clean room (Resident #48). The facility staff also failed to keep flying insects to a minimum throughout the hallways and in resident care areas for 6 of 20 residents reviewed (Residents #6, #48). The facility reported a census of 82 residents. Findings include: 1. The Minimum Data Set (MDS) dated [DATE] for Resident #39 documented a Brief Interview for Mental Status (BIMS) of 15 indicating no cognitive impairment. On 7/27/26 at 3:38 PM an observation revealed brown, smeared fecal matter on the side of the commode with brown, dried liquid on the floor in Resident #39's room. On 7/27/26 at 3:38 PM Resident #39 stated that he does not have a private bathroom so he utilizes a bedside commode in his room. Resident #39 further explained that the staff cleans the inside of the commode though does not clean the outside of it. On 7/28/26 at 9:37 AM an observation revealed smeared, brown fecal matter on the side of the commode and brown, dried liquid on the floor in Resident #39's room. On 7/29/26 at 1:33 PM an observation revealed smeared, brown fecal matter on the side of commode and brown, dried liquid on the floor in Resident #39's room. 2. The MDS dated [DATE] for Resident #6 documented a BIMS score of 5 indicating severe cognitive impairment. The MDS further documented Resident #6's functional abilities are dependent on toileting hygiene. On 7/27/26 at 3:00 PM an observation revealed several flying insects in the main hall. On 7/28/26 at 12:00 PM an observation revealed multiple flying insects present in Resident #6's room and landing on the resident during incontinence care. On 7/30/26 at 9:20 am Staff H, Housekeeping stated it was the Certified Nurse Assistant's (CNA) duty to clean the commodes located in the resident's room because housekeeping is not allowed to handle any bodily fluids. 3. The Significant Change MDS for Resident #48 dated 6/12/26 provided the BIMS was not able to be administered to the resident. The Staff Assessment for Mental Status revealed the resident was normally able to recall the current season, staff, location of room, they were in a facility and were modified independent with daily decision making. The MDS coded the resident required total assistance from staff with oral hygiene, toilet hygiene, dressing, personal hygiene, setup for eating, and total assistance for all mobility (bed, transfers, moving to/from lying and sitting). The document disclosed the resident was always incontinent of bowel and bladder. The clinical record's Clinical Census revealed the resident began unpaid hospital medical leave on 8/2/26. The clinical record's Progress Note dated 8/2/26 11:25 AM contained documentation that the resident left the facility by emergency medical services at approximately 11:18 AM. Continuous observation on 8/3/26 at 11:10 AM revealed the following of Resident #48's room: The door to the resident's room was closed. The room upon entry smelled of room deodorizer. Multiple flies were moving and landing throughout the room. A wadded tissue stuck to the heating/cooling unit on the constant fan control. An open bottle soda with less than 1/4 left sat on the bedside table. A wadded/used tissue on the electrical cord of the heating/cooling unit and a third wadded/used tissue near the wheelchair in the room. A red spilled substance on the floor near the used tissue. Trash and wrappers under the bed. On the floor between the bed and the wall was a yellow colored fibrous cotton object, a brown stain, a pillow, blanket, and crumbs/food particles. The resident's refrigerator contained a thermometer that read 80 degrees and bottles of water. The refrigerator was plugged in. No temperature log was on the refrigerator On 8/4/26 at 10:24 AM Resident #24's family stated multiple times when she visited the resident the room and the resident were dirty. The family member stated there would be food trays left from meals provided several hours earlier, food around the room, trash on the floors including soiled briefs. On 8/4/26 at 12:32 PM Staff Q, Registered Nurse (RN)/Case Manager, stated she had visited the resident and observed food and trash on the floor, room trays still in the room, liquids spilled on the floor. The staff stated food would also be in the resident's bed as well. Staff Q stated she usually visited the resident a couple of hours after the noon meal. On 8/5/26 12:33 PM the Housekeeping and Laundry Director stated the housekeeping department cleans residents' rooms once daily. The staff stated the resident would remove her brief (soiled or clean) and throw, along with food items. The staff stated the resident would rip briefs, remove stuffing and throw against the walls. The staff stated housekeeping tried to keep the resident's room cleaned but was difficult. The Housekeeping and Laundry Director stated the facility has once monthly treatment for pests, but will also come in if extra treatments are required. The staff acknowledged there was an increase in flies/gnats in the facility for an unknown reason. The staff stated the housekeeping department monitors the temperatures of the residents' refrigerators and Resident #48's had been thrown away due to the condition of the document. Review of the Resident Grievance/Complaint Log 1/26 - 7/26 revealed 3 grievances related to cleanliness of rooms and/or trash removal. The facility's Resident Rights revealed residents had the right to reasonable accommodation of individual needs and preferences. The facility's Homelike Environment Policy dated February 2021 disclosed residents were to be provided with clean, comfortable, and homelike environment. The document included the environment should be clean, sanitary, and orderly.

Based on Electronic Health Record (EHR) review, staff interview and policy review the facility failed to represent an accurate picture of the resident's status during the observation period of the Minimum Data Set (MDS) for 1 of 5 residents reviewed (Resident #39). The facility reported a census of 82 residents. Findings Include: The MDS dated [DATE] for Resident #39 documented Resident #39 utilized insulin medication during the look back period.Review of the EHR page titled, Physician's Orders documented no orders for insulin or antidiabetic medications.On 7/29/26 at 2:33 PM the Director of Nursing (DON) stated Resident #39 had a triggered insulin on the MDS because the resident was started on the medication Ozempic. The DON stated she was unaware of the drug classification of Ozempic and believed it was an antidiabetic medication. The DON further explained she would expect an MDS to be accurate with residents current medications. Review of a facility provided policy dated 3/22 titled, Azria Resident Assessments documented a comprehensive assessment of every resident's needs is made at intervals designated by the Omnibus Budget Reconciliation Act (OBRA) and Prospective Payment System (PPS) requirements. The policy documented OBRA required assessments are federally mandated and must be performed for all residents of Medicare and/or Medicaid certified nursing homes. The PPS assessment is provided information about the clinical condition of beneficiaries receiving Part A Skilled Nursing Facility (SNF) level of care in order to be reimbursed under the SNF PPS for both SNF's and swing bed providers. The policy documented the interdisciplinary team to use the MDS form mandated by federal and state regulations to conduct the residents assessment. The persons who have computed any portion of the MDS resident assessment form must sign the document attesting to the accuracy of such information.

Based on clinical record review, interviews, and policy review the facility failed to develop and implement a Baseline Care Plan for 1 of 7 residents (Resident #90) reviewed. The facility failed to update the Baseline Care Plan to reflect the resident's risk for elopement and use of a Wander Guard. The facility reported a census of 82 residents. Findings include: The Entry Minimum Data Set (MDS) dated [DATE] for Resident #90 revealed it was export ready. The document disclosed the resident was admitted from a short term general hospital on 7/23/26. The clinical record's Medical Diagnoses included unspecified dementia, syncope (fainting) and collapse, depression, and Alzheimer's Disease. The clinical record's Elopement Risk, completed on 7/23/26 revealed the resident completed mobility independently, exhibited goal directed wandering, cognitive impairment, history of elopement while at home, family concerns regarding elopement, resident expressing desire to go home and not accepting of current situation of facility, and admission within the past 30 days. The document identified a focus area for wandering and elopement with goals and interventions. The Baseline Care Plan dated 7/23/26 revealed the document was signed as completed by the Social Worker and the Director of Nursing (DON). The document did not contain a reference to the resident's risk for elopement.The clinical record's Physician Orders disclosed an order to check the placement and function of Wander Guard each shift and to monitor skin integrity with an order date of 7/26/26. The resident's Care Plan still under development reviewed on 8/3/26 at 12:25 PM revealed it had not been updated to reflect the risk for wandering and elopement with the use of the Wander Guard. On 8/3/26 at 4:26 PM the Director of Nursing (DON) stated she updated the Care Plans and completed the MDS assessments. The staff acknowledged if the resident had a risk for wandering and elopement that should be identified on the Care Plan. The DON further acknowledged if the resident had an update since the Baseline Care Plan was developed, including adding a Wander Guard, then the Baseline Care Plan should be updated to reflect the resident's current status. The staff agreed that at the time of the interview the Baseline Care Plan had not been revised. The facility's Baseline Care Plan Policy dated December 2016 disclosed the Baseline Care Plan will be updated and used until the interdisciplinary team can conduct the comprehensive assessment and develop a comprehensive interdisciplinary person-centered care plan.

Based on observation, electronic health record review, resident and staff interview, and policy review the facility failed to develop a comprehensive care plan that included a resident's indwelling urinary catheter and care for one (Resident #12) and a resident's toileting assistance/care for one (Resident #52) of 16 residents reviewed. The facility reported a census of 82 residents.Findings include:1. A Minimum Data Set (MDS) assessment dated [DATE] for Resident #12, included diagnoses of neurogenic bladder (loss of bladder control leading to urine leakage, frequent infections, or trouble emptying the bladder), urinary tract infection in the past 30 days, and dementia. The MDS identified the resident had an indwelling urinary catheter and a Brief Interview for Mental Status (BIMS) score of 6, indicating severe cognitive impairment.On 7/28/26 at 10:32 AM, observed Resident #12 sitting in a wheelchair in his room, with a catheter tube in a catheter dignity bag hanging from the resident's wheelchair.Review of Resident #12's comprehensive care plan, initiated date 6/18/26, revealed the care plan lacked documentation/interventions/monitoring for the resident's indwelling urinary catheter, history of urinary tract infections. and interventions.2. A MDS assessment dated [DATE] for Resident #52, included diagnoses of End Stage Kidney Disease and heart failure. The MDS identified the resident required supervision or touching assistance with toileting and transfers, was occasionally incontinent of urine and bowel, and was not on a toileting program. The MDS identified the resident had a BIMS score of 15, indicating no cognitive impairment.Interview on 7/27/26 at 3:55 PM, Resident #52 stated he leaks urine frequently, that he has no control with his bladder as the urine just comes out, and he frequently soaks through his pull-up to his clothing and bed.Interview on 7/29/26 at 12:33 PM, Staff B, Certified Nursing Assistant stated Resident #52 needed assist of 1 staff for all cares and transfers. Staff B stated the resident is frequently incontinent of urine and is a big soaker, frequently wets through his pull-up and pants, and is usually wet before he is able to call for assistance. Staff B stated try to check on the resident about every 2 hours but he is s usually wet before staff get to him, so the staff just change his pull-up.Review of Resident #52's comprehensive care plan, initiated 6/24/26, revealed the care plan lacked documentation/interventions/monitoring for the resident's toileting, assistance, and incontinent needs.Facility Comprehensive Person-Centered Care Plans Policy revised March 2022, revealed a comprehensive, person -centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial, and functional needs is developed and implemented for each resident.Interview on 7/30/26 at 1PM, the Director of Nursing stated her expectation for an indwelling urinary catheter and toileting/incontinence cares to be included in residents' care plans.

Based on observation, clinical record review, staff interviews, and policy review the facility failed to provide professional standards of care by not flushing a peripherally inserted central catheter (PICC) (tube into a vein in the upper arm and guided to a large vein near the heart to administer medication) for 1 of 1 resident reviewed. (Resident #91). The facility failed to provide professional standards of care by providing medication outside of recommended parameters for 1 of 10 residents (Resident #1). The facility also failed to discontinue a medication for one resident (Resident #24) per physician orders. The facility reported a census of 82 residents. Findings include: 1. The Minimum Data Set (MDS) for Resident #91, dated 7/19/26, revealed the resident was admitted with an intravenous line (IV) (tube inserted into vein to provide fluids/medication into the bloodstream) and received antibiotics. The MDS indicated the resident had a Brief Interview for Mental Status score of 15, indicating no cognitive impairment for decision-making. Resident #91's Medication Administration Record for 7/1-7/31/26, revealed a physician's order for Vancomycin (antibiotic) IV one time a day. Observation on 7/29/26 at 10 AM, Staff I, Assistant Director of Nursing (ADON) entered R#91's room, primed the bag of Vancomycin, cleansed the lumen (tip of the PICC line to attach the medication bag tubing to), attached the medication tubing to the lumen, and started the medication in an IV pump, failed to flush the PICC line prior to attaching the medication. Interview on 7/29/26 at 10:10 AM following the observation, the ADON confirmed he did not flush the IV line prior to administering the Vancomycin and stated he should have flushed the PICC line before administering the medication. Facility Peripheral and Midline IV Catheter Flushing and Locking Policy dated 2001, revealed the purposes of this procedure are to maintain catheter patency and function, prevent mixing of incompatible medications and solutions, and ensure the entire dose of solution or medication is administered into the venous system. The following steps for flushing before medication administration: disinfect needleless access device (end cap, access port) with disinfecting wipe, attach prefilled saline syringe to needleless access device, flush with the saline solution, and attach medication or infusion solution and infuse as prescribed. Interview on 7/30/26 at 1 PM, the Director of Nursing stated her expectation for an IV PICC line to be flushed prior to and after medication administration. 2. Resident #1's Significant Change MDS dated [DATE] revealed a BIMS score of 3/15 indicating severe impairment. The document included the resident had diagnoses of coronary artery disease, heart failure and high blood pressure. The resident's Care Plan revised 7/13/26 revealed the resident had high blood pressure and used medication (revised 3/11/26) with the intervention of not taking blood pressure reading after physical activity or emotional distress. Review of Resident #1's 6/26 Medication Administration Record (MAR) revealed an order for Metoprolol Succinate ER 50 milligram (mg), 1 tablet daily, hold if heart rate is <60 and /or SBP <90 with an order date of 6/10/26. The document disclosed the resident received the medication 2 times when the resident's heart rate was below 60. Review of Resident #1's 7/26 MAR revealed the order for Metoprolol Succinate ER was administered 4 times when the resident's heart rate was below 60. The Pharmacy Medication Regimen Review (MRR) dated 6/22/26 revealed the resident was taking Metoprol Succinate ER 50 mg with specific parameters to hold if the heart rate is below 60 and the medication was administered on 6/21/26. The document included recommendations to ensure parameters were still current, review documentation of medication administration with staff and notify prescriber of any medication administration errors. On 8/3/26 at 4:26 PM the Director of Nursing stated medication should only be provided within the parameters specified within the physician orders. The facility's Medication and Treatment Orders Policy dated July 2016 disclosed physician orders shall be followed as written. 3. The MDS for Resident #24 dated 6/29/26 provided the BIMS was not able to be administered to the resident. The Staff Assessment for Mental Status revealed short term and long term memory impairments, resident recognizes own room and staff names/faces, and severe impairment of daily decision making. The document revealed the resident had diagnoses of Alzheimer's Disease, Non-Alzheimer's Dementia, depression, and psychotic disorder. The MDS documented the resident received antipsychotic, antianxiety and antidepressant medications during the last 7 days of the assessment reference period. Resident #24's Care Plan, revised 7/29/26, revealed a focus area with the use of antidepressant medication revised 5/14/26 with interventions for attempted non drug approaches, and monitoring/reporting adverse reactions of the medication. The pharmacy Medication Regimen Review (MRR) dated 5/19/26 documented the resident taking Sertraline Tab 25 mg: take 1 tablet by mouth daily for depression. The document included a recommendation to the physician for discontinuation of Sertraline Tab 25 mg and an outcome of agreed 6/16/26. The pharmacy MRR dated 6/16/26 documented the resident had an order to discontinue Sertraline on 6/12/26, but during review on 6/16/26 the medication was still active in the electronic record. The document disclosed the Medication Administration Record (MAR) revealed the resident was provided Sertraline Tab 25 mg: take 1 tablet by mouth daily. The pharmacy MRR dated 7/14/26 documented the resident was no longer taking Sertraline but the MAR documented the resident was still being monitored for the medication. The Pharmacist's Recommendation to Provider dated 5/19/26 disclosed recommendation for discontinuation of Sertraline Tab 25 mg with agreement by physician on 6/12/26 at 11:30. The document included noted by nursing staff. The 6/26 MAR disclosed an order for Sertraline HCI Oral Tablet 25 mg, give 1 tablet daily for major depressive disorder, recurrent, severe with psychotic symptoms with an order date of 5/12/26 and discontinue date of 6/24/26. The document revealed the facility dispensed or attempted to dispense Sertraline to the resident for 12 days following an order for discontinuation. The facility failed to follow a physician order signed on 6/12/26 and noted by nursing staff for discontinuation of Sertraline 25 mg tab. On 8/4/26 at 8:45 AM the Director of Nursing (DON) stated if a medication was ordered to be discontinued, then it should be discontinued and not continue to be given.

