Every finding on record at Bayside Manor LLC

Based on observation, interview, and document review the facility failed to ensure staff followed sanitary guidelines on appropriate food handling during 1 of 1 meal service. This had the potential to affect all 29 residents who received meals served from the kitchen. Findings include: Observations on 12/9/25 of the noon meal service identified multiple incidents of potential cross contamination. At:12:00 a.m., Cook-A applied gloves and arranged serving utensils on top of the covered steam table pans. She removed the covers from the food items on the steam table and picked up a plate, picked up the individual menu choice slip and plated food items which were them placed on the tray to be delivered by dining room staff. 12:08 p.m., she picked up a menu slip, read it and placed it on the tray located on top of the steam table shield. Wearing her same gloves she went to the refrigerator, opened the door with her gloved hands, retrieved 1/2 an unwrapped sandwich with her same gloved hand and returned to the steam table where she placed the sandwich on the plate, and continued with serving the meal foods. Cook-A used a scoop to dish up chicken nuggets which she put on a plate, and using her same gloved hands, held the nuggets with her left gloved hand as she cut them into bite sized pieces with a knife, she picked up from the ledge area of the steam table. At 12:09 p.m. she used her right gloved hand and pushed up her glasses and returned to serving without any glove change or hand hygiene. Cook-A continued with serving as she picked up a breadstick with her same gloved hand and placed it on the plate with the cut-up chicken pieces. 12:11 p.m., she repeated the process of scooping chicken nuggets onto a plate and using her same gloved hand to hold and cut up the chicken. She repeated this process several times, with no glove change or hand hygiene. At 12:12 p.m. she again pushed up her glasses with her same gloved hands and continued to repeat the same process of serving. 12:16 p.m. cook-A again went to the refrigerator, opened the door with her same gloved hands, retrieved a tray containing dishes of pears and returned to the steam table where she placed the tray of pears to be included on the trays being served. Still no glove change or hand hygiene performed. Cook-A continued the same process of using her same gloved hands to hold and cut the chicken into bite size pieces as she prepared each plate of food. 12:18 p.m. cook-A picked up a small container of cranberry sauce she reported she had forgotten to place on a resident's tray and took it into the dining room where she placed it onto a resident's plate. She returned to the kitchen, picked up a dish of pears and returned to the dining room and placed it on a resident's tray. Cook-A returned to the kitchen, still no glove change or hand hygiene and resumed her process of picking up a plate, scooping and cutting up chicken nuggets and dishing other food items onto the plate, and delivered it to the dining room and placed on the table for a waiting resident. Upon return to the kitchen without changing her gloves or performing hand hygiene she resumed serving from the steam table. She repeated this process two more times without glove change or hand hygiene. 12:25 p.m. cook -A reported there were only 2 more residents needing to be served, and she proceeded to repeat her process of holding chicken with her gloved hand as she cut it up, picked up a breadstick and placed it onto the plate and placed the plate on the tray to be taken to the dining room. 12:30 p.m., she returned to the steam table, used a tong to pick up an un-breaded chicken breast from a container on the steam table, placed it on a plate and using her same gloved hands picked up a knife and used to left hand to hold the chicken as she cut it into bite sized pieces. Interview on 12/9/25 at 12:31 p.m. with cook-A reported this was her normal routine. She normally washed her hands before the meal service and applied gloves when she began serving a meal. She would use the same pair of gloves throughout the meal services without changing her gloves and performing hand hygiene. She confirmed did not usually change her gloves or perform hand hygiene during the serving process after completing specific tasks. When staff were busy, she assisted by delivering plates to residents in the dining room and was not aware of the potential of cross contamination from going out of the kitchen or using her same gloved hands to touch other items ant then food during the serving process. Interview on 12/9/25 at 12:35 p.m. with the certified dietary manager (CDM) identified he was not aware cook-A was not changing her gloves or performing hand hygiene when she touched potentially contaminated items such as the refrigerator door, or other items in the kitchen. Cook-A should not be leaving the steam table to deliver trays to residents and agreed she should have changed her gloves and performed hand hygiene before returning to resume serving food if she left the steam table to retrieve items from another area of the kitchen. He expected food service employees followed policies for safe food handling and hand hygiene practices. Review of the April 2019 Food Preparation and Service policy identified appropriate measures were to be utilized to prevent potential cross contamination. Food service staff were to ensure hand hygiene and infection control practices were followed to prevent the potential of food borne illness. The policy identified gloves were to be worn when handling food directly and changed between tasks. The policy failed to identify gloves should be changed and hand hygiene performed if the person serving handled other items or food and especially if the person serving left the kitchen and then returned to resume serving the meal.

Based on interview and document review, the facility failed to have a current, ongoing system of surveillance for preventing, identifying, reporting, investigating, and controlling infections and communicable diseases that included facility staff. This had the ability to affect all 29 residents. Findings include: EMPLOYEE SURVEILLANCEReview of the current Staff listing with Title identified a total of 57 current facility staff: 1 administrator, 1 business office manager (BOM), 18 NA's, 9 DA's. 6 cooks (C), 1 DM, 1 director of nursing/infection preventionist (DON), 1 health information management staff (HIM), 1 licensed practical nurse (LPN), 1 LPN coordinator, 1 maintenance assistant, 1 maintenance director, 7 nurse aides in training, 2 registered nurses (RN),1 RN manager, 1 social worker (SW), 1 AA, and 1 AA director (AAD). Review of the employee surveillance data sheet for the past year, that the facility identified was used as the employee infection control (IC) tracker, labeled Staff Illnesses was used to capture employee illnesses or other reasons for absenteeism from work. The list captured only 22 of the current 57 facility staff and had 1 previous employee listed: 1 dietary manager (DM), 1 health information assistant (HIM), 12 nurse aides (NA) (including former staff member (NA-C)), 1 activity aide (AA-A), 4 unknown staff, and 1 dietary aide (DA).The form noted each staff member, the location they worked and absences numbered 1 through 8. Staff absences were noted on the form for dates and reason for the absence. The document was shared to all department heads, who were expected to fill out the form for their respective employees. The form had limited data. Sampled staff data that was captured was as follows:Activity Aid (AA)-A, was noted to be COVID positive and was absent from work on 2/13/25 through 2/19/25. No other data was captured. Nursing assistant (NA)-A who was noted to be absent from work on 1/2/25 and had body aches listed. NA-A was also listed as absent on 2/1/25, with nausea/vomiting. No other data was captured for the illnesses.NA-B was noted to have diarrhea and was absent from work on 12/27/25. No other data was captured for the illness. The Staff Illnesses log failed to include surveillance of all staff, identify critical data such as the date of symptom onset, the last date worked, the location or unit the staff had last worked, when symptoms had resolved, the date they were allowed to return to work, or what national standards the facility would use to determine appropriateness for the above staff to return to work. Interview on 12/9/25 at 9:27 a.m., with the dietary manager (DM) identified when staff call in and report illnesses, he would complete a form and list the employees name, department they worked in, and their symptoms. He then gave that form to an (unidentified) office person. He was unable to recall what staff he would give the form to. Interview on 12/9/25 at 9:40 a.m., with the licensed practical nurse (LPN)-A identified when staff call in for their shift and report illness, he would the staff ask about their symptoms. He would then report the staff illness call-in and symptoms to the scheduler, so the facility could attempt to cover the shift. He was aware staff should not return to work at least 24 after a fever has resolved or 72 hours after nausea, vomiting, or diarrhea resolved. LPN-A was unaware of any guidance or direction from management to advise an employee about when they could return to work. Interview on 12/9/25 at 10:03 a.m., with the administrator identified she was not aware of the form that the facility was using for staff illness and did not know who the dietary manager (DM) would be submitting his employee absence forms to. She expected supervisors of each department to use the staff log noted above to document staff illnesses and absences. In addition, she would expect the infection preventionist (IP) to incorporate staff illness reports into her infection control (IC) program for surveillance. She was not aware prior to the survey that the infection preventionist was not using that log for surveillance of staff illnesses. She noted staff were to follow the employee handbook for return-to-work guidance. Interview on 12/8/25 at 7:44 p.m., with the infection preventionist and the nurse consultant identified staff were to call in to their unit supervisor for absences. The call-in were to be logged onto the shared Staff Illness document mentioned above. She tried to look at it at least once a week. She does not monitor call ins from other departments as much as I should. The November 2024, Infection Prevention and Control Program policy identified the facility would use surveillance tools for recognizing the occurrence of infections, monitoring employee infections, and detecting unusual pathogens with infection control implications. The information obtained from infection control surveillance activities will be reviewed month over month and compared with that from the facilities baseline and used to assess the effectiveness of established infection prevention and control practices. Standard criteria are used to distinguish community-acquired from facility acquired infections. Data gathered during surveillance was used to oversee infections and spot trends. The Facility was to have established policies and procedures regarding infection control among employees, contractors, vendors, visitors, and volunteers, including situation when these individuals should report their infections or avoid the facility (for example, draining skin wounds, active respiratory infections with considerable coughing and sneezing, or frequent diarrheal stools). There was no mention of standards of practice that were to be used to determine the appropriate length of time employees should be prohibited from work or criteria to return to work, if all staff were captured, nor critical data required in order to comprehensively oversee surveillance. Review of the current, undated, Employee Handbook, page 55 provided identified staff who were out sick or on an extended leave must ensure adequate communication with their manager so an anticipated return to work date and/or time has been discussed. There was no mention of standards of practice that were to be used to determine the appropriate length of time employees should be prohibited from work or criteria to return to work.

Based on observation, interview and document review the facility failed to destroy expired over the counter medication (OTC) for 1 of 2 sampled medication rooms. In addition, the facility failed to ensure 1 of 1 resident's (R10) lorazepam (anti-anxiety medication) was immediately removed from 1 of 2 medication carts and not co-mingled and stored with in-use medications for other residents. Findings include: Observation and interview on 12/08/25 at 12:25 p.m., of 1 of 2 sampled medication rooms located across from the dining room with registered nurse (RN)-B, identified over the counter (OTC) medications and house stock medications that was both in bottles stored in multiple plastic bags and in blister packs. The medications were placed in a pile on the counter in the medication room. RN-B identified the nurse consultant from the local pharmacy had visited the facility last month for a routine visit. The consultant completed an audit of the medication carts and medication room and found expired medications that were placed in the medication room to be destroyed by the nursing staff. In addition, the facility implemented assigning an overnight nurse to complete medication destruction as a part of their duties, however, the nurse no longer worked at the facility. Day shift staff nurses were informed to complete medication destruction as a part of their duties, when available, however, the OTC medications remained in the medication room and had not been destroyed. Review of December 2025 Medication Destruction/Return log of the above identified medications waiting for destruction listed: 1) House stock loratadine (used to treat allergies) 10 milligrams (mg). The quantity total was 267 tablets.2) House stock of aspirin (pain reliver) 325 mg. The quantity total was 100 tablets. 3) House stock of Prostat liquid supplement (liquid protein used for wound healing) bottle. The quantity was 30 ounces.4) OTC vitamin B6 (multivitamin) 25 mg. The quantity total was 100 tablets. 5) OTC docusate (used to treat constipation) 100 mg. The quantity total was 68 tablets.6) OTC ibuprofen (pain reliver) 200 mg. The quantity total was 54 tablets.7) House stock of apple cider vinegar (used for weight loss, blood sugar regulation, and digestive health) 300 mg tablets. The quantity was 250 tablets.8) House stock of glucosamine and chondroitin (used to treat joint pain) 750/600 mg supplements. The quantity was 250 tablets.9) OTC guaifenesin (cold medicine used to help clear mucus) 400 mg. The quantity was 100 tablets. 10) OTC zinc (used to treat immune system and wound healing) 50 mg. The quantity was 100 tablets.11) OTC cetirizine (used to treat allergy medication) 10 mg. The quantity was 3 tablets.12) OTC magnesium oxide (used to treat indigestion, upset stomach, or constipation) 400mg. The quantity was 15 tablets. Review of undated continuous Non-Controlled Drug Destruction Inventory sheet for medication awaiting destruction identified: 1) OTC magnesium oxide (supplement used to treat migraines and constipation) 400mg. The quantity was 15 tablets.2) OTC melatonin (used to treat insomnia) 1 mg. The quantity was 16 tablets. Observation and interview on 12/08/25 at 12:40 p.m., with RN-B during a controlled narcotic count on the medication cart assigned to the Oak wing identified R10 had one blister pack containing lorazepam. Review of the pharmacy label on the lorazepam blister pack order was to give 0.5 milligram (mg) tablet once with an RX # 403171669 and an expiration date of 6/27/25. The narcotic was found to be expired 164 days after the order was discontinued. Review of the Controlled Drug Receipt/Record/Disposition form for R10's lorazepam noted it had been received on 6/28/24. RN-B acknowledged R10's narcotic was discontinued and remained in the double locked medication cart, as directed until the medication was to be destroyed. RN-B stated R10 was admitted [DATE]. Review of June 2024, Medication Administration Record (MAR) identified R10 had taken 0.5 mg, 1 tablet as needed for anxiety 30 minutes prior to dental/vision/doctor appointments on 6/27/24 at 08:47 a.m. The order date was ordered on 1/25/24 and was discontinued on 5/07/25. R10's medication was not removed after the medication was discontinued and remained in the cart and remained co-mingled with in-use medications for other residents. Interview on 12/10/25 at 3:01 p.m., with RN-C, who is a nurse consultant for Polaris pharmacy identified, she had last visited the facility on 11/24/25 to complete her quarterly medication audits. During her visit to the facility, she would perform audits on the medication carts, medication rooms and observation of medication administrations. Once her audits were completed, she was to provide a copy of her audits to the director of nursing (DON) of her findings. She acknowledged it was not uncommon to find expired medications, however, the audits were completed to ensure the facility was aware of her findings. Review of RN-C's Polaris Rx Medication Unit Review sheet audit identified on: 1) 10/09/25, under Nurse Cart identified melatonin was expired on 11/2025 and loratadine was expired on 10/2025.2) 10/09/25, under Section D. Narcotic Records Review that R10 had expired lorazepam dated 6/27/25.3) 11//24/25, under additional comments identified aspirin 325 mg was expired on 8/2025 and 10/2025, vitamin B6 was expired on 5/2025, 8/2025, and 11/2025, stool softeners was expired on 9/2025 and magnesium oxide tablets was expired on 8/2025. Interview on 12/10/2025 at 4:24 p.m., with director of nursing (DON) identified the facility did not have a process in place for licensed nursing staff, including nurse managers to review on a routine basis and destroy medications when they are found to be expired or discontinued. Her expectation would be to revise and implement addition assignment for nurses working on the day shift to complete medication destruction, in a timely manner of expired or discontinued medications. Review of May 2022 Medication Destruction for Non-Controlled Medications policy identified the facility was to remove unused, unwanted and non-returnable medications to a secured storage area until destroyed. The licensed healthcare professional witnessing the destruction of medications on the medication disposition form must ensure the date of destruction, resident's name, name and strength of medication, prescription number, amount of medication destroyed, and signature of witnesses. Review of May 2022 Controlled Substance Disposal policy identified the facility's director of nursing, along with consultant pharmacist was responsible of the facility's compliance with Federal and State laws and regulations with handling of controlled medications. Controlled medications that was to remain in the facility after a resident has been discharged or the medication order was discontinued was disposed of in the facility by the administrator, director of nursing and/or consultant pharmacist, by returning to the Drug Enforcement Administration (DEA), or retained for destruction by an agent of the DEA, or send to the appropriate state agency or pharmacy as directed. When controlled medication was destroyed the facility, licensed staff as allowed by state law was to witness the destruction and ensure the information was recorded in the individual controlled substance accountability record/book.

Based on interview and document review, the facility failed to ensure the administrator and State Agency (SA) were notified within 2 hours of an allegation of physical and verbal abuse for 1 of 1 resident (R27). Findings include: Review of the 12/1/25 at 9:14 a.m., report to the State Agency (SA) identified on 11/30/25 at around 5:00 p.m., NA-C was assisting to turn R27 with NA-D and NA-E when he placed his hand on NA-E's breast. NA-C responded by smacking R27's hand away and raised her voice at him. NA-D reported the incident to the charge nurse, who notified the director of nursing (DON) (identified had received the call at 4:36 p.m.). The DON instructed RN-D to have the NAs provide a written statement and place it under the DON's office door for review the next morning. Review of NA-C's 11/30/25, timecard identified she continued to work her assigned shift providing patient care until the end of her shift at 10:30 p.m. There was no indication the facility administrator was notified of the incident until 8:00 a.m. on 12/1/25. NA-C was later suspended on 12/1/25 following notification of the administrator and pending the investigation. Review of the 12/5/25, 5-day investigation results identified the facility staff interviewed multiple residents and staff and there were no additional allegations of mistreatment by NA-C. Both NA-D and NA-E who were present with NA-C during the incident on 11/30/25 confirmed she had raised her voice at R27. The facility confirmed verbal abuse took place, but due to conflicting staff statements and R27's inability to participate in the interview process, (due to his impaired cognition), physical abuse was not substantiated. Following completion of the investigation the facility terminated NA-C's employment following interview on 12/4/25 due to substantiated verbal abuse. R27's 12/8/25, Significant Change Minimum Data Set (MDS) assessment identified his cognition was moderately impaired. He required extensive assistance with activities of daily living (ADLS), required the assistance of 2 staff for transferring with a mechanical lift, and utilized a Broda type wheelchair (a specialized, ergonomic mobility device known for exceptional comfort, posture support and pressure relief), and was transported by staff. He had diagnoses of Dysarthria (a motor speech disorder that makes it hard to articulate works clearly), following a stroke, had cognitive communicative deficit, and mild cognitive impairment. R27's current, undated care plan identified alteration in communication due to cognitive communication deficit and cerebral infarction. R27 was identified to be a vulnerable adult, therefore at risk of abuse due to decreased cognition and physical abilities. Staff were to monitor him for emotional distress and mood and/or behavioral changes and follow facility abuse reporting policy. Interview on 12/9/25 at 4:55 p.m. with the DON reported RN-D phoned her on 11/30/25 at 4:35 p.m., to report the incident and stated the situation was chaotic and everyone was busy. She confirmed with staff R27 was not harmed, and then requested RN-D to have the involved staff write a statement and place it under her office door for review upon arrival the morning of 12/1/25. She reported she did not think of the incident as potential or actual abuse at that time. Upon arrival on 12/1/25, the DON reported she reviewed the written statements. At that time, she became aware of the allegation NA-C had smacked R27's hand and raised her voice. She then reported the incident to the administrator on 12/1/25 at 7:44 a.m The administrator had immediately informed her she should have been notified immediately on 11/30/25 and re-educated her on the steps for reporting an alleged abuse situation and protecting residents. It was confirmed NA-C had finished working her shift providing resident care, and no action was initiated until the following morning. The investigation was initiated with appropriate notifications completed, and interviews of residents and staff. The DON confirmed NA-C had been allowed to finish working her shift on 11/30/25 providing residents' their care and had not been suspended until following notification to the administrator on 12/1/25. Interview and timecard review on 12/09/25 at 3:04 p.m., with the administrator and regional director of operations (RDO) confirmed the incident occurred on 11/30/25 at 5:00 p.m The DON was phoned and updated, but the administrator was not notified until 12/1/25 a.m The employee involved continued to work providing residents' care for the remainder of her shift. She was not placed on suspension until 12/1/25 following review of documentation by the DON and administrator. The report was filed to the SA on 12/1/25 at 9:14 a.m., (16 hours after the incident was reported). They both confirmed the alleged incident was abuse and should have been filed within 2 hours of notification of the incident, the administrator notified immediately, and any staff members suspected of potential or actual abuse were to be suspended immediately and not allowed to finish the remainder of their shift. Review of NA-C's timecard identified she was terminated related to the substantiated allegation of verbal abuse, effective 12/4/25. Review of NA-C's personnel file identified a final warning had been issued August 2, 2025, for misconduct regarding a Vulnerable Adult report. Following the substantiated verbal abuse allegation NA-C's employment was terminated on 12/4/25. Review of NA-C's timecard identified she had worked the remainder of her scheduled shift on 11/30/25, but no additional shifts were identified. Interview on 12/09/25 at 3:27 p.m. with NA-E confirmed the report that R27 reached out and placed his hand on the side of her breast. She responded by telling him that was inappropriate and pulled his hand away and placed it on his chest. She did not think he did it intentionally as he was afraid of falling and would attempt to grab or hold on to objects or people when being turned toward the edge of the bed. NA-E was focused on keeping R27 on the bed. She did report NA-C had spoken loudly to R27 as they were working with him. Interview on 12/9/25 at 3:37 p.m., with RN-B reported she was familiar with NA-C and there had been incidents of her attitude, which she defined as a negative acceptance of provided education. NA-C became defensive when coaching was provided. RN-B reported she was not aware of any additional complaints of mistreatment from residents or staff related to NA-C. RN-B confirmed she was aware of the policy for abuse. Interview on 12/10/25 at 3:54 p.m., with NA-C reported she had been assisting NA-E with R27, and NA-D was observing because she was training. As he was being changed, R27 reached over placed his hand on NA-E's breast. She reported NA-E was upset and told R27 not to do that. She intervened and reached over and tapped his hand. She stated she did not hit him hard and denied raising her voice. She did not know why she was being investigated for this incident and reiterated she had only tapped him on his hand and denied hitting or yelling at him. Attempts to contact RN-D were made on 12/9/25 at 3:30 p.m. and again 12/10/25 at 3:00 p.m. without success and unable to leave a voice mail requesting a return call. Attempts to contact NA-D were made on 12/9/25 at 3:35 p.m. and again on 12/10/25 at 4:30 p.m. without success and unable to leave a message requesting a return call. Review of the November 2025 Abuse Prohibition/Vulnerable Adult Policy identified staff were to notify the supervisor and facility administrator immediately and take necessary steps to protect residents from any possible subsequent incidents of misconduct. An incident that alleged staff to resident abuse directed the involved staff member was to be suspended until the investigation was completed, in addition to notification of corporate Human Resources. Abuse was defined as willful, meaning the individual acted deliberately, not necessarily intending to cause injury or harm the vulnerable adult. Suspected abuse was to be reported to the SA within 2 hours of being informed of the allegation of abuse. Review of the undated Monarch Abuse Prohibition/Vulnerable Adult Policy identified staff were to identify and intervene for any potential abuse situations. Staff were also responsible for reporting any situation that could be considered abuse according to facility policy and procedure. The supervisor was to be notified immediately upon becoming aware of an alleged incident to determine any actions necessary. If the incident was an alleged staff to resident occurrence the staff person was to be immediately suspended pending completion of the investigation in addition to notification of HR, the facility administrator was to be notified immediately for incidents of actual or alleged resident abuse, injury of unknown origin, neglect, financial exploitation, or involuntary seclusion. Suspected abuse was to be reported to the SA using the online reporting process not later than 2 hours after the notification of suspected abuse.

