Every finding on record at Brookside Rehab & Nursing Center

Based on staff interview, facility document review, and clinical record review, the facility staff failed to provide adequate supervision for three of 14 residents in the survey sample, Residents #2, #11, and #6.The findings include:1. For R2, facility staff failed to provide supervision to prevent playing with and ingesting fecal material. R2 was admitted to the facility with diagnosis that included but was not limited to bipolar disorder (1) and dementia (2). On the most recent comprehensive MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 09/13/2025, R2 scored 0 (zero) out of 15 on the BIMS (brief interview for mental status), indicating R2 was severely impaired of cognition for making daily decisions. The Psychiatric Note for R2 dated 09/27/2025 documented in part, Relevant Interval History (Symptoms) Staff reported observing concerning behavior where the patient had a bowel movement and was subsequently playing with and eating her own feces, though the timing of when this behavior started is uncertain. The patient does not exhibit any anxiety, depression, delusional thoughts, or hallucinations at this time . Review of R2's comprehensive care plan dated 11/12/2024 failed to evidence documentation to address behaviors of play with and ingesting fecal material. Review of R2's clinical record failed to evidence documentation of R2 playing with or ingesting fecal material and failed to evidence a plan for supervision to prevent R2 from engaging in playing with or ingesting fecal material. On 10/20/2025 at approximately 3:50 p.m. an interview was conducted with CNA (certified nursing assistant) #1 regarding R2. CNA #1 stated she was usually assigned and provided care to R2. When asked if she recalled an incident of R2 ingesting feces CNA #1 stated yes. She further stated that R2 frequently puts her hands in her pants and removes feces and having it on her hands and lips. CNA #1 also stated that even after being toileted R2 would engage in the behavior of removing fecal material with her hands. When asked if she was aware of a plan or supervision to prevent R2 from removing and ingesting feces she stated no. On 10/20/2025 at approximately 4:00 p.m. an interview was conducted with CNA (certified nursing assistant) #2 regarding R2. CNA #2 stated she was usually assigned and provided care to R2. When asked if she recalled an incident of R2 ingesting feces CNA #2 stated yes. She further stated that R2 frequently puts her hands in her pants and removes feces and ingests it . CNA #2 also stated that even after being toileted R2 would engage in the behavior of removing fecal material with her hands. When asked if she was aware of a plan to prevent R2 from removing and ingesting feces she stated that when she sees R2 reaching into her pant CNA #2 stated she intervenes and either redirects R2 or takes her to the bathroom. When asked if she was aware of a plan or supervision to prevent R2 from removing and ingesting feces she stated no. On 10/21/2025 at approximately 12:39 p.m. an interview was conducted with LPN (licensed practical nurse) #1 regarding R2 playing with and ingesting feces. LPN #1 stated she was aware of two incidences of R2 playing with her feces with her hands and one of the incidences LPN #1 witnessed. When asked if she was aware of a plan or supervision to prevent R2 from removing and ingesting feces she stated no. The facility's policy Safety and Supervision of Residents documented in part, Individualized, Resident-Centered Approach to Safety. 1. Our individualized, resident-centered approach to safety addresses safety and accident hazards for individual residents. 2. The interdisciplinary care team will analyze information obtained from assessments and observations to identify any specific accident hazards or risks for individual residents. 3. The care team will target interventions to reduce individual risks related to hazards in the environment, including adequate supervision and assistive devices. 4. Implementing interventions to reduce accident risks and hazards shall include the following: a. Communicating specific interventions to all relevant staff; b. Assigning responsibility for carrying out interventions; c. Providing training, as necessary; d. Ensuring that interventions are implemented; and e. Documenting interventions. On 10/21/2025 at approximately 3:05 p.m. ASM (administrative staff member) #1, administrator, ASM #2, director of nursing, ASM #3, regional director of clinical operations and ASM #4 risk nurse, were made aware of the above findings. No further information was provided prior to exit. Reference: (1) A brain disorder that causes unusual shifts in mood, energy, activity levels, and the ability to carry out day-to-day tasks. This information was obtained from the website: https://www.nimh.nih.gov/health/topics/bipolar-disorder/index.shtml. (2) A loss of brain function that occurs with certain diseases. It affects memory, thinking, language, judgment, and behavior. This information was obtained from the website: https://medlineplus.gov/ency/article/000739.htm. 2. For Resident #11 (R11), the facility failed to provide adequate supervision. On 5/27/25, R11 grabbed the collar of Resident #10's (R10's) shirt. A final facility synopsis of events dated 6/3/25 documented actions taken were a room change and one on one supervision, but these interventions were not implemented until 6/3/25, after R11 was involved in a physical altercation with Resident #12 (R12). R11's comprehensive care plan initiated on 2/27/25 documented, BEHAVIORS: (R11) has behaviors of anxiety, related to dementia, bipolar disorder, depression. (R11) noted to have periods of agitation AND aggression. A review of R11's clinical record revealed a nurse's note dated 5/27/25 that documented, Please describe the behavior demonstrated: Resident grabbed resident (R10) by her shirt. Resident was redirected by multiple staff to release (R10) shirt. Describe any Interventions attempted: Resident redirected to his room. N/P (Nurse Practitioner) (name) notified, R/P (Responsible Party) (name) notified. Per Unit Manager Psych (Psychiatric) NP (Nurse Practitioner) notified via Email [sic]. An initial facility synopsis dated 5/27/25 documented, It is alleged that resident (R11) grabbed the collar of resident (R10's) shirt and would not let go. Residents immediately separated by staff and assessed for injury. No injuries were noted. Admin (Administrator) and DON (Director of Nursing) notified. Further review of R11's clinical record revealed the below nurses' notes regarding R11's behaviors after the 5/27/25 incident: 5/28/25- Resident was trying to communicate that he wanted to shower, while a CNA (Certified Nursing Assistant) and the UM (Unit Manager) were talking. Resident became irritated because he thought he was being ignored and kicked the half door at the nursing station. 