Based on observation, electronic health record review, family and staff interview, and policy review the facility failed to provide appropriate catheter and incontinence care for one (Resident #6) of three residents reviewed. The facility reported a census of 82 residents. Findings include: The Minimum Data Set (MDS) assessment for Resident #6, dated 4/28/26, included diagnoses of End Stage Kidney Disease, obstructive uropathy (blockage in the urinary tract that stops urine from flowing normally), and stroke. The MDS identified the resident was dependent on staff for toilet hygiene, was frequently incontinent of bowel, and had an indwelling urinary catheter. incontinent of urine and bowel. The MDS indicated the resident had a Brief Interview for Mental Status score of 5, indicating severe review. Observation on 7/28/26 at 12:00 PM, Staff C, Certified Nursing Assistant (CNA) and Staff D, CNA applied gowns and gloves and transferred Resident #6 from the wheelchair to the bed with a full body mechanical lift. Staff D drained the catheter bag into a urinal and reclipped the catheter bag drainage port without cleaning the port tip. With visible large amounts of loose stool on resident's peri area, catheter, catheter tubing, and legs, Staff C cleansed the catheter by wiping up and down toward and then away from the catheter insertion site several times with the same side of the wipe and with a new wipe proceeded to wipe several areas of the resident's peri area and legs with the same wipe, without turning the wipe. Staff C removed his gown and gloves and exited the resident's room. Staff D turned the resident to his right side, removed the brief from under the resident, and wiped stool from the resident's back side of legs using the same side of wipe to wipe 4 different areas on the legs. Staff D removed her gloves, applied new gloves without performing hand hygiene, and proceeded to bag the trash of the dirty wipes and dirty brief. Staff C returned to the resident's room and Staff D rolled the resident to his left side. Staff C applied a new gown and gloves without performing hand hygiene, and proceeded to wipe different areas of stool form the resident's legs using the same side of the wipe. Staff C, using a new wipe, swiped the resident's buttocks 3 times with the same side of one wipe. Staff D removed her gown and gloves, exited the room, reentered the room, and applied gloves only. Staff C and Staff D applied a new brief on the resident. Staff D handled the catheter tubing while putting clean pants on the resident. Staff C bagged more trash and took the trash to the bathroom across the hall. Staff D took the uncovered urinal with urine across the hall to the restroom, emptied the urinal, removed her gloves, returned the urinal to the resident's room, placed the urinal in a bag tied to the towel rack beside the sink, and exited the room with no hand hygiene completed. Interview on 7/28/26 at 9:44 AM, Resident #6's wife stated the resident seems to get a urinary tract infection every time the facility changed his catheter. Resident #6's urine culture report (test to find appropriate antibiotic to treat infection) from urine sample dated 6/26/26, revealed proteus mirabilis (bacterial infection common for causing urinary tract infections) and a new order for an antibiotic for 7 days.Facility Urinary Catheter Care Policy revised August 2022, revealed for a male resident use a wipe to cleanse around the meatus (tip of penis), cleanse the glans (head of penis), using circular strokes from the meatus outward, change the position of the wipe with each stroke. Use a clean wipe to cleanse and rinse the catheter from insertion site to approximately four inches outward.Interview on7/30/26 at 1 PM, the Director of Nursing stated expectation for staff to wipe down the catheter away from the catheter insertion site and to complete 1 swipe with each wipe when providing incontinence care.

Based on observations, staff interviews, resident interviews, Electronic Health Record (EHR) review and policy review the facility failed to provide respiratory care and services in accordance with professional standards of practice for 1 of 2 residents reviewed (Resident #8). The facility failed to obtain a physician's order for tracheostomy suctioning and the facility failed to assess Resident #8's competency and to provide education regarding the resident's ability to perform self- suctioning and tracheostomy care. The facility reported a census of 82 residents. Findings Include:The Minimum Data Set (MDS) dated [DATE] for Resident #8 documented a Brief Interview for Mental Status (BIMS) of 15 indicating no cognitive impairment. The MDS further documented the resident had an active tracheostomy status with tracheostomy care and suctioning documented as scheduled in section O part D1. Review of Resident #8's EHR dated 7/28/26, titled, Order Summary failed to document physician's order's to suction residents tracheostomy, for the resident to independently provide care and for resident to independently suction her tracheostomy.Review of Resident #8's EHR titled, Care Plan failed to document the suctioning needs, including the resident's competency to independently perform tracheostomy site care and self-suctioning.Review of Resident #8's EHR titled, Progress Notes documented on the date of 3/10/26 at 11:47 PM that Resident #8 continues to self suction as phlegm builds up.Observation on 7/28/26 at 2:42 PM revealed light brown colored liquid in the suction canister.Observation on 7/29/26 at 11:00 AM revealed light brown colored liquid in the suction canister.On 7/28/26 at 2:42 PM Resident #8 stated she frequently suctioned her tracheostomy when needed and the staff at the facility also suctioned her tracheostomy when she asked for assistance. Resident #8 explained the facility provided the supplies needed for tracheostomy care and suction equipment. Resident #8 stated she was not observed for competency prior to self suctioning tracheostomy and denied having an assessment done during the admission process or after. On 7/28/26 at 2:40 PM Staff G, Registered Nurse (RN) stated she had worked at the facility frequently and was familiar with Resident #8. Staff G further explained she had not personally suctioned Resident #8 before and denied knowing if the resident was able to independently suction her tracheostomy.On 7/28/26 at 3:10 PM Staff E, Licensed Practical Nurse (LPN) stated Resident #8 was independent with tracheostomy cares such as cleansing tracheostomy site though resident was unable to suction tracheostomy independently and does not self suction.On 7/28/26 at 3:16 PM the Director of Nursing (DON) stated Resident #8 is able to independently do tracheostomy cares including cleaning the outside tracheostomy site, cleaning inner cannula and suctioning her tracheostomy. The DON stated the facility staff does assist the resident if needed with tracheostomy care including suctioning. The DON further explained her expectations to have a physician's order for suctioning Resident #8's tracheostomy, a physician's order for the resident to independently suction tracheostomy and an assessment performed and charted in her EHR to identify the residents competency to independently provide care for Resident #8's tracheostomy.Review of a facility provided policy dated 3/22 titled, Care plans, Comprehensive Person-Centered documented a comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. Further documentation revealed the comprehensive, person-centered care plan to include measurable objectives and timeframes; described the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being including the resident's rights, which professional services are responsible for each element of care; residents stated goals upon admission with desired outcomes; residents strengths and recognized standards of practice for problem areas and conditions.Review of a facility provided policy dated 3/22 titled, Resident Assessments documented a comprehensive assessment included a completion of the MDS, completion of the care area assessment (CAA) process and development of the comprehensive care plan are mandated and therefore must be performed for all residents of Medicare and/or Medicaid certified nursing homes. The policy further documented that all resident assessments completed within the previous 15 months are maintained in the resident's active clinical record. The results of the assessments are used to develop, review and revise the resident's comprehensive care plan.Review of a facility provided policy dated 8/2013 titled, Tracheostomy Care documented procedure guidelines for preparation and assessment included to check the physician order, to document the procedure, condition of the site and the residents response to suction, inner cannula cleansing and other tracheostomy cares.Review of a facility provided policy dated 7/2016 titled, Medication and Treatment Orders documented medications and treatments shall be administered only upon the written order of a person duly licensed and authorized to prescribe such medications/treatments in this state. The policy further documented physician orders shall be followed and if unable to follow physician orders to notify the Director or Nursing or designee as appropriate.

Based on Electronic Health Record (EHR) review, observations, staff interviews and policy review the facility failed to develop and implement person-centered care plans that addressed the specific dementia care needs for 3 of 5 residents reviewed (#1, #3 and #24). The facility reported a census of 82 residents.Findings Included:1. Review of Resident #1's Minimum Data Set (MDS) dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 3 indicating severe cognitive impairment. The MDS further documented Resident #1's diagnosis of dementia.Review of Resident #1's EHR titled, Care Plan Report failed to document Resident #1's individualized dementia cares including verbal, behavioral, or environmental prompts to assist the resident in completion of specific tasks or activities. On 7/27/26 at 9:45 AM observation revealed Resident #1 sitting in a wheelchair in the common area with the TV on the movie screen title and not actively playing the movie.On 7/29/26 at 12:45 PM observation revealed Resident #1 laying in bed on her stomach.On 7/30/26 at 8:46 AM observation revealed Resident #1 laying in bed. 2. Review of Resident #3's MDS dated [DATE] documented a BIMS score of 2 indicating severe cognitive impairment. The MDS further documented Resident #3's diagnosis of dementia. Review of Resident #3's EHR titled, Care Plan Report failed to document Resident #3's individualized dementia care including verbal, behavioral, or environmental prompts to assist the resident in completion of specific tasks or activities. On 7/30/26 at 1:34 PM observation revealed Resident #3 sitting in a recliner in the common area with 4 other residents with the TV on a movie title screen without a movie actively playing.3. Review of Resident #24's MDS dated [DATE] documented a BIMS score of 3 indicating severe cognitive impairment. The MDS further documented Resident #24's diagnosis of Alzheimer's Disease and dementia.Review of Resident #24's EHR titled, Care Plan Report failed to document Resident #24's individualized dementia care including verbal, behavioral, or environmental prompts to assist the resident in completion of specific tasks or activities. On 7/30/26 at 1:34 PM Staff N, Certified Medication Assistant (CMA) stated the staff have an activity binder they documented what daily activities have been performed and what residents attended.0n 7/30/26 AT 1:34 PM Staff M, Certified Nurse Assistant (CNA) stated she believed the activities residents liked were located on the Kardex but if it is not listed then they would just ask the resident what they would like to do.On 7/30/26 at 1:53 PM the Director of Nursing (DON) stated she expected the care plans to be individualized per resident. The DON further explained each care plan should have specific activities the resident liked to do with specific behaviors with interventions related to dementia for the facility staff to better care for the residents. Review of a facility provided policy dated 11/2018 titled, Dementia-Clinical Protocol documented for the individual with confirmed dementia, the Interdisciplinary Team (IDT) will identify a resident-centered care plan to maximize remaining function and quality of life. The IDT will adjust interventions and the overall plan depending on the individual's responses to those interventions, progression of dementia, development of new acute medical conditions or complications, changes in resident or family wishes and other relevant factors.