Based on interview, document review, the facility failed to ensure 1 of 1 resident (R27) was free from verbal abuse. Findings include: Review of the 12/1/25 at 9:14 a.m., report to the State Agency (SA) identified on 11/30/25 at around 5:00 p.m., NA-C was assisting to turn R27 with NA-D and NA-E when he placed his hand on NA-E's breast. NA-C responded by smacking R27's hand away and raised her voice at him. NA-D reported the incident to the charge nurse, who notified the director of nursing (DON) (identified had received the call at 4:36 p.m.). The DON instructed RN-D to have the NAs provide a written statement and place it under the DON's office door for review the next morning. Review of NA-C's 11/30/25, timecard identified she continued to work her assigned shift providing patient care until the end of her shift at 10:30 p.m. There was no indication the facility administrator was notified of the incident until 8:00 a.m. on 12/1/25. NA-C was later suspended on 12/1/25 following notification of the administrator and pending the investigation. Review of the 12/5/25, 5-day investigation results identified the facility staff interviewed multiple residents and staff and there were no additional allegations of mistreatment by NA-C. Both NA-D and NA-E who were present with NA-C during the incident on 11/30/25 confirmed she had raised her voice at R27. The facility confirmed verbal abuse took place, but due to conflicting staff statements and R27's inability to participate in the interview process, (due to his impaired cognition), physical abuse was not substantiated. Following completion of the investigation the facility terminated NA-C's employment following interview on 12/4/25 due to substantiated verbal abuse. R27's 12/8/25, Significant Change Minimum Data Set (MDS) assessment identified his cognition was moderately impaired. He required extensive assistance with activities of daily living (ADLS), required the assistance of 2 staff for transferring with a mechanical lift, and utilized a Broda type wheelchair (a specialized, ergonomic mobility device known for exceptional comfort, posture support and pressure relief), and was transported by staff. He had diagnoses of Dysarthria (a motor speech disorder that makes it hard to articulate works clearly), following a stroke, had cognitive communicative deficit, and mild cognitive impairment. R27's current, undated care plan identified alteration in communication due to cognitive communication deficit and cerebral infarction. R27 was identified to be a vulnerable adult, therefore at risk of abuse due to decreased cognition and physical abilities. Staff were to monitor him for emotional distress and mood and/or behavioral changes and follow facility abuse reporting policy. Interview on 12/9/25 at 4:55 p.m. with the DON reported RN-D phoned her on 11/30/25 at 4:35 p.m., to report the incident and stated the situation was chaotic and everyone was busy. She confirmed with staff R27 was not harmed, and then requested RN-D to have the involved staff write a statement and place it under her office door for review upon arrival the morning of 12/1/25. She reported she did not think of the incident as potential or actual abuse at that time. Upon arrival on 12/1/25, the DON reported she reviewed the written statements. At that time, she became aware of the allegation NA-C had smacked R27's hand and raised her voice. She then reported the incident to the administrator on 12/1/25 at 7:44 a.m The administrator had immediately informed her she should have been notified immediately on 11/30/25 and re-educated her on the steps for reporting an alleged abuse situation and protecting residents. It was confirmed NA-C had finished working her shift providing resident care, and no action was initiated until the following morning. The investigation was initiated with appropriate notifications completed, and interviews of residents and staff. The DON confirmed NA-C had been allowed to finish working her shift on 11/30/25 providing residents' their care and had not been suspended until following notification to the administrator on 12/1/25. Interview and timecard review on 12/09/25 at 3:04 p.m., with the administrator and regional director of operations (RDO) confirmed the incident occurred on 11/30/25 at 5:00 p.m The DON was phoned and updated, but the administrator was not notified until 12/1/25 a.m The employee involved continued to work providing residents' care for the remainder of her shift. She was not placed on suspension until 12/1/25 following review of documentation by the DON and administrator. The report was filed to the SA on 12/1/25 at 9:14 a.m., (16 hours after the incident was reported). They both confirmed the alleged incident was abuse and should have been filed within 2 hours of notification of the incident, the administrator notified immediately, and any staff members suspected of potential or actual abuse were to be suspended immediately and not allowed to finish the remainder of their shift. Review of NA-C's timecard identified she was terminated related to the substantiated allegation of verbal abuse, effective 12/4/25. Review of NA-C's personnel file identified a final warning had been issued August 2, 2025, for misconduct regarding a Vulnerable Adult report. Following the substantiated verbal abuse allegation NA-C's employment was terminated on 12/4/25. Review of NA-C's timecard identified she had worked the remainder of her scheduled shift on 11/30/25, but no additional shifts were identified. Interview on 12/09/25 at 3:27 p.m. with NA-E confirmed the report that R27 reached out and placed his hand on the side of her breast. She responded by telling him that was inappropriate and pulled his hand away and placed it on his chest. She did not think he did it intentionally as he was afraid of falling and would attempt to grab or hold on to objects or people when being turned toward the edge of the bed. NA-E was focused on keeping R27 on the bed. She did report NA-C had spoken loudly to R27 as they were working with him. Interview on 12/9/25 at 3:37 p.m., with RN-B reported she was familiar with NA-C and there had been incidents of her attitude, which she defined as a negative acceptance of provided education. NA-C became defensive when coaching was provided. RN-B reported she was not aware of any additional complaints of mistreatment from residents or staff related to NA-C. RN-B confirmed she was aware of the policy for abuse. Interview on 12/10/25 at 3:54 p.m., with NA-C reported she had been assisting NA-E with R27, and NA-D was observing because she was training. As he was being changed, R27 reached over placed his hand on NA-E's breast. She reported NA-E was upset and told R27 not to do that. She intervened and reached over and tapped his hand. She stated she did not hit him hard and denied raising her voice. She did not know why she was being investigated for this incident and reiterated she had only tapped him on his hand and denied hitting or yelling at him. Attempts to contact RN-D were made on 12/9/25 at 3:30 p.m. and again 12/10/25 at 3:00 p.m. without success and unable to leave a voice mail requesting a return call. Attempts to contact NA-D were made on 12/9/25 at 3:35 p.m. and again on 12/10/25 at 4:30 p.m. without success and unable to leave a message requesting a return call. Review of the November 2025 Abuse Prohibition/Vulnerable Adult Policy identified staff were to notify the supervisor and facility administrator immediately and take necessary steps to protect residents from any possible subsequent incidents of misconduct. An incident that alleged staff to resident abuse directed the involved staff member was to be suspended until the investigation was completed, in addition to notification of corporate Human Resources. Abuse was defined as willful, meaning the individual acted deliberately, not necessarily intending to cause injury or harm the vulnerable adult. Suspected abuse was to be reported to the SA within 2 hours of being informed of the allegation of abuse. Review of the undated Monarch Abuse Prohibition/Vulnerable Adult Policy identified staff were to identify and intervene for any potential abuse situations. Staff were also responsible for reporting any situation that could be considered abuse according to facility policy and procedure. The supervisor was to be notified immediately upon becoming aware of an alleged incident to determine any actions necessary. If the incident was an alleged staff to resident occurrence the staff person was to be immediately suspended pending completion of the investigation in addition to notification of HR, the facility administrator was to be notified immediately for incidents of actual or alleged resident abuse, injury of unknown origin, neglect, financial exploitation, or involuntary seclusion. Suspected abuse was to be reported to the SA using the online reporting process not later than 2 hours after the notification of suspected abuse.

Based on interview and document review the facility failed to ensure an as needed psychoactive medication Lorazepam (antianxiety medication) was not used beyond 14 days without a rationale for continued use and an identified review date for 2 of 5 sampled residents (R2 and R11) reviewed for unnecessary medications.Findings include: R2's 11/28/25, date accepted comprehensive Minimum Data Set (MDS) assessment identified R2's cognition was moderately impaired. R2 had no behaviors, and he required partial assistance for cares. R2 took an antidepressant, diuretic, opioid, anticonvulsant, and insulin daily and was on hospice. R2's 12/10/25, medical diagnosis list identified chronic kidney disease with heart failure, diabetes, localized edema (swelling), major depressive disorder, history of a heart attack, and a history of alcohol abuse in remission. R2's 11/11/25, hospice orders and care plan identified he was admitted to hospice services on 11/11/25 for chronic kidney disease with heart failure, cancer of the kidney, end stage heart failure with high doses of diuretic (fluid medication) to manage edema. Medication changes within last 2 weeks had included scheduled Tylenol with all other current medication meeting the residents' symptom needs. There was no mention of anxiety. The care plan identified R2 was alert, withdrawn, with a flat affect. R2's 11/11/25, hospice standing orders identified for symptoms of anxiety: lorazepam oral/sublingual 0.5 milligrams (mg) every 4 hours as needed (PRN) for anxiety. If not effective, staff may increase to 1 mg. and required a provider prescription. R2's November 2025, medication administration record (MAR) identified an order for lorazepam oral tablet 0.5 mg give 1 tablet by mouth every 4 hours PRN for anxiety/nausea/vomiting/insomnia. Start with 1 tablet by mouth or under the tongue every 4 hours. If 1 tablet is not effective, increase dose to 2 tablets (1mg) start date of 11/11/25. The order had no identified end date. Interview on 12/9/25 at 10:04 a.m., with registered nurse (RN)-A the facility consultant nurse identified that a facility nurse had entered the lorazepam PRN order from the hospice standing orders upon admission to hospice. She confirmed there was no end date on the lorazepam PRN order. Anti-anxiety PRN orders had 14 days unless the provider documented a rationale with an identified review date even if it was a hospice order. Interview on 12/10/25 at 11:17 a.m., with the consulting pharmacist identified she would expect that all psychoactive PRN medications to have an end date identified. She reported an anti-anxiety PRN order, could be extended beyond 14 days only if the provider documented a rationale and an identified review date. She revealed that the order had been placed following her last visit so she would not have been aware of the order until her visit to the facility today. Review of the May 2025, Psychotropic Medication Use policy identified psychotropic PRN orders would be limited to 14 days unless the provider documented a rationale to extend the medication beyond 14 days. Anti-psychotic PRN orders would be limited to 14 days and could not be renewed unless the provider evaluated the resident for appropriateness of the medication. All psychotropic medication would be reviewed during care conferences, target behavior meetings and by the pharmacist during their review. R11's 10/14//25, Significant Change MDS assessment identified severe cognitive impairment, she needed staff assistance for activities of daily living (ADLS) and used a wheelchair for mobility. R11 received daily medications for anxiety, depression, an antibiotic, opioid for pain, an anticonvulsant, and antipsychotics and was receiving hospice services. She had diagnosis of Parkinson's Disease with dsyskinesia (involuntary and uncontrollable movements), dementia with behaviors, anxiety, and major depressive disorder. R11's 10/14/25, Care Area Assessment (CAA) was triggered for Behavioral symptoms for refusal of cares. R11's had orders for quetiapine for dementia, lorazepam for restless, and mirtazapine for depression. R11's 10/3/25, hospice standing orders identified for symptoms of anxiety: lorazepam oral/sublingual 0.5 milligrams (mg) every (Q) 4 hours as needed (PRN) for anxiety. If not effective may increase to 1 mg and required provider prescription. R11's November 2025, Medication Administration Record (MAR) identified an order for lorazepam oral tablet 0.5 mg give 1 tablet by mouth BID for restlessness beginning 11/21/25. The order had no identified end date. A second order for Lorazepam 0.5 mg, 1 tablet PO Q2H PRN for anxiousness, restlessness, and nausea. If ineffective, staff may increase dose to 1 mg (2 tablets). Indication feeling anxious or restless with a start date of 11/21/25 and no identified end date. R11's 11/19/25, hospice orders and care plan identified she was admitted to hospice services 10/6/25, with a terminal diagnosis of Parkinson's disease with dyskinesia (involuntary movements) with fluctuations, loss of weight, frequent falls, dementia, sepsis (life-threatening infection) due to an unspecified organism, and chronic pain syndrome. There were no medication changes in the last 2 weeks. R11's current Medication Administration Record (MAR) listed orders for lorazepam 0.5 milligrams (mg) by mouth (PO) twice daily (BID) for restlessness started 11/14/25. Staff may give 0.5 mg PO every (Q) 2 hours(H) as needed (PRN) anxiousness, restlessness beginning 11/14/25. There was no end date identified for reassessment of the need to continue the lorazepam. R11's current, undated care plan identified she was at risk for alteration in her psychosocial well-being due to adjustment to placement, Parkinson's with dyskinesia, and sleep disorder. The care plan identified staff were to administer medications as ordered, but there was no indication of the for 14-day reassessment for continued use of Lorazepam. Interview on 12/9/25 at 10:04 a.m., with registered nurse (RN)-A, the facility consultant nurse identified that a facility nurse had entered the lorazepam PRN order from the hospice standing orders upon admission to hospice. She confirmed there was no end date on the lorazepam PRN order. Anti-anxiety PRN orders were limited to 14 days unless the provider documented a rationale, even if it was a hospice order. Interview on 12/10/25 at 11:17 a.m., with the consulting pharmacist identified she would expect that all psychoactive PRN medications to have an end date identified. She reported an anti-anxiety PRN order, could be extended beyond 14 days only if the provider documented a rationale and an identified a new review date. She revealed the order had been placed following her last visit, so she would not have been aware of the order until her visit to the facility today. Review of the May 2025, Psychotropic Medication Use policy identified psychotropic PRN orders would be limited to 14 days unless the provider documented a rationale to extend the medication beyond 14 days. Anti-psychotic PRN orders would be limited to 14 days and could not be renewed unless the provider evaluated the resident for appropriateness of the medication. All psychotropic medication would be reviewed during care conferences, target behavior meetings and by the pharmacist during their review.

Based on interview and record review the facility failed to ensure safety for 1 of 4 sampled residents (R27) by suspending 1 of 1 nursing assistant (NA)-C, following an allegation of abuse. Findings include: Review of the 12/1/25 at 9:14 a.m., report to the State Agency (SA) identified on 11/30/25 at around 5:00 p.m., NA-C was assisting to turn R27 with NA-D and NA-E when he placed his hand on NA-E's breast. NA-C responded by smacking R27's hand away and raised her voice at him. NA-D reported the incident to the charge nurse, who notified the director of nursing (DON) (identified had received the call at 4:36 p.m.). The DON instructed RN-D to have the NAs provide a written statement and place it under the DON's office door for review the next morning. Review of NA-C's 11/30/25, timecard identified she continued to work her assigned shift providing patient care until the end of her shift at 10:30 p.m. There was no indication the facility administrator was notified of the incident until 8:00 a.m. on 12/1/25. NA-C was later suspended on 12/1/25 following notification of the administrator and pending the investigation. Review of the 12/5/25, 5-day investigation results identified the facility staff interviewed multiple residents and staff and there were no additional allegations of mistreatment by NA-C. Both NA-D and NA-E who were present with NA-C during the incident on 11/30/25 confirmed she had raised her voice at R27. The facility confirmed verbal abuse took place, but due to conflicting staff statements and R27's inability to participate in the interview process, (due to his impaired cognition), physical abuse was not substantiated. Following completion of the investigation the facility terminated NA-C's employment following interview on 12/4/25 due to substantiated verbal abuse. R27's 12/8/25, Significant Change Minimum Data Set (MDS) assessment identified his cognition was moderately impaired. He required extensive assistance with activities of daily living (ADLS), required the assistance of 2 staff for transferring with a mechanical lift, and utilized a Broda type wheelchair (a specialized, ergonomic mobility device known for exceptional comfort, posture support and pressure relief), and was transported by staff. He had diagnoses of Dysarthria (a motor speech disorder that makes it hard to articulate works clearly), following a stroke, had cognitive communicative deficit, and mild cognitive impairment. R27's current, undated care plan identified alteration in communication due to cognitive communication deficit and cerebral infarction. R27 was identified to be a vulnerable adult, therefore at risk of abuse due to decreased cognition and physical abilities. Staff were to monitor him for emotional distress and mood and/or behavioral changes and follow facility abuse reporting policy. Interview on 12/9/25 at 4:55 p.m. with the DON reported RN-D phoned her on 11/30/25 at 4:35 p.m., to report the incident and stated the situation was chaotic and everyone was busy. She confirmed with staff R27 was not harmed, and then requested RN-D to have the involved staff write a statement and place it under her office door for review upon arrival the morning of 12/1/25. She reported she did not think of the incident as potential or actual abuse at that time. Upon arrival on 12/1/25, the DON reported she reviewed the written statements. At that time, she became aware of the allegation NA-C had smacked R27's hand and raised her voice. She then reported the incident to the administrator on 12/1/25 at 7:44 a.m The administrator had immediately informed her she should have been notified immediately on 11/30/25 and re-educated her on the steps for reporting an alleged abuse situation and protecting residents. It was confirmed NA-C had finished working her shift providing resident care, and no action was initiated until the following morning. The investigation was initiated with appropriate notifications completed, and interviews of residents and staff. The DON confirmed NA-C had been allowed to finish working her shift on 11/30/25 providing residents' their care and had not been suspended until following notification to the administrator on 12/1/25. Interview and timecard review on 12/09/25 at 3:04 p.m., with the administrator and regional director of operations (RDO) confirmed the incident occurred on 11/30/25 at 5:00 p.m The DON was phoned and updated, but the administrator was not notified until 12/1/25 a.m The employee involved continued to work providing residents' care for the remainder of her shift. She was not placed on suspension until 12/1/25 following review of documentation by the DON and administrator. The report was filed to the SA on 12/1/25 at 9:14 a.m., (16 hours after the incident was reported). They both confirmed the alleged incident was abuse and should have been filed within 2 hours of notification of the incident, the administrator notified immediately, and any staff members suspected of potential or actual abuse were to be suspended immediately and not allowed to finish the remainder of their shift. Review of NA-C's timecard identified she was terminated related to the substantiated allegation of verbal abuse, effective 12/4/25. Review of NA-C's personnel file identified a final warning had been issued August 2, 2025, for misconduct regarding a Vulnerable Adult report. Following the substantiated verbal abuse allegation NA-C's employment was terminated on 12/4/25. Review of NA-C's timecard identified she had worked the remainder of her scheduled shift on 11/30/25, but no additional shifts were identified. Interview on 12/09/25 at 3:27 p.m. with NA-E confirmed the report that R27 reached out and placed his hand on the side of her breast. She responded by telling him that was inappropriate and pulled his hand away and placed it on his chest. She did not think he did it intentionally as he was afraid of falling and would attempt to grab or hold on to objects or people when being turned toward the edge of the bed. NA-E was focused on keeping R27 on the bed. She did report NA-C had spoken loudly to R27 as they were working with him. Interview on 12/9/25 at 3:37 p.m., with RN-B reported she was familiar with NA-C and there had been incidents of her attitude, which she defined as a negative acceptance of provided education. NA-C became defensive when coaching was provided. RN-B reported she was not aware of any additional complaints of mistreatment from residents or staff related to NA-C. RN-B confirmed she was aware of the policy for abuse. Interview on 12/10/25 at 3:54 p.m., with NA-C reported she had been assisting NA-E with R27, and NA-D was observing because she was training. As he was being changed, R27 reached over placed his hand on NA-E's breast. She reported NA-E was upset and told R27 not to do that. She intervened and reached over and tapped his hand. She stated she did not hit him hard and denied raising her voice. She did not know why she was being investigated for this incident and reiterated she had only tapped him on his hand and denied hitting or yelling at him. Attempts to contact RN-D were made on 12/9/25 at 3:30 p.m. and again 12/10/25 at 3:00 p.m. without success and unable to leave a voice mail requesting a return call. Attempts to contact NA-D were made on 12/9/25 at 3:35 p.m. and again on 12/10/25 at 4:30 p.m. without success and unable to leave a message requesting a return call. Review of the November 2025 Abuse Prohibition/Vulnerable Adult Policy identified staff were to notify the supervisor and facility administrator immediately and take necessary steps to protect residents from any possible subsequent incidents of misconduct. An incident that alleged staff to resident abuse directed the involved staff member was to be suspended until the investigation was completed, in addition to notification of corporate Human Resources. Abuse was defined as willful, meaning the individual acted deliberately, not necessarily intending to cause injury or harm the vulnerable adult. Suspected abuse was to be reported to the SA within 2 hours of being informed of the allegation of abuse. Review of the undated Monarch Abuse Prohibition/Vulnerable Adult Policy identified staff were to identify and intervene for any potential abuse situations. Staff were also responsible for reporting any situation that could be considered abuse according to facility policy and procedure. The supervisor was to be notified immediately upon becoming aware of an alleged incident to determine any actions necessary. If the incident was an alleged staff to resident occurrence the staff person was to be immediately suspended pending completion of the investigation in addition to notification of HR, the facility administrator was to be notified immediately for incidents of actual or alleged resident abuse, injury of unknown origin, neglect, financial exploitation, or involuntary seclusion. Suspected abuse was to be reported to the SA using the online reporting process not later than 2 hours after the notification of suspected abuse.