5/29/25- Please describe the behavior demonstrated: Took assignment book from desk .Describe any Interventions attempted: I asked him for the book back. He cursed at me and went into his room and shut the door. He later was sitting in the dining (room) with the book. A CNA asked him for the book and he refused to give it to her and cursed at her. Night supervisor made aware. 5/29/25- Spent the majority of the night walking the halls. Denies having the assignment book. Night supervisor aware. 5/29/25- Please describe the behavior demonstrated: Asked for water and then threw the cup of water over the desk onto the floor. 5/29/25- Please describe the behavior demonstrated: Resident is opening other residents [sic] doors and entering rooms .Describe any Interventions attempted: Redirected to his room but refused to enter, cursing, threatening, what he would do if we kept bothering him! 5/31/25- Please describe the behavior demonstrated: Resident stated to resident (number) daughter 'don't [sic] look at me or I'll put your head through the f***ing window .' Describe any Interventions attempted: Resident redirected to his room with a snack/juice Ativan (anti-anxiety medication) 0.5 mg (milligrams) po (by mouth). 6/1/25- Please describe the behavior demonstrated: Resident approached resident (number) family member in her personal space. Family member was standing up talking to resident (number) in dining room when (R11) approached her .Describe any Interventions attempted: Resident redirected to a chair in the dining room, snack provided. 6/1/25- Please describe the behavior demonstrated: Resident took resident (number) by her elbow and attempted to assist her to stand from her wheelchair .Describe any Interventions attempted: Residents separated. 6/2/25- Please describe the behavior demonstrated: Resident attempted to slap resident (number) hand. Verbally threatened resident (number) with physical harm .Describe any Interventions attempted: offered snacks in room. 6/3/25- Please describe the behavior demonstrated: Resident standing at nurses [sic] station and noted to come into contact with resident (number) .Describe any Interventions attempted: Residents immediately separated to different areas of unit. Resident pacing unit, unable to redirect resident to his room for rest/snacks. Lorazepam (anti-anxiety medication) 0.5 mg PO administered NP (Nurse Practitioner) (name) notified. Notification for psych (psychiatry) in notebook. R/P (Responsible Party) (name) notified. 6/3/25- Spoke with resident's guardian, (name). Offered room change to south unit with wander guard placement. Staff notes that resident seems to be triggered by other resident's behaviors and is acting as a 'protector' by his perceptions of interactions. South (unit) may be a more suitable environment. Guardian agreeable to trialing room change with initial 1:1 (one on one) supervision to decrease behaviors. A final facility synopsis of events regarding the 5/27/25 incident and dated 6/3/25 documented, On May 27, 2025, staff witnessed resident (R11), grab onto another resident's shirt collar and would not let go. The other resident was identified as (R10). Staff was able to separate the residents and redirect. No injuries were noted. No other residents were affected. Actions Taken .Room change to south unit for less stimulating environment with 1:1 (one on one) supervision pending follow-up with psych. Further review of R11's clinical record revealed the resident was not moved to the South Unit or provided one on one supervision until after another incident on 6/3/25. An initial facility synopsis of events dated 6/3/25 documented, It is alleged that (R12) grabbed (R13's) hair. (R11) and (R12) exchanged physical contact with their hands. Residents immediately separated and assessed for injury. DON (Director of Nursing) and admin (Administrator) notified. A witness statement signed by CNA (Certified Nursing Assistant) #3 on 6/3/25 documented, I was inside the nurse station area when (R12) was drinking water out of a plastic cup. Then suddenly, (R13) approached (R12) and snatched his water from his hands. In response, (R12) shouted at her and grabbed her by the hair. At that point (R11) trying [sic] to intervene and attepting [sic] to restrain (R12) grabbed him by the neck, hoping to protect (R13). A witness statement signed by RN (Registered Nurse) #4 on 6/3/25 documented, This writer noticed another resident (R12) come up to (R13) and grabbed her hair. This writer attempted to dissolve situation. (R12) would not let go of (R13's) hair. When another resident (R11) stepped in and attacked (R12) in attempts to defend (R13) . A final facility synopsis of events regarding the 6/3/25 incident and dated 6/10/25 documented, (R12) was drinking a cup of water on the memory care unit, when a female resident, (R13) approached him and took the cup of water from his hands. In response, (R12) yelled at her and grabbed her by the hair. (R11) attempted to intervene to protect (R13), he grabbed (R12) trying to stop him from hurting (R13). No injuries noted. On 10/20/2025 at 3:58 p.m., an interview was conducted with CNA #1. CNA #1 stated R11 was very aggressive, and staff were afraid of the resident. CNA #1 stated there were not enough staff to supervise R11 and incidents happened. On 10/21/25 at 8:55 a.m., an interview was conducted with ASM (Administrative Staff Member) #1 (the Administrator). ASM #1 stated R11 there was no evidence that R11 was placed on one-on-one supervision until the resident was trialed a room change on 6/3/25. ASM #1 stated that sometimes R11 was agreeable to one-on-one supervision but sometimes the supervision triggered the resident and made his behaviors worse. ASM #1 stated one on one supervision was implemented based on the situations but there was no documentation regarding the decision making for this. On 10/21/25 at 12:26 p.m., an interview was conducted with LPN (Licensed Practical Nurse) #1. LPN #1 stated R11 was a strong, large, tall, big built man, and multiple staff had to assist her with removing the resident from R10 on 5/27/25. LPN #1 stated a lot of activity occurs in the dining room