Based on record review, resident interview, staff interview, and policy review the facility failed to provide needed assistance in making appointments for dental services for 1 of 1 residents (Resident #10). The facility reported a census of 82 residents.Findings include:Review of Resident #10's Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15 indicating intact cognitive functioning. The MDS further indicated that Resident #10 admitted into the facility on 1/26/26 from a short-term general hospital stay. Interview 7/27/2026 at 11:38 AM with Resident #10 revealed that he does have a lot of broken teeth that are bothering him. Resident #10 then revealed that he has been trying to get into a dentist for the last 5 months. Resident #10 then revealed that the facility did have a dentist come to the facility who did some cleaning, but did not pull the teeth that needed to be pulled.Review of Resident #10's Electronic Healthcare Record (EHR) page titled, Progress Notes revealed an entry dated 6/11/26 at 8:48 AM indicating Resident #10 had gone to a scheduled dental appointment with staff. Further review of the Progress Notes revealed another entry on 6/11/26 at 11:01 AM Resident #10 had returned from the scheduled dental appointment with a consult sheet stating Resident #10 had multiple fractured teeth with caries causing discomfort. The note further revealed the facility was to consult with an oral surgeon for extraction of all remaining teeth with the routine dentist to follow up after 8 weeks after extractions were completed.Interview 7/28/26 at 12:40 PM with Staff A revealed that she does the scheduling for appointments. Staff A then revealed that she would be having the dentist come back on the 11th of next month to see Resident #10. Staff A further revealed that she has faxed an oral surgeon who does not take Resident #10's insurance, and would have the dentist see him the 11th of August to see what to do next. Staff A continued that she had not called anyone else about completing Resident #10's extractions. Interview 7/28/26 at 2:31 PM with the Director of Nursing (DON) revealed she would have expected documentation of when dentists, or doctors were notified of dental work that was not scheduled. The DON further revealed that she would expect if an oral surgeon did not accept the insurance for dental work that the facility would reach out to another surgeon, and the physician or dentist to notify them as well as completing the dental visits in a timely manner. Review of a facility provided document titled, Dental Services with a revised date of December 2016 indicated routine and emergency dental services are provided through referrals to the resident's personal dentist, and referrals to community dentists.

Based on Electronic Health Records (EHR) review and staff interviews the facility failed to provide written notice, including the reason for the change, before the resident's room at the facility was changed for 3 of 3 residents reviewed (Resident #1, #7 and #8). The facility reported a census of 74 residents.Findings include:1. The Minimum Data Set (MDS) dated [DATE] revealed Resident #1 had a Brief Interview for Mental Status (BIMS) of 9 indicating moderate cognitive impairment. Review of Resident #1's EHR titled, Assessment documented Social Services Roommate Change Notification on [DATE] and no documentation of Social Services Relocation Notification.Review of Resident #1's EHR titled, Progress Notes documented room change on [DATE] and [DATE].Review of Resident #1's EHR documented no other notification of room change.2. The MDS dated [DATE] revealed Resident #7 was rarely/never understood. Review of EHR titled, Progress Notes documented Resident #7 expired on [DATE].Review of EHR titled, Census documented Resident #7 changed rooms on [DATE], [DATE], [DATE], [DATE] and [DATE].Review of EHR titled, Assessment documented Social Services Room Relocation on [DATE] the day after the survey team requested documentation of room change.Review of Resident #7's EHR documented no other notification of room change.3. The MDS dated [DATE] revealed Resident #8 did not have a BIMS score completed because Resident #18 returned from the hospital [DATE] after a stroke which expired on [DATE]. Review of EHR titled, Census documented Resident #8 changed rooms on [DATE] and [DATE].Review of Resident #8's EHR titled, Assessment documented no Social Services Roommate Change Notification. Review of Resident #8's EHR documented no other notification of room change.On [DATE] at 10:49 AM Staff A, Social Service Director stated she would call the family before a room change occurred but, if it was medically necessary the facility would change rooms and then try to call the family. Staff A said sometimes families are not the best to answer the phone. Staff A stated she would try to get a hold of the family before moving the resident. Staff A stated when she was by herself in the office she did not do the room change family notification very well but, she really tried to get a hold of the family first. Staff A explained when called the family she would put the documentation of the room change in the Room Location Assessment. Staff A reported the room Resident #7 was in the facility turned into the Director of Nurse's (DON) office. Staff A revealed the room number was 320 and Resident #7 changed rooms on [DATE]. Staff A stated she did not see the assessment completed with the room change for Resident #7 at all. Staff A acknowledged neither Resident #7 or Resident #7's Power of Attorney (POA) for care and financial were notified appropriately of the room change notification completed. Staff A stated for quite a while Resident #1 did not have any POA. Staff A explained if the resident did not have a POA they told the resident of the upcoming room change and there would be an assessment completed. Staff A stated there was a Room Location Assessment completed on [DATE] but it was when she got a new roommate. Staff A stated Resident #1 was in room [ROOM NUMBER] until [DATE]. Staff A stated she could not find any notification for the POA when the room change occurred on [DATE]. Staff A explained Resident #1 was spoken to and she was ready to move and would move today was documented in the EHR titled, Progress Notes. Staff A stated if the resident was able to make their own decisions then there was no reason to notify the POA. Staff A stated Resident #8's family was at the bedside when he returned and they were aware of the room change. Staff A stated Resident #8 was changed to hospice that day with daughter and son present when the hospice papers were signed. Staff A acknowledged there was no formal documentation to the POA of that room change. Staff A stated the son was called on [DATE] returned and was moved upstairs in an EHR titled, Progress Notes by the nurse that did the return assessment. Staff A stated she had never presented a resident with written notice of room change but did enter the room change in the EHR titled, Assessments when it occurred.On [DATE] at 10:49 AM Staff B, Social Service stated when she had a resident that was going to have a room change she always tried to notify the family. Staff B stated there were 2 assessments completed for Resident #1 one for getting a new roommate and one for when they are getting moved. Staff B explained the assessments were entered in the EHR titled, Assessments and were titled Social Service relocation notification and Social Service roommate change notification. Staff B explained Resident #1 had a room change notification on [DATE] with notification to POA because Resident #1 was getting a new roommate. On [DATE] at 10:38 AM the Administrator stated the facility does not have a policy for resident room change notice. The Administrator stated she would expect the room change assessment form to be utilized and filled out at least 2 days prior to room change and for staff to notify family or POA if the resident's BIMS is less than 15.

Based on observations, staff interviews, Electronics Health Record (EHR) review and policy review the facility failed to ensure residents received required direct supervision during meals and failed to implement specific care-planned interventions during meals with 2 of 2 residents reviewed (Resident #5 and #6). The facility reported a census of 74 residents. Findings Include:1. The Minimum Data Set (MDS) dated [DATE] for Resident #5 did not document a Brief Interview for Mental Status (BIMS) score. The MDS documented Resident #5 had severely impaired daily decision making skills.Review of Resident #5 Electronic Health Record (EHR) titled, Care Plan documented an intervention for eating that Resident #5 required supervision during meals, was at high risk for aspiration, tried to eat quickly and required cues to slow down. On 6/9/26 at 8:49 AM a continuous observation revealed Resident #5 unsupervised feeding himself for 16 minutes. On 6/9/26 at 9:51 AM Staff F, Certified Nurse Assistant (CNA) stated Resident #5 needs assistance but he eats on his own. Staff explains Resident #5 should not be unattended and that she did not watch him eating breakfast this morning.2. The MDS dated [DATE] for Resident #6 documented a BIMS score of 10 indicated moderate cognitive impairment.Review of Resident #6 EHR titled, Care Plan documented an intervention for eating that Resident #6 required supervision.On 6/9/26 a continuous observation revealed from 9:30 AM till 9:42 AM Resident #6 feeding herself unsupervised in the dining room.On 6/9/26 at 9:33 AM an observation revealed no CNA's present in the dining room with 6 residents eating breakfast.On 6/10/26 at 2:49 PM Staff G, Certified Nurse Assistant (CNA) stated when she worked with Resident #6 she would assist the resident with meals. On 6/11/26 at 10:38 AM the Administrator stated she expected the staff to follow the current care plan and physician orders for supervision with eating needed for each resident.Review of facility provided policy titled, Azria Therapeutic Diets dated 2017 documented therapeutic diets are prescribed by the attending physician to support the resident's treatment and plan of care and in accordance with his or her goals and preferences.

2. The Minimum Data Set (MDS) dated [DATE] for Resident #39 documented a Brief Interview for Mental Status (BIMS) score of 13 indicating no cognitive impairment. The MDS documented diagnoses of acute and chronic respiratory failure with hypercapnia. Review of Resident #39's EHR titled, Orders documented a physicians order for albuterol sulfate inhalation aerosol solution 2 puffs inhaled orally every 4 hours as needed as needed for 2-4 puffs may keep at bedside. Review of Resident #39's EHR titled, Assessments revealed no medication self administration assessment completed. Review of Resident #39's EHR titled, Care Plan documented no medication self administration plan in place. On 6/9/25 at 1:18 PM an observation in Resident #39's room revealed an albuterol inhaler present on the bed side table next to the resident's bed. On 6/9/25 at 1:18 PM Resident #39 stated she self administered the albuterol when she needed it. On 6/10/25 at 3:10 PM the DON stated Resident #39 recently requested to self administer her own medications. The DON explained to Resident #39 she would have to have a self administration assessment completed. The DON stated Resident #39 had not had an assessment completed and did not know how Resident #39 had the medication. The DON stated medications should not be left in the room for the resident to self administer without a self administration assessment. The DON explained Resident #39 should not have medications left in her room and should have the self administration assessment completed. 3. The MDS dated [DATE] for Resident #77 documented a BIMS score of 15 indicating no cognitive impairment. The MDS documented diagnoses of severe persistent asthma with (acute) exacerbation and morbid (severe) obesity due to excess calories. Review of Resident #77's EHR titled, Orders documented a physicians order for Nystatin external powder 100000 unit/GM applied to abdominal fold and groin topically one time a day for open areas and redness and an order for albuterol sulfate inhalation aerosol solution 2 puffs inhale orally every 4 hours as needed for wheezing. Review of Resident #77's EHR titled, Assessments revealed no medication self administration assessment completed. Review of Resident #77's EHR titled, Care Plan documented no medication self administration plan in place. On 6/10/25 at 8:23 AM an observation in Resident #77's room revealed an inhaler and powder next to the bed on the bed side table. On 6/10/25 at 8:23 AM Resident #77 stated the powder was for under his abdomen and was left in the room by the overnight nurse. Resident #77 stated he liked to apply the powder himself. Resident #77 stated he has had his inhaler in his room since he first entered the facility. Resident #77 stated he administered it when he needed it. On 6/10/25 at 8:24 AM Staff L, Assistant Administrator / CNA stated she did not know what the powder was. Staff L stated it should not have been left in Resident #77's room. On 6/10/25 at 3:33 PM the DON acknowledged Resident #77 did not have a self administration assessment completed and should not have medication left in his room. The DON stated Resident #77 should have had a self administration assessment completed. The DON explained Resident #77 would not be happy without the Albuterol inhaler in his room. The DON stated a self-administration assessment should have been completed. Review of policy revised 2/21 titled, Self-Administration of Medications documented that residents had the right to self-administer medications if the interdisciplinary team had determined that it was clinically appropriate and safe for the resident to do so. If it was deemed safe and appropriate for a resident to self-administer medications, this was documented in the medical record and the care plan. The decision that a resident could safely self-administer medications should be re-assessed periodically based on changes in the resident's medical and/or decision-making status. Based on observations, interviews of residents, family and staff, Electronic Health Record (EHR) reviews, and review of policies the facility failed to provide the needed services in accordance with professional standards by not completing assessments for 3 of 26 residents (Resident #14, Resident #39 and Resident #77). The facility failed to complete thorough assessments for a resident following a fall with a subsequent fracture, and completion of self administration of medication assessments for 2 residents. The facility reported a census of 86 residents. Findings include: 1. According to the Minimum Data Set (MDS) assessment dated [DATE] Resident #14 scored 2/15 on the Brief Interview for Mental Status (BIMS) indicating severe cognitive impairment. The document revealed diagnoses of cerebrovascular accident/transient ischemic attack/stroke, hemiplegia or hemiparesis, and anxiety disorder. The assessment disclosed the resident required substantial/maximal assistance for rolling, sitting to/from lying, sit to stand, and transfers, and partial/moderate assistance for walking up to 50' with 2 turns. The document indicated the resident utilized a manual wheelchair with substantial/maximal assistance. The MDS documented the resident had fallen since admission/entry or reentry. The Care Plan dated 6/5/25 revealed a focus area related to Activities of Daily Living (ADLs). The interventions provided for staff use included: provide staff 1 assist -partial revised on 8/13/24, and toileting with 1 staff assist - partial revision on 8/13/24. A Falls Focus Area provided staff interventions of assistance of 2 staff members for transfers and ambulation initiated on 5/12/25. The EHR Witnessed Fall Without Injury dated 5/9/25 revealed the Resident #14 was lowered to the floor when the resident's legs got weak and gave out. The document disclosed the resident ambulated with assistance with a walker and had a gait imbalance. The EHR Fall Risk Evaluation completed on 5/9/25 revealed a score of 12 indicating At Risk. The document identified the resident had sustained 1-2 falls in the past 3 months, and was ambulatory and incontinent. The EHR Unwitnessed Fall with Injury dated 5/28/25 revealed Resident #14 was found lying on her left side by the bedside table, a blanket wrapped around her legs, and the lift recliner was all the way up. The resident had a skin tear on the left side. The resident range of motion (ROM) was within normal limits (WNL). The document did not identify any pain. The EHR Fall Risk Evaluation completed 5/28/25 revealed a score of 22 indicating At Risk. The document identified the resident had 3 or more falls in the past 3 months and was ambulatory/incontinent. The document further revealed the resident had balance problems while standing and walking, decreased muscular coordination, and required use of assistive devices. The 5/25 Medication Administration Record (MAR)/Treatment Administration Record (TAR) revealed documentation for Pain Evaluation for 2 shifts daily initiated 7/1/24. The document revealed the Resident #14 had 0/10 pain from 5/1 to 5/30/25 during both shifts. On 5/30 the first shift identified pain at 3/5 and the second shift 5/10. On 5/31 the document indicated the resident had pain 4/10 during the first shift. The document further revealed Resident #14 had an order for as needed (PRN) Tylenol Extra Strength 500 mg (Acetaminophen). Give 1 tablet by mouth every 6 hours as needed for mild pain or fever initiated 8/17/22. The resident required the PRN on 5/3, 5/28, and 5/29/25. The 6/25 MAR/TAR revealed the resident required the PRN Tylenol Extra Strength 500 mg (Acetaminophen) on 6/1/25. The EHR Progress Notes provided the following: -On 5/28/25 at 6:30 PM Resident #14 sustained a fall with the physician notified. -On 5/29/25 at 1:09 PM the eINTERACT SBAR summary for providers revealed a change in condition with functional decline. The document indicated the resident required more assistance with ADLS, general weakness and decreased mobility, and the resident had pain. The document revealed awaiting response from the provider. -On 5/29/25 at 5:17 PM the resident has pain in wound when ambulating. -On 5/30/25 at 3:00 PM the resident will be admitted to hospice on 6/2/25. -On 6/1/25 at 3:54 PM the resident complained of pain in the left hip in the morning and the physician contacted. X-rays were ordered and completed approximately 3:45 PM. -On 6/2/25 at 3:46 AM X-ray findings returned with notifications completed. A fax dated 5/30/25 to the physician revealed Resident #14 had a decline. The document revealed the resident had increased pain with ambulation and generalized overall weakness. The document contained a time stamp of 6/2/25 2:01 PM with a statement of hospice consult? by the physician. The Trident Care Radiology Report dated 6/1/25 revealed Resident #14 had a left intertrochanteric (hip) fracture with minimal callus and modest displacement. The joint shows no dislocation. Pubic rami were intact. On 6/10/25 at 8:52 AM the resident's family member stated the resident had complained of pain during visits on 5/29 and 6/1/25. On 6/11/25 at 8:54 AM Staff N, Certified Nurses Aide (CNA) stated upon finding Resident #14 on her left side on the floor she had complaints of pain, but when repositioned with the nurse onto her back the resident had no further complaints of pain. The staff stated the resident continued to transfer with the use of a gait belt and walker during the rest of the shift. The staff stated on the next shift worked 5/31/25 the resident had increased complaints of pain and was using an EZ Stand (weight bearing lift) for all transfers. Staff N stated the resident had more bruising on the right side of her body; the opposite side from the original injury of the fall. The staff stated she reported the increase in pain and bruising to the nurse on duty who stated the resident had bruising all over. On 6/11/24 at 9:40 AM Staff O, Social Services Designee/PRSC, and the Administrator stated the resident had no complaints of pain at the time of the fall on 5/28/25. The staff acknowledged there was a change in condition on 5/29/25 where the resident was more lethargic and a fax communication was sent to the provider. When asked if a call to the physician should have been made to the physician for further assessment, the Administrator acknowledged a call should have been made. On 6/11/25 at 11:00 AM Staff Q, Licensed Practical Nurse (LPN), stated on 5/28/25 Resident #14 stated her left hip hurt upon initial contact following the fall. However when the resident was repositioned on her back the resident had no further complaints of pain. The staff stated the only injury was the skin tear on the left elbow. The staff stated PRN Tylenol was provided for the resident's complaint of pain in her back. The staff stated the resident required assistance of 2 staff for ambulation with a gait belt and walker to and from the bathroom. On 6/11/25 at 11:35 AM the Medical Director (MD) stated he was notified of the resident's fall on 5/28/25 while he was at the facility. The MD stated he did not see the resident as she was not on his schedule. The MD stated he left instructions with the notifying nurse to obtain an x-ray if it was thought one was needed. On 6/11/25 at 11:56 AM Staff R, Physical Therapist, stated the Resident #14 was receiving physical therapy services twice weekly. The staff stated the resident was transferring with assistance of staff with the use of a walker, and the resident was not using an EZ Stand consistently. On 6/11/25 at 1:25 PM Staff Q acknowledged the physician had stated the resident could have an X-ray if needed. The staff stated she did not think the resident required one at that time. The staff confirmed she verbally notified the next shift of the doctor's statement, but did not put it into the written exchange document. On 6/11/25 at 2:44 PM Staff S, CNA, stated Resident #14 had complaints of pain during repositioning and transfers during her shifts on 5/28 and 5/29/25. The staff stated she notified the nurses that were on duty. The staff stated she did not use an EZ Stand with the resident before or after the fall. On 6/12/25 at 10:30 AM Staff T, LPN, stated he was not aware of the physician statement to obtain an X-ray if one was needed. The staff stated he would look in the written shift exchange nursing documentation for information on residents. The staff stated he was notified by the prior shift nurse that the Resident #14 was using the EZ Stand for all transfers at the time of the scheduled shift on 5/29/25. Staff T acknowledged there was more bruising on the resident on 5/29, but did not document the additional bruises since a skin assessment had been completed after the fall. On 6/12/25 at 10:53 AM the Director of Nursing (DON), stated if the physician indicated to obtain an X-ray if needed, it should have been documented on the nurses written shift exchange for all nurses to know. The DON acknowledged if there had been a change in pain level as indicated on the MAR-TAR a call should have been made to the physician for further assessment of the resident's pain. The staff stated the increase in bruising should have had a root cause analysis initiated as to the cause, especially if it was not noted on the skin assessment after the fall. The DON stated with the resident having plans for transitioning to hospice services on 6/2/25 the facility was trying to navigate the gray area. The staff did acknowledge that the plan for transition to hospice services should not change how a resident was treated. On 6/12/25 at 11:37 AM the Administrator stated a skin assessment should be performed when there is new bruising noted and try to find the cause of it. The facility Assessing Falls and Their Causes Policy, dated 3/18, revealed assessments and documentation should continue for approximately 72 hours after the fall for changes in mobility, pain, swelling and bruising. The document indicated relevant risk factors including underlying medical conditions and overall functional decline must be addressed promptly.