Based on interview, and record review the facility failed to protect 1 of 2 residents (R1), who did not have the capacity to consent from inappropriate touching from an assisted living resident (AL-R) who was visiting. This resulted in an immediate jeopardy (IJ) when R1 was inappropriately touched repeatedly over the course of approximately 38 minutes without intervention by staff. The IJ began on 11/21/25, when staff members suspected AL-R of inappropriate touching and did not remove and/or intervene to stop the touching which resulted in AL-R repeatedly inappropriately touching of R1's thighs and in-between her legs by AL-R. The Administrator, director of nursing (DON), resident service coordinator, and regional director of operations (via phone) were notified of the past non-compliance (PNC) IJ on 12/5/25 at 1:50 p.m. The facility immediately implemented and began corrective action on 11/22/25, with ongoing education and the deficient practice was corrected, 11/22/25 prior to the start of the survey and was therefore issued as a PNC IJ. Findings include R1's face sheet dated 12/4/25, identified diagnoses of Parkinson's with dyskinesia (involuntary erratic movements), and dementia (affects cognitive ability including language and problem solving). R1's significant change Minimum Data Set (MDS) dated [DATE], indicated R1 had severe cognitive impairment and never/rarely made decisions, sometimes had the ability to understand others and make needs known, used a wheelchair and was dependent on staff to move locations, dependent on staff for dressing, incontinent of bowel, bladder, required hygiene assistance with toileting, and assistance with eating. R1's care plan dated 7/10/25, identified R1 was a vulnerable adult and at risk for decreased cognitive and physical abilities with a goal to remain free from abuse or neglect. Corresponding interventions included (but not limited to) directed staff to follow vulnerable adult and abuse reporting policy. The care plan also included a risk for alteration in cognition related to adjustment of placement with interventions that included allow R1 time to communicate his/her needs/wants, document changes in orientation, provide and maintain consistent environment, provide cues, reorientation, supervision as needed. The communication care pan informed staff R1 was very soft spoken with interventions that directed staff to face R1 when speaking and allow time to answer. The care plan also informed staff R1 required total assist with locomotion in Broda (specialized wheelchair for improved comfort and mobility) wheelchair, did not walk, assist of two staff with mechanical stand and step by step cues. Police incident report indicated the administrator reported an allegation of criminal sexual conduct on 11/22/25 at 8:28 a.m. for an incident that had occurred on 11/21/25 between alleged perpetrator (assisted living resident (AL-R)) and R1. The report identified the officer arrived at the facility on 11/22/25 at 8:58 a.m. and met with administrator and regional director of operations in which the following information was discussed/disclosed; R1 was not alert, orientated, and incapable of decision making. AL-R was believed to have slight mental/cognitive decline but still capable of decision-making. The administrator stated on 11/21/25 at 5:50 p.m., AP entered the facility and placed himself to the right of R1 who was positioned in front of the television. Between 5:57 p.m. and 6:38 p.m., facility surveillance system showed AP lifted up R1's skirt and made skin to skin contact to the area of R1's leg with his hand. At different points during this time period, AP removed his hand when he became aware of the presence of facility staff and would scan the area to see if staff were present, then return to placing his hand to the area of R1's leg. Exactly what other parts of R1's anatomy were touched by AP could not be determined. At 6:37 p.m., a facility staff member went to speak to R1 for unknown reasons. Following the staff members departure, AP resumed groping of R1. At 6:44 p.m., AP left the common area. Administrator noted AP had a reputation for making lewd comments to facility staff but no other issues since his arrival at facility in 2015. The administrator had informed law enforcement to ensure the safety of all residents, facility protocol was put in place wherein a qualified staff member would monitor AP at all times until 11/24/25, at which time the staff would reassess the situation and determine further steps, AP was banned from facility, and family notified of situation. The report also identified on 11/26/25, police officer returned to facility and met with Administrator. Video footage reviewed with Administrator and identified AP sitting next to R1. During the video: -AP would occasionally scan the surrounding. -AP would position his left hand on R1's arm rest and R1's right leg over her skirt. -AP would then lift up R1's skirt and start touching her right leg. -AP would then stop touching R1's leg and bring her skirt back down to cover her legs. -AP would then lift R1's skirt back up and touch her leg again. -AP would then reach higher on R1's leg touching her in the vaginal area. -AP would immediately move his hand away from R1's vaginal area when another resident was passing them. -As soon as the resident passed, AP began touching R1's vaginal area. -While AP was touching R1's vaginal area, AP would constantly look around. Clips of video surveillance recordings of the incident were provided on 12/4/25 and reviewed. The recorded footage was consistent with law enforcements report. Administrator explained the entire recordings was not available because the video system deleted after seven days. R1's progress note dated 11/22/25 at 10:54 a.m., identified call placed to hospice and medical doctor to update on status of R1. At 11:27 a.m., social service director (SS)-D met with R1 and watched the birds. R1 appeared calm and at baseline with no anxiety or distress noted. R1's weekly skin inspection dated 11/22/25, identified R1 had no skin issues. R1's physician rounding note dated 11/25/25, identified R1 was seen following an incident on where another resident (AL-R) from the Assisted Living facility was at the facility and observed on camera footage reaching into R1's pubic area and touching her. The incident was unwitnessed by staff but captured on camera footage. The alleged perpetrator admitted to the act when questioned by police. R1 did not appear distressed during the incident. R1 is unable to participate in a trauma assessment due to her current inability to answer questions. Staff are monitoring for behavioral changes or signs of distress. The facility investigation dated 11/25/25, identified staff observed AL-R acting unusually, watching staff closely and remaining near a resident he is not typically around. Staff also noted R1's skirt appeared bunched up on more than one occasion, which was concerning as she is unable to adjust her knee-length skirt independently due to her weakness. Staff did not witness any specific incident, as reflected in their statements, but discussed the situation felt abnormal. RN informed of these concerns. Administrator initiated an investigation and was able to substantiate that unwanted physical contact had occurred. AL-R admitted during an interview to engaging in unwanted physical contact with R1. During an observation on 12/3/25 at 3:52 p.m., R1 was in a Broda wheelchair, with family member (FM)-A sitting beside her, looking at the bird aviary. During an observation on 12/4/25 at 10:31 a.m., R1 was at an activity, she was wearing a skirt. At 2:46 p.m., FM-A sat next to R1 in front of the bird aviary, family member (FM)-A had a cellphone and was sharing the screen between them with a video and music playing. During an interview on 12/4/25 at 2:50 p.m., FM-A stated R1 wears a skirt because of their religious beliefs and specifically from a passage from Deuteronomy 22:5 where it stated that a woman should not wear men's clothing. R1 was a very chaste and pure woman. Even in her younger years if someone asked her to have intercourse, she would have said no. R1 would have kicked the guy in the mouth or hollered or done something. FM-A did not think R1 even realized what was happening when it was going on. FM-A wondered if the incident was recorded on tape for 40 minutes, why was no one at the facility more eyes open on it? During a phone interview on 12/4/25 at 10:47 a.m., trained medication assistant (TMA)-A stated she was not sure how often AL-R came to facility, but he would act normal when he came over to sit and watch television with all the residents. AL-R did not normally sit by R1. TMA-A stated on 11/21/25, the whole living room was full watching television, and staff needed to have an eye kept on them. During a follow-up phone interview on 12/4/25 at 2:11 p.m., TMA-A reiterated that someone needed to be watching the residents, and they should not be left alone. TMA-A told nursing assistant (NA)-A to keep an eye on R1 and AL-R because they were sitting there, and she had never seen AL-R talk to R1. TMA-A was unsure if R1 could make her own decisions and if it was her involved in the situation, where AL-R put his hand on her thigh, she would not like it all. TMA-A ended the call with what does it matter what I think?, I saw nothing, I know nothing. During a phone interview on 12/4/25 at 11:36 a.m., NA-A stated AL-R came to the facility daily. On 11/21/25, TMA-A asked NA-A to sit and watch AL-R because she thought she noticed AP touching R1. NA-A then went to the common area where R1 an AL-R were sitting and found R1's skirt pulled up above her knees, so she pulled it down. NA-A then went back to nurses' station, every few seconds she would look up from her work to see R1's skirt up above her knees again and AL-R's hand would move away from R1, however, she never saw AL-R move R1's skirt up or touch her. NA-A explained when she wasn't looking, she felt like AL-R was watching her. At no point did NA-A move AL-R away from R1 or tell him to leave R1 alone because she did not know how to handle a situation like that. NA-A told TMA-A that what [TMA-A] thought happened, did happen, and they told RN-A. After the incident, NA-A asked family member (FM)-A if R1 ever wore pants. FM-A told NA-A no, it was a religious belief; women always wore skirts and men always wore pants or suits. During a follow-up interview on 12/4/25 at 1:43 p.m., nursing assistant (NA)-A further explained when she thought AL-R was watching her, she thought but was unsure if AL-R was watching her to see if she was watching him, however him watching was what caught her attention and made her feel uneasy. NA-A had to walk over to R1 three times because she had noticed R1's skirt up. The most she saw was AL-R's hand on the handle of R1's wheelchair. AL-R left about five minutes after NA-A pulled her skirt down for the third time. NA-A was irritated that the situation went on for 45 minutes. NA-A was not sure if AL-R was pulling up R1's skirt but indicated she suspected he was moving R1's skirt up because of how he was looking around. NA-A reiterated she did not know what to do or how to handle the situation and was fearful of AL-R's reaction if she moved R1 away from him. R1 would not be able to say no or get away in a situation like what happened; she is unable to get her hands to the wheels of her wheelchair and staff must move her. During an interview on 12/3/25 at 3:41 p.m., registered nurse (RN)-A stated AL-R comes to facility, walks the corridors, and will sit in the common television area and have conversations with staff and residents and leave. RN-A did not witness the incident on 11/21/25 but overheard NA-A and TMA-A talking about it around 11:00 p.m. on 11/21/25, when they were finished with their shift. RN-A was unsure why he did not notify Administrator or director of nursing (DON) immediately. On 11/22/25 at 6:00 a.m., RN-A returned for a shift at facility and remembered the incident from the evening prior, so she notified the Administrator and DON. R1 was a very quiet resident; RN-A never thought R1 would be able to have a conversation with AL-R because she did not have capacity to engage or start a conversation with anyone. R1 would sometimes have appropriate answers to questions but sometimes would give off the wall responses. RN-A was provided education which included the two-hour timeframe for reporting suspected abuse. During a phone interview on 12/4/25 at 9:27 a.m., AL-R stated he was at facility to visit a female resident that used to live by him. R1 was sitting out in the area and stated her leg hurt. AL-R called to staff, and they did not listen, so AL-R went to R1 and rubbed her leg. AL-R stated he was just trying to be kind. During an interview on 12/4/25 at 11:02 a.m., regional nurse consultant (RNC)-A stated R1 did not have a mood/behavior, or psychological assessment after the incident because R1 was severely cognitively impaired and would not be able to have the back-and-forth discussion or answer questions appropriately. During an interview on 12/5/25 at 11:33 a.m., social worker (SW)-A stated she came to the facility on [DATE] and sat with R1 by the bird aviary. R1 did not appear or act any different than she would on any other day, conversation veered away from topic. SW-A was at facility until 5:00 p.m. and would occasionally check on R1 during that time. SW-A interviewed residents and included education on who they should report to if they have any concerns. SW-A did not discuss what staff should have done in the situation. During an interview on 12/5/25 at 9:26 a.m., DON, clinical manager (CM)-A, and licensed practical nurse (LPN)-B were present. When they became aware of the incident on 11/22/25, a skin check was completed on R1, staff checked all residents to ensure they felt safe at the facility, AL-R had not had unwanted contact with them and immediately began staff education on abuse and neglect. It was the expectation staff would ensure the safety of the resident immediately by removing them from the situation and immediately report. During an interview on 12/5/25 at 9:04 a.m., Administrator stated she found out about the incident on 11/22/25 at 7:34 a.m. Administrator immediately banned AL-R from the facility and put AL-R on 1:1 supervision at his adjoining facility. Administrator initiated education on abuse and abuse prevention with staff that included a verbal quiz. Administrator conducts quarterly drills with staff, in which a resident participated to time how long an accusation of abuse would take to reach her. During an interview on 12/5/25 at 11:27 a.m., Administrator, resident service coordinator (RSC)-A, and director of nursing (DON) were interviewed together. DON, and RSC-A did not watch the video of the incident, and Administrator stated she watched the video twice, including once with the police officer. Administrator and DON stated NA-A was a reliable witness and cares for all the residents. Administrator indicated AL-R historically made lewd comments to staff a lot but comments were nothing crazy, comments that you hear typically in a nursing home, like dirty jokes. None of them had heard him make comments in front of residents. The facility Abuse Prohibition/Vulnerable Adult policy dated 11/2025, identified the purpose was to protect residents against abuse by anyone, including, but not limited to, facility staff, other residents, consultants or volunteers, staff of other agencies serving the individual, family members or legal guardians, friends or other individuals, or self-abuse. To promptly report, document and investigate all incidents of alleged or suspected abuse/neglect, to identify and remedy any potentially abusive situations.instances of abuse, irrespective of any mental or physical condition. It includes verbal, sexual, physical and mental abuse. The PNC IJ that began on 11/21/25, was removed on 11/22/25, when it was verified, the facility implemented the following: Education began on 11/22/25 and was completed on 12/3/25, for all staff and covered the topics of: -definitions and types of abuse -staff responsibilities for prevention and reporting -mandatory reporting timelines and procedures -internal facility reporting process -resident rights and protections -zero-tolerance policy and disciplinary actions -AP banned from facility 11/22/25 -assessment of R1 for injury and mental anguish as able

Based on observation, interview and document review the facility failed to convey a resident's most current Provider Order for Life Sustaining Treatment (POLST) form to the receiving provider when 1 of 1 resident (R1) was transferred to the emergency department (ED), reviewed for discharge. Findings include: R1's POLST dated [DATE], identified Section A: if R1 has no pulse and is not breathing do not attempt resuscitation. Section B: Comfort-Focused Treatment (Allow Natural Death). Relieve pain and suffering through the use of any medication by any route, positioning, wound care and other measures. Use oxygen, suction and manual treatment of airway obstruction as needed for comfort. Patient prefers no transfer to the hospital for life-sustaining treatments. Transfer if comfort needs cannot be met in current location. Section C: R1's documentation of discussion and was signed by R1. Section D: signed by certified nurse practitioner and dated [DATE]. Section E: additional preferences- no artificial nutrition by tube, no antibiotics, use other methods to relieve symptoms when possible. R1's care plan dated [DATE], identified a focus of current code status; see POLST. Interventions included an advanced Directive in place and will be honored during the review period, arrange MD consultation as necessary, assess resident for ability to cope with information provided, review resident's Advance Directive PRN per resident and/or family request and staff to follow POLST guidelines. R1's POLST dated [DATE], identified Section A: if R1 has no pulse and is not breathing do not attempt resuscitation. Section B: Comfort-Focused Treatment (Allow Natural Death). Relieve pain and suffering through the use of any medication by any route, positioning, wound care and other measures. Use oxygen, suction and manual treatment of airway obstruction as needed for comfort. Patient prefers no transfer to the hospital for life-sustaining treatments. Transfer if comfort needs cannot be met in current location. Section C: R1's documentation of discussion and was signed by R1. Section D: signed by certified nurse practioner and dated [DATE]. Section E: additional preferences- no artificial nutrition by tube, no antibiotics, use IV/IM antibiotics. R1's order summary dated [DATE] identified R1 was Do Not Resuscitate (DNR). R1's admission Minimum Data Set (MDS) dated [DATE], identified that R1 had moderately impaired cognition and diagnoses included paranoid schizophrenia, unspecified intellectual disabilities and diabetes mellites. R1 nursing progress note dated [DATE] at 6:43 p.m., R1 was sent to hospital per care coordinators and provider - R1 had been refusing all cares and being aggressive towards staff. R1's ED to hospital admission documents dated [DATE], R1's hospital course identified had chronic cognitive impairment, paranoid schizophrenia, type 2 diabetes insulin-dependent, lower extremity lymphedema, presented from facility via EMS due to increased confusion, agitation and refusal of cares. Review of R1's POLST shows comfort measures only, DNR DNI and no antibiotics. Was able to discuss case with R1's family he does not have a court appointed guardian as he has remained his own guardian. Review of the POLST was that it was signed by R1. It stated that he does not wish to have any antibiotics including oral and wants comfort measures only. After discussion with family, she reported that we should follow the POLST recommendations as that would be his wishes. R1 was admitted for possible right lower lobe pneumonia and left lower extremity cellulitis. Given R1's wishes noted on previous POLST signed on [DATE], that R1 would not wish to have any antibiotics including oral antibiotics and comfort measures only. This was confirmed with R1's family member. Based on this R1 will plan to discharge back to his facility possibly on hospice. R1's Discharge summary dated [DATE], identified R1 was discharged with the plan to initiate hospice based on the initial POLST form from 2023. However, with the new information and further conversation with R1 at his skilled nursing facility hospice has not been initiated. Given that R1 was hemodynamically stable, afebrile, not requiring supplemental oxygen it was reasonable that R1 was discharged on oral antibiotics with close outpatient follow-up with primary care provider. Therefore, R1 will be discharged on a course of Augmentin for presumptive right lower lobe pneumonia. R1 should return to the emergency room if he has worsening symptoms or concern for clinical decline. Otherwise recommend follow-up with primary care provider in 1 to 2 days. R1's progress note dated [DATE] at 1:59 p.m., At 3:15 p.m., R1 was sent back to the facility from the hospital with a diagnosis of pneumonia. During an interview on [DATE] at 3:25 p.m., R1 was seated in his wheelchair in the hallway. R1 stated he was in hospital a couple weeks ago because he was out of his diet mountain dew, and he got dehydrated. R1 stated he thought he had an infection somewhere but really couldn't remember. During an interview on [DATE] at 10:56 a.m., licensed practical nurse care coordinator (LPNCC)-A stated she worked on [DATE], and R1 was not himself that day had been refusing cares for several hours and was combative with staff. LPNCC-A stated they did get an order form a provider to send R1 to the ED. LPNCC-A further stated she printed out his face sheet and his medication administration record, for the nurse that would be sending R1 out. LPNCC-A stated she did not print R1's POLST. LPNCC-A stated she had left the building before R1 was sent to the ED, so she was unsure if R1's most recent POLST was printed and sent with. During a phone interview on [DATE] at 1:17 p.m., licensed practical nurse (LPN)-A stated he worked on [DATE], and was the nurse responsible for R1. LPN-A stated he did not print out any additional forms to send with R1 to the ED. LPN-A verified he did not print out R1's most recent POLST to send with to the ED. During an interview on [DATE] at 1:33 p.m., nurse manager (NM)-A stated when a resident is sent to the hospital emergently the following forms should be sent with; the face sheet, order summary, medication administration record and a current POLST form. NM-A stated all the forms should be handed to ambulance person. During an interview on [DATE] at 1:37 p.m., regional nurse consultant (RNC)-A stated the process for sending a resident to the ED, was to have a provider order and send the following forms with the resident: face sheet, order summary, medication administration record and a current POLST form. RNC-A stated it looked like R1's POLST did not get sent with him to the hospital, so the hospital had R1's old POLST that identified R1 was not to receive antibiotics. RNC-A stated they are in the process of educating all nursing staff on what forms are to be sent with residents during an emergent transfer to ensure the receiving provider can honor resident wishes. Advanced directive policy requested and not received. Emergency transfer document requested and not received. Facility policy, POLST Documentation Procedure, dated 4/2025, identified a purpose to identify a code status consistent with resident wishes and to facilitate providing emergency care and services in accordance with the resident's plan of care. The Resident and/or Resident Representative's decision will be entered into the individualized plan of care/electronic medical record, and will be communicated throughout the facility, so that staff know immediately what action to take or not take when an emergency arises. 1. Resident's and/or Resident Representative's wishes will be discussed and verified by referring to the discharge orders. 2. If the resident's or resident representative's wishes no longer align with the discharge orders, a physician's order must be obtained immediately to support these modified wishes. 3. The physician order should be placed into Point Click Care per the following process.' o When indicating the Code Status of choice, please utilize the standardized abbreviation of DNR or CPR which is located in the Monarch admission Order Sets. o Advance Directive status should be listed as Current and Verified before completing and saving the new order entry. o Order type should be Advanced Directive. 4. Code Status will be reflected in multiple areas within the electronic medical record. This includes Care Profile section located under residents' picture in Point Click Care and Point of Care, and on the MAR/TAR. 5. In the event of an interruption of the electronic health record, refer to the MAR backup software to verify code status. 6. POLST should be uploaded in PCC documents/Misc. tabs. pending signature from Physician/NP and entered POLST (Unsigned). 7. Upload the signed POLST and the unsigned POLST will be deleted out of PCC. The paper POLST will be shredded after uploading. Current POLST that is uploaded, should have verbiage CURRENT POLST. If there are any other POLSTS uploaded into the Documents/Misc., these POLSTS should remain listed and named VOID POLST. 8. A routine audit of the POLST documentation should be completed to ensure consistent and accurate documentation of the POLST form, physician orders, the care plan and entry in PCC.