on the North (memory care) Unit and the stimulation upset R11. LPN #1 stated R11 was only provided one on one supervision at times, and she did not recall the supervision triggering any behaviors. On 10/21/25 at 1:12 p.m., an interview was conducted with LPN #2. LPN #2 stated R11 could be really nice then would turn aggressive, on a dime. LPN #2 stated R11 was big, strong, fast, and scary. LPN #2 stated she occasionally provided one on one supervision for R11, and this did not trigger the resident's aggression as long as she didn't stay on top of the resident. LPN #2 stated it was important for R11 to receive adequate supervision because the resident was dangerous, but residents wandered on the North Unit and staff were not always able to keep their eyes on the residents all the time. On 10/21/25 at 3:11 p.m., ASM #1, and ASM #2 (the Director of Nursing) were made aware of the above concerns. ASM #1 stated R11's room change to another unit was not made until 6/3/25 because the interdisciplinary team came together to brainstorm and review the resident's care. ASM #1 stated the team was hesitant to change R11's environment. ASM #1 stated one-on-one supervision agitated R11 so the decision to implement one on one supervision was made on a case-by-case basis. No further information was presented prior to exit. 3. For Resident #6 (R6), the facility staff failed to provide adequate supervision to prevent multiple resident to resident incidents. On 1/24/25, R6 was found in another resident room, slapping Resident #7 (R7). On 1/26/25, R6 was found lying in Resident #4's (R4's) bed with R4. On 2/26/25, R6 was found in another resident bathroom slapping Resident #1 (R1), and on 3/20/25, R6 was found in another resident room hitting Resident #14 (R14). R6's comprehensive care plan revised on 2/28/24 documented, (R6) was involved in a resident-to-resident altercation .Monitor resident closely and anticipate needs. A review of R6's clinical record revealed a nurse's note dated 1/24/25 that documented, Resident found across the hall in another residents [sic] room. Witnessed by staff, both were slapping at each other, pushing each other, pulling hair. Immediately separated and assessed for injuries, none found. RPs (Responsible Parties), Geri-pysch [psychiatry], DON (Director of Nursing), and unit manager notified/aware. A review of R7's clinical record revealed a nurse's note dated 1/24/25 that documented, Resident (R6) entered residents [sic] room and residents began slapping each other. Residents were immediately separated. Resident assessed for injury no injury noted. Geri psych NP (Nurse Practitioner), NP (name) notified Unit Manager, R/P (name) notified. Further review of R6's clinical record revealed a nurse's note dated 1/26/25 that documented, Please describe the behavior demonstrated: At 2000 (8:00 p.m.) this writer observed resident fully clothed lying in bed, with another male resident who was also fully clothed, in his room .Describe any Interventions attempted: Resident taken out of male resident's room . A review of R4's clinical record revealed a nurse's note dated 1/26/25 documented, Please describe the behavior demonstrated: Resident observed fully clothed with female resident, also fully clothed, laying down on top of his sheet on his bed .Describe any Interventions attempted: Separated residents immediately . Further review of R6's clinical record revealed a nurse's note dated 2/26/25 that documented, Resident was in anothers [sic] bathroom with another resident and they were slapping at each other. Residents immediately separated and assessed for injuries, none found. RP, NP and unit manager notified. A review of R1's clinical record revealed a nurse's note dated 2/26/25 that documented, Resident exhibiting aggressive behaviors toward other residents, by biting, hitting and slapping. Immediately separated and all involved assessed for injuries, none found. RP (name) notified. NP notified, arrived to unit and prescribed ativan (anti-anxiety medication) 0.5 mg (milligrams) PO (by mouth) stat. Resident was medicated and placed on 1;1 (one on one supervision) observation for safety. Further review of R6's clinical record revealed a nurse's note dated 3/20/25 that documented, This nurse was informed by a staff member that the resident had hit another resident (R14) on her back when she had told her to get out of her room .This nurse did not witness the incident. This nurse approached resident (R6) and redirected her back into her room. Resident (R6) has no recollection of what had happened. Skin assessment completed and no injuries at this time .UM (Unit Manager), DON, NP, RP and the Administrator all informed on all parties involved. Police notified. Labs were drawn for residents [sic] agitation and aggressive behavior. Will continue to monitor. A review of R14's clinical record revealed a nurse's note dated 3/20/25 that documented, (R14) was noted to be in an altercation with another resident .dayshift nurse caring for resident noted to have informed RP of incident and per Dayshift nurse assigned to resident no new injuries at this time. On 10/20/25 at 3:58 p.m., an interview was conducted with CNA (Certified Nursing Assistant) #1. CNA #1 stated it's hard to monitor every resident going into every resident's room. CNA #1 stated when there is less staff, each CNA has a bigger assignment and has less time to supervise residents because the CNAs are providing care in resident rooms and can't be in the dining room or halls to supervise residents going in and out of other resident rooms. On 10/21/25 at 12:26 p.m., an interview was conducted with LPN (Licensed Practical Nurse) #1. LPN #1 stated R6 wandered into other resident rooms multiple times a week and could be combative. LPN #1 stated if the unit census was full (60 residents), staff wasn't always able to keep R6 out of other resident rooms. On 10/21/25 at 1:12 p.m., an interview was conducted with LPN #2. LPN #2 stated R6 was always protective of her space, even if it wasn't her space. LPN #2 stated R6 was always easily agitated and very confrontational. LPN #2 stated residents wander on the North Unit and staff are not always able to keep their eyes on the residents all the time. LPN #2 stated it was important to provide adequate supervision for R6 and to keep all residents safe. On 10/21/25 at 3:11 p.m., ASM (Administrative Staff Member) #1, (the Administrator) and ASM #2 (the Director of Nursing) were made aware of the above concerns. No further information was presented prior to exit.