Based on observations, staff interviews, resident interview and clinical record review the facility failed to implement interventions to prevent the worsening of pressure sores for 2 of 3 residents reviewed. While Resident #16 was a resident at the facility, she developed on a pressure sore on her heel. Staff failed to implement orders in a timely manner, failed to use the recommended pressure relieving boots, and failed to apply the treatment properly. Resident #17 had a chronic pressure area on his buttocks and staff failed to use the protective barrier creams as recommended. The facility reported a census of 65 residents. Findings include: The MDS (Minimum Data Set) assessment identifies the definition of pressure ulcers: Stage I is an intact skin with non-blanchable redness of a localized area usually over a bony prominence. Darkly pigmented skin may not have a visible blanching; in dark skin tones only it may appear with persistent blue or purple hues. Stage II is partial thickness loss of dermis presenting as a shallow open ulcer with a red or pink wound bed, without slough (dead tissue, usually cream or yellow in color). May also present as an intact or open/ruptured blister. Stage III Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle is not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling. Stage IV is full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar (dry, black, hard necrotic tissue). may be present on some parts of the wound bed. Often includes undermining and tunneling or eschar. Unstageable Ulcer: inability to see the wound bed. Other staging considerations include: Deep Tissue Pressure Injury (DTPI): Persistent non-blanchable deep red, maroon or purple discoloration. Intact skin with localized area of persistent non-blanchable deep red, maroon, purple discoloration due to damage of underlying soft tissue. This area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue. These changes often precede skin color changes and discoloration may appear differently in darkly pigmented skin. This injury results from intense and/or prolonged pressure and shear forces at the bone-muscle interface. 1) According to the MDS assessment dated [DATE], Resident #16 had a Brief Interview for Mental Status (BIMS) score of 12 (moderate cognitive deficit). She was totally dependent on staff for dressing, hygiene, toileting and transfers. She was always in continent of urine and bowel. Diagnosis included atrial fibrillation, heart failure, renal insufficiency, chronic pain and morbid obesity. The Care Plan dated 12/12/23, showed that Resident #16 was at risk for impaired skin integrity due to limited mobility and cardiovascular disease. Staff were directed to observe for signs and symptoms of worsening and to encourage the resident to shift weight evaluate [NAME] integrity, utilize pressure relieving devices on appropriate surfaces. The Care Plan for Resident #16, updated on 3/22/24, showed that the resident had developed a foot ulcer on her right heel that was surgically debrided. She was non-weight bearing and staff were to ensure that her right heel was off-loaded at all times, and that she had Prevalon boots (protective boots with a cushioned bottom that help reduce the risk of bedsores by keeping the heel floated, relieving pressure) to bilateral heels. According to a Comprehensive Skin Evaluation, dated 3/5/24 at 10:34 AM, Resident #16 did not have any identified skin concerns on her heels. A New Skin Alteration Evaluation dated 3/19/24 at 10:56 PM, showed that she had a right heel sore, Stage 2, with a scant amount of serous drainage that measured 2 centimeters (cm) x 3 cm x 0.1 cm. The physician was notified. A Physician's Order was entered on 3/23/24 at 7:00 AM, to clean the heel wound with wound cleanser, pat day and apply collagen pad to the heel. Cover area with Allevyn (foam wound dressing) until healed. The Treatment Administration Record (TAR) showed that the first treatment for the developing wound was on 3/23/24, four days after it was first discovered. On 3/25/24 an order was entered for a specialize wound care service to evaluate and treat. A Wound Care Visit Detail Report, (WCVDR) dated 3/26/24, showed that Resident #16 had been seen on that date and reported that she did not have much feeling in her feet so, initially, she was unaware she had a wound on her heel. She was found to have a Deep Tissue Injury (DTI) that most likely started with a small area. The resident was a sit to stand for all transfers and spent a majority of time in her recliner. She was to continue to wear the Prevalon boots at all times. Orders at this visit included; cleanse the wound with soap and water, pat dry, scrub the wound bed to mechanically debride. Apply skin prep to the entire heel, and change the dressing daily and as needed for soiling. Keep the right foot in Prevalon boot or heels floated at all times. The electronic Physician Order Set showed that the wound order had not been entered until 4/3/24 at 11:30 AM and indicated that the dressings were to be changed every 3 days and as needed if dressing soiled. A WCVDR, dated 4/9/24 showed that while cleansing the wound, the resident indicated it being very sore. There was maceration (lighter in color, wrinkly, soft or soggy, occurs when skin is in contact with moisture too long) in surrounding peri wound. Orders include an addition of calcium alginate to dressing due to drainage and slough. The wound specialist stated that she preferred the Prevalon boot applied going forward as it covers more proximity of the right lower extremity, and was better for off-loading the heels. The ulcer was consistent with pressure as the primary etiology. The heel laid on the foot rests of recliner, very heavy legs with chronic lymphedema. Wound drainage and peri-wound status deteriorated compared to the conclusion of the previous visit. Change dressing every three days and as needed for soiling. The order was to cleanse the wound, scrub the wound bed and apply Fibracol Collagen/Alginate (103 sq. cm or less) and cover with bordered gauze (103 sq. cm or less) and change the dressing every three days and as needed. Keep the right foot in Prevalon boot or heel floated at all times. The orders entered into the electronic chart on 4/10/24 at 6:15 PM, failed to include the measurement of the Alginate medication. The WCVDR dated 4/16/24, showed that the patient was complaining of more pain to the right heel in last few days. Wound assessment revealed a change in status with increase in length and width, and an odor with increased slough. The area was debrided (procedure to remove infected/dead tissue). Notes included direction to staff to ensure that they cut the calcium alginate to borders of wound, today it was extending over all the maceration of the wound borders, which encouraged the spread of bacteria. The resident asked why the wound was worsening and the Nurse Practitioner (NP) answered that she suspected it was because of non application of Prevalon boots as ordered. Staff were aware and were coming up with a plan to ensure staff was placing the boots on as directed. Staff were also educated to ensure that the nurses understood that primary wound dressing needed to fit within the borders of wound. Frequency of dressing change every other day and as needed for soiling, saturation or unscheduled removal. Odor improved post debridement. Order entered into the electronic chart included instructions to ensure Alginate was cut to size, but indicated dressing changes every 3 days rather than every other day. The WCVDR dated 4/23/24, showed that the wound appeared smaller, but was more concerning for infection. There was an odor that was not eliminate after cleaning. The NP decided to start an antibiotic, and to change treatment. She was unable to clear slough from wound base due to patients pain and increased drainage. Stage 3 full thickness tissue loss subcutaneous fat may be visible but bone tendon or muscle is not exposed. A nursing note dated 4/24/24 at 9:43 PM showed that earlier in the day, Resident #16 had been anxious, crying and feeling like she was going to die. She was sent to the emergency room where they determined she had fluid overload and was being transferred to a different hospital to deal with the infection in her right foot. According to the hospital report dated 4/24/24, the chief complaint was shortness of breath but the doctor was concerned about the necrotic skin on her right heel due to a pressure ulcer with a foul smell. She was given an antibiotic and transfer to hospital at 5:12 PM. According to the Hospital Encounter Summery dated 4/30/24, upon admission on 4/24/24, the patient had a stage 3 pressure ulcer on the right heel. She was referred to surgery for irrigation and debridement right heel ulcer and went to the operating room on 4/27/24. A nursing note dated 4/30/24 at 8:34 PM showed that she was readmitted to the nursing home on that date with surgical wound with 5 staples. On 7/17/24 at 10:56 AM, the Wound Care Nurse Practitioner (WCNP) said that she first saw Resident #16 on 3/26/24, and the resident had a Deep Tissue Injury (DTI). The WCNP recommended that Prevalon Boots be used at all times. She saw the resident again on 4/2/24, at that time, the wound was partially open, so she added an order for Collagen/Allginate. On the 4/9 visit, the heel was macerated with sloth and the resident reported more pain. At that visit, the resident was wearing blue heeled booties for protection, and the staff said that they didn't have the Prevalon boots, so the WCNP recommended that they should at least try to float the heels. On the 4/16 visit, when she took that dressing off to look at the wound, there was a distinct odor with increased sloth, and was determined to be a Stage 3 pressure. The WCNP said that the Alginate had been cut bigger than the open wound so she educated the staff on ensuring that that fabric was cut to the size of the wound because when it was bigger, bacteria tends to spread. Again, the resident was not wearing the Prevalon boots at this visit. On 4/23 the resident was in a lot of pain, the wound was odorous and she could smell it as soon as she walked in the room. She did some debriding, but was unable to continue due to the resident's pain. The WCNP started the resident on an antibiotic and ordered labs. She said that she would have wanted a phone call sooner, when the odor and infection had gotten worse through the week. She said that the wound had a very rapid deterioration and quick intervention was the key. If they could have gotten an antibiotic sooner, it may have changed the outcome. The resident was unable to lift her legs and the boots that they were using did not provide adequate support to her heel as the Prevalon boots could. On 7/17/24 at 9:39 AM Staff C Licensed Practical Nurse (LPN) said that she had changed the residents bandage on her heel several times. She did not remember the dates, but did remember that there was an odor at one point. She reported to the next shift and knew that the resident would be seen by wound care. On 7/17/24 at 12:33 PM Staff D, Certified Nurse Aide (CNA) said that she did work with Resident #16 during the time that the spot on her heel was getting bad. She said that she told at least two nurses that there was increased in odor, and she thought that they had assessed it, but she wasn't sure. Staff D said that she noticed the odor about a week or 2 before the resident went to the hospital. On 7/18/24 at 9:17 AM Staff A, CNA said that she had worked with Resident #16 quite a bit during the time the ulcer was developing on her heel. She said they were using the small blue boots for protection, and they didn't fit her very well, I just used what they gave me to use. She thought they had used them for about a month. Staff A had given the resident bed baths during that time, and she was told not to unwrap the bandage on the heel, so she hadn't seen the wound. On 7/17/24 at 3:25 PM Staff G, CAN, remembered when the blister started on the heel of Resident #16. Staff G said that the resident had a lot of swelling in her feet and legs, and the protective boots that they put on her for support were too small. On 7/17/24 at 12:49 PM, Staff J, Assistant Director of Nursing (ADON), and wound care nurse said that he had no knowledge of signs of infection in the heel wound, and none of the staff reported an odor. He said that he would have contacted the Primary Care Physician (PCP) or the wound care services, but there was no report of odor or worsening of the ulcer. He maintained that the heel was getting better. According to the WCVDR notes, Staff J was present for the wound care visit on 4/16/24 and on 4/23/24 when there was mention of an odor. On 7/18/24 at 9:10 AM Staff J, and Staff Z, Nurse Consultant, said that there was just one time when the wound nurse came and the resident was not wearing the Prevalon boots and that was because they were soiled, and in the laundry. They maintained that the heels were always floated. On 7/18/24 at 11:00 AM, Staff J and Staff Z said that while doing rounds, they found that they needed to do some education with staff because some pressure prevention interventions were not being implemented. They had the in-service on 4/18/24 and educated the nurses on how to apply the Calcium/Alginate treatments. 2) According to the MDS assessment dated [DATE], Resident #17 had a BIMS score of 15 (intact cognitive ability). He was totally dependent on staff for dressing, and toileting hygiene. He was frequently incontinent of urine and always incontinent of bowel. His diagnosis included; anemia, benign prostatic hyperplasia, neurogenic bladder, wound infection, paraplegia, anxiety disorder, and unspecified intellectual disability. The Care Plan revised on 5/29/24 showed that he had urinary incontinence related to a neurogenic bladder and spinal cord injury. Staff were directed to apply barrier cream to peri area after each incontinent episode, to monitor for incontinence episodes and to keep the skin clean and dry. On 7/15/24 at 1:03 PM, Resident #17 said that he had a pressure area to his bottom and it hurt sometimes. According to a Comprehensive Skin Evaluation dated 7/14/24 at 12:15 AM the resident did not have any skin concerns and they were applying barrier cream as preventative measure. On 7/15/24 at 1:07 PM, Staff A CNA, and Staff B CNA transferred Resident #17 to his bed and provided incontinence cares. When they removed his brief and cleaned his buttocks, it was revealed that the resident had three reddened spots on the upper right thigh and a small open area. They asked him if he wanted lotion or house powder. The resident replied you tell me. They then said that they would have the nurse come in later and proceeded to apply a clean brief without barrier cream on his sores. A nursing note dated 7/15/24 at 4:00 PM showed that the resident had a fluid filled blister on the right thigh measuring 1.5 cm x 1.0 cm. On 7/17/24 at 1:10 PM, the Director of Nursing (DON) said that she would expect staff to apply a barrier cream after every incontinence episode. On 7/18/24 at 11:47 AM, Staff J said that the resident had a heavy cream that was used three times a day on the resident's buttocks and thighs. He said it was very thick and stayed on between incontinence episodes, so there was no need to use a barrier cream unless the resident was getting a bath. When pointed out that there was no cream on the resident at the time of observation, he said he couldn't speak to that, and the aides should have gotten the nurse to put on the cream. According to a facility policy titled: Prevention of Pressure Injuries, revised in 2020, the prevention of pressure injury included cleaning promptly after episodes of incontinence. Use a barrier product to protect skin from moisture. Staff were to select appropriate support surfaces based on the residents risk factors.