Based on observation, interview, and document review, the facility failed to ensure dietary staff followed appropriate infection control practices when handling cups and performing hand-hygiene during food service in the dining room and passing meal trays to resident rooms. In addition, the facility failed to ensure dishwasher chemical sanitization solution was monitored to ensure dishes were properly sanitized. This had the potential to affect all 34 residents who resided in the facility. Findings include: Meal tray delivery On 10/13/24 at 11:52 a.m. dietary aide (DA)-C was observed and pushed a cart with meal trays through the hallway and entered R20's room. R20 was observed lying in bed and DA-C placed R20's tray on R20's stomach area. DA-C used bare hands and touched R20's bed remote to adjust R20's bed, moved R20's bedside table, and touched R20's blankets on her bed. DA-C was observed to exit R20's room and failed to disinfect hands. DA-C proceeded to push the meal cart through the hallway and entered R50's room with a meal tray and used bare hands and gave R50's family member a glass of apple juice from the meal tray, and then DA-C exited the room with no hand washing observed entering or exiting R50's room. DA-C proceeded to push the meal cart through the hallway and entered R51's room with a meal tray. R51 was seated in a recliner with a tray table in front of the recliner, DA-C placed the meal tray on a tray table placed in front of R51. DA-C with ungloved hands, opened the seal off a butter container, and took of clear plastic wrap off a piece of pie, then picked a piece of debris off the floor and placed in R50's garbage, and used a Kleenex to pick a bug off the floor and placed in R50's garbage and exited the room with no hand hygiene observed, and pushed the two meal carts through the hallway back into the kitchen. On 10/15/24 3:35 p.m. dietary director (DD)-F stated dietary staff were expected to complete hand hygiene prior to entering and exiting a resident room during meal delivery. 42073 Dining room food service During observations on 10/13/24, at 12:07 p.m., culinary services aide (CSA)-B was passing beverages to residents seated in the dining room. CSA-B was observed holding plastic drinking cups by the rim when serving juice and water to R5. At 12:17 p.m., CSA-B served chocolate milk, juice, and water to R16, holding cups by the rim when setting them on the table. During observation on 10/14/24, at 11:58 a.m., CSA-A passed beverages to residents R8 and R19, holding cups by the rim. At 12:11 p.m., CSA-A was observe picking her nose or teeth (not able to clearly determine which) and did not clean hands before serving beverages to R4. During an observation and interview on 10/14/24, at 12:24 p.m., observed CSA-A put her finger in her right ear. CSA-A was informed of the observations and the need to clean her hands after touching any part of her body before passing beverages or food to residents. CSA-A stated she touched her face a lot -- it was a habit. CSA-A was also informed of observations of her holding cups by the rim as she placed them on tables. CSA-A stated she understood a resident would place his/her mouth on the rim and stated she should hold the cup closer to the bottom. During an interview on 10/15/24, at 9:55 a.m., CSA-B was taken aside and with a cup, asked to demonstrate the proper way to hold it when serving residents. CSA-B held it by the lower half of the cup. Surveyor informed CSA-B of observations on 10/13/24, when she held cups by the rim. CSA-B stated she had training on the proper way to hold a cup when serving residents and was not aware she held it by the rim. CSA-B stated she understood the rim was where a resident would place his/her mouth. Dishwasher Chemical Sanitation During an observation and interview on 10/15/24, at 10:05 a.m., observed CSA-B test the chemical sanitizing solution at the dishwasher using a chlorine test strip. The dishwasher had been in use immediately prior to this. The test strip measured 25 parts per million (PPM). CSA-B was asked to run another load and test it again. Again, it measured 25 ppm. According to facility policy, the chemical solution should test at 50-100 ppm. The culinary services director (CSD)-F was requested to test the solution, which also tested at 25 ppm. CSD-F stated he would contact the dishwasher vendor. CSD-F stated he did not do periodic spot checks to ensure staff were performing testing properly and according to policy. CSD-F stated staff received training for testing the sanitizing solution upon hire, but he didn't document the content of the training, or when the training occurred. The water temperature on the dishwasher read 120 degrees Fahrenheit (F) which was correct according to regulation, but both CSA-B and CSD-F thought the temperature needed to be 150 degrees F. A paper log titled Dishwashing Record Low Temperature/Chemical posted on the wall by the dishwasher indicated for the month of October, three times a day, all ppm were read as 50 ppm and all but three water temperatures read as 150 degrees F. The log for September indicated the same. The log for August indicated ppm ranging from 10 to 50 ppm and temperatures ranging from 83 to 150 degrees F. During a telephone interview on 10/15/24, at 3:28 p.m., vendor representative (VR)-G for the dishwasher stated the facility utilized a low temperature unit. VR-G stated the water temperature should be set at 120 degrees F, and the chemical sanitizing solution should test between 50-100 ppm. While talking to VR-G, CSD-F came to the conference room and stated the test strips were darker now, but still not up to 50 ppm. Over speaker phone, VR-G advised CSD-F to switch to paper products until the dishwasher unit could be serviced, which CSD-F stated had been arranged for on 10/16/24. Facility Dishwashing Machine Use policy dated 2001, indicated food service staff required to operate the dishwashing machine would be trained in all steps of dishwashing machine use by the supervisor or a designee proficient in all aspects of proper use and sanitation. A supervisor would check the dishwashing machine for proper concentrations of sanitizer solution (measured as parts-per-million [PPM] or mL/L) after filling the dishwashing machine and once a week thereafter. Concentrations would be recorded on a facility approved log. Corrective action would be taken immediately if sanitizer concentrations were too low. The operator would check temperatures using the machine gauge with each dishwashing machine cycle and would record the results on a facility approved log. The operator would monitor the gauge frequently during dishwashing machine cycle. Inadequate temperatures would be reported to the supervisor and corrected immediately. If hot water temperatures or chemical sanitation concentrations did not meet requirements, the dishwashing machine would cease immediately until temperatures or PPM were adjusted. Type of Solution: chlorine, and minimum concentration 50-100 ppm.

Based on interview and document review, the facility failed to implement a process for antibiotic review to determine the efficacy and resident outcomes (appropriate medication, dose, and duration) for 4 of 4 residents R12, R27, R1, and R31 reviewed. Further, this had the potential to affect all 34 residents living in the facility. Findings include: R12's Face Sheet dated 5/4/23, included diagnoses of quadriplegia, neurogenic bowel, and neuromuscular dysfunction of the bladder. R12's care plan dated 8/6/24, indicated R12 will be free from signs/symptoms of urinary tract infection (UTI). Interventions included morning bowel program, assistance with peri-care in the morning, bedtime, and as needed, provided incontinence products, monitored for signs/symptoms of UTI, monitored suprapubic catheter output, change the suprapubic catheter per physician orders, and suprapubic catheter care per facility policy. The facility's Monthly Resident Infection Statistics documentation for the month of August 2024, indicated R12 was treated for a catheter associated urinary tract infection (CAUTI). R12 was prescribed ciprofloxacin 250 mg two times per day for five days. No outcome/s was documented on the facility's Monthly Resident Infection Statistics log to determine the efficacy of R12's treatment plan. R27's Face Sheet dated 2/12/24, included diagnoses of a nondisplaced intertrochanteric fracture of the right femur, type 2 diabetes, dementia, and weakness. R27's care plan dated 9/9/24, indicated R27 was at risk for altered elimination related to mobility and recurrent UTI's. Interventions included assistance with peri-care in the morning, bedtime, and as needed, incontinence products were to be provided as needed, monitor for signs/symptoms of UTI and report suspected signs/symptoms of UTI. The facility Monthly Resident Infection Statistics documentation for the month of July 2024, indicated R27 was treated on two separate dates (7/5/24 and 7/17/24) for UTI. On 7/5/24, R27 was prescribed Macrobid capsule 100 mg two times per day for five days. On 7/7/24, the antibiotic was changed to Keflex due to aggressive behavior related to antibiotics. No outcome/s was documented on the facility Monthly Resident Infection Statistics log to determine the efficacy of R27's treatment plan. R1's Face Sheet dated 5/8/2, included diagnoses of type 2 diabetes, chronic kidney disease stage 3, and urinary tract infection. R1's care plan dated 10/8/24, indicated R1 had functional bowel and bladder incontinence related to persistent mood, hemiplegia, cerebrovascular accident (CVA), obesity, and frequently incontinent of urine and stool. Interventions included assistance to the bathroom before and after meals, at bedtime, as needed, and to wear incontinence pads. The facility Monthly Resident Infection Statistics for June and August 2024, indicated R1 was treated for a UTI once in June and once in August. On 6/15/24, R1 was prescribed cefadroxil 500 mg two times per day for five days. On 8/28/24, R1 was prescribed amoxicillin-pot clavulanate (Augmentin) tablets 875/125 mg two times per day for seven days. On 8/3/24, R1 was treated for pneumonia and acute cystitis and prescribed azithromycin 250 mg tablets daily for four days and cefuroxime tablets 500 mg two times per day for seven days. On 9/5/24, R1 was treated for sepsis of an unclear source and prescribed Augmentin 875/125 mg two times per day. No outcome/s was documented to determine the efficacy of R1's treatment plan for above noted infections. R31's Face Sheet dated 4/9/24, included a diagnosis of cough. R31's care plan dated 9/5/24, had no focus areas and/or interventions for R31's cough. Interventions indicated on the facility monthly resident infection statistics included a chest x-ray on 6/18/24. R31 was prescribed azithromycin 500 mg once, then 250 mg daily for five days. No outcome/s was documented to determine the efficacy of R31's treatment plan for upper respiratory infection (URI). On 10/15/24 at 2:03 p.m., during interview with the infection preventionist and director of nursing (DON), the facility's Monthly Resident Infection Statistics log documentation for 6/2024 to 9/2024, was reviewed for infection prevention and control. The documentation for 6/2024 to 9/2024, lacked documented outcomes for R12, R27, R1, and R31 including susceptibility, signs/symptoms of infection, any prolonged treatment, side effects, and/or change in antibiotic. After review of the documentation, the infection preventionist and DON acknowledged no resident outcomes were documented and stated that the resident outcomes needs to be documented when residents are prescribed antibiotics for appropriate antibiotic stewardship. Further, the infection preventionist stated it's expected that nursing monitored signs/symptoms of infection, monitored vital signs, followed the care plan, and notified the provider and family with the resident's condition. On 10/15/24 at 12:26 p.m., during a telephone call, the consulting pharmacist (CP)-A stated the facility was expected to complete timely and address urine culture results and follow up with the provider regarding UC results. CP-A stated failure to address or follow up with the provider regarding urine culture results can lead to ineffective treatment, specifically, if the prescribed medication is not susceptible with the culture results, it may exacerbate the infection or prolong treatment. The facility Antibiotic Stewardship policy revised on 3/13/23, indicated: 1. The medical director, consultant pharmacist, DON, and infection preventionist will be responsible for promoting and overseeing antibiotic stewardship activities in the facility. 2. Tracking- the infection preventionist, along with the consultant pharmacist, will monitor antibiotic use by utilizing a facility approved infection/antibiotic surveillance tracking form and thru monthly medication reviews. The information gathered will include resident name, unit and room number, date symptoms appeared, name of antibiotic, start date of antibiotic, pathogen identified, site of infection, date of culture, stop date, total days of therapy, outcome, and adverse events if applicable. 3. Reporting- the infection preventionist and the pharmacy consultant will provide regular feedback on antibiotic use and outcomes to the facility staff and the QAPI committee.

Based on observation, interview, and document review, the facility failed to ensure resident rights and choices were protected for 1 of 1 resident (R16) when his recliner was removed from his room against his wishes. Findings include: R16's admission Minimum Data Set (MDS) dated [DATE], indicated an admitted [DATE], intact cognition, no rejection of care, and diagnoses of heart failure, kidney failure, and edema. R16's care plan dated 7/9/24, focus area titled cognition indicated R16 was at risk for alteration in cognition related to adjustment to placement with interventions listed as allow resident time to communicate his needs/wants, provide and maintain consistent environment. R16's Physician's orders dated 7/2/24, indicated elevating legs to the level of the heart or above for 45-60 minutes, pump ankles while sitting in chair, elevate foot of bed, prop feet up on a pillow when sitting in recliner every shift. R16's Behavior note dated 7/4/24 at 3:37 a.m., indicated R16 was annoyed with staff due to not having his (personal ) recliner at the facility yet from his prior facility. Notes further indicated R16 stated he slept in his chair, couldn't sleep in a bed, and needed his chair by that night. R16's New Admission Note dated 7/5/24 at 3:38 a.m., indicated R16 had a hard time falling asleep that night because he was upset about not having his recliner from his prior facility. R16's New Admission Note dated 7/6/24 at 4:58 a.m., indicated R16's recliner had arrived from his prior facility, he was very happy to have his recliner since being without it since admission on 7/3/24, and was resting quietly in his recliner with his eyes closed. R16's Health Status progress note dated 9/15/24 at 3:37 a.m., indicated R16 rested well throughout the night and slept in his recliner with legs elevated for comfort. During interview on 10/14/24 at 8:31 a.m., R16 stated his recliner was taken from his room several days ago to be cleaned and he was unsure when it would be returned. R16 further stated he slept in his recliner every night and had been sleeping in his wheelchair since his recliner was removed. R16 stated he wanted to put his feet up but could not due to his recliner being gone. R16 further stated he did not sleep in his bed due to it being too small and uncomfortable. During interview on 10/14/24 at 2:03 p.m., R16 stated he did not give permission for his chair to be taken, he had asked for a sheet to be put over it instead, he was sick of sleeping in his wheelchair, and he wanted his chair back by evening. During observations from 10/13/24 through 10/15/24, R16 was observed in his wheelchair with his legs down on footrests. His personal recliner was absent from his room. An alternate recliner from the facility common area was provided after 5 p.m. on 10/14/24. R16's personal recliner was returned on 10/15/24. During interview on 10/14/24 at 2:06 p.m., director of nursing (DON) stated R16's recliner was wet with urine and had a foul smell and she had to take it on 10/10/24 or 10/11/24. DON confirmed she did not ask permission to take the chair. DON further confirmed she was unsure who was going to clean the chair and if or when it would be returned. During interview on 10/15/24 at 10:20 a.m., social services director (SSD) stated she had not been involved in the conversation to remove R16's recliner and was informed after it was removed. SSD further stated R16's recliner was very important to him when he admitted to the facility, and she would have expected R16's chair to be cleaned and immediately returned or a replacement chair offered and accepted prior to removing the chair. SSD further stated due to resident rights, they should have had his permission to remove the recliner. During interview on 10/15/24 at 1:10 p.m., administrator stated they had a discussion about the recliner and decided to remove it due to odor and infection control. Administrator stated she was unsure if anyone confirmed permission from R16. A policy on resident rights and personal property was requested but not received.

Based on observation, interview and document review the facility failed to ensure personal protective equipment (PPE) was utilized for 1 of 2 residents (R136) reviewed for enhanced barrier precautions (EBP). Additionally, the facility failed to ensure proper glove use and hand hygiene was performed during wound care for 1 of 3 residents (R136) reviewed for pressure ulcers. Finding include: R136's admission Minimum Data Set (MDS) dated [DATE], indicated no cognitive impairment, one stage two pressure ulcer present on admission, two unstageable pressure ulcers present on admission, and diagnosis included stage two pressure ulcer of sacral region. R136's care plan printed 10/15/24, indicated R136 was on enhanced barrier precautions due to wound to coccyx requiring treatment and interventions included: staff to follow enhanced barrier precautions, use appropriate communication to follow EBP, explain reason for use of enhanced barrier precautions, staff to don/doff PPE per enhanced barrier precautions when providing high contact cares; admitted with ulcer on coccyx from prior facility and redness to right heel and interventions included: treatment to open areas per order, weekly measurements and assessment of wound. On 10/14/24 at 8:48 a.m., a sign was observed on R136's door and indicated Enhanced Barrier Precautions, . providers and staff must wear gloves and gown for the following .transferring, providing hygiene, wound care. A cart outside of R136's room was observed with PPE and included gowns and gloves. Trained medication aide (TMA)-A and nursing assistant (NA)-B entered R136's room and failed to don PPE, and were observed to use a mechanical lift to transfer R136 from the wheelchair to the bathroom. TMA-A and NA-B used bare hands to move R136's feet from the wheelchair onto the mechanical lift and NA-B was observed to pull down R136's brief with ungloved hands. On 10/14/24 at 1:17 p.m. TMA-A confirmed no PPE was worn during the transfer of R136 earlier in the day. TMA-A stated gown and gloves were expected to be worn during transfers for residents placed on EBP. On 10/15/24 at 7:37 a.m., NA-C entered R136's room and put on gloves and assisted R136 with removing his shirt and washed R136's upper body with gloved hands and no gown. NA-C further was observed to remove R136's pants and removed the fastening tabs from R136's brief and washed R136's peri area with gloved hands and no gown. R136's coccyx had a dressing cover the pressure area. On 10/15/24 at 8:15 a.m., licensed practical nurse (LPN)-C entered R136's room with gloves, gown, and wound care supplies. NA-C (with gloved hands and no gown) and LPN-C turned R136 to his right side in bed. LPN-A with gloved hands, removed the old dressing from R136's buttock, sprayed the wound with wound cleanser, used same gloved hands and opened a gauze package and used the gauze to dab the wound. NA-C (gloved not gowned), assisted LPN-C and again rolled R136 side to side and R136's brief was removed. LPN-C sprayed the wound again, measured the wound, and applied cream with same gloved hands, opened a clean dressing and placed the dressing on the wound, then applied skin prep around the wound . LPN-C further opened another dressing with same gloved hands and placed the dressing on the buttocks area, and then grabbed a clean brief and with assistance of NA-C a new brief was placed on R136. LPN-C removed gloves and placed in the trash and removed gown and exited R136's room. On 10/15/24 at 8:24 a.m., LPN-A confirmed gloves were not changed during R136's wound care and stated he was expected to change gloves and complete hand hygiene after removing the old dressing and place new clean gloves on prior to applying the new dressing. LPN-A stated gown and gloves were expected during wound care, however was not sure if staff had to wear PPE if they were not completing wound care and were assisting with the transfer. LPN-A proceeded to read the sign on R136's door and stated after reading the sign staff were expected to wear gown and gloves with transfers, hygiene, and dressing the resident with EBP. On 10/15/24 at 8:26 a.m., NA-B confirmed gloves or gown was not worn when she toileted or transferred R136. NA-B stated the facility had not provided education that PPE including gown and gloves was required when cares or transfers were completed for residents with a wound or catheter. On 10/15/24 at 10:54 a.m., LPN-A, known as the nurse manager, confirmed R136 was on EBP due to a wound on his coccyx, and stated staff were expected to wear gown and gloves during high contact care including transfers, brief changes, and dressing. LPN-A further stated staff were expected to change gloves after old dressing was removed, wash hands and place new gloves. On 10/15/24 at 11:21 a.m., NA-C confirmed R136 was in EBP and stated a gown was not worn during morning cares for R136, and stated a gown and gloves were expected to be worn for residents on EBP. On 10/15/24 at 12:45 p.m., during an interview the director of nursing (DON) confirmed R136 was on EBP and stated staff were not expected to wear gown and gloves when a resident on EBP during transfers. DON was observed to read the EBP signs that were posted on EBP residents doors. After the DON reviewed the EBP precautions, the DON stated for EBP, staff should wear gowns and gloves for all high contact resident care activities and not just with cares related to the reason for being on EBP. The DON further stated staff were not trained to wear gown and gloves during transfers for residents on EBP . The DON further stated, during a dressing change staff were expected to remove gloves, complete hand hygiene, and get new gloves prior to the clean dressing applied . On 10/15/24 at 3:35 p.m., registered nurse (RN)-C stated she was the infection preventionist at the facility and stated staff were expected to wear gown and gloves when providing cares and transfers for resident with EBP. RN-C stated staff were expected to change gloves and wash hands during wound care when the old dressing was removed. Facility policy Enhanced Barrier Precautions dated 4/1/24, indicated All staff receive training on enhanced barrier precautions upon hire and at least annually and are expected to comply with all designated precautions. All staff receive training in high-risk activities and common organisms that require enhanced barrier precautions. Implement enhanced barrier precautions for residents with any of the following: Wounds (e.g., chronic wounds such as pressure ulcers, diabetic foot ulcers, unhealed surgical wounds, and chronic venous stasis ulcers) High-contact resident care activities include: a. Dressing b. Bathing c. Transferring d. Providing hygiene e. Changing linens f. Changing briefs or assisting with toileting g. Device care or use: central lines, urinary catheters, feeding tubes, tracheotomy/ventilator tubes. h. Wound care: any skin opening requiring a dressing. Enhanced barrier precautions should be followed outside the resident ' s room when performing transfers and assisting during a high contact activity such as bathing in a shared/common shower room and when working with residents in the therapy gym, specifically when anticipating close physical contact while assisting with transfers and mobility, or any high-contact activity. Facility Policy titled Wound Care Treatment procedure dated 2/24, indicated Steps to complete addressing change: Prior to starting, wash your hands and prepare the dressing supplies in an established clean field. Apply clean gloves Remove the previous dressing Dispose of previous dressing and designated container Remove your gloves and complete hand hygiene Evaluate the wound Clean the wound Remove gloves dispose of them in the designated container and complete hand hygiene Apply clean gloves and complete dressing change while following the provider's order When the treatment is completed remove your gloves dispose of any additional items and complete hand hygiene