Based on staff interview, facility document review, and clinical record review, the facility staff failed to provide sufficient nursing staff for three of 14 residents in the survey sample, Residents #2, #11, and #6.The findings include:1. For R2, facility staff failed to provide sufficient nursing staff to prevent playing with and ingesting fecal material. R2 was admitted to the facility with diagnosis that included but was not limited to bipolar disorder (1) and dementia (2). On the most recent comprehensive MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 09/13/2025, R2 scored 0 (zero) out of 15 on the BIMS (brief interview for mental status), indicating R2 was severely impaired of cognition for making daily decisions. The Psychiatric Note for R2 dated 09/27/2025 documented in part, Relevant Interval History (Symptoms) Staff reported observing concerning behavior where the patient had a bowel movement and was subsequently playing with and eating her own feces, though the timing of when this behavior started is uncertain. The patient does not exhibit any anxiety, depression, delusional thoughts, or hallucinations at this time . Review of R2's comprehensive care plan dated 11/12/2024 failed to evidence documentation to address behaviors of play with and ingesting fecal material. Review of R2's clinical record failed to evidence documentation of R2 playing with or ingesting fecal material and failed to evidence a plan for supervision to prevent R2 from engaging in playing with or ingesting fecal material. On 10/20/2025 at approximately 3:50 p.m. an interview was conducted with CNA (certified nursing assistant) #1 regarding R2. CNA #1 stated she worked on the North Wing and was usually assigned and provided care to R2. When asked if she recalled an incident of R2 ingesting feces CNA #1 stated yes. She further stated that R2 frequently puts her hands in her pants and removes feces and having it on her hands and lips. CNA #1 also stated that even after being toileted R2 would engage in the behavior of removing fecal material with her hands. 1. CNA #1 stated staff sufficiency depended on the day, weekends were the worst, and more incidents occurred on the weekends. CNA #1 stated that when there is less staff, each CNA has a bigger assignment and has less time to supervise residents. CNA #1 stated it is impossible to supervise residents unless there is an adequate number of staff. When asked if there were enough staff to monitor R2 from engaging in removal and ingesting feces CNA #1 stated no. On 10/20/2025 at approximately 4:00 p.m. an interview was conducted with CNA (certified nursing assistant) #2 regarding R2. CNA #2 stated she worked on the North Wing and was usually assigned and provided care to R2. When asked if she recalled an incident of R2 ingesting feces CNA #2 stated yes. She further stated that R2 frequently puts her hands in her pants and removes feces and ingests it . CNA #2 also stated that even after being toileted R2 would engage in the behavior of removing fecal material with her hands. When asked if she was aware of a plan to prevent R2 from removing and ingesting feces she stated that when she sees R2 reaching into her pant CNA #2 stated she intervenes and either redirects R2 or takes her to the bathroom. When asked if there were enough staff to monitor R2 from engaging in removal and ingesting feces CNA #2 stated no. On 10/21/2025 at approximately 12:39 p.m. an interview was conducted with LPN (licensed practical nurse) #1 regarding R2 playing with and ingesting feces. LPN #1 stated she worked on the North Wing and was aware of two incidences of R2 playing with her feces with her hands and one of the incidences LPN #1 witnessed. LPN #1 stated there have been times that there was not sufficient staff and staff were not able to provide adequate supervision. On 10/21/25 at 1:12 p.m., an interview was conducted with LPN #2. LPN #2 stated that in the past, staffing was awful and there were not enough staff to monitor residents and supervise each area of the unit. The facility's policy Staffing documented in part, Our facility provides sufficient numbers of staff with the skills and competency necessary to provide care and services for all residents in accordance with resident care plans and the facility assessment. On 10/21/2025 at approximately 3:05 p.m. ASM (administrative staff member) #1, administrator, ASM #2, director of nursing, ASM #3, regional director of clinical operations and ASM #4 risk nurse, were made aware of the above findings. No further information was provided prior to exit. Reference: (1) A brain disorder that causes unusual shifts in mood, energy, activity levels, and the ability to carry out day-to-day tasks. This information was obtained from the website: https://www.nimh.nih.gov/health/topics/bipolar-disorder/index.shtml. (2) A loss of brain function that occurs with certain diseases. It affects memory, thinking, language, judgment, and behavior. This information was obtained from the website: https://medlineplus.gov/ency/article/000739.htm. 2. For Resident #11 (R11), the facility failed to provide sufficient nursing staff for adequate supervision of the resident. On 5/27/25, R11 grabbed the collar of Resident #10's (R10's) shirt. A final facility synopsis of events dated 6/3/25 documented actions taken were a room change and one on one supervision, but these interventions were not implemented until 6/3/25, after R11 was involved in a physical altercation with Resident #12 (R12). A review of R11's clinical record revealed a nurse's note dated 5/27/25 that documented, Please describe the behavior demonstrated: Resident grabbed resident (R10) by her shirt. Resident was redirected by multiple staff to release (R10) shirt. Describe any Interventions attempted: Resident redirected to his room. N/P (Nurse Practitioner) (name) notified, R/P (Responsible Party) (name) notified. Per Unit Manager Psych (Psychiatric) NP (Nurse Practitioner) notified via Email [sic]. An initial facility synopsis dated 5/27/25 documented, It is alleged that resident (R11) grabbed the collar of resident (R10's) shirt and would not let go. Residents immediately separated by staff and assessed for injury. No injuries were noted. Admin (Administrator) and DON (Director of Nursing) notified. Further review of R11's clinical record revealed the below nurses' notes regarding R11's behaviors after the 5/27/25 incident: 5/28/25- Resident was trying to communicate that he wanted to shower, while a CNA (Certified Nursing Assistant) and the UM (Unit Manager) were talking. Resident became irritated because he thought he was being ignored and kicked the half door at the nursing station. 