Based on clinical record review, staff interviews, provider interview and policy review the facility failed to provide a professional standard of quality of care by not following physician orders and failing to maintain continence for 2 of 4 residents reviewed (Resident #61, #17). The facility reported a census of 65 residents. Findings include: 1. Review of Resident #61's MDS assessment dated [DATE] indicated no bladder or bowel appliances, and occasional incontinence. The resident required partial to moderate assistance for toileting transfers and dependence for toileting hygiene. Review of Resident #61's Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15 indicating no cognitive deficit. The MDS further revealed diagnoses of urinary tract infection (UTI), and septicemia. The resident had an indwelling catheter and urinary continence was not rated. Resident #61's Care Plan revealed a focus area of bladder incontinence related to confusion, impaired mobility, inability to communicate needs, hypoxia with exertion, urinary retention on tamsulosin, and saw gynecology related to a pelvic mass - initiated on 11/7/23 and revised on 6/27/28. Interventions for staff included the following: -Use of disposable briefs/pull up briefs, -Monitoring and documentation of signs/symptoms (s/sx) for UTI: pain, burning, blood tinged urine, cloudiness, no output, deepening of urine color, increased pulse, increased temp, urinary frequency, foul smelling urine, fever, chills, altered mental status, change in behavior, and change in eating patterns with initiation date of 11/07/2023. -Staff were to monitor/document/report to the provider as necessary possible medical causes of incontinence: bladder infection, constipation, loss of bladder tone, weakening of control muscles, decreased bladder capacity, diabetes, stroke, and medication side effects with date initiated of 11/07/2023. -Staff were to check for incontinence episodes often, assist to wash, rinse and dry the perineum and change clothing after incontinence episodes as needed with the initiation date of 11/07/2023. An additional focus area of risk for dehydration or potential fluid deficit related to sepsis, recurring UTI's, and respiratory infections was initiated on 7/1/24. Interventions for staff included monitoring/documenting, reporting s/sx of dehydration. Review of Resident 61's electronic health record (EHR) Progress Notes provided the following: On 6/10/24 to 6/16/24 revealed no complaints of pain, decreased fluid intake or increased confusion. On 6/16/24 at 2:55 PM Resident #61's daughter contacted the facility with a request for a urinary analysis (UA) due to concerns the resident had a urinary tract infection (UTI) as the resident was complaining of pain and had increased confusion. The nurse faxed a request for a UA with culture and sensitivity (C&S) if indicated. On 6/17/24 at 11:30 AM the document titled, eINTERACT SBAR, indicated the resident's temperature was 98.0, resident had an increase in morphine, no changes in mental status evaluation, was alert and oriented, had no tremors, and lung sounds were diminished. The provider's response to the document was a fax was sent for order dated 6/16/24. On 6/18/24 at 12:52 PM the record indicated a one time UA with C&S was ordered. On 6/19/24 at 8:18 AM it was documented the resident was lying in bed with her head hanging over the bed touching the floor and complained of pain in the left side that made her jump. On 6/19/24 at 7:15 PM Resident #61 was found to be lethargic and weak, and was transferred to the emergency room . The resident was admitted to the hospital for Acute Kidney Injury, Pneumonia, and UTI. On 6/20/24 at 8:11 PM the facility received the results from the UA and faxed the results to the provider. On 6/21/24 at 9:10 the results of the C&S were received and faxed to the provider. On 6/24/24 Resident #61 readmitted to the facility with diagnoses of Sepsis and UTI, and antibiotics of Doxycycline and Metronidazole. The EHR indicated a prescriber written order entered on 6/18/24 for a one time UA with C&S with a start date of 6/18/24 at 1:00 PM and end date of 6/19/24 at 12:59 PM. The Hospital Discharge Record dated 6/24/24 revealed the principal problem for Resident #61 was Sepsis due to UTI and active problems of acute metabolic encephalopathy and anemia requiring transfusions. The document revealed there was a component of polypharmacy to her mentation, although the UTI was the main reason for encephalopathy at presentation. Resident #61 had a urinary Foley catheter placed during the hospitalization with a voiding trial in 1 week. Resident's hemoglobin was stable at discharge, mentation had improved to baseline, and acute kidney injury was improving. The resident received Cefepime and Rocephin IV as well as Flagyl orally during hospitalization . On 7/17/24 at 9:40 AM the Advanced Registered Nurse Practitioner (ARNP) stated there were multiple missed opportunities for prevention of Resident #61's hospitalization . The ARNP stated the family called the facility on the morning of 6/16/24 indicating Resident #61 complained of back pain and decreased mental abilities, which were signs of the resident developing a UTI. The facility nurse proceeded to send a fax requesting a UA rather than calling the on-call provider and getting a verbal order due to a change in condition. The ARNP indicated on 6/17/24 she signed the order for the UA and faxed it back to the facility. On 6/18/24 the provider completed rounds at the facility and was notified the UA had not been completed. The facility stated they had not received an order for the UA. The ARNP stated she provided the order for completion on 6/18/24. On 6/19/24 the provider received a notification in the morning that the resident had fallen in her room and hit her head. At the time of the fall the ARNP stated the UA had not yet been completed. The ARNP received a call later in the evening indicating the resident had a further decline in mental status. The provider ordered Resident #61 be sent to the emergency room by 911. The provider believed had the staff called with the initial change in status on 6/16/24 the outcome of falling and hospitalization would have been prevented. The provider expected that the facility would notify the provider by phone with any change in status, especially with changes of mental/cognition and shortness of breath. The provider stated there was always a staff on call for notification of change in status, including after hours and weekends. The expectation with UA orders would be to complete with a straight catheterization if the resident is unable to move or complete toileting and correctly utilize a hat for urine capture. The ARNP stated since this incident communication has improved with the facility and had no further concerns. On 7/17/24 at 2:09 PM Staff K, Director of Nursing, Registered Nurse, indicated the order for the UA was faxed as the request for it was on the weekend. The staff indicated another request for a UA was obtained as she was unsure if the first order got passed along. Staff K stated a nurse's response if there was a change in condition would be to complete a full change of condition assessment, call the physician, and carry out the orders. The staff expected orders would be carried out within an hour or 2, write a hard note, place it in Point Click Care (PCC) and note the order. If the order involved medications a call would be placed to the pharmacy, especially if it was a new medication or change in medication. On 7/17/24 at 3:21 PM Staff Q, the Administrator, stated orders should be followed as urgent as needed based on the severity and diagnosis. With regards to Resident #61 the staff indicated there had been a break in communication, obtaining and completing the orders for the UA. The facility met with the Provider on 6/20/24 and a plan was put into place for prevention of further breakdown including training nurses and auditing of orders. On 07/18/24 at 10:48 AM Staff L, LPN, stated nurses should be calling the on call provider on the weekend with any changes in conditions noted to residents. Orders frequently were faxed over the weekend as no one is in the providers' office. Staff L stated there was an in-service on this incident where all the nurses participated in an in-service and signed the education. On 7/18/24 at 10:50 AM Staff M, RN, indicated had just started working in the facility on this date. Staff stated if a physician was needed on the weekend, would check the profile page for the on-call doctor. On 07/18/24 at 11:12 AM Staff N, Assistant Administrator / Certified Nursing Assistant (CNA)/Certified Medication Aide (CMA) stated the staff should be calling physicians with any changes in conditions and not faxing. The unnamed facility training form revealed faxes come through the main fax. The DON or designee M-F during normal business hours will hand the orders to the day shift nurses. Weekends, nights, holiday's and outside normal business hours it is the nurses responsibility to check the fax machine for any new orders. It further revealed obtaining orders for physicians whether it is a telephone order, verbal order, or written order. ( if need for order on the weekend occurs, contact the on call physician. The on-call physician list is at each nurses station and above the fax machine). Place order into Point Click Care. Complete the order - If it is a medication order, fax and call pharmacy to get the medication sent to facility. If it is a lab order, collect the blood draw or urine sample as soon as possible. If it is an x-ray order, go onto trident care and place order for x-ray, then print requisition off to fax to physician to sign and send back. Once a lab specimen is collected, the specimen needs to be taken down to the lab. Document that the lab specimen was obtained and who took the lab specimen down to lab. Once lab results are obtained, call the physician for further orders. (if it is the weekend, call the on-call physician). Ensuring that the nurse is using the SBAR note for communicating with the physician. 41785 2. According to the MDS assessment dated [DATE], Resident #17 had a BIMS score of 15 (intact cognitive ability). He was totally dependent on staff for dressing, toileting hygiene. He was frequently incontinent of urine and always incontinent of bowel. His diagnosis included; anemia, benign prostatic hyperplasia, neurogenic bladder, wound infection, paraplegia, anxiety disorder, and unspecified intellectual disability. The Care Plan revised on 5/29/24 showed that Resident #17 had urinary incontinence related to a neurogenic bladder and spinal cord injury. Staff were directed to apply barrier cream to peri area after each incontinent episode, to monitor for incontinence episodes and to keep the skin clean and dry. On 7/15/24 at 1:03 PM, Resident #17 said that he had a pressure to his bottom and it hurts sometimes. On 7/15/24 at 1:07 PM, Staff A CNA, and Staff B CNA transferred Resident #17 to his bed and provided incontinence cares. They transferred the resident with the use of the Mechanical Lift and as they lifted him from the wheelchair, it was revealed that there was a protective pad in the wheelchair soaked with urine and his shorts were soiled. They asked him what time he had gotten up that morning and he said he had been in his chair since after his bath at 8:30 AM. On 7/17/24 at 10:07 AM, Staff X CNA said that at one time, Resident #17 would use his urinal more throughout the day and would ask for help, but recently he hadn't been asking and so he was usually incontinent, and he needed help with the urinal. On 7/17/24 at 10:08 AM, Staff Y CNA said that in the past, Resident #17 would ask for help with the urinal or he would tell staff when he needed to use the toilet. But most recently, he didn't ask, and he would be in his wheelchair all day. Because he had a large belly, it was difficult for him to use the urinal while sitting in his chair so he mostly was incontinent throughout the day and used the urinal at night. On 7/17/24 at 1:10 PM, the Director of Nursing (DON) said that she would expect staff to offer to toilet the resident at least every 2 hours. According to the facility policy dated August 2022 titled: Continence and Incontinence - Assessment and Management. The physician and staff would provide appropriate services and treatment to help residents improve bladder function and prevent urinary tract infections. Staff and physicians will evaluate the effectiveness of interventions and implement additional pertinent interventions as indicated.