Based on interview and document review the facility failed to ensure the provider's response to the monthly medication review was followed for 1 of 5 (R18) residents reviewed for unnecessary medications. Findings include: R15's quarterly Minimum Data Set (MDS) dated [DATE], indicated R15 had moderate cognitive impairment, diagnosis included diabetes mellitus, and received insulin injections. R15's consultant pharmacist (CP)-A recommendation to physician dated 9/10/24, indicated consider redrawing A1C ( measures your average blood sugar levels over the past three month) and adjusting insulin doses as needed. The provider responded to the recommendation on 9/17/24, and ordered A1C. R15's provider and nursing orders were reviewed and lacked documentation the facility had completed the physician ordered A1C. On 10/15/24 at 7:28 a.m., licensed practical nurse (LPN)-A confirmed R15's physician ordered A1C was not addressed by nursing staff as expected. LPN-A stated the order for the A1C was not sent to nursing before the order was scanned into the electronic medical record (EMR) by health information management (HIM)-A. LPN-A stated HIM-A was expected to make sure documents including orders were signed and dated by a nurse prior to scanned into the EMR to ensure orders were addressed. On 10/15/24 at 12:51 p.m., the director of nursing (DON) stated the pharmacist emailed the nurse managers with the provider recommendations, and stated the nurse managers were responsible to follow up with the pharmacy recommendations and provider response. The DON stated she would expect HIM to bring the order back to nursing if the order was not signed and dated by nursing. The DON stated she would expect the order for 9/17/24, addressed and completed. A facility policy was requested and not received.

Based on observation, interview and document review, the facility failed to follow provider's order of catheter flush for 1 of 1 resident (R12) reviewed with indwelling catheter to minimize the risk for urinary tract infections (UTI). Additionally the facility failed address urinalysis (test of the urine to detect infection) results for 2 of 2 residents (R5 and R12) reviewed for UTI. Findings include: R5's significant change Minimum Data Set (MDS) dated [DATE], indicated R5 was dependent on staff for toileting hygiene, toilet transfer, and utilized a wheelchair, frequently incontinent of urine, taking an antibiotic, diagnoses included: chronic kidney disease, hemiplegia and hemiparesis following cerebral infarction affecting left dominant side (conditions that cause weakness or paralysis on one side of the body after a stroke), dementia, and altered mental status R5's care plan dated 10/13/24, indicated alteration in elimination r/t (related to) dx (diagnosis) of urinary incontinence, will be free from signs/symptoms of UTI, obtain/review labs per MD (medical doctor) order R5's progress note dated 9/10/24 at 3:09 p.m., the director or nursing (DON) indicated R5 returned from hospital and does have a UTI, antibiotics initiated. R5's progress note dated 9/10/24 at 5:24 p.m., registered nurse (RN)-B indicated R5 returned from the hospital with an order for cefdinir (antibiotic used to treat infections) 300 mg bid (twice a day) for 7 days due to a UTI. Family aware. Order faxed to pharmacy. R5's document transfer report dated 9/10/24, emergency provider notes dated 9/10/24, indicated R5 urinalysis consistent with UTI, will plan to discharge back to facility with prescription for cefdinir pending urine culture. R5's urine culture results with a fax dated 9/24/24, to the facility indicated R5's urine culture results. The document did not list the the current antibiotic, cefdinir, R5 was prescribed. R5's record review failed to indicated R5's urine culture results were addressed by the facility. On 10/15/24 at 11:11 a.m., licensed practical nurse (LPN)-A, known as the nurse manager, stated the urine culture result was scanned into electronic medical record (EMR) without the nurse reviewing the result. LPN-A stated the results are dated and signed by the nurse when reviewed. LPN-A stated health information was expected to make sure documents were signed and dated by a nurse prior to scanned into the EMR to ensure results were addressed. LPN-A confirmed R5's UC result dated 9/10/24, and faxed to the facility 9/23/24, was not reviewed by a nurse as expected and was important to ensure R5 was on the correct antibiotic for her UTI. On 10/15/24 at 12:26 p.m., during a telephone call consulting pharmacist stated the facility was expected to timely review and address urine culture results and follow up with the provider regarding UC results. CP-A stated failure to address or follow up with the provider regarding urine culture results can lead to ineffective treatment, specifically, if the prescribed medication is not susceptible with the culture results, it may exacerbate the infection or prolong treatment. On 10/15/24 at 12:37 p.m., the DON, stated the nurse manager were expected to be aware of residents who had a UC pending and confirmed there was a breakdown in the process. The DON further stated HIM was not expected to scan documents in the EMR until signed and dated by nursing. On 10/15/24 at 1:33 p.m., health information management (HIM)-D stated she scanned documents in the EMR, and confirmed the documents were expected signed and dated prior to scanned into the EMR. HIM-D stated documents not signed or dated by nursing were expected brought back to nursing to ensure the document or order was reviewed and entered. HIM-D stated UA's and UC's results were also expected signed and dated prior to scanned into the EMR. HIM-D confirmed documents were scanned into the EMR without nurse signature or date and the facility had provided education ensuring nursing had reviewed prior to her scanning into the EMR. R12's quarterly MDS dated [DATE], indicated R12 was cognitively intact, had an indwelling urinary catheter, dependent on staff for toileting hygiene and toilet transfers, utilized a wheelchair, diagnoses included traumatic spinal cord dysfunction, neurogenic bladder (a condition that affects bladder control due to nerve damage or brain disorders), and quadriplegia (paralysis that affects all of a person's limbs). R12's physician orders start date 6/26/24, indicated flush and irrigate catheter every other day with 60 cc (cubic centimeter) normal saline for oliguria (low urine output) and progress note needed at 8:00 p.m. R12's treatment administration record (TAR) dated 9/1/24-9/30/24, indicated the provider order flush and irrigate catheter every other day with 60 cc normal saline for oliguria and progress note needed scheduled at 8:00 p.m., was completed 10 out of the 15 times, and was not completed five times. R12's progress note dated 9/27/24 at 6:13 a.m., licensed practical nurse (LPN)-B indicated R12 was bypassing her catheter catheter, nurse flushed her catheter at that time, there was 250 cc out at the time she flushed it. R12's progress note dated 9/28/24 at 5:37 a.m., LPN-B indicated R12's brief was wet, nurse flushed her catheter and emptied her bag to ensure that it was following [flowing] properly, catheter has sediment that was clogging it. R12's progress note dated 10/3/24 at 3:53 a.m., LPN-B indicated R12 requested for her catheter flushed because she could feel it bypassing, nurse flushed it and had CNA's apply a brief. R12's progress note dated 10/7/24 at 4:30 a.m., LPN-B indicated R12 was having trouble with her catheter, R12 indicated her catheter had been clogged for a while and they had to change her brief a total of six times, nurse attempted to flush her catheter without any success, there was so much sediment that the water was not going through. Nurse then proceeded to change her catheter, it is currently patent, she had 700 cc's out. Nurse sent an email to the provider requesting an order for UA/UC, her urine is dark, odorous, and full of sediment. The lat time time it was changed was eight days ago, she is to have it changed every 14 days , but it has not been lasting that long. R12's progress note dated 10/9/24 at 5:33 a.m., LPN-B indicated nurse applied a new catheter bag and collected a UA, urine dark with slight odor, a lot of sediment, urine sample in the refrigerator, waiting for it to be sent to lab. R12's progress note dated 10/11/24 at 1:45 p.m., LPN-A indicated writer collected UA and sent over with order to pharmacy, awaiting results. R12's progress note dated 10/12/24 at 12:54 a.m., LPN-B indicated received the UA results from lab department, the following results were abnormal; urine appearance was turbid (murky or unclear, instead of its normal clear or slightly cloudy appearance), urine ph is higher than 9 (normal urine pH ranges from 4.6 to 8.0), urine leukocyte esterase 3 (sign of infection), urine protein 3 (can be a sign of kidney problems), urine blood 2 (sign of infection), results faxed to provider waiting for response. On 10/13/24 at 6:16 p.m., R12 was seated in her motorized wheelchair in her room with family member (FM)-E. R12 stated she had problems with her urine and clogging of the catheter tubing within the last month. R12 stated staff were supposed to flush the catheter every other day so sediment does not build up in the catheter tubing. R12 stated the staff do not routinely flush the catheter tubing every other day. R12 stated she had in the last month problems with the catheter not flowing properly due to the sediment built up and was urine was leaking around the catheter and she had to wear a brief due to the urine leaking from the catheter. R12 stated she had a recent urine collection to see if she had an infection and stated she must not because she had not heard from the staff. R12 stated the urine test was due to the smell, dark color, and lots of sediment in the urine. FM-E stated R12 had never had a UTI prior to her admission the facility. On 10/15/24 at 9:59 a.m., physician assistant (PA)-H stated he was R12's medical provider and comes to the facility on ce a week. PA-H stated the facility was expected to fax UA results on the weekend to the on call provider and was not aware of any pending UA results for R12. PA-H stated the staff were expected to follow the order and flush R12's catheter every other day. PA-H stated not flushing the catheter every other day could cause sediment to build up and could cause a UTI. PA-H stated staff were expected to follow up with the provider within 24 hours if a provider had not addressed a residents UA results. On 10/15/24 at 10:56 a.m., LPN-A, known as the nurse manager stated R12 was known to have sediment build up in her catheter. LPN-A stated she was not aware staff were not flushing R12's catheter as ordered every other day, and would expect staff follow provider orders LPN-A was observed to check the EMR for R12 and confirmed there were five dates in September when R12's catheter was not flushed as ordered. LPN-A stated R12 had problems with her catheter not flowing and her catheter leaking and R12 had to wear a brief. LPN-A stated R12's catheter not flushed could cause sediment to build up. LPN-A further stated a UA was cooled on 10/11/24, and the results were faxed to the provider on 10/13/24, and confirmed the UA result had not been addressed by the provider, LPN-A further stated the facility was responsible to follow up within 24 hours if a result was not addressed by the provider. On 10/15/24 at 12:53 p.m., the DON stated staff were expected to follow provider orders and flush R12's catheter every other day. The DON stated nurse managers were expected to run a daily report that indicates residents missed orders. The DON was observed to run report on the EMR and confirmed R12 had missed catheter flushes in September. The DON stated the catheter flushes were important so sediment does not build up and could cause a UTI. The DON stated she has educated facility staff all orders were expected completed prior to staff leaving their shift. Further, the DON stated R12's UA result from 10/13/24 was expected to be addressed by the provider and if not addressed would expect the nurse manager to reach out the provider within 24 hours. Policy on UA/UC results was requested and not received. Facility policy Infection Prevention and Control Program dated 3/13/23, indicated : The infection prevention and control committee is responsible for reviewing and providing feedback on the overall program. s surveillance data and reporting information is used to inform the committee of potential issues and trends. Some examples of committee reviews may include: a. whether physician management of infections is optimal; b. whether antibiotic usage patterns need to be changed because of the development of resistant strains; c. whether information about culture results or antibiotic resistance is transmitted accurately and in a timely fashion; and d. whether there is appropriate follow-up of acute infections Culture reports, sensitivity data, and antibiotic usage reviews are included in surveillance activities. 2. Medical criteria and standardized definitions of infections are used to help recognize and manage infections.

Based on observation, interview, and document review, the facility failed to conduct a comprehensive reassessment after a fall incident and ensure new interventions were implemented to prevent further falls for 1 of 1 resident (R11) reviewed for falls. Findings include: R11's admission record printed 10/15/24, indicated diagnoses of chronic obstructive pulmonary disease (a lung disorder), muscle weakness, and history of falling. R11's admission Minimum Data Set (MDS) dated [DATE], indicated severe cognitive impairment, no rejection of care, use of a wheelchair for mobility, substantial assistance with transfers, and fall history prior to admission. R11's facility Kardex printed 10/14/24, indicated independent with toileting, assist of one staff with bathing, shaving, dressing, and bed mobility, assistance of one staff, walker, and gait belt for walking, and safety intervention of gripper socks at bedtime. R11's care plan dated 10/11/24, listed focus area of fall risk related to COPD, epilepsy, muscle weakness, and history of falls. Interventions included gripper socks or shoes to feet when not in bed and follow PT and OT instructions for mobility function. R11's progress note dated 9/28/24, listed a Brief Interview for Mental Status (BIMS) score of 6, indicating severe cognitive impairment. R11's progress note dated 9/29/24, indicated R11 attempted to self-transfer to the bathroom from his bed and had a fall. Staff educated R11 on call light use and waiting for assistance. R11 had a skin tear to right knee from the fall. A facility incident review and analysis dated 9/29/24, was started but not comprehensively completed. The incident review and analysis lacked review of the fall to determine cause and intervention to prevent future falls. In addition, no new intervention was identified on the care plan. A facility incident note dated 10/11/24, indicated R11 had an additional fall on 10/11/24 at 4:25 a.m., when found on the floor next to his bed after attempting to walk to the bathroom independently. An incident review and analysis was completed after this fall and intervention including gripper socks when out of bed. During observation on 10/13/24 at 1:16 p.m. and 2:33 p.m., R11 was observed walking in the hall without walker or staff assistance. During interview on 10/14/24 at 9:40 a.m., nursing assistant (NA)-B indicated she was not aware of what interventions were in place for R11 other than having him wear gripper socks. During interview on 10/15/24 at 10:00 a.m., licensed practical nurse (LPN)-A stated no comprehensive fall assessment had been completed after R11's fall on 9/29/24. LPN-A further stated an interdisciplinary team (IDT) risk assessment meeting was held on 9/30/24 and R11's fall was reviewed with suggested intervention of leaving R11's walker next to his bedside. LPN-A confirmed the intervention was discussed at the meeting but a fall assessment had not been completed and the intervention had not been implemented or added to the care plan. LPN-A stated without the intervention on the care plan staff would not be able to see it on their Kardex tool and would not know the intervention had been put in place. During interview on 10/15/24 at 12:28 p.m., director of nursing (DON) stated she would expect a post fall assessment done within 48 hours of a fall and an intervention be put in place immediately, reviewed at the next facility risk management meeting, and then placed on the care plan. DON confirmed R11's fall dated 9/29/24, was discussed at the facility risk management meeting and an intervention of leaving R11's walker at bedside was discussed but had not been implemented. DON further stated timely implementation of interventions was important for reducing fall risk for residents. Facility policy Fall Prevention and Management updated 2/2024, indicated the following; Assessing and Evaluating Falls and Causal Factors When a fall occurs: Nursing staff will complete an incident review and analysis. Facility staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and minimize complications from falling. Staff may implement relevant interventions to try to minimize serious consequences of falling and monitor and document each resident's response to interventions.

Based on observation, interview and document review, the facility failed to follow physician orders for leg elevation for 1 of 1 resident (R16) reviewed for edema. Findings include: R16's admission Minimum Data Set (MDS) dated [DATE], indicated intact cognition, no rejection of care, and diagnoses of heart failure, kidney failure, and edema. R16's care plan dated 7/9/24, focus area titled cognition indicated R16 was at risk for alteration in cognition related to adjustment to placement with interventions listed as allow resident time to communicate his needs/wants, provide and maintain consistent environment. Care plan focus area titled skin integrity indicated R16 had alteration in skin integrity related to congestive heart failure (CHF), diabetes mellitus type two (DM2), chronic gout as evidenced by (AEB) wounds. Interventions included encouraging resident to sleep in his bed, monitoring skin integrity, and pressure reducing devices to bed and recliner. R16's Physician's orders dated 7/2/24, indicated elevating legs to the level of the heart or above for 45-60 minutes every shift, pump ankles while sitting in chair, elevate foot of bed, prop feet up on a pillow when sitting in recliner. During interview on 10/14/24 at 8:31 a.m., R16 stated his recliner was taken from his room several days ago to be cleaned and he was unsure when it would be returned. R16 further stated he slept in his recliner every night and had been sleeping in his wheelchair and had not elevated his feet since his recliner was removed. R16 stated he wanted to put his feet up but could not due to his recliner being gone. During interview on 10/14/24 at 1:22 p.m., R16's family member (FM)-J indicated she had not observed his legs elevated since removal of his recliner. FM-J further stated R16 had been sleeping in his wheelchair with his legs down since removal of his recliner and the only option he had been given was to sleep in his bed for elevation, which he didn't like due to the bed being too short and hard. FM-J stated the facility was aware R16 did not like the bed. During interview on 10/14/24 at 10:45 a.m., nursing assistant (NA)-A stated R16 usually sat in his recliner with his legs elevated. NA-A further stated she did not know how he would elevate his legs in his wheelchair or if his legs had been elevated since his recliner had been removed from his room. NA-A also stated R16 usually slept in his recliner. During interview on 10/14/24 at 1:49 p.m., registered nurse (RN)-B stated R16 had been without his recliner since the middle of last week. RN-B further stated he had been sleeping in his recliner and elevating his legs in his recliner prior to it being removed. RN-B was unsure if R16's order for elevating his legs had been completed since his recliner was removed and it would be concerning if R16 was not elevating his legs due to his edema. During interview on 10/14/24 at 2:32 p.m., licensed practical nurse (LPN)-A also known as care coordinator stated they had offered to put R16 in bed to take swelling down in lower legs and feet but he refused. LPN-A further stated he often refused to elevate his legs. LPN-A stated she was unsure if R16's legs had been elevated since his recliner was removed and she would check the nurse charting. During interview on 10/24/24 at 2:06 p.m., director of nursing (DON) stated she was unsure if R16's legs were being elevated since his chair was removed. DON stated she talked to R16 and he told her he had not been sleeping in his bed and had been in his wheelchair since his recliner was removed from his room. DON further stated R16 frequently refused to elevate his legs and she would have expected staff to inform her if R16 was unable to elevate his legs and was sleeping in his wheelchair with his legs down. R16's treatment administration record (TAR) dated 10/1/24 through 10/14/24, indicated no refusals of leg elevation during the time period. A facility policy on edema was requested but not received.