5/29/25- Please describe the behavior demonstrated: Took assignment book from desk .Describe any Interventions attempted: I asked him for the book back. He cursed at me and went into his room and shut the door. He later was sitting in the dining (room) with the book. A CNA asked him for the book and he refused to give it to her and cursed at her. Night supervisor made aware. 5/29/25- Spent the majority of the night walking the halls. Denies having the assignment book. Night supervisor aware. 5/29/25- Please describe the behavior demonstrated: Asked for water and then threw the cup of water over the desk onto the floor. 5/29/25- Please describe the behavior demonstrated: Resident is opening other residents [sic] doors and entering rooms .Describe any Interventions attempted: Redirected to his room but refused to enter, cursing, threatening, what he would do if we kept bothering him! 5/31/25- Please describe the behavior demonstrated: Resident stated to resident (number) daughter 'don't [sic] look at me or I'll put your head through the f***ing window .' Describe any Interventions attempted: Resident redirected to his room with a snack/juice Ativan (anti-anxiety medication) 0.5 mg (milligrams) po (by mouth). 6/1/25- Please describe the behavior demonstrated: Resident approached resident (number) family member in her personal space. Family member was standing up talking to resident (number) in dining room when (R11) approached her .Describe any Interventions attempted: Resident redirected to a chair in the dining room, snack provided. 6/1/25- Please describe the behavior demonstrated: Resident took resident (number) by her elbow and attempted to assist her to stand from her wheelchair .Describe any Interventions attempted: Residents separated. 6/2/25- Please describe the behavior demonstrated: Resident attempted to slap resident (number) hand. Verbally threatened resident (number) with physical harm .Describe any Interventions attempted: offered snacks in room. 6/3/25- Please describe the behavior demonstrated: Resident standing at nurses [sic] station and noted to come into contact with resident (number) .Describe any Interventions attempted: Residents immediately separated to different areas of unit. Resident pacing unit, unable to redirect resident to his room for rest/snacks. Lorazepam (anti-anxiety medication) 0.5 mg PO administered NP (Nurse Practitioner) (name) notified. Notification for psych (psychiatry) in notebook. R/P (Responsible Party) (name) notified. 6/3/25- Spoke with resident's guardian, (name). Offered room change to south unit with wander guard placement. Staff notes that resident seems to be triggered by other resident's behaviors and is acting as a 'protector' by his perceptions of interactions. South (unit) may be a more suitable environment. Guardian agreeable to trialing room change with initial 1:1 (one on one) supervision to decrease behaviors. A final facility synopsis of events regarding the 5/27/25 incident and dated 6/3/25 documented, On May 27, 2025, staff witnessed resident (R11), grab onto another resident's shirt collar and would not let go. The other resident was identified as (R10). Staff was able to separate the residents and redirect. No injuries were noted. No other residents were affected. Actions Taken .Room change to south unit for less stimulating environment with 1:1 (one on one) supervision pending follow-up with psych. Further review of R11's clinical record revealed the resident was not moved to the South Unit or provided one on one supervision until after another incident on 6/3/25. An initial facility synopsis of events dated 6/3/25 documented, It is alleged that (R12) grabbed (R13's) hair. (R11) and (R12) exchanged physical contact with their hands. Residents immediately separated and assessed for injury. DON (Director of Nursing) and admin (Administrator) notified. A witness statement signed by CNA (Certified Nursing Assistant) #3 on 6/3/25 documented, I was inside the nurse station area when (R12) was drinking water out of a plastic cup. Then suddenly, (R13) approached (R12) and snatched his water from his hands. In response, (R12) shouted at her and grabbed her by the hair. At that point (R11) trying [sic] to intervene and attepting [sic] to restrain (R12) grabbed him by the neck, hoping to protect (R13). A witness statement signed by RN (Registered Nurse) #4 on 6/3/25 documented, This writer noticed another resident (R12) come up to (R13) and grabbed her hair. This writer attempted to dissolve situation. (R12) would not let go of (R13's) hair. When another resident (R11) stepped in and attacked (R12) in attempts to defend (R13) . A final facility synopsis of events regarding the 6/3/25 incident and dated 6/10/25 documented, (R12) was drinking a cup of water on the memory care unit, when a female resident, (R13) approached him and took the cup of water from his hands. In response, (R12) yelled at her and grabbed her by the hair. (R11) attempted to intervene to protect (R13), he grabbed (R12) trying to stop him from hurting (R13). No injuries noted. On 10/20/2025 at 3:58 p.m., an interview was conducted with CNA #1. CNA #1 stated R11 was very aggressive, and staff were afraid of the resident. CNA #1 stated there were not enough staff to supervise R11 and incidents happened. CNA #1 stated staff sufficiency depended on the day, weekends were the worst, and more incidents occurred on the weekends. CNA #1 stated it's hard to monitor every resident going into every resident's room. CNA #1 stated that when there is less staff, each CNA has a bigger assignment and has less time to supervise residents. CNA #1 stated it is