Based on observations, clinical record review, staff interviews, facility investigative file review, review of the State Operations Manual, and facility policy review, the facility failed to provide adequate nursing supervision and assistance devices to prevent hazards for 1 of 3 residents reviewed. Resident #1 admitted from another facility due to increased exit-seeking behaviors and the need for a facility that offered a memory care unit to provide safety and increased supervision in an attempt to prevent elopement (when a resident leaves the facility without staff knowledge or permission). The facility failed to complete an elopement risk assessment for Resident #1 upon admission. Resident #1's current record showed many examples of her continued exit-seeking behavior, anxiety, confusion, and severe cognitive impairment after admit. On 5/25/2021 at approximately 6:45 PM, the facility attempted to unsuccessfully locate Resident #1 in the memory care unit and imitated a search throughout the rest of the facility, the grounds, and outside of the perimeter. At 7:30 PM, a member of the community member called the facility and reported Resident #1 was located at a football field. The door alarm system required staff to enter a code to open the door and the system had a 15 second delay pre-programmed into it that occurred before the door locked and re-armed. The facility concluded Resident #1 had likely exited the memory care unit following a staff member during the 15 second delay after they entered the code and exited, but before the door automatically locked. The facility surmised Resident #1 then left through the front door either by walking with or by following behind a visitor. These findings constituted an Immediate Jeopardy to resident health and safety. The facility reported a census of 67 residents. Findings include: The State Operations Manual (SOM) with a revision date of 11/22/17 provided the following definitions: a) Wandering-is random or repetitive locomotion b) Elopement- when a resident leaves the premises or a safe area without authorization According to the Admission Minimum Data Set (MDS) dated [DATE], Resident #1 had the following diagnoses: alcohol dependence with alcohol induced dementia, [CONDITION(S)], and diabetes mellitus. The MDS documented the resident scored 4 on the Brief Interview of Mental Status (BIMS) test which meant the resident demonstrated severe cognitive impairment. The MDS also documented she required extensive assist of 1 staff for toilet use and supervision while walking outside her room, but could ambulate (walk) independently in her room. The MDS revealed Resident #1 wandered on 4-6 days during the 7 day review period and did not have a wander or elopement alarm in place. Resident #1's care plan with a revision date of 4/21/2021 documented behaviors such as wandering, exit-seeking, pacing, yelling, cursing, and name calling related to dementia. The care plan also documented the facility implemented the following interventions: a. On 4/22/2021: staff documented the resident displayed exit-seeking behaviors at a prior facility and admitted to the facility for security on the memory care unit. b. On 5/26/2021: Staff implemented 1:1 supervision due to 5/25/21 elopement and plan made to provide Resident #1 an iPad to play games per family recommendations c. On 5/28/2021: the facility placed a wander guard on her left wrist. Review of Resident #1's Electronic Health Record (EHR) revealed the following progress notes: a. On 4/12/2021 at 10:56 AM: Resident #1 admitted to secured memory care unit due to increased wandering and exit-seeking behaviors at her previous facility. b. On 4/12/2021 at 3:45 PM: Resident paced the unit, walked up and down the hallway, and looked for her husband. Staff provided 1:1 staffing and redirection which proved effective. c. On 4/13/2021 at 6:26 AM: Resident #1 tried to leave via every door and slept only 20-30 minutes at a time. Staff provided redirection without success and noted the resident became agitated when told she needed to stay. d. On 4/15/2021 at 3:26 PM: Resident walked fast and continued to exit-seek but responded to redirection by calling staff names and swearing at them. e. On 4/17/2021 at 6:55 PM: Resident walked before supper and since 5:45 PM demonstrated anxiety and exit-seeking and asked to use the phone to call police or her mother. The resident reported she waited for her husband or family. f. On 4/18/2021 at 5:12 PM: Resident #1 very anxious, constantly walked in the dining room, set off the set off alarm at the far end of hall 4 times when she tried to open the door, attempted to exit through the dining room door, and also tried to open the dining room window as a door several times. The resident repeatedly told staff she needed to go to her parent's house and staff attempted redirection without success. g. On 4/25/2021 at 2:28 PM: The resident's exit-seeking behavior and walking quickly up and down the halls and dining room continued non-stop throughout the shift, although staff repeatedly redirected her. h. On 4/26/2021 at 9:30 PM: Resident appeared visibly anxious while she searched for her husband, paced constantly, and attempted to leave the memory care unit. Staff provided 1:1 support most of the evening and attempted to engage her in activities such as word search, coloring, snacks and fluids, movies, and reading materials. i. On 4/27/2021 at 3:02 PM: Resident walked up and down hallway seeking an exit and was redirected. Resident #1 folded washcloths and played with cards for a bit, then again began pacing the halls trying to find a way out. j. On 4/29/2021 at 2:50 PM: Resident continued to pace up and down the halls, repeatedly asked how to leave, and continued to set off alarms. Staff redirected the resident several times but the resident did not sit still very long. k. On 5/2/2021 at 6:54 PM: The resident paced most of shift but increased even more since supper time. Resident #1 searched for her husband, tried to go outside to the car, set off the South door alarm 2 times, and approached the door another 2-3 times, but staff redirected her. l. On 5/3/2021 at 2:25 PM: The resident exhibited restlessness and paced the hall in an attempt to find a way out of the building. m. On 5/5/2021 at 2:41 PM: the resident continued exit-seeking and activating alarms. Staff redirected her several times. n. On 5/8/2021 at 2:32 PM: Resident repeatedly looked for an exit and set off the door alarms. When staff redirected her it only lasted for few seconds and then she said, well I'm going home, and I'll see you later. She would then repeat the process several times. Staff documented the resident didn't redirect easily. o. On 5/9/2021 at 1:52 PM: Resident asked how to get out of here, set off alarms, and went from one door to another quickly. The staff redirected her several times, although the resident did not stay focused on activities for very long. p. On 5/12/2021 at 2:12 PM: Resident paced the hallway, and activated alarms while staff continued to redirect her. Staff opened door to the patio for fresh air, resident went out and came back in and refused to go back out on the patio, although she continually walked out the other doors and set off the alarms. q. On 5/15/2021 at 6:15 PM: Starting at 3:00 PM, the resident walked the hallways attempting to leave and activating the alarms looking for her husband. r. On 5/19/2021 at 10:09 PM: The resident paced the hall and dining area asking for her husband and after supper she began exit seeking. s. On 5/20/2021 at 3:45 PM: The resident paced and attempted to exit the doors this morning. She told the staff she had to leave. t. On 5/22/2021 at 10:34 PM: The resident paced throughout the memory care unit in the afternoon. Staff noted exit seeking behavior but she did not push on the doors and although she appeared visibly anxious, staff easily redirected her for short moments before she again became restless and told staff she had to go. u. On 5/23/2021 at 2:25 PM: The resident paced the hallways and exhibited exit-seeking behavior and staff redirected her. The resident went outside in the fenced in area for about 10 minutes with her husband and then paced up and down the hall with her husband again trying to find a way out. She also changed her clothes several times today. v. On 5/24/2021 at 10:13 PM: The resident paced the halls and dining room within the memory care unit this evening and stated she had to go, although she did seem to enjoy sitting outdoors on the patio with other residents and staff. w. On 5/25/2021 at 2:33 PM: The resident paced up and down hallway, set off alarms and staff continued to redirect her while she repeatedly told them she had to go while she approached each door, went back to the other and kept going back and forth. The resident did not sit very long to eat her meals. Staff redirected her several times to sit down to eat, but she kept standing up again. x. 5/25/2021 8:40 PM: The nurse documented the CNA reported at 7:00 PM that they could not locate Resident #1 in the memory unit. The nurse spoke to staff, started a search in the unit, called the Administrator at 7:14 PM and then continued looking for the resident. At 7:30 PM, a member of the public called and asked if the facility was missing a resident. The nurse answered in the affirmative and obtained the location (the football field) so facility staff could retrieve her. Staff returned to the facility with Resident #1 at 7:45 PM. A wandering assessment dated [DATE] documented the resident had a diagnosis of dementia, a history of wandering, exhibited confusion or disorientation, did not show resistance to facility placement, and remained independently ambulatory. The assessment also revealed the facility did not place a wanderguard on the resident's wrist or ankle at that time. Resident #1's clinical record failed to contain an elopement assessment dated [DATE] upon her admission. An elopement evaluation completed on 5/26/21 identified the resident had a risk of elopement due to a history of wandering (aimlessly at times and at other times with a purpose) which could affect her safety. The facility's investigative file dated 5/26/2021 documented at 6:45 PM, a CNA attempted to locate Resident #1 to help her with provide bedtime cares, but could not find her. The CNA informed the charge nurse and another CNA on duty. They searched again and noted the back door and enclosed patio attached to the dining room of the unit was secured. At approximately 7:00 PM, they still could not find the resident on the unit so the charge nurse notified the RN, who broadened the search to the entirety of the property. At 7:14 PM, they notified the Administrator who instructed her to call 911 and contact the resident's family. At about 7:30 PM, a community member phoned the facility to inform them they found the resident at the football field. At that point, an off duty LPN picked up the resident in her vehicle and returned to the facility at approximately 7:45 PM. An assessment revealed no injuries and vital signs within normal limits. The resident wore a pink and gray sweater, blue jeans, and socks and shoes. At 7:50 PM, the Administrator, the Regional Nurse Manager, and the Director of Nursing investigated and tested the memory care unit doors. They found them secured from the outside of the facility and the rest of the facility by magnetic locks released by codes put into the key pad. If someone entered an incorrect code it caused the door to alarm; two doors had such mechanisms, one to the outside of the building at the south end of the hall and one to the rest of the facility at the hall's north end. They tested the alarms/locks/doors and found all functioning properly, including the 15 second delay on the memory care unit door. The facility concluded no staff reported seeing the resident outside of the memory care unit prior to her departure from the facility. They noted Staff C, Dietary Aide reported they entered and exited through the memory care unit door and was the last person to exit the unit prior to staff reporting the resident missing. The facility identified given the 15 second delay and location of the resident when Staff C left the unit, a person in the location of the resident with the same mobility as the resident could have exited the unit prior to the door's lock engaging. The resident then followed one of the front visitors who would not necessarily have recognized the resident to be a resident of a nursing facility, out of the building. She then most likely walked to the football field/track, where she struck up a conversation with a couple that called to notify the facility of her location, from which she returned safely. During a staff interview on 6/3/21 at 11:07 AM, Staff A, CNA reported Resident #1 demonstrated some confusion, and required staff assistance to choose her clothes. Staff A stated on 5/25/2021 the resident kept going to the doors and wandering, frequently looking out the window, and insisting the car outside belonged to her and she needed to get to it. Staff A commented it was her second day working on the memory care unit and other staff had told her Resident #1 wandered frequently. Staff A reported she and Staff H, CNA, the other aide on the unit, had finished assisting with dinner and then began assisting residents to get ready for bed. As Staff A helped another resident to their room, she saw Resident #1 in her night gown with a sweater on her arms at about 6 or 6:15 PM. Staff A asked Resident #1 if they could take it to the laundry and the resident declined. Staff A stated Resident #1 continued to walk up the hall toward the exit and set off the door alarms. Staff H and Staff B LPN went to assist Resident #1 and also turned off the alarms. Staff A said she went to assist other residents and had not seen Resident #1 after that, but at about 6:35 PM-6:45 PM Staff B, Staff H, and Staff A initiated a comprehensive search throughout the building. Staff H notified another CNA on Main and they searched the grounds. When asked, Staff A reported the doors always alarmed when opened, although she did not think they had any outside visitors on the unit that day. Staff A reported once the alarm is shut off, the door then locked (before the elopement). She also said when someone exited the unit, the doors locked but it took a couple of seconds. Staff A stated they have 3 staff on the memory care unit: a nurse, a CNA and an activity care giver. On 6/3/2021 at 11:24 AM an attempt was made to call Staff H and a message left with no call returned before the conclusion of the investigation. The facility's investigative file contained a statement from Staff H as follows: Staff H CNA indicated she and Staff A began to take residents to the bathroom after supper around 6:00 PM. Staff H heard the alarm at the end of the hallway activate and she left the bathroom to shut it off and observed Resident #1 walking back down the hallway at approximately 6:15 PM. She and Staff A continued to assist the residents to the bathroom. Staff H remembered walking out of the bathroom again at approximately 6:30-6:40 PM to take a resident back to their recliner and Staff B approached and asked if she had seen Resident #1 recently. She responded in the negative and started to help look. When they could not find her in the unit, Staff H walked to Main to inform another CNA they could not find Resident #1 at approximately 6:45 PM. They continued to search everywhere in all halls as well as looking out the windows. When it became apparent she was not in the building, Staff B called the DON around 7:10 PM. Staff H reported when she had last seen the resident, she wore blue jeans, tan socks, black shoes, a gray night gown, and pink sweater. On 6/3/2021 at 11:52 AM the Director of Nursing (DON) stated on 5/25/2021 staff from the facility called to tell her they could not locate Resident #1, so she went to the facility. When she arrived, she saw staff escorting Resident #1 back home and she immediately began interviewing and educating staff. The DON reported Resident #1 lived on the memory care unit, could ambulate (walk) independently, had a history of wandering, and continued to do so in the present. She described the resident's pacing as her norm and said she is always ready to go and exit-seeking; staff constantly redirects her. The DON stated Resident #1 has been at the facility for about 6 weeks and continued to adjust. The DON said the alarmed memory care unit doors automatically locked when someone entered or exited after a 15 second delay, although after the elopement they changed it to a 5 second delay. She explained the facility had previously set the door to 15 seconds to allow someone to silence the alarm behind the desk and leave. The DON said she, the Administrator, and the Regional Nurse Consultant conducted the investigation and concluded she may have followed someone out of the memory care doors as the kitchen staff left that evening and since the facility had visitors in and out of a building, Resident #1 may have been left with them because the visitors may have not known she was a resident. The DON stated that is what she thinks is the only logical thing that could have happened and added upon occasion she noted 1 or 2 residents walk with her out of the memory care unit in the same way, although she was right there so they would walk back in together. The DON reported the football field is about 4 blocks from the facility and verified the facility did not utilize cameras. During a staff interview on 6/3/21 at 12:16 PM Staff B LPN described the resident as very active and independent and could go to the toilet independently, but she needed assistance with directions related to the location of the bathroom, reminders about when to eat and help with changing her clothes. Staff B reported the resident exhibited confusion, did not know where she was or what she was doing, and went to the back and front doors and set the alarms off, even when staff consistently redirected her. Staff B stated Resident #1 became angry if staff told her she lived at the facility and had made comments the evening she eloped about wanting to leave the unit. On 5/25/21, Resident #1 finished eating supper, went to the backdoor, and then set off the alarm, so the CNA reset it. Staff B stated she saw Resident #1 walking up the hall but had 2-3 other residents in the dining room that were at risk for falls and trying to stand up, so she had to redirect them. Staff B said she thought the resident went to the bathroom but then couldn't find her. She stated kitchen staff had come in and out around the time she last saw the resident (about 6:30 PM-6:40 PM) and then noticed Resident #1's absence about 6:45 PM. She immediately searched the unit, checked with the CNA's, and then continued her search throughout the facility. She commented there were no outside visitors on the memory care unit that afternoon, but after someone exited there was a 10 second delay on the door before it locked at that time. Staff B was asked if the memory care unit doors had always been alarmed when opened, she stated as far as she knew they had been, and reported the facility shortened the door delay after the elopement. Staff B stated the facility staffed 2 CNAs and 1 nurse on the unit and they check residents at least every 15 minutes. She added now Resident #1 always had a staff with her and wore a wanderguard. During a staff interview on 6/3/2021 at 12:48 PM, Staff C, Dietary Aide stated after collecting dinner dishes on the memory care unit, he had his back against the door on the way out and could see everyone from that vantage point, including Resident #1, in the hall. After he walked out he stated he pushed the door shut so Resident #1 could leave through the door. He stated Staff D CNA in the main dining room as he walked out of the unit saw him push the door shut. When asked what time he picked up the dinner dishes on the memory care unit, he stated he had no idea because he did not look at the clock. Staff C was asked if he saw Resident #1, he stated he saw her down the hall when he left and he felt there was no way she could have walked down the hall in 15 seconds to get out of the unit. Staff C was asked if the doors had locked after he left the memory care unit, he stated it takes 15 seconds for them to lock after they are opened but he heard the door latch after he walked out. During a staff interview on 6/3/2021 at 1:30 PM, Staff D CNA said on 5/25/2021, she was working on the main hall and when she came up to collect one of the residents around 7:00 PM, Staff H came out of the memory care unit and asked if she saw Resident #1, because they could not find her. Staff D stated she walked into the memory care unit to help the staff look for her and when they determined Resident #1 was not on the memory care unit, she exited and started to look on the main hall. When she could not locate her on the main hall, she went to east court to see if they saw her, and no one had. She then looked down the locked stairwells, down terrace hall, the assistant living hall, and out the door on assisted living to look outside. Staff D stated she went walked around the building outside and Resident #1 was not there. Staff D stated she walked toward the cemetery calling Resident #1's name. She noticed another staff member was driving around the area, so she got in with him and drove around to look for Resident #1. She stated when they saw pedestrians they would describe Resident #1 to them and asked if they saw her; no one had. They drove around town, came back to the facility, then drive down back of the building. Another staff member came out and started to search around the premise and in backyards, sheds, garages that were opened. Someone had called the facility and reported she was at the football field. Staff drove down and Resident #1 was sitting with the person that called along with another staff member that was off duty that day was down there with her. Staff D stated they had planned to walk with her back to the facility, but it was hot and she was hot. When asked how she could tell if Resident #1 was hot, she stated she was red in the face, short of breath had to walk with her when she usually walks herself. She said staff drove the resident back and walked her to the memory care unit. Staff D told staff to get her water because she was hot and sweaty. After that Staff D went back out to the main hall. Staff D was asked when Resident #1 was back in the facility, she stated by 7:45 PM. Staff D was asked if she saw anyone come in or out of unit she stated about 6:15 PM Staff C had walked out of the unit. Staff D stated she was in the dining room from 6:15 PM-6:30 PM. She stated about 6:30 PM she lift the main dining room which is located off of the memory care unit doors, to use the restroom. When asked if the memory care unit doors had a delay, she stated after leaving the unit it would delay but it was less than a minute. When asked in a staff interview on 6/3/2021 at 3:12 PM, the DON did not know for sure if they completed elopement assessments on everyone. She stated they should be doing them on admission but would need to ask the MDS coordinator. She came back and stated they transitioned from paper to an EHR on 5/1/2021 and Resident #1 would have had a paper assessment completed. When asked where it was because Resident #1's clinical record and EHR lacked an elopement assessment, she provided the resident's clinical record and a Wandering Assessment and stated they completed this on admission. When asked if they had an elopement assessment, she stated it had the same questions so they used that assessment. At 3:39 PM the MDS Coordinator and DON returned and the DON stated the facility updated the elopement/wandering policy on d 5/26/2021. The MDS Coordinator stated she previously completed wandering assessments on everyone that come to the facility. As of 5/26/2021, every resident had an elopement assessment completed, but previously they only did an elopement assessment if the wander assessment directed staff to do so (based on the responses to the questions.) When asked for the location of the elopements, she responded in the EHR since the transition of the new company, recently. They stated they transitioned from paper charting to electronic charting and will continue the assessments as they are due. The DON then commented that the wandering and elopement assessments were the same thing. When it was brought to her attention the paper wandering assessment did not include the following questions: has a history of or attempted elopement at home, history of or attempts to leave the facility without informing staff, resident verbally expressed the desire to go home pack belongings to go home or stayed near an exit door, she said its open to interpretation. In a subsequent interview on 6/3/2021 at 3:54 PM, the DON reported the previous policy directed staff to complete a wandering assessment for everyone upon admission and on 5/26/2021 they updated the policy to include the elopement assessments. The Regional Nurse Consultant verified the facility had not completed an elopement assessment upon Resident #1's admission. The Regional Nurse Consultant explained after the resident eloped, they reviewed the policy and determined they needed to implement elopement assessments and proceeded to complete one for all of the residents at that time on 5/26/2021. She reported after this initial assessment and going forward, staff will complete additional assessments for new admissions, readmissions, and when they do the MDS assessments. At 4:39 p.m., the Regional Nurse Consultant also verified the facility implemented a 1-1 staff person to stay with Resident #1 after she returned to the facility and would continue to provide 1-1 supervision for her safety until 6/4/2021 or 6/5/2021 when a wanderguard alarm is installed at the main entrance. After that time, the team will evaluate her need for continued 1-1 supervision. On 6/4/2021 at 9:10 AM, the Regional Nurse Consultant and Administrator reported the facility added bookcase wall coverings to the fire exit and double doors in the memory care unit and noted a decrease in the resident's attempts to leave the unit. With regard to wanderguards, if a resident scored high on the wandering assessment they would put a wanderguard on the resident or place them in the memory care unit. They would only apply a wanderguard if a resident on the unit engaged in exit-seeking behavior, otherwise, they would not. In a telephone interview on 6/8/2021 at 1:30 PM the State Climatologist reported a clear sky with no precipitation on 5/25/2021 at 6:30 PM, a temperature of 83 degrees Fahrenheit (F) with 30% humidity, and a NW wind at 10 miles per hour (MPH). At 7:30 PM, 76 F with 36% humidity and a 10 MPH wind from the N/NW. During the findings and exit meeting on 6/8/2021 at 10:30 AM, the facility reported the wanderguard installation at the main entrance continued and reinforced that Resident #1 remained under 1-1 supervision until they completed the alarm installation and still planned to review the resident's need for 1:1 supervision as a team after that. The updated Wandering and Elopement Policy dated 5/26/2021 defined wandering as the act of moving (walking or locomotion in a wheelchair) from place to place with or without a specified course or known direction. Wandering may or may not be aimless. The same policy defined elopement as when a cognitively impaired resident leaves the community/secured area without necessary authorization (i.e. an order for discharge or leave of absence) and/or necessary supervision to do so. The policy directed a licensed member of the clinical staff would complete a wandering/elopement risk evaluation tool for each resident to identify the level of risk which may lead to an elopement. The policy also directed when the staff would complete the assessment: upon admission or readmission, quarterly, upon a change in status/condition as it relates to unsafe wandering, after an elopement or elopement attempt or as required by state regulations. The facility was notified of the Immediate Jeopardy on 6/3/21. Upon further review, it was determined the facility abated the Immediate Jeopardy on 5/26/21 by implementing the following: a) The facility completed education regarding the elopement policy for all employees present and prior to the employee's next shift worked. b) Staff completed a new elopement risk assessment for all residents and revised the care plans of the residents identified as at risk for elopement by 5/26/2021. c) The facility reduced the 15 second delay on the memory care unit door to A 5 second delay on 5/26/2021. d) The facility added elopement education the new hire orientation list on 5/26/2021. e) Staff submitted a requested for relocation of the wanderguard censor on 5/26/2021. h) Facility management ordered wanderguards on 5/26/2021 and planned to apply them to residents that scored high on the wandering assessment and exhibited exit-seeking behaviors. i) The facility implemented 1:1 supervision for Resident #1 on 5/26/21 The facility also implemented the following corrective measures after the abatement date: j) The facility provided education to visitors to have staff escort them when they exit the facility. k) The facility initiated elopement drills on each shift daily for one week then 2 times weekly for 4 weeks. l) The facility changed the door code on 5/27/21 and implemented monthly scheduled door code changes for the future. m) Staff applied a bookcase themed wallpaper applied to both exit doors on the memory care unit on 6/1/2021 n) Observation on 6/4/2021 revealed the door company relocating the wanderguard sensor (which the facility requested on 5/26/21). :