Based on observation, interview and document review, the facility failed to ensure resident status was accurately identified in the Minimum Data Set (MDS) assessment for 1 of 1 resident (R5) reviewed for hospice. Findings include: R5's Face Sheet dated 10/15/24, indicated R5 primary payer was hospice, care providers included hospice, and diagnoses hemiplegia and hemiparesis following cerebral infarction affecting left dominant side (conditions that cause weakness or paralysis on one side of the body after a stroke), dementia, and altered mental status. R5's significant change in status MDS dated [DATE], section O, K1 under special treatments and programs, did not include hospice care services . Section J 1400 Prognosis: conditions or chronic diseases that may result in a life expectancy of less than 6 months indicated no. R5's hospice plan of care printed 10/15/24, indicated R5's hospice start of service date was 9/11/24. R5's care plan dated 10/13/24, indicated hospice Cares r/t (related to) end stage kidney disease, enrolled for services with hospice. On 10/15/24 at 11:49 a.m., registered nurse (RN)-A, also identified as MDS specialist, indicated R5 was admitted to the facility on hospice. Upon review of admission MDS, RN-A confirmed section 0 was not coded as R5 receiving hospice services. On 10/15/24 at 12:37 p.m., the director of nursing (DON) stated the MDS should have been completed accurately and hospice services should have been indicated on the admission MDS. On 10/15/24 at 2:54 p.m., the administrator stated the facility followed the RAI (resident assessment instrument) Manual and doesn't utilize a specific MDS policy.

Based on interview and document review, the facility failed to ensure an advance directives was accurately documented on the resident's electronic health record (EHR) banner and physician orders which affected 1 of 30 residents (R14) reviewed for advance directives. This resulted in an immediate jeopardy (IJ) for R14 who would have been denied cardiopulmonary resuscitation (CPR) contrary to their wishes, in the absence of a pulse or respirations. The IJ began on [DATE] when R14's Provider Orders for Life-Sustaining Treatment (POLST) identified R14 wished to have CPR administered, however, the physician orders in the EHR and EHR banner indicated R14 was do-not-resuscitate (DNR). The administrator was notified of the IJ on [DATE], at 8:03 p.m. The IJ was removed on [DATE] at 1:07 p.m., but non-compliance remained at the lower scope and severity level of D, isolated with no actual harm but potential to cause more than minimal harm. Findings include: R14's quarterly Minimum Data Set (MDS) assessment dated [DATE], indicated moderately impaired cognition, required assistance from staff with activities of daily living (ADL), and diagnoses of stroke, diabetes, non-Alzheimer's dementia, and anxiety disorder. On [DATE] at 2:30 p.m., R14's face sheet/banner in point click care (PCC) (computer program) indicated R14's code status was DNR. R14's most current Physician's Orders For Life Sustaining Treatment (POLST) located in the scanned EHR, signed by R14's family member (FM)-A on [DATE], and certified nurse practitioner (CNP)-A on [DATE], identified R14's wishes were full code status. R14's Order Summary report dated [DATE], indicated DNR status. The order summary failed to reflect the POLST of full code status signed by FM-A and CNP-A. During an interview on [DATE] at 2:35 p.m., registered nurse (RN)-A stated if a resident was found unresponsive and not breathing he would call the ambulance, then call the doctor, and would check the code status of the resident using the computer. Observed RN-A check the EHR stated R14 was DNR based on the code status reflected on the banner in PCC. RN-A confirmed he would not do CPR on R14. During an interview on [DATE] at 2:40 p.m., licensed practical nurse (LPN)-A stated the first placed she looked for code status (if a resident was found unresponsive) was the Kardex. LPN-A indicated the resident's Kardex was located inside the cupboard door of a resident's bathroom. Observed LPN-A open R14's bathroom cupboard door, inspected the Kardex, and confirmed the code status was missing from R14's Kardex. LPN-A stated she would then check the EHR and identified R14 had POLST completed recently and was a full code, and stated the banner on the EHR indicated DNR. LPN-A further stated she would do CPR because of the code discrepancy. During an interview on [DATE] at 2:45 p.m., RN-B stated R14's code status was DNR, and further stated she knew R14's code status because she worked with R14 last week. RN-B confirmed she would not implement CPR for R14. During an interview on [DATE] at 2:47 p.m., RN-C, also known as the regional nurse consultant, stated the first-place nurses should look to identify a resident's code status was on the EHR banner in PCC. RN-C further stated the health information coordinator (HIC), or the nurse was responsible for changing the order in the EHR based on POLST. RN-C verified R14's EHR banner of DNR would not have been correct because R14's POLST. signed by FM-A [DATE] and CNP-A on [DATE], indicated she's a full code. On [DATE] at 2:59 p.m., FM-A stated R14's wishes were to be full code. During an interview on [DATE] at 3:00 p.m., the HIC confirmed she was aware R14's code status had changed when she scanned the physician order dated [DATE], into the EHR and confirmed she should have updated the order at that time in the EHR from DNR to CPR for accuracy. During an interview on [DATE] at 3:35 p.m., the interim director of nursing (DON) stated if a resident's POLST was updated he expected the POLST scanned in the EHR, and the banner on the EHR changed when the order was scanned into the EHR. The DON stated typically the orders are processed within 24 hours, and the nurse was responsible ensure the orders were updated in the EHR accurately. The DON confirmed if staff don't follow this process/procedure resident wishes would not be followed. The facility Cardiopulmonary Resuscitation policy dated ,d+[DATE], indicated: The philosophy of Monarch Healthcare Management is to provide quality long and short-term caring and safe environment. Individual medical emergency response plans are developed for each resident based upon their individualized assessment, needs, preferences and advanced directives. A POLST form will be completed upon admission by the nurse manager or designee and reviewed upon readmission, quarterly, and as needed (when there is a substantial change in the resident's health status; when the resident's treatment preferences change). A POLST form is a medical order, which means it us must be signed by a medical provider to be valid. When an emergency occurs, the nurse and/or clinical team will guide care provided, according to the resident and/or resident's representative identified preferences indicated on the physician's order within the plan of care. CPR will not be initiated if the resident has a valid DO NOT RESUSCITATE order in place OR he resident shows signs of irreversible death. The IJ was removed on [DATE], at 1:07 p.m., when the facility developed and implemented a systemic removal plan which was verified by interview and document review. On [DATE] at 3:30 p.m., the facility completed an audit of all resident's code status to ensure residents have matching code status order, POLST, and was reflected in the EHR, and the facility also completed a root cause analysis. The facility initiated training on [DATE] at 4:00 p.m., for all licensed nurses and HIC and were trained immediately or prior to their next scheduled shift regarding the updated POLST procedure and where to find a residents' code status. On [DATE] at 10:00 p.m., and on [DATE] at 6:00 a.m., oncoming licensed staff were educated regarding the updated POLST procedure and where to find a residents' code status. and continued for staff prior to their next shift. On [DATE] the facility reviewed the policy regarding code status and updated the policy, which outlined where the staff would locate the code status.

Based on observation, interview, and document review, the facility failed to provide sufficient staffing to ensure residents received care and assistance as needed and requested. These deficient practices had the potential to affect all 30 residents who resided in the facility. Findings include: Refer to F677: Based on observation, interview and document review, the facility failed to provide timely toileting, incontinence care and repositioning for 2 of 3 residents (R17 and R18) who were dependent upon staff for assistance with activities of daily living (ADL). Refer to F688: Based on interview, observation and document review, the facility failed to ensure staff provided walking program to meet the assessed needs for 1 of 2 residents (R14) reviewed for restorative services. Refer to F689: Based on observation, interview and document review, the facility failed to ensure assessed and care planned interventions to prevent falls were implemented for 1 of 3 residents (R13) reviewed for falls. MDS: R6's significant change Minimum Data Set (MDS) assessment dated [DATE], indicated severe cognitive impairment, no rejection of care, at risk for development of pressure ulcers, no unhealed pressure ulcers, no turning and repositioning program. R6 was dependent upon staff for most activities of daily living (ADL's) including repositioning. R8's quarterly MDS assessment dated [DATE], identified R8 had moderate cognitive impairment, no behaviors or rejection of care, required partial/moderate assistance with toileting, shower/bathe, lower body dressing, personal hygiene, and was dependent on staff for toilet transfer, and used a wheelchair for mobility. R9's quarterly MDS assessment dated [DATE], indicated R9 was cognitively intact, no behaviors or rejection of care, dependent on staff for shower/bathe, lower body dressing, required partial/moderate assistance with personal hygiene, and used a wheelchair for mobility. R11's quarterly MDS assessment dated [DATE], indicated R11 was cognitively intact, no behaviors or rejection of care, required substantial/maximal assistance with personal hygiene, upper body dressing, shower/bathe, dependent on staff for lower body dressing and transfers, and used a wheelchair for mobility. R12's significant change in status MDS assessment dated [DATE], indicated R12 required supervision with toileting, hygiene, shower/bathe, personal hygiene, independent wit sit to stand, toilet transfer, chair/bed transfer, and used a wheelchair for mobility. R14's quarterly MDS assessment dated [DATE], indicated R14 had a moderate cognitive deficit, no behaviors, no rejection of care, utilized a walker and wheelchair, required substantial/maximal assistance with toileting, shower/bath, lower body dressing, dependent on staff for putting on/taking off footwear, set up with personal hygiene, partial/moderate assistance with upper body dressing. R15's quarterly MDS assessment dated [DATE], indicated R15 was cognitively intact, had clear speech, could understand and be understood. R15 required substantial/maximal staff assistance or was dependent upon staff for activities of daily living (ADL's). R16's significant change MDS dated [DATE], indicated R16 had severe cognitive impairment, clear speech, could understand and be understood. R16 required partial/moderate staff assistance or substantial assist with ADL's. R17's quarterly MDS assessment dated [DATE], indicated R17 was rarely/never understood, no behaviors or rejection of care, utilized a walker, required substantial/maximal assistance with toileting, shower, dressing, personal hygiene, always incontinent of urine and bowel, and diagnoses included non-traumatic brain dysfunction, heart failure, non-Alzheimer's dementia, difficulty in walking, muscle weakness, and history of falling. R18's quarterly MDS assessment dated [DATE], indicated R18 had severe cognitive impairment, clear speech, could understand and be understood. R18 required partial/moderate assistance with ADL's including toileting and repositioning. R18 was occasionally incontinent of urine and always continent of bowel. R18 used a wheelchair for mobility. R20's quarterly MDS assessment dated [DATE], indicated R20 was cognitively intact and was dependent on staff for toileting, shower/bath, lower body dressing and personal hygiene, toilet transfer, chair to bed transfer, and used a wheelchair for mobility. R23's quarterly MDS assessment dated [DATE], indicated R20 required substantial/maximal assistance with shower/bathe, dressing, and personal hygiene, and used a wheelchair for mobility. Resident and Family Interviews: On 2/5/24 at 11:08 a.m., R23 stated it was not uncommon for him to wait for up to one hour for staff assistance to provide cares. On 2/5/24 at 11:48 a.m., R9 stated the shortest amount of time her call light was answered was 20 minutes and had to wait up to an hour. On 2/5/24 at 12:15 p.m., family member (FM)-E stated the facility did not have enough staff on the evening shift, and stated the staff on the evening shift were consistently agency staff who were unfamiliar with R14's cares and routines, and caused R14 delayed assitance for bedtime. On 2/5/24 at 12:30 p.m., R8 stated the facility did not have enough staff on the evening shift and consistently takes staff 30 minutes to answer her call light. R8 stated at times she waits up to an hour and half for staff to respond to her call light when she is requesting help to go to bed. On 2/5/24 at 1:34 p.m., R20's FM-I stated staff answered the call light between five minutes and 45 minutes. FM-I stated the number of agency staff impact R20's care, due to not knowing his plan of care and not trained for his routines. On 2/5/24 at 2:18 p.m., R12 stated he waited 15-30 minutes for staff to answer the call light, and further stated he took himself to the bathroom. On 2/5/24 at 2:26 p.m., R15 stated staff answered call lights anywhere from five minutes to one hour. R15 further discussed an incident in August 2023, when she was put on a bedpan and left for more than an hour. R15 stated an unidentified nursing assistant (NA) stated she would tell the oncoming NA she was on the bedpan, but no one found her until another staff came into her room. R15 stated her call light was on the whole time. On 2/5/24 at 3:38 p.m., FM-G stated the facility was understaffed and that required R16 to have to sit in his wheelchair too long after supper. FM-G further stated there was not enough staff and waited too long for staff assistance to put R16 to bed. FM-G stated at times R16 waited 30 minutes to an hour for staff to respond to his call light. On 2/5/247 at 5:14 p.m., during a phone interview FM-F stated she routinely visited the facility after 3:00 p.m., and stated R17 was usually still seated at the dining room table or slumped in a chair in the common room. FM-F stated on one incident when she visited the facility at 3:30 p.m., R17 was seated at the dining table by herself and staff stated R17 had been at dining table since 11:30 a.m. FM-F stated other times she visited the facility she had to ask staff to toilet R17, was frequently found slumped in recliner in the common room and her brief wet with urine. FM-F stated she had voiced her concerns to the social worker and had not seen any improvement in care. FM-F stated R17 was not able to voice to staff when she needed assistance and stated she expected R17 toileted and not in a wet brief. During a follow up interview on 2/7/24 at 5:08 p.m., FM-F stated on 12/7/23, when visiting R17 she put R17's room call light on to get assistance and after 35 minutes went out to the hallway to get help from staff to toilet R17. FM-F located a staff member in the hallway and asked the staff working if it always took this long to answer call lights and the staff stated she was not sure as it was her first time working at the facility. FM-F further stated when she came to the facility today (2/7/24), she found R17 in her room in bed and was surprised she was not slumped in the chair in the common room. On 2/7/24 at 2:17 p.m., during resident council meeting, R8, R11, R14, R15, and R18 voiced concerns and voiced agreement regarding staffing concerns of the facility and long wait times for call lights to be answered. R8, R11, R14, R15, R18 further stated delay in receiving staff assistance with going to bed, and stated there was mainly agency staff that usually worked in the evenings and they were not familiar with the care needed. Further, staff did not routinely use the care plan that was provided in the cupboards in the bedroom or bathroom that directed their care. R11 stated when staff were not familiar with her care she was able to tell staff what to do. R11 further stated she was not sure how staff were caring for residents who could not communicate their needs. R15 and R11 stated staff will enter the room shut the call light off, exit the room and did not assist them, and further discussed they would put the call light back on again, because staff did not provide the assistance when the call light was shut off. R15 stated within the last six months there was an incident where staff left her on the bedpan for over 2 1/2 hours. Staff Interviews: On 2/5/24 at 12:05 p.m., NA-D stated the facility consistently utilized agency nursing for the evening shift for several months, and staff from the day shift were required to stay for the evening shift. NA-D stated she consistently worked the evening shift two to three times a week because the evening shift was short staffed. NA-D discussed the evening staff had been short for several months, and at least six months. NA-D stated the day and overnight shift was staffed with facility staff who were familiar with resident cares, and the evening shift used agency staff who come one hour before the shift to orientate, and stated there was not consistent evening staff to follow up resident cares, complete timely bedtime routines, and answer call lights timely. NA-D stated the inconsistent staff on the evening shift caused a delay in answering call lights, delayed meals, and missed baths, due to staff not familiar with resident routines and interventions. On 2/6/24 at 10:28 a.m., registered nurse (RN)-B and RN-E stated they were agency nurses at the facility. RN-E stated she was the only nurse until 9:30 a.m., when RN-B came for her shift. RN-B stated she was late for her shift because she worked until 10:30 p.m., last night. RN-B and RN-E stated when there was one nurse and one TMA for the scheduled shift there was not enough skilled nursing staff to complete cares and get resident treatments completed timely. RN-E stated the current census was 30 and that it was overwhelming as the only nurse. RN-B and RN-E stated resident cares and treatments were a lot responsibility for one nurse, and overwhelming when there was a not facility nursing staff available to assist. On 2/6/24 at 11:54 a.m., NA-A stated at times there were only two NA's for the evening shift, and then a NA from the day shift would be required to stay for the evening shift. NA-A stated many of the residents at the facility required extensive assistance from staff and many of the residents were assist of two that caused delays in the resident evening cares, unable to take the time needed to care for residents properly, and a delay in answering call lights. On 2/6/24 at 12:14 p.m., social services (SS)-A stated a new process started about three months ago and the call light logs were ran after each shift by the nurse, and the staff working that shift were expected to assess the call light times and stated if the nursing staff feel that was longer then expected call light time staff were expected to hand write an explanation next to the time on the paper call light log audit. SS-A stated daily she looked over the call light logs, data, and explanation if any for why there was a long call light, and the information is shared during the day stand up meeting with management. SS-A stated the trend at the facility with higher call light times was on the evening shift, in morning, and when residents wanted to go to bed. SS-A stated education was given routinely to all staff that nurses can answer call light, use walkie talkies, and continued daily reminders. SS-A confirmed long call light at the facility, and stated there would be days there would not be delay in call lights and then would see a trend in longer call lights again. SS-A stated the nurse manger RN-D, RN-C, director of nursing (DON) were responsible for educating staff. During the interview the call light log audits were reviewed for the past 30 days with SS-A and confirmed long call times for residents, and stated it had been improvement from several months ago. On 2/6/24 at 2:34 p.m., licensed practical nurse (LPN)-B stated she was pulled to work as a NA today today as the facility did not need her as a nurse. LPN-B stated the facility had four NA's today, however there was usually only two-three NA's on the day and evening shift. LPN-A stated consistently staff called in and did not come in for their shift, and for several months the facility had relied on agency staff to fill the schedule. LPN-A stated the short staffing and unfamiliarity with the resident care led to a delay in answering resident call lights. LPN-A stated some staff struggled to know the residents routine and care required to ensure residents ADL's were completed and completed timely, which caused missed baths, call light delays, residents not going to bed at the time they want. LPN-A stated specific concerns when residents require two staff assist with mechanical lifts and there are only two or three staff working to assist residents. On 2/7/24 at 7:21 a.m. NA-E stated the evening staffing schedule was consistently not filled and staff on a routine basis had to work a double shift. NA-E stated the night shift consisted of one NA and one nurse and residents that required assist of two, would need to wait and for the NA and the nurse to be available at the same time to assist residents. NA-E stated resident care was not always performed per the Kardex, delay with transfers and delay with call lights answered due to staff not consistently carrying a walkie talkie, openings in the evening schedule, increased agency staff on evening shift and not having the knowledge of the specific resident care. On 2/7/24 at 8:02 a.m., the administrator stated the facility's expectation for staff to respond to call lights was within 20 minutes, and stated the longer call light times on some of the call light logs were due to residents requesting the call light be left on. The administrator stated she was not sure why the residents requested to have their call light left on and confirmed residents had not been asked about the reasoning. The administer stated she did not see a concern with not having enough staff and stated the long call light times were due to resident requesting to leave their call lights on. The administrator stated if there were excessively long call light response times, the facility looked at what was going on at the time,if there had been many lights going off at the same time, that increased the wait time for other residents. The administrator did not correlate long call light times with the number of staff on duty. During a follow up interview on 2/7/24 at 10:20 a.m., the administrator stated the facility was staffed according to census and case mix. The adminstartor stated the long call light times identified on the call light log audits were expected to have a reason behind the time, and was a concern if staff were not addressing the long call light times. The administrator stated the facility had not identified trends due to agency staff not answering call lights timely. The administrator stated she was aware that the nurse and NA might go on break at the same time and could cause less staff on the floor at the time to assist residents. The administrator stated agency staff came in an hour before their shift and completed an orientation checklist with another NA or nurse. The administrator stated she has made observations of staff going into the rooms to assist residents and the call lights not shut off by staff that could indicate longer call light times. The administrator stated the star system was implemented to help with staffing holes and call ins. The administrator stated if a staff has a star by their name and there was a hole in the schedule or a call in, the staff member with a star by their name stayed for the next shift, ideally would only be four hours, but at times staff worked an additional eight hour shift. The administrator stated the facility was currently accepting admissions, however ensured the residents were not complex. The administrator stated the facility currently had one day and evening nurse that was not agency; six open nurse positions, and eight open NA positions. The administrator stated the facility had been trying to recruit staff and have had difficulty in retaining staff and hiring staff. The administrator stated she was not aware resident needs were not consistently met. She further indicated the facility continued to work on achieving and maintaining staffing levels. During an interview on 2/7/24 at 1:22 p.m., NA-D stated she felt like she didn't remember or didn't have time to reposition residents some days, but admitted it was important. NA-D stated she was assigned to 11 residents by herself this day; six of whom needed mechanical lift transfers. NA-D stated it was a lot to do and remember. On 2/7/24 at 3:14 p.m.,during an interview with human resources director (HR)-D stated the facility had multiple open NA and skilled nursing positions, and further stated finding licensed staff was difficult as they are non-existent. Staffing schedules: Review of the facility's staffing schedules for 2/7/24 through 1/8/24. The schedules lacked required nursing assistants for the following: 1/22/4: 4 hours on the evening shift 1/14/24: one NA on day shift 1/13/24: one NA on day shift 1/10/24 one NA on day shift 1/9/24: 4 hours on the evening shift 1/8/24: 4.5 hours on the evening shift Grievance Reports dated 5/20/23-1/22/24: 22 grievance reports related to staffing concerns and timeliness of staff. Grievance summaries indicated: 8/11/23, R15 reported Saturday was a bear .put on the bedpan at 6:30 p.m. and didn't take be off until 9:00 p.m., staff came in to assist roommate and did not take R15 off bedpan. Summary of findings indicated call light on for extended period of time, staff education and corrective action as necessary. 10/23/23, FM-F reported R17 still in dining room eating lunch at 3:10 p.m., when FM-F arrived. Summary of investigation indicated R17 was often in the dining room for an extended period of time. Actions taken indicated staff to help assist to dining room at beginning of mealtime to provide long time to eat, aides to toilet once meal are finished, staff to allow R17 to eat for 1 to 1 1/2 hours. 9/13/23, FM reported R20 was not getting up in a timely manner in the morning and then gets to breakfast at 10:00 a.m. and at noon meal, FM reports R20 is not removed from table in timely manner. Summary of actions taken new sunrise shift has been established to give more support to the morning shift so there will be 4 NA's in the morning to assist with getting residents up per preferences, staff to continue to assist residents with their preferences as able. 10/9/23, FM reported R6 wasn't put to bed until 10:51 p.m. on 10/9/23. Summary of investigation indicated a number of outside agency staff were working on 10/9, and didn't realize R6's bedtime preferences, summary of actions taken indicated order added to ensure R6 was assisted to be per her time preference. 12/13/23, R6 FM reported R6 had not been toileted in a timely manner. Summary of investigation indicated R6 was not toileted according to care plan, actions taken indicated DON verbally educated staff to follow residents plan of care. Call light logs: Review of the call light response logs, provided by the facility revealed numerous occasions of longer than 20 minutes wait times. The following were examples of the long wait times. These included but were not limited to the following: 1/8/24-2/6/24, R17: longest wait times were 37 minutes, 27 minutes 1/6/24-2/6/24, indicated room R20's longest wait times were longest wait times were 2 hours and 22 minutes, 32 minutes, 24 minutes 1 hour and 4 minutes, 28 minutes, 47 minutes, 1 hour and 47 minutes, 48 minutes, 33 minutes, 46 minutes, 33 minutes, 23 minutes, 1 hour and 14 minutes, 47 minutes, 33 minutes, 23 minutes, 25 minutes, 43 minutes, 52 minutes, 28 minutes, 39 minutes, 31 minutes, 34 minutes. 1/7/24-2/6/24, indicated R8's longest wait times 22 minutes, 33 minutes, 39 minutes, 29 minutes, 28 minutes, 32 minutes, 37 minutes, 23 minutes. 1/6/24-2/6/24, indicated R25's longest wait times 29 minutes, 26 minutes, 22 minutes, 37 minutes, 43 minutes, 27 minutes, 42 minutes, 27 minutes, 35 minutes, 24 minutes, 33 minutes, 25 minutes, 39 minutes. 1/6/24-2/6/24, indicated R9's longest wait times 45 minutes, 59 minutes, 23 minutes, 33 minutes, 23 minutes, 1 hour and 22 minutes, 35 minutes, 59 minutes, 42 minutes, 27 minutes. 1/6/24-2/6/24, indicated R22 longest wait times 23 minutes, 29 minutes, 55 minutes, 33 minutes. 1/6/24-2/6/24, indicated R16's longest wait times 33 minutes, 22 minutes, 23 minutes, 37 minutes, 34 minutes, 21 minutes, 37 minutes, 29 minutes, 50 minutes, 25 minutes, 52 minutes, 1 hour 45 minutes. 1/6/24-2/6/24, indicated R23's longest wait times 33 minutes, 22 minutes, 1 hour and 34 minutes, 26 minutes, 29 minutes, 36 minutes, 34 minutes, 27 minutes, 30 minutes. 1/6/24-2/6/24, indicated R15's longest wait times 32 minutes, 39 minutes, 22 minutes, 32 minutes 54 minutes, 33 minutes, 29 minutes, 26 minutes, 1 hour and 24 minutes, 55 minutes, 26 minutes, 35 minutes, 27 minutes, 37 minutes, 38 minutes, 48 minutes, 39 minutes, 1 hour, 40 minutes. 1/6/24-2/6/24, indicated R12's longest wait times: one hour and 13 minutes, 25 minutes, 27 minutes, 38 minutes, 22 minutes, 54 minutes, 41 minutes, 35 minutes Facility call log audits dated 12/31/23-2/5/24, (that nursing completed after each shift), indicated 142 times call lights were marked and hand written notes indicated: Two staff on break : 15 times Awaiting second assist 10 times Staff doing shower 3 times Waiting for female 11 times Resident did not know 1 times Refused call light off 3 times All aides feeding 1 time Staff forgot to shout off light 5 times Staff in room [ROOM NUMBER] times Awaiting bed 22 times No reason indicated 67 times Call light printout dated 1/18/24 at 2:15 p.m. handwritten note indicated short staffed. A policy regarding staffing was requested and the administrator stated the facility did not have a policy specific to staffing. The Facility assessment dated [DATE], indicated Part 1: Our Resident Profile Numbers 1.1. The number of residents we are licensed to provide care for: 42 1.2. Average daily census for the overall facility is 28-33. Short Term Care averages a daily census of 0 - 5 residents. Long Term Care Averages a daily census of 28 - 33 residents. 1.2.a. The number of persons admitted and discharged on a bi-weekly basis are listed on the chart below. Our staffing levels are reviewed daily to determine if additional staff are needed to support the change in census. Other 7. Other Factors that impact staffing. On an ongoing daily basis, the scheduler, Director of Nursing and other key interdepartmental team members review staffing levels based upon our current resident population, acuity, and resident specific needs. (e.g., residents ' preferences with regard to daily schedules, morning and evening ADLs, bathing, activities, naps, meal & snack times, 1:1 ' s, etc.) Staffing plan 3.2. Staffing is reviewed daily by the Scheduler, Director of Nursing, and Administrator to ensure that the staffing level supports our resident centered care needs. A copy of the staffing ratio is posted on the Facility Community Communication Board located in the hallway by the main dining room. This board is in a conspicuous location, visible to all staff, residents, and visitors. Table 1 demonstrates our average daily staffing based on our average census and resident acuity. The staffing level represents the staff in all units within the Gardens at Foley. (View an example Nursing Staff Ratio Matrix in Appendices II.) Position AM PM NOC RN Nursing Leadership 1-2 0 0 Licensed nurses providing direct care 1-2 1-2 1 Nurse aides 2-3 2-3 1-2 TMA 0-1 0-1 0 Individual staff assignment 3.3. Staffing is reviewed daily by the Scheduler, Director of Nursing, and Administrator to ensure that the staffing level supports our resident centered care needs. When looking at staffing levels, the team also reviews staff performance and compatibility within the assigned unit, then adjustments are made accordingly. Staffing challenges are reported each weekday at IDT meetings, weekends, and as needed to DON and/or Administrator outside of normal business hours. Resident ' s continuity of care is completed by having consistency in our staff schedules by assigning them to the same unit as frequently as permitted. This provides consistency and familiarity for the residents and staff on daily routines, preferences and builds entrusting relationships. Though, resident safety is priority and this may not be realistic each day. Staff training/education and competencies 3.4. Bayside Manor, in accordance with Monarch Healthcare Management policy and procedure requires Licensed and certified staff to provide proof of licensure/certification during the application process. Holding a current license/certification relevant to their position is a condition of hire. Once the offer has been extended, the Human Resources department verifies the required licensure/certifications are valid. Licensed staff include but are not limited to: Administrator, Registered Nurse, Licensed Practical Nurse, Social Services Director, and Health Unit Coordinator Certified Staff include but are not limited to: Therapeutic Recreational Director or designee, Certified Nursing Assistants (CNA), Human Resources, Maintenance Director,and Culinary Director. Required Staff Competencies (This is not an inclusive list and competencies requirements correlate to positional needs): Person-centered care - This includes but not be limited to person-centered care planning, education of resident and family /resident representative about treatments and medications, documentation of resident treatment preferences, end-of-life care,and advance care planning. Activities of daily living - bathing (e.g., tub, shower, bed), bed-making, toileting (including colostomy, urostomy needs), dressing, feeding, nail and hair care, perineal care (female and male), mouth care (brushing teeth or dentures), transfers, using gait belt, using mechanic lifts and other assistive devices. Disaster planning and procedures - elopement, fire, flood, power outage, tornado, disaster preparedness Infection control- hand hygiene, isolation, standard universal precautions including use of personal protective equipment, environmental cleaning. Medication administration - injectable, oral, subcutaneous, topical, g-tube, PICC line, sublingual, crushed medications, and rectal Measurements: blood pressure, orthostatic blood pressure, body temperature, height and weight, radial and apical pulse, respirations, recording intake and output, Specialized care - catheterization insertion/care, colostomy care, diabetic blood glucose testing, oxygen administration, suctioning, trach care/suctioning, tube feedings, wound care/dressings