impossible to supervise residents unless there is an adequate number of staff. On 10/21/25 at 8:55 a.m., an interview was conducted with ASM (Administrative Staff Member) #1 (the Administrator). ASM #1 stated R11 there was no evidence that R11 was placed on one-on-one supervision until the resident was trialed a room change on 6/3/25. ASM #1 stated one-on-one supervision triggered R11's behaviors and was implemented based on the situations but there was no documentation regarding the decision making for this. On 10/21/25 at 12:26 p.m., an interview was conducted with LPN (Licensed Practical Nurse) #1. LPN #1 stated there have been times that there was not sufficient staffing and staff were not able to provide adequate supervision. LPN #1 stated R11 was a strong, large, tall, big built man, and multiple staff had to assist her with removing the resident from R10 on 5/27/25. LPN #1 stated a lot of activity occurs in the dining room on the North (memory care) Unit and the stimulation upset R11. LPN #1 stated R11 was only provided one on one supervision at times, and she did not recall the supervision triggering any behaviors. On 10/21/25 at 1:12 p.m., an interview was conducted with LPN #2. On 10/21/25 at 1:12 p.m., an interview was conducted with LPN #2. LPN #2 stated residents wander on the North Unit and staff are not always able to keep their eyes on the residents all the time. LPN #2 stated that in the past, staffing was awful and there were not enough staff to monitor residents and supervise each area of the unit. LPN #2 stated R11 could be really nice then would turn aggressive, on a dime. LPN #2 stated R11 was big, strong, fast, and scary. LPN #2 stated she occasionally provided one on one supervision for R11, and this did not trigger the resident's aggression as long as she didn't stay on top of the resident. LPN #2 stated it was important for R11 to receive adequate supervision because the resident was dangerous, but residents wandered on the North Unit and staff were not always able to keep their eyes on the residents all the time. On 10/21/25 at 3:11 p.m., ASM #1, and ASM #2 (the Director of Nursing) were made aware of the above concerns. ASM #1 stated R11's room change to another unit was not made until 6/3/25 because the interdisciplinary team came together to brainstorm and review the resident's care. ASM #1 stated the team was hesitant to change R11's environment. ASM #1 stated one-on-one supervision agitated R11 so the decision to implement one on one supervision was made on a case-by-case basis. No further information was presented prior to exit. 3. For Resident #6 (R6), the facility staff failed to provide sufficient staffing to prevent multiple resident to resident incidents. On 1/24/25, R6 was found in another resident room, slapping Resident #7 (R7). On 1/26/25, R6 was found lying in Resident #4's (R4's) bed with R4. On 2/26/25, R6 was found in another resident bathroom slapping Resident #1 (R1), and on 3/20/25, R6 was found in another resident room hitting Resident #14 (R14). A review of R6's clinical record revealed a nurse's note dated 1/24/25 that documented, Resident found across the hall in another residents [sic] room. Witnessed by staff, both were slapping at each other, pushing each other, pulling hair. Immediately separated and assessed for injuries, none found. RPs (Responsible Parties), Geri-pysch [psychiatry], DON (Director of Nursing), and unit manager notified/aware. A review of R7's clinical record revealed a nurse's note dated 1/24/25 that documented, Resident (R6) entered residents [sic] room and residents began slapping each other. Residents were immediately separated. Resident assessed for injury no injury noted. Geri psych NP (Nurse Practitioner), NP (name) notified Unit Manager, R/P (name) notified. Further review of R6's clinical record revealed a nurse's note dated 1/26/25 that documented, Please describe the behavior demonstrated: At 2000 (8:00 p.m.) this writer observed resident fully clothed lying in bed, with another male resident who was also fully clothed, in his room .Describe any Interventions attempted: Resident taken out of male resident's room . A review of R4's clinical record revealed a nurse's note dated 1/26/25 documented, Please describe the behavior demonstrated: Resident observed fully clothed with female resident, also fully clothed, laying down on top of his sheet on his bed .Describe any Interventions attempted: Separated residents immediately . Further review of R6's clinical record revealed a nurse's note dated 2/26/25 that documented, Resident was in anothers [sic] bathroom with another resident and they were slapping at each other. Residents immediately separated and assessed for injuries, none found. RP, NP and unit manager notified. A review of R1's clinical record revealed a nurse's note dated 2/26/25 that documented, Resident exhibiting aggressive behaviors toward other residents, by biting, hitting and slapping. Immediately separated and all involved assessed for injuries, none found. RP (name) notified. NP notified, arrived to unit and prescribed ativan (anti-anxiety medication) 0.5 mg (milligrams) PO (by mouth) stat. Resident was medicated and placed on 1;1 (one on one supervision) observation for safety. Further review of R6's clinical record revealed a nurse's note dated 3/20/25 that documented, This nurse was informed by a staff member that the resident had hit another resident (R14) on her back when she had told her to get out of her room .This nurse did not witness the incident. This nurse approached resident (R6) and redirected her back into her room. Resident (R6) has no recollection of what had happened. Skin assessment completed and no injuries at this time .UM (Unit Manager), DON, NP, RP and the Administrator all informed on all parties involved. Police notified. Labs were drawn for residents [sic] agitation and aggressive behavior. Will continue to monitor. A review of R14's clinical record revealed a nurse's note dated 3/20/25 that documented, (R14) was noted to be in an altercation with another resident .dayshift nurse caring for resident noted to have informed RP of incident and per Dayshift