Based on clinical record review, facility policy, and interviews, the facility failed to ensure 1 of 6 residents received kind and considerate care at all times and had been free from mental abuse. Staff interviews revealed while Resident #1 had been sitting on the toilet, Staff G made a video recording of Resident #1's bowel incontinent accident that was on the floor. Staff interviews revealed Resident #1's leg had been visible in the video. Staff interviews revealed Staff G posted the video recording on a social media site Snapchat sharing the video with Staff E and Staff A. Resident #1 did not recall the incident and a reasonable person would feel humiliated, degraded, and experience mental anguish knowing a staff had recorded their bowel incontinent accident while he/she had been sitting on the toilet and then shared the video on social media/with others. The facility failed to ensure staff displayed respect for Resident #1 when Staff G shared the video recording with others and Staff A then showed the video to two other staff (Staff C and Staff D). The facility reported a census 110 residents. Findings: The Minimum Data Set (MDS) assessment dated [DATE], identified Resident #1 had been [DIAGNOSES REDACTED]. The MDS indicated the resident needed limited assistance of 1 staff with transfer and toileting and frequently incontinent of urine. The MDS balance during transition and walking revealed Resident #1 did not walk or could not turn around and face the opposite direction while walking. A Brief Mental Status (BIMS) documented a score of 11. A score of 11 represented moderate cognitive impairment. Resident #1 used a wheelchair for mobility. A care plan with a focus area dated 4/87/16 identified alteration in activities of daily living (ADL) function and needed staff assistance. Resident #1's care plan directed staff to assist with transfer/s and toileting. The care plan identified Resident #1 had Major [MEDICAL CONDITION] (MDD) with psychotic symptoms, anxiety disorder, and dementia with behavioral disturbance. The resident's [DIAGNOSES REDACTED]. The care plan identified Resident #1 had altered thought process/cognitive loss, and the resident's physician determined the resident's dementia with behavior disturbance was an appropriate diagnosis. Progress notes dated 3/1/17 at 4:57 p.m. documented the resident received Magnesium [MEDICATION NAME] Suspension 800 milligrams (mg)/5 milliliters (ml) - give 30 ml as needed for the prevention of constipation, and to promote a bowel movement. The facility's investigation dated 3/2/17 identified Staff F had provided cares for Resident #1 when the resident had an incontinent episode of feces on the bathroom floor. Staff F asked Staff G to assist the resident while she left to obtain more supplies (and clean off her shoes). A facility investigation revealed at approximately 8:00 p.m. Staff G, a certified nursing assistant (CNA) recorded a video of loose stool (feces) in the bathroom. Allegedly, the video showed visible stool (feces) on the floor and a part of Resident #1's leg. According to staff reports, the video was then Snapchatted to two other employees. The facility's investigation identified Staff A reported she had received a Snapchat from Staff G on 3/1/17. The video showed loose feces on the floor and a part of the resident's leg. Staff A asked Staff G who the resident was in the video. Staff G identified Resident #1 by his/her first name. She responded oh nice and concluded the conversation. The investigation revealed Staff C (CNA) reported she saw the Snapchat video on Staff E's, CNA phone. She reported Staff E shared the video with her and Staff D, CNA while they were on break. On 3/2/17 at 3:00 p.m. Staff B, certified medication aide (CMA) reported she witnessed staff in the hallway discussing an incident that took place in the resident's bathroom. She asked staff what they were doing and Staff G, CNA showed her a video of feces on the floor which included a portion of Resident #1's leg. She directed staff to get back to work and they shouldn't being doing this. (Staff B notified the DON the next day and the facility timely reported the incident to the State Agency.) As part of the facility's investigation Staff G reported he went into the resident's room after another CNA stated there had been a big mess on the floor. Staff G reported he took a Snapchat video of the mess (bowel incontinence) and sent the video to two (2) other staff. Staff G reported the video had not been saved to his phone and was unaware if any other staff had seen the video. On 3/20/17 at 12:34 p.m., Staff F, CNA stated she worked the evening shift on 3/1/17. She had gone into Resident #1's room as he/she needed to use the bathroom. Staff F assisted Resident #1 from the bed and transferred him/her to a wheelchair. Staff F then assisted Resident #1 to the bathroom and to a standing position and lowered the resident's pants and brief. She started to assist the resident with sitting on the toilet when the resident became incontinent of bowel on the floor, and on her clothing (pants, socks and shoes.) Staff F assisted the resident with sitting on the toilet and called Staff G to stay with the resident so she could leave to clean her shoes and clothes. Staff G left the resident's room as soon as she had returned. Staff F cleaned the floor and dressed the resident in clean clothes. Staff F reported she had not been in the room when Staff G had taken the video. She reported she had not been sent the video or seen the video. During an interview dated 3/20/17 at 9:00 a.m., Staff A reported she did not work at the facility on 3/1/17 but received a Snapchat photo from Staff G around 8:30 p.m. to 9:30 p.m. Staff A reported the photo showed a resident's thigh and knee (Resident #1) and loose feces on the floor. The Snapchat had written message, A resident had a blowout. Staff A reported she texted Staff G and asked who the resident was in the photo and Staff G responded with Resident #1's (first) name. During an interview dated 3/20/17 at 12:55 p.m. Staff C reported she had been on dinner break with Staff D and Staff E (on 3/1/17). They were sitting at a table in the breakroom when Staff E shared the video with them. The video showed feces on the floor and toilet seat. Staff C reported the video had been inappropriate and wanted nothing to do with it. She reported she got up from the table and left the area. During an interview dated 3/20/17 at 9:50 a.m., Staff B reported she worked the evening of 3/1/17 as the medication aide on C-hall. She heard Staff F, CNA & Staff G, CNA telling other CNA's about Resident #1's diarrhea incident. Staff B stated Staff G walked up to her and showed her a video. Staff B reported Staff G laughed and said the resident had a huge mess and Staff F shoes had feces on them. The next day she reported the incident to the Director of Nursing. Staff B reported the resident is continent of bowel but had received a laxative earlier that evening and needed staff assistance for toileting. During an interview, Staff G, Certified Nurse Aide (CNA) stated on 3/20/17 at 2:10 p.m., he had been working at the facility for approximately 6 months. Staff G stated he routinely worked with Resident #1. Staff G stated the evening shift of 3/1/17 had been stressful and they were short 2 staff. While he walked down the hall, Staff F asked him for help. When he entered Resident #1's room, he saw Resident #1 resident standing in the bathroom with his/her pants and briefs around his/her ankles. Staff G stated he took a short video, recording of the floor from the sink to the toilet. Staff G did not remember if the video included a portion of the resident's body however he remembered both Resident #1 and Staff F being present during the video recording. According to Staff G, other staff came in and looked at the bathroom; though he can't remember who. Staff G stated he sent a Snapchat video and text message saying The Daily Life of a CNA to Staff A & Staff E. Staff G stated he used poor judgement in making a video and sharing it with others. He reported the incident was, in a way, funny. During an interview dated 3/16/17 at 1:45 p.m. the Director of Nursing reported Staff G stated he didn't know why he took the video (of Resident #1). The DON stated she expected staff, including Staff G to perform their duties in a professional manner. The DON stated she expected staff to follow the facility's policy not to take photos or videos of residents. She stated Staff G used poor judgement when he took the video of Resident #1 and the incontinent episode. According to the Employee Recognition Report Concern Report dated 3/3/17, Staff G had taken a video of a resident (Resident #1) bowel moment that showed a small portion of the resident's leg-knee area. Staff G had shared a video with co-workers. Staff G documented he was unaware of the extent of his actions. Snapchat is a video messaging application whereas using the user can take photos, record videos, add text and drawings. The sent videos are known as Snaps.Snapchat community guidelines directed their users to keep it legal and directed users to not take Snaps of people without their knowledge or consent. The community guidelines address invasion of privacy and urged their users to not take Snaps of people not to violate their privacy in spaces, like bathrooms. The community guidelines did not address humiliation. The facility investigation revealed all staff had been educated on the new abuse policy on 9/9/16. Staff were again re-educated on the new abuse policy on 12/20/16. The facility's Abuse Prevention, Identification, Investigation and Reporting Policy dated 12/21/16, identified all residents had the right to be free from abuse and should not be subject to abuse by anyone including but not limited to the facility staff. The policy identified mental abuse is not limited to humiliation and mistreatment meant inappropriate treatment of [REDACTED]. The policy revealed the following under the Federal Certification Guidelines: distribution of photographs or recording on social media which showed a resident in a compromised position, including showing the limbs or labeling a resident's picture, providing comments, keeping unauthorized photographs, recordings or distribution through multimedia and or social media networks. The policy noted for resident to resident abuse, the facility will presume instance of abuse caused mental anguish in residents with cognitive impairments which may result in a resident unable to communicate mental anguish in the absence of evidence to the contrary. The facility investigation dated 3/2/17 identified the following: Resident #1 had been assessed for physical injuries with no concerns noted. When interviewed, Resident #1 did not recall any situation from the prior evening of staff being inappropriate. The resident's legal representative had been notified. Staff G had been immediately removed from working with residents. Any staff involved with this situation were verbally counselled by the DON on 3/2/17 and the abuse policy was reviewed with them on 3/3/17. The quality assurance (QA) nurse re-trained all staff from 3/2/17 to 3/6/17 on reporting allegations of abuse timely and the abuse policy regarding the Federal definition of Abuse. All staff were provided a copy of the abuse policy specifically the Federal definition section on mental abuse/taking photograph/s and or making a recording that depicted a resident in a demeaning manner while toileting, showering, showing a body part of a limb/s, labeling a resident's picture and or providing comments that would show a resident in a comprising position. The facility continued to monitor staff regarding the abuse policy. The investigation identified the facility corrected the noncompliance prior to the arrival of this investigation and there was sufficient evidence the facility was in substantial compliance on 3/6/17.