Based on observation, interview, and document review the facility failed to ensure safe transfer techniques using a gait belt and failed to complete a comprehensive post fall analysis and investigation for 2 of 3 residents (R1, R2) reviewed for falls. The facility's failures resulted in actual harm when R1 sustained a pelvic and R2 sustained a rib fracture. Findings include: R1's quarterly Minimum Data Set (MDS) dated [DATE], identified R2 had diagnoses that included hemiplegia/hemiparesis with fluctuating cognition. R1 required extensive physical assistance from one staff for bed mobility, transfers, locomotion on and off the unit, dressing, and toilet use. R1 had impaired balance and was not steady with transitions without staff assistance to maintain balance. R1 had functional range of motion impairments on one side and used a walker and wheelchair. The MDS also indicated R1 did not have any falls since the last assessment. R1's fall care plan dated 9/30/22 identified R1 was at risk for falls related to alteration in mobility, altered balance, unsteady gait, pain, and buckling of knee joints. Corresponding interventions included: -Physical/occupational therapy to evaluate and treat for strengthening related to increased weakness noted with ambulation (start date 11/10/2022.) -Analyze previous resident falls to determine whether pattern/trend can be addressed (start date 3/10/22), -R1 to ear proper and non slip footwear (start date 10/10/22). -Encourage R1 to use handrails or assistive devices properly. Make sure before letting go of grab bar that she has her footing (start date 10/10/22) -Physical/occupational therapy to evaluate and treat related to weakness, fell ing of knees giving out (start date 1/11/23.) R1's fall care plan included an intervention dated 1/17/23, but canceled on 4/25/23, included when resident is feeling week and/or feels that she is unsteady, staff is to use two assist for safety. R1's mobility care plan dated 4/7/23, indicated R1 had limited physical mobility related to hemiplegia and hemiparesis status post cerebral vascular accident (stroke) affecting the right dominant side. R1 required minimum assist of one staff with gait belt and walker for transfers. For ambulation R1 required moderate assist of one staff with gait belt and walker with wheelchair to follow. Care plan also indicated R1 could tolerate walking 50 feet. R1's incident progress note dated 6/30/23 at 8:46 a.m., indicated nurse was called R1's room. R1 was sitting on the floor in her room by the closet, nursing assistant (NA) was with the resident. Gait belt was on the R1. NA reported she had lowered R1 to the floor. R1 had a large lump with a bruise on her right side of her forehead that measured 4.5 centimeters (cm) x 4.5 cm. R1 was assisted off the floor with a full body mechanical lift and into her recliner chair. R1 did not complain of pain at the time. R1's Incident Review and Analysis dated 6/30/23, identified on 6/30/23 at 8:05 a.m. when R1 was walking with a gaitbelt on from the bathroom with a nursing assistant. No other information was included in the description of the fall. Contributing factors were identified were R1 had unsteady gait and no other potential causal factors were identified. The review did not identify an intervention to reduce and/or prevent re-current falls associated with unsteady gait. Further the review did not include a root cause analysis and did not identify interventions associated causal analysis that identified root cause R1's hospital After Visit Summary (AVS) dated 6/30/23, indicated R1 was seen in the emergency department for a fall and diagnosed with closed left pubic ramus fracture, hematoma (bruise) of right thigh, and contusion of forehead. The AVS did not include details of the visit. R1 was discharged back to the facility on [DATE]. R1's progress note dated 6/30/23 at 5:24 p.m. indicated R1 returned to the facility from the hospital. R1's progress note dated 6/30/23 at 6:15 p.m. indicated when physical therapy and nursing transferred R1 to the toilet and was passing gas when R1 suddenly went unresponsive. Staff called 911. Sternal rub brought R1 around, opened her eyes, and was conversing with staff when paramedics arrived. R1 was transferred back to the hospital for further evaluation. R1's hospital Admission record dated 7/1/23 at 12:15 a.m. indicated R1 presented to the ED for right facial scalp contusion, pelvic fracture, and large right thigh hematoma, and acute blood loss anemia. R1 had a fall where her right leg gave out on the morning of 6/30/23. She was discharged back to the facility however, when she was on the toilet suffered a syncopal event where she was seen to have loss consciousness for over 10 minutes. Noted to have ongoing anemia due to blood loss, but normal vital signs. Physical exam identified R1 had scalp hematoma over the right frontal scalp with some bruising, no active bleeding. Able to move right hip actively, significant ecchymoses (bruising) on the right lateral hip and over right buttock. Right thigh hematoma likely large enough that it is causing acute blood loss anemia that was symptomatic with subsequent syncope that was multifactorial from micturition and blood loss. R1 was discharged back to the facility on [DATE], with diagnoses that included mildly comminuted fracture of the left superior and inferior pubic rami near the pubic symphysis, acute blood loss from hematoma, recurrent falls, and hematoma of right thigh and scalp. During an interview on 10/5/23 at 1:14 p.m., R1 indicated she remembered the fall on 6/30/23 and remembered the NA who was involved. R1 explained NA-L had walked her out of the bathroom with a gait belt on to her reclining chair. R1 was in front and facing her chair when NA-L let go of her gait belt to get something out of her closet. While NA-L was doing that her leg gave out and she fell to the floor. R1 stated with conviction she was not lowered to the floor. R1 could not recall anything after falling, however she remembered getting a bump on the right side of her face and being told she broke her pelvis. R1 was not aware of what she hit her head on. Once R1 fell , R1 could not remember anything after that. R1 stated she used to be able to walk into the bathroom with one staff, but now she she had to use the mechanical standing lift with two staff to go to the bathroom and was working with therapy. During an interview on 10/5/23 at 2:02 p.m., NA-L indicated stated she was working with R1 on 6/30/23. NA-L explained she was certified as an NA at the beginning of September and had never worked with R1 before. NA-L at the time of the fall R1 was assist of one with a gait belt. When she transferred R1 to the bathroom with one and a gait belt it made her uncomfortable because R1 was unsteady and really weak. NA-L stated she used the radio to confirm with other staff R1 was one assist. She was told yes. NA-L stated when she was walking R1 out of the bathroom with the gait belt on, R1's leg gave out and she lowered her to the floor and went down with her. NA-L had been behind R1 and to the side (could not recall which side) when R1 started falling. NA-L called for assistance over her radio for help. NA-L stated R1 hit the right side of her head because it was swollen but did not know what she hit her head on. NA-L stated that at the time of the fall, R1 was assist of one staff, with gait belt and walker for transfers and walking in room. During interview on 10/5/23 at 4:10 P.M., social worker (SW) indicated she thought NA-L had been shadowing someone else and was still in training at the time of the fall. There was another NA who had been working with NA-L that day however, that NA had responded to another call light, and NA-L responded to R1's call light by herself. SW was the first staff person to arrive to R1's room after NA-L called for help over the radio. Upon entering the room, R1's was on the floor facing the bathroom and both closet doors open behind her. NA-L was behind R1 holding R1 in a sitting position. R1's right leg was bent at the knee and underneath her with a goose egg on the right forehead. SW stated R1 had reported she had been standing by her chair and the next thing she knew she was on the floor. Later that morning R1 had kept saying that she was having shooting pain in her right arm, which she hadn't any feeling in that arm for [AGE] years due to stroke. R1 was sent to the emergency room . SW did not think the care plan was followed at the time and questioned if NA-L thoroughly understood how to care for R1. SW indicated she was not interviewed by previous administration as part of the fall investigation despite being the first person to respond. During an interview on 10/10/23 at 1:11 p.m., licensed practical nurse (LPN)-D stated she was called to R1's room and found R1 sitting on the floor between the closet and the recliner, R1 was closer to the closet. The closet door was open and the bathroom door was slightly opened. NA-L was standing behind her. R1's right leg was bent underneath her and the left leg was straight in front of her. R1 had a gait belt on. LPN-D was told by NA-L, she was walking R1 back from the bathroom to the chair. NA-L wanted to change the pad on the chair and turned to get the pad out of the closet and then R1 fell . LPN-D remembered R1 had bruise or a bump on her forehead. LPN-D indicated later that morning R1 had started to complain of pain and was sent to the emergency room for further evaluation. LPN-D thought NA-L had the proper training, but probably not competent enough to work with R1 independently. During an interview on 10/6/23 at 3:16 p.m., physical therapist (PT)-A stated R1 had right sided weakness. With right sided weakness, NA's should be on the resident's right hand side and maybe a half a step back. Their hands should be on the back part of the belt. PT-A indicated the position in which R1 was found in after the fall was not consistent with a controlled lowering to the floor after her leg gave out, however was not there at the time. PT-A indicated therapy used to do safe transfer training that would teach NA-A how to transfer and use the gait belt however, they had stopped some time ago. During an interview on 10/10/23 at 10:17 a.m. interim director of nursing (IDON) indicated R1's fall investigation could not be found. She reached out to the previous IDON who reported she had completed the investigation and should be at the facility. Since they could not find the investigation, the facility completed the investigation on 10/6/23, all the staff who were working at the time of the fall were interviewed. IDON explained according to interviews it was a controlled fall until NA-L fell too. NA-L had reported that before the fall R1 had been leaning to the right and indicated she did not request assistance from other staff. R1 had reported NA-L was not holding onto the gait belt when her leg gave out. IDON indicated NA-L had completed the NA training and was competent at the time of the fall. During an interview on 10/10/23 at 11:08 A.M., administrator stated they were not able to find the investigation for R1's fall on 6/30/23. R2 During an observation and interview on 10/6/23 at 9:15 a.m. R2 was seated in her wheelchair with a gait belt applied loosely around her stomach. R2 explained she needed assist of two staff to pivot transfer. On 10/4/23 after breakfast during a transfer one NA was standing in front of her, grabbed the gait belt and twisted it, digging her knuckles in to R2's left rib cage. R2 stated she had instant pain, she said Ouch!! right away. The NA laughed when R2 reported she thought her rib was broken. R2 thought it was NA-R who dug her knuckles in but could not be for sure. R2 did not remember who the other NA was that was assisting with the transfer. R2 stated she was given Tylenol for the pain, which helped a little bit. R2 stated she still had chest pain when she stands up and walks, but did not hurt when she laid down or when she was breathing. R2's quarterly MDS dated [DATE], indicated intact cognition with diagnoses of Parkinson's disease, osteoporosis, anxiety, dizziness, anxiety disorder and was legally blind. R2 required extensive assist of one staff for bed mobility, transfers, walking in room, locomotion on and off unit, and toilet use. R2's fall care plan dated 4/18/23, directed the following: -Encourage R2 to stand tall, stop and take rests when needed and assist R2 to sit in wheelchair when needed (start date 4/20/23) R2's activity of daily living care plan dated 4/7/23, directed the following: -Transfers: minimal assist of two with gait belt and walker. Cue to stand tall if unable to stand please use Hoyer (start date 9/26/23). R2's progress note dated 10/5/23 at 2:00 p.m., indicated that at 8:50 a.m., nurse manager (NM)-A was in room to assist nursing assistant (NA)-L with a pivot transfers of R2 from bed to wheelchair to the bathroom. R2 stated that NA-R hit R2 in the left rib cage area the day before and R2 was having pain. R2 was still able to lift left arm above her head and to grab hold of grab bar and stand up. Skin assessment completed at this time, no new concerns noted, continued to have redness under left breast that was identified on 10/4/23. Provider was notified at 12:20 p.m., order received for x-ray, and R2 went to local clinic at 1:31 p.m. Review of R2's x-ray report dated 10/5/23, at 1:15 p.m. indicated a possible left seventh rib fracture. A facility reported incident report (FRI) submitted to the State Agency on 10/5/23, at 12:11 p.m. alleged on 10/4/23 at 8:00 a.m. R2 reported to the social worker (SW) NAs were transferring her into bed. R2 stated an NA dug her knuckles into the side of her ribs/breast area causing pain when she was being transferred into bed. During an interview on 10/6/23 at 10:40 a.m., NA-R stated R2 required assist of two staff for pivot transfer and she was able to make her needs known. NA-R stated on 10/4/23, she thought R2 was weak and thought she could have used the standing lift or full body lift, but R2 would refuse and it would take too long. NA-R explained on 10/4/23, when she went to assist NA-L with R2's transfer from the bed the belt was on really loose. When they stood R2 up NA-L tightened the gait belt by twisting it versus using the buckle portion. After R2 sat down NA-R, she tightened the gait belt appropriately, switched sides with NA-L, and transferred R2 from wheelchair to the toilet. NA-R explained NA-L had not applied the gait belt correctly or tightened it up correctly. NA-R reiterated R2 was not transferring well that morning. NA-R did not remember R2 reporting pain during the transfer. During an interview on 10/6/23, at 3:16 p.m. physical therapist (PT)-A reviewed R2's incident and indicated staff did not apply the gaitbelt correctly. Staff should never twist the gaitbelt for tightening. the gaitbelt should be straight and not turned; the buckle should be used. The gait belt should be cinched tighter once the resident stands up. PT-A explained there used to be transfer training which included gait belt training, however the facility was no longer providing. During an interview on 10/10/23 at 12:25 p.m., NA-C indicated she was familiar with R2's transfers. NA-C explained R2 hunches over and thought it was hard for her to stand. Sometimes R2's legs were very weak, so then we have to lift or provide more support. NA-C reported on 10/4/23, she had transferred R2 twice with NA-L. One of the times R2 reported pain in her left chest. NA-C stated the gait belt was snug and placed correctly. The physician had been in the facility that day and checked R2 for injuries shortly after that transfer. During an interview on 10/6/23 at 12:50 p.m. interim director of nursing (IDON) stated they have suspended NA-L and NA-R until their investigation was completed. NA-C they have ruled out for abuse, through their investigation. IDON stated they thought that R2 had mistaken NA-L for NA-R per their investigation at this time. NA-L was assigned to R2 on 10/4/23. Review of facility abuse policy stated residents are not subjected to abuse by anyone, including, but not limited to, facility staff, other residents, consultant or volunteers, staff of other agencies serving the individual, family members or legal guardians, friend or other individuals, or self-abuse.