nurse assigned to resident no new injuries at this time. On 10/20/25 at 3:58 p.m., an interview was conducted with CNA (certified nursing assistant) #1. CNA #1 stated staff sufficiency depended on the day, weekends were the worst, and more incidents occurred on the weekends. CNA #1 stated it's hard to monitor every resident going into every resident's room. CNA #1 stated when there is less staff, each CNA has a bigger assignment and has less time to supervise residents because the CNAs are providing care in resident rooms and can't be in the dining room or halls to supervise residents going in and out of other resident rooms. CNA #1 stated it is impossible to supervise residents unless there is an adequate number of staff. On 10/21/25 at 12:26 p.m., an interview was conducted with LPN (licensed practical nurse) #1. LPN #1 stated R6 wandered into other resident rooms multiple times a week and could be combative. LPN #1 stated if the unit census was full (60 residents), staff wasn't always able to keep R6 out of other resident rooms. LPN #1 stated there have been times that there was not sufficient staffing and staff were not able to provide adequate supervision. On 10/21/25 at 1:12 p.m., an interview was conducted with LPN #2. LPN #2 stated R6 was always protective of her space, even if it wasn't her space. LPN #2 stated R6 was always easily agitated and very confrontational. LPN #2 stated residents wander on the North Unit and staff are not always able to keep their eyes on the residents all the time. LPN #2 stated it was important to provide adequate supervision for R6 and to keep all residents safe but in the past, staffing was awful and there were not enough staff to monitor residents and supervise each area of the unit. On 10/21/25 at 3:11 p.m., ASM (Administrative Staff Member) #1, (the Administrator) and ASM #2 (the Director of Nursing) were made aware of the above concerns. No further information was presented prior to exit.

Based on staff interview and clinical record review, it was determined that the facility staff failed to review or revise the comprehensive care plan for one of 14 residents, Residents in the survey sample, Resident #2 (R2). The findings include:For R2, the facility staff failed to review or revise comprehensive care plan to address behaviors of play with and ingesting fecal material. R2 was admitted to the facility with diagnosis that included but was not limited to bipolar disorder (1) and dementia (2). On the most recent comprehensive MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 09/13/2025, R2 scored 0 (zero) out of 15 on the BIMS (brief interview for mental status), indicating R2 was severely impaired of cognition for making daily decisions. The Psychiatric Note for R2 dated 09/27/2025 documented in part, Relevant Interval History (Symptoms) Staff reported observing concerning behavior where the patient had a bowel movement and was subsequently playing with and eating her own feces, though the timing of when this behavior started is uncertain. The patient does not exhibit any anxiety, depression, delusional thoughts, or hallucinations at this time .Review of R2's comprehensive care plan dated 11/12/2024 failed to evidence documentation to address behaviors of play with and ingesting fecal material. On 10/20/2025 at approximately 3:50 p.m. an interview was conducted with CNA (certified nursing assistant) #1 regarding R2. CNA #1 stated she worked on the North Wing and was usually assigned and provided care to R2. When asked if she recalled an incident of R2 ingesting feces CNA #1 stated yes. She further stated that R2 frequently puts her hands in her pants and removes feces and having it on her hands and lips. CNA #1 also stated that even after being toileted R2 would engage in the behavior of removing fecal material with her hands. When asked if she was aware of a plan to prevent R2 from removing and ingesting feces she stated no. On 10/20/2025 at approximately 4:00 p.m. an interview was conducted with CNA (certified nursing assistant) #2 regarding R2. CNA #2 stated she worked on the North Wing and was usually assigned and provided care to R2. When asked if she recalled an incident of R2 ingesting feces CNA #2 stated yes. She further stated that R2 frequently puts her hands in her pants and removes feces and ingests it . CNA #2 also stated that even after being toileted R2 would engage in the behavior of removing fecal material with her hands. When asked if she was aware of a plan to prevent R2 from removing and ingesting feces she stated that when she sees R2 reaching into her pant CNA #2 stated she intervenes and either redirects R2 or takes her to the bathroom. When asked if she was aware of a plan to prevent R2 from removing and ingesting feces she stated no. On 10/21/2025 at approximately 12:39 p.m. an interview was conducted with LPN (licensed practical nurse) #1 regarding R2 playing with and ingesting feces. LPN #1 stated she worked on the North Wing and was aware of two incidences of R2 playing with her feces with her hands and one of the incidences LPN #1 witnessed. After reviewing R2's comprehensive care plan dated 11/12/2024 LPN #1 stated that the care plan failed to document or address R2's behavior involving feces. When asked to describe the purpose of a resident's care plan she stated the purpose of the care plan is for all disciplines to have a picture of the resident. On 10/21/2025 at approximately 3:05 p.m. ASM (administrative staff member) #1, administrator, ASM #2, director of nursing, ASM #3, regional director of clinical operations and ASM #4 risk nurse, were made aware of the above findings. No further information was provided prior to exit. Reference:(1) A brain disorder that causes unusual shifts in mood, energy, activity levels, and the ability to carry out day-to-day tasks. This information was obtained from the website: https://www.nimh.nih.gov/health/topics/bipolar-disorder/index.shtml. (2) A loss of brain function that occurs with certain diseases. It affects memory, thinking, language, judgment, and behavior. This information was obtained from the website: https://medlineplus.gov/ency/article/000739.htm.