Based on observation, record review and staff interviews, the facility failed to provide adequate supervision to prevent accidents and failed to provide services in order that each residents ' needs are met for 1 of 5 residents reviewed (Resident #1). The facility reported a census of 103 residents. Resident #1 was taken to the dining room on 9/5/2011 for the noon meal. Staff G left the resident in the dining room without staff in the dining room. The resident did not receive adequate supervision and fell out of the wheelchair. The resident was identified as a fall risk and the plan directed staff to use an alarm to alert staff when the resident attempted to rise from the chair. The chair alarm did not activate and the resident was found on the floor in the dining room. No staff were present at the time of the fall. The resident fractured the second cervical (neck) vertebrae. Findings include: 1. Resident#1 had a Minimum Data Set (MDS) assessment, with a reference date of 8/29/11, which identified [DIAGNOSES REDACTED]. The MDS documented the resident required extensive assistance of two staff members for transfers, toileting, and extensive assistance of one staff person for bed mobility, dressing, and personal hygiene. The assessment reflected the resident to be unsteady at all times and did not ambulate. The MDS revealed Resident #1 had one fall since admission. The Fall Risk Agreement Form dated 8/2/11 identified the resident had a score of 10 which represented a high risk for falls (total score of 10 or greater represents high risk for falling). On 9/15/11, the resident had a score of 13. The Care Plan of 8/2/11 identified a problem with falls due to noncompliance, uncooperative and confusion. The resident currently working with therapy for strength and mobility. An intervention dated 8/3/11 directed the staff to use an alarm. The Accident/Incident Report dated 9/5/11 at 12:20 p.m. indicated the staff found the resident in the dining room. Kitchen staff stated the resident fell forward and out of the chair, hitting head. The resident stated had attempted to get up for a drink of water. Staff documented the resident had no apparent injury at the time and with 24-hour follow up. The Skilled Nurse's Notes dated 9/5/11 at 12:35 p.m. indicated when the nurse arrived, Resident #1 lay on the floor on his/her left side. The resident had full range of motion (ROM) with all extremities, complained of head pain and had no symptoms of injury. Staff initiated cranial checks and found the checks within normal limits for the resident. The resident received Ultram (analgesic) for pain. The notes of 9/6/11 at 11:22 a.m. documented a 24 hour post fall assessment done at that time. The resident continued to complain of headache, especially in back of the head. Staff faxed the resident's physician and spoke with a nurse working for that physician. At 11:56 a.m. staff from the physician's office called the facility and ordered Resident #1 to be seen in emergency room . The resident left the facility at 12:10 p.m. Review of the resident's History and Physical dated 9/6/11 revealed Resident #1 had a history of [REDACTED]. The same document revealed a Cat Scan (CT) of the head and neck that demonstrated a C2 fracture (cervical neck vertebrae #2). On 9/19/11, at 11:15 a.m., Staff G, CNA (Certified Nursing Assistant) stated she attended to Resident #1 in his/her room when his/her personal alarm sounded and she found the resident standing. Staff G stated she replaced the alarm, assisted the resident into the dining room, locked the wheelchair brakes and left the resident up at the table. Staff G then returned to answer lights and get residents up for lunch. Staff G stated she saw a couple of residents in the dining room when she left Resident #1 and thought a dietary aide had been in the dining room; but then stated couldn ' t remember. Staff G thought she turned the alarm on when she replaced it and she stated she felt the dining room to be the safest place at that time. She stated they normally have the dining room covered with staff, it had been early and Resident #1 was one of the first residents to get up and taken into the dining room. Staff G further stated staff are expected to supervise residents when are at risk for falling. Resident #1 usually sits in a Geri chair because he/she is so tall and would slide out of the wheelchair. Staff G stated the wheel had been broken and the resident had been using a wheel chair while the Geri chair was being repaired. During an interview on 9/19/11 at 4:00 PM, Staff J, Dietary Aide (DA) stated when he entered the dining room a resident pointed to Resident #1, lying on the floor and no other staff around. Staff J stated prior to the fall, the resident had been pushing on the table, trying to get up. Staff J remembered requesting the resident to wait, stating a nurse would be right in and he returned to the kitchen. Staff J stated he went to the hall immediately, saw a nursing assistant and told her that Resident #1 was lying on the floor. During an interview on 9/19/11 at 2:50 PM, Staff K, CNA stated she did not witness the fall; she found out from the dietary aide and she immediately went into the dining room. Staff K found Resident #1 on the floor, face down and lying to the left side. Staff K stated she got the charge nurse right away. After the nurse completed the assessment, the staff assisted the resident into the chair. During an interview on 9/19/11 at 2:15 PM, Staff I, Licensed Practical Nurse (LPN) stated she found Resident #1 on the floor lying toward his/her left side with left arm under, face down and head on the floor. Staff I stated she completed her assessment and found full range of motion and only had a head ache. Staff I stated she found the pressure alarm in the off position and not sounding. Staff I stated after her assessment, staff completed a 2-man lift into the chair and she administered an analgesic for the headache. Staff I further stated when a resident is at risk for falls, they are to be observed or in their bed. Staff I stated she activated the alarm for the resident after transferring the resident into the chair. During an interview on 9/19/11 at 2:30 PM, Staff L, Certified Medication Aide (CMA) stated if a resident is at risk for falling, they are not to be left alone, staff are expected to supervise them when they are at risk and set them in the hall or close to the nursing station where nursing staff can see them. During an interview on 9/19/11 at approximately 4:00 PM, the Director of Nursing (DON) stated when a resident is at risk of falling she expects her staff to place the resident in a safe place where supervision can be provided. During an observation on 9/20/11 at 7:40 AM, Staff M, CNA and Staff N, CNA completed a transfer with use of a wheeled walker and the assistance of 2 staff persons and placed the resident into a Geri chair. Staff provided grooming and positioning and a C-Collar (cervical collar) remained in place the entire observation period. During an interview on 9/27/11 at 9:50 AM, the resident's Primary Care Physician stated and completed a form which identified the resident had a major injury.