Based on interview and document review, the facility failed to implement interventions to minimize skin breakdown for 1 of 3 residents (R49) reviewed for pressure ulcers. This resulted in actual harm for R49 who acquired three pressure ulcers while in the facility, one of which progressed to Stage 4 (full thickness tissue loss with exposed bone, tendon or muscle), and resulted in the resident being scheduled for surgical amputation of the digit. Findings include: R49 was admitted on [DATE], and the admission Minimum Data Set (MDS), dated [DATE], indicated R49's cognitive skills were severely impaired. R49 required extensive assistance for bed mobility, transfers, personal hygiene, and toilet use. The MDS assessment identified R49 was at risk for the development of pressure ulcers. The MDS also identified R49 had [DIAGNOSES REDACTED]. The Care Area Assessment (CAA) completed on 7/13/13, identified R49 was at risk for pressure ulcer development due to needing extensive assistance with mobility, frequent incontinence of bowel and bladder, altered mental status, the use of antidepressants, and [DIAGNOSES REDACTED]. R49 was to be repositioned every two hours and her skin was to be observed twice a day with a.m. and p.m. cares for any signs of breakdown in skin, and if any changes were noted, the charge nurse was to be notified immediately. A review of the Braden Scale for Predicting Pressure Sore Risk tool, dated 7/1/13, indicated R49 was a "low risk" with a score of 17. Review of the admission Skin Collection Tool, dated 7/1/13, indicated R49 a "vascular" on the left buttock that measured .5 cm x .6 cm. There was no evidence that a temporary care plan was developed or made available to staff when R49 was admitted . R49's plan of care, that was initiated 7/21/13, included alteration in skin integrity and mobility but did not include interventions for pressure ulcer prevention such as pressure redistribution devices for bed or chair, turning and positioning schedule, or other nursing interventions to prevent pressure ulcers. The POC only included the dressing treatment for [REDACTED]. Review of the admission progress note, dated 7/1/13, at 10:25 p.m., indicated R49's "Skin and color was normal (pink)..." A history and physical completed by the physician assistant certified (PAC)-A, dated 7/2/13, indicated R49 was brought to the facility for skilled nursing care and rehabilitation after a left ankle fracture. Upon physical examination, R49's skin was "smooth, no [MEDICAL CONDITION], purpura (purple) or abnormal moles noted," and examination of R49's extremities indicated, "peripheral pulses 2+, no cyanosis (blue or purple coloration of the skin or mucous membranes due to the tissues near the skin surface having low oxygen) clubbing, or deformities noted. CAM boot (type of air boot) on left lower leg." Review of progress notes, dated 7/3/13, at 9:20 p.m. indicated "Day shift reported there may be a sore on her right buttock but no sore was noted at hs (hours of sleep) cares." On 7/5/13, at 10:53 a.m. a progress note indicated, "Weekly diabetic foot check done this shift...On the top of the (L) foot there is a 7 cm x 8 cm reddened area that ascends up the second toe with a 1 cm x 0.7 cm scabbed area on the middle of that second toe...resident expressed tenderness and pain with palpation of this area." On 7/5/13, at 10:57 a.m. a progress note indicated a fax was prepared for PAC-A to address the reddened area on R49's left foot. Review of a Problem Sheet to R49's physician, dated 7/5/13, at 11:00 a.m., included a description of the area on the (L) foot as noted above. There was no documentation or evidence to indicate the physician or PAC-A responded to this until 7/9/13, when PAC-A made a routine visit to the facility. Orders from PAC-A on 7/9/13, included, "Needs to be [MEDICATION NAME] 500 mg (one by mouth) daily x 10 days. Dx (diagnosis): [MEDICAL CONDITION] ulcerated area with wound cleanser. Pat dry. Apply Repara [MEDICATION NAME] to wound. Dx: Pressure ulcer L 2nd toe...Recheck ulcer and [MEDICAL CONDITION] on 7/11/13." A review of the Shower Day Worksheet, dated 7/9/13, indicated no skin issues. On 7/9/13, at 10:50 p.m. a progress note indicated, "Resident's sore on her left cheek on her bottom is 0.5 cm by 0.7 cm. Edges are red inside is a dark reddish color." A Problem Sheet addressed to PAC-A, on 7/14/13, at 1:35 p.m. included, "Please examine black spot on left buttocks. Any treatment?" A response from PAC-A on 7/15/13 indicated, "Change foam dressing on L buttocks if soiled. Recheck 7/18/13. Dx: Buttocks ulcer." A progress note on 7/19/13, at 11:50 a.m. included "Diabetic foot check done this shift. Bilateral Feet are warm and of normal color. +1 [MEDICAL CONDITION] of the feet. Sore on resident's left 2nd toe is covered, dressing intact. Pea sized area of redness on the tip of resident's left great toe as well as on the resident's left 2nd toes (above sore) No redness otherwise noted or swelling around the area." On 7/21/13, at 6:44 a.m. a progress note included, "1.5 x 2 cm. Stage II ulcer (Partial thickness loss of dermis presenting as a shallow open ulcer with a red or pink wound bed, without slough) on right shoulder. Red around edges. Cleansed and covered with Allyven dressing." On 7/22/13, at 7:00 a.m. a progress note indicated, "(R49) is starting to develop a red area on her right shoulder that has a brown center. Will have PA examine on rounds." A review of a Problem Sheet addressed to PAC-A, dated 7/22/13, at 7:00 a.m. indicated, R49 "is starting to develop a pressure ulcer on her R shoulder. Please examine and advise on treatment." PAC-A responded on 7/22/13, with orders including "Repara dressing applied. Ulcer stage 1-2. 3.5 cm diameter of [DIAGNOSES REDACTED] (redness). 1.5 cm diameter grey ulcerated center. No depth to lesion. No drainage. Change dressing and recheck on Thursday 7/25/13." There was no re-assessment of the resident's risk for pressure ulcer development, despite the new development of pressure ulcer. A review of a Physician Visit form, dated 7/22/13, included orders from PAC-A indicating a specialist needed to evaluate R49's left 2nd toe due to "Bone exposed to air." Orders also included, "Wound culture. Dx: osteo[DIAGNOSES REDACTED]." Antibiotics were ordered and the boot was removed from her left foot, with orders to discontinue the use of the boot until further notice. On 7/23/13, at 6:30 p.m. a progress note indicated ".75 cm dark scab on right buttocks. 3 cm red inflamed area around scab. Allyven dressing applied." There was no re-assessment of the resident's risk for pressure ulcer development, despite the new development of pressure ulcer. On 7/25/13, at 9:00 a.m. a progress note indicated R49 left the facility for a follow up orthopedic appointment "related to her open sore on her toe from the Cam boot." A progress note on 7/25/13, at 1:36 p.m., indicated "Resident returned from dr visit. Dr wrote "patient will be undergoing second toe amputation mon (Monday) July 29. She will be scheduled at an outpatient surgery center but will require a pre-op H&P (history and physical). She may discontinue the boot as the ankle fracture looks stable and continues to heal. Keep toe covered with clean, dry dressing." A review of a progress note dated, 7/26/13, at 1:31 p.m., indicated R49's electrocardiogram (EKG) showed [MEDICAL CONDITION] (slow heart rate) and the surgery to amputate her toe would probably be postponed. A physician's progress record note on 7/29/13, included, "Cardiology was consulted...surgery for [REDACTED]." R49 was to have a follow up at the Heart Clinic to clear her for surgery. A progress note, dated 7/26/13, at 9:00 p.m. included, "Nar (nurse aide) reports reddened (sic) area midback on left side, resident positioned with pillows to keep off of area." There was no re-assessment of the resident's risk for pressure ulcer development, despite the new development of pressure ulcer. On 7/30/13, at 8:40 a.m. a progress note titled, "discharged ," indicated R49 was picked up and transported to an appointment, and then would be returning to the facility where she resided prior to admission to this facility. During an interview on 11/21/13, at 3:58 p.m. registered nurse (RN)-A and licensed practical nurse (LPN)-A, both remembered caring for R49. LPN-A verified R49 had a boot on her left foot on admission and recalled there were no orders or directions as to how to care for her left foot or directions for use of the boot. When asked what interventions were put into place for R49, in regards to the boot and to prevent pressure ulcers such as the one that developed on her second toe, LPN-A was unable to locate that information in the electronic system. During an interview on 11/21/13, at 4:20 p.m. PAC-A reported she had no information about R49's left ankle fracture upon her admission to the facility and had requested R49's old medical records and orthopedic records from her ankle fracture when she saw her on 7/2/13. When asked about the pressure ulcer that was identified on 7/5/13, on R49's 2nd toe on her left foot, PAC-A stated she was not aware of the ulcer until she saw R49 on 7/9/13, when she visited the facility. PAC-A verified, according to the fax, the charge nurse sent information regarding the area on the left foot and 2nd toe on 7/5/13, at 11:00 a.m. to R49's physician. There was no evidence that the physician responded to the fax or that the facility staff attempted to contact the physician when no response was received. PAC-A stated, "If this is what it looked like, it should have been handled a little more aggressively." During an interview on 11/21/13, at 4:43 p.m. director of nursing (DON) reported they had no orders upon admission regarding R49's boot on her left foot. When asked about the skin collection tool, dated 7/1/13, DON verified there was no documentation of any concerns on R49's feet or shoulders. DON stated she did not know what was meant by the description "vascular" that was documented on the Skin Collection Tool, noted on R49's left buttocks. DON stated, "apparently they saw something and they didn't know what to call it." When asked about R49's care plan, DON verified there were no interventions on the care plan to prevent further pressure ulcers, stating, "We have a turning and repositioning plan but I would expect to see that on the care plan." DON verified that pressure ulcers were triggered on the CAA, and stated, "It didn't get carried to the care plan." When asked about the fax that was sent to R49's physician on 7/5/13, at 11:00 a.m. that noted the concern on R49's left foot and toe, and there was no documentation of a response from the physician or follow up from the staff, DON stated, "The order should have been addressed with more urgency." A request was made for a Care Plan policy and a Pressure Ulcer policy. DON stated, "We don't have one."

Based on interview and document review the facility failed to ensure changes in clinical status including significantly elevated blood sugars were clinically monitored and promptly reported to the physician for 1 of 2 residents (R31) reviewed in the sample for hospitalization . The lack of clinical monitoring and failure to notify the physician resulted in harm for R31. Findings include: R31 was admitted ,[DATE], with [DIAGNOSES REDACTED]. The admission minimum data set ((MDS) dated [DATE], identified R31 had an altered level of consciousness and a brief interview for mental status (BIMS) was not completed because R31 was rarely understood. The care area assessment (CAA) dated [DATE], identified R31 was unable to talk due to a recent stroke. Speech therapy worked with R31 to use a communication board with pictures. R31 had a physician order [REDACTED]. On [DATE], staff were to check accuchecks daily and fax to the physician after one week. Review of nursing notes revealed the following: On [DATE], the physician assistant (PA)-A saw R31 at the facility at 11:20 a.m. due to R31's congested cough. R31 was started on an antibiotic, [MEDICATION NAME], for pneumonia. On [DATE], at 5:30 a.m. R31 had a temperature of 99.4, had a non productive congested cough. The head of the bed was elevated. R31 was noted to have slept well and nursing staff would continue to monitor. On [DATE], at 1:11 p.m. R31 had run an low grade temperature from 99 to 100.6. [MEDICATION NAME] suppository 650 mg was given rectally for relief and comfort. R31 had been restless on and off the shift, R31's color was flushed and skin was warm to touch. R31's vital signs were blood pressure: ,[DATE], pulse 80, respirations 22, temperature 100.3. R31 was noted to continue to have a congested cough. On [DATE], at 2:30 p.m. a fax was sent to PA-A in regards to R31's blood sugars. Per the electronic weights and vital summary R31's blood sugars were the following; on [DATE] blood sugars were 329, on [DATE] blood sugars were 326, on [DATE] blood sugars were 391. On [DATE], at 10:00 p.m. an order was received from PA-A to increase [MEDICATION NAME] and continue with blood sugar checks daily. On [DATE], at 5:07 a.m. the on call physician was contacted and gave an order to start oxygen (O2) at 2 liters per nasal cannula and to keep O2 levels above 90%. The on call physician also indicated to watch for temperature and if there was a continued problem with the O2 to check with family on what to do (if they wanted R31 to be seen in the emergency room ). If R31's condition did not improve the on call physician indicated R31 would need to be seen in the emergency room . There was no evidence if the physician was made aware of the blood sugars that had increased in the last two days with readings of 329 on [DATE], 326 on [DATE] and 391 on [DATE]. A nursing note on [DATE], at 2:37 p.m. indicated R31 had been resting in bed most of the shift and was repositioned every 2 hours. R31 was up in the wheelchair for a short time and was alert with eyes open most of the shift. [MEDICATION NAME] was given for comfort and family was there to visit. R31's temperature was recorded on [DATE], at 10:10 a.m. at 98.6 and again recorded at 2:11 p.m. at 100.1. Per the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED] Per the electronic weights and vital summary R31's blood sugar was recorded on [DATE], at 12:30 p.m. at 464. Neither PA-A nor the on call physician were notified of this elevated reading. A nursing note dated [DATE], at 5:45 p.m. indicated the on call physician was contacted due to R31's blood sugar reading (464). An order was given to administer 12 units of [MEDICATION NAME] times one dose, recheck blood sugars in one hour and to call to update the on call physician with the reading. On [DATE], at 6:03 p.m. the on call physician was again contacted with the blood sugar that read high (the nursing note did not indicate what the high reading was). On [DATE], at 6:10 p.m. the on call physician called to the facility and noted to clamp and stop the tube feeding and continue with the previous order to re-check the blood sugar and call to update with the reading. On [DATE], at 6:45 p.m. the on call physician was called and updated with the resident's blood sugar results that were 577. The facility let the physician know that resident was hot and clammy and was very pale. R31's vital signs were the following; blood pressure ,[DATE], pulse 116, respirations 26, temperature 100.2, and O2 was 85% at 2 liters via nasal cannula. The on call physician's orders [REDACTED]. R31 was transported to the hospital and later admitted to the hospital on [DATE]. The on call physician was the same physician that saw R31 in the emergency room . The history and physical from the emergency room with the admission date of [DATE], included the following: "Patient recently had a stroke with right [MEDICAL CONDITION]. He was started with a NG ([MEDICAL CONDITION] tube). Patient has a history of diabetes. He was not on insulin therapy. Blood sugars on the day of transfer from nursing home were high, over 600. The day before, blood sugars were high as well, over 400, however, doctor not informed about blood sugars. When patient was transferred today to ER (emergency room ), he was unresponsive". Physical examination of R31 was [AGE] year old male, unresponsive, in critical condition. When presented to the ER blood pressure was 90's systolic, heart rate ,[DATE], O2 saturations 88% on four liters. Impression included hyperglycemic hypersomolal (sic) coma (Diabetic hyperglycemic hyperosmolar syndrome (HHS) is a complication of type 2 diabetes that involves extremely high blood sugar (glucose) levels without the presence of [MEDICATION NAME]. [MEDICATION NAME] are byproducts of fat breakdown). The plan from the ER included R31 was in critical condition and family did not want to transfer R31 anywhere. The hospital discharge summary with an admission date of [DATE] and discharge of [DATE], included the following: "[AGE] year old male who was admitted Acute Care for hyperglycemic hyperosmolol (sic) coma. Today patient is still unresponsive. Patient was seen in the morning". "Patient continued to be unresponsive during the morning hours". "Discussed with family and they were thinking comfort care. Code status for patient was DNR (do not resuscitate). He expired peacefully at 3:45 p.m." The facility filed a report to the state agency on [DATE]. The facility investigation included, "R31 was admitted on [DATE] and was discharged to the hospital on [DATE]. LPN (licensed practical nurse) charted initials on electronic MAR for a TMA (trained medication aide) in regards to resident having a blood sugar at 464. LPN stated she notified RN (registered nurse) concerning the blood sugar levels. Physician not notified of residents blood sugar level. Director of nurses and social services investigated the failure to notify physician and the lack of charting on progress notes. LPN stated she notified RN and when facility contacted RN she responded with, 'I vaguely remember, I think I forgot, I actually had a lot of things going on, I forgot the minute they told me'. When SS (social services) and DON (director of nursing) attempted to view charting on progress notes, LPN did not chart blood sugar levels, LPN stated 'I did what I was supposed to do' by notifying the RN of the residents condition. DON and SS notified the facility administrator, CEP and OHFC (state agency)." An interview was conducted with the registered nurse/MDS coordinator (RN-B) on [DATE], at 1:40 p.m. who indicated the facility policy was to notify the physician with any blood sugar reading that was over 300. After a brief review of the electronic medical record, RN-B verified the physician was not notified. An interview was conducted with the director of nursing (DON) on [DATE], at 2:30 p.m. The DON stated the facility self reported to the state agency when they learned of the situation. The DON indicated on Monday [DATE], she heard from the nursing staff the on call physician from the weekend was rude to the staff. When probed why the on call physician was rude, the staff at the facility stated he was upset because R31's blood sugar was high and the on call physician wanted to know why he was not notified. The DON indicated it was her expectation that nursing staff would notify the physician (either primary or on call physician) when there was a blood sugar reading that was over 300 and verified the blood sugar reading on [DATE], of 464 was not reported to the physician per the facility policy. An interview was conducted with the physician assistant (PA)-A on [DATE], at 11:30 a.m. The PA-A verified that she came to the facility to see R31 on [DATE], and R31 was diagnosed with [REDACTED]. When the PA-A reviewed the blood sugars on [DATE], she identified she was not concerned with the blood sugars at that time. R31 was not a brittle diabetic and the blood sugars were going up gradually ([DATE] was 219, [DATE] was 282, [DATE] was 329, [DATE] was 326, and [DATE], was 391). When the PA-A saw R31 on [DATE], the readings that were available were 282, 319 and 329. A fax was sent on [DATE], in regards to the blood sugar reading of 391. At that time the PA-A ordered to increase the [MEDICATION NAME] to 1000 mg BID and to continue with blood sugar checks daily. The PA-A also indicated to recheck blood sugar the following week and if not improved would move to [MEDICATION NAME]. The next blood sugar reading on [DATE], was 464. The PA-A identified the nursing staff should have "definitely reported" to a physician about the high reading and, "it was missed". The PA-A verified the nursing staff lacked clinical judgment with R31's over all medical condition and should have reported to the on call physician when R31's blood sugar went from 391 to 464 on [DATE]. The policy for [MEDICAL CONDITION] protocol (dated ,[DATE]) included staff "shall promptly notify the resident's physician for medical intervention orders and responsive party in accordance with State and Federal regulation in the event of a significant [MEDICAL CONDITION] which results in a change of condition or plan of treatment." Procedure 1 included, "the nurse supervisor will notify the resident's attending physician/on call physician when: the resident's blood sugar is above 300 and there is not current medication/insulin treatment guidelines to address the hyperglycemic state".