Based on clinical record review and staff interview, facility staff failed to provide care and services in a timely manner for one of 14 residents in the survey sample, Resident #8 (R8). The findings include:For R8, facility staff failed to act on the results of an x-ray in a timely manner. R8 was admitted with diagnosis that included but not limited to dementia (1). On the most recent comprehensive MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 09/21/2025, R8 scored 0 (zero) out of 15 on the BIMS (brief interview for mental status), indicating R8 was severely impaired of cognition for making daily decisions. The facility's incident report dated 11/19/2024 documented in part, Incident date: 11/18/2024. Resident involved: (Name of R8). Incident type: Injury of unknown injury. Resident noticed w/ (with) bruise on left leg. Resident was in her bed. The facility's nursing notes for R8 dated 11/18/2024 at 6:42 a.m. documented Note Text: Staff reported bruise on resident left front leg, pain to touch, MD (medical doctor) notified, MD stated, called (Name of After-Hours Provider Organization). (Name of After-Hours Provider Organization) was contacted via (by) iPad, response is pending. POA (power of attorney) was notified. Morning will follow up. The facility's nursing notes for R8 dated 11/18/2024 at 6:50 a.m. documented Note Text: Received a call from (Name of After-Hours Provider Organization) (Name of Representative) to use ice for pain as needed. The facility's nursing notes for R8 dated 11/18/2024 at 2:45 p.m. documented Note Text: Writer was informed this morning about a bruise on the left leg. The resident was monitored for any signs of pain. The resident reported 0 (zero) pain, and no discomfort was noted during morning shift. The facility's nursing notes for R8 dated 11/18/2024 at 11:05 p.m. documented Note Text: New orders given X-ray for left hip and left lower leg 2 (two) views. The physician's order for R8 dated 11/18/2024 documented in part, Left lower leg xray (X-ray) 2 (two) view. For bruise. The report from (Name of X-ray Company) for R8 documented in part, Exam date: 11/19/2024. Impression: Comminuted, angulated, intertrochanteric (2) fracture of the left femur (thigh bone). The facility's nursing notes for R8 dated 11/20/2024 at 9:41 a.m. documented Note Text: X-ray of left hip received at 0845 (8:45 a.m.). (Name of Nurse Practitioner) notified of results immediately. No new orders received at this time. Plan of [sic]is ongoing. The facility's nursing notes for R8 dated 11/20/2024 AT 10:56 a.m. documented Note Text: Order recvd (received) from (Name of Nurse Practitioner) to send resident to (Name of Hospital) for evaluation and treatment Fracture of left femur. R/P (responsible party) (Name of Responsible Party) notified of xray (X-ray) results and transfer to (Name of Hospital) via (by) EMS (emergency medical services). The (Name of Hospital) Emergency Department Visit Note for R8 dated 11/20/2024 documented in part, The patient is a [AGE] year old female who is seen in the Emergency Department for hip fracture. General Appearance: no apparent distress, normally reactive to environment (Baseline according to nursing. On 10/21/2025 at approximately 10:27 a.m. a telephone interview was conducted with OSM (other staff member) #2, workflow coordinator for (Name of X-ray Company). When asked to describe the procedure for contacting a nursing home for X-ray results he stated that if the results have a positive finding (fracture) they call the facility the same day with the results. When asked about notifying the facility with the findings of the X-ray taken on 11/19/2024 OSM #2 stated that (Name of X-ray Company) records indicated that the facility was notified of R8's fracture on 11/19/2024 and that they spoke to (Name of Registered Nurse #5). OSM #2 was asked if he would provide a copy of the record documenting the (Name of X-ray Company's) contact with RN #5. He stated that the request for the document would be sent to his supervisor and have the supervisor contact the surveyor. At the time of exit no further information or telephone call was received from (Name of X-ray Company). On 10/21/2025 at approximately 12:47 p.m. an interview was conducted with LPN (licensed practical nurse) #1. When asked to describe the procedure for a resident with a bruise that is identified as an injury of unknown origin she stated that the director of nursing, nurse practitioner and responsible party are notified of the injury, assess for pain level and conduct a head-to-to-toe assessment. She also stated that if the physician or nurse practitioner orders an X-ray it is scheduled and obtain as soon as possible with the X-ray company. When asked about receiving the results of a resident's X-ray she stated that the X-ray company calls the facility if the results indicate a broken bone or fracture. When asked what a nurse should do if a phone call has not been received from the X-ray company by the end of the day that the X-ray was obtained she stated that the nurse should call the X-ray company for the results. After reviewing the nurse's notes and X-ray report for R8 LPN #1 stated that the nurse should have called the X-ray company for the result. LPN #1 agreed that there was a delay in treatment for R8. On 10/21/2025 at approximately 1:25 p.m. an interview was conducted with RN (registered nurse) #5. When asked if she recalled receiving a telephone call from (Name of X-ray Company) on 11/19/2024 with the results of R8's X-ray RN #5 stated she did not recall receiving a call. After reviewing the nurse's notes and X-ray report for R8 RN #5 stated that the X-ray company should have been called for the result and it was a delay in treatment. On 10/21/2025 at approximately 3:05 p.m. ASM (administrative staff member) #1, administrator, ASM #2, director of nursing, ASM #3, regional director of clinical operations and ASM #4 risk nurse, were made aware of the above findings. No further information was provided prior to exit. References:(1) A loss of brain function that occurs with certain diseases. It affects memory, thinking, language, judgment, and behavior. This information was obtained from the website: https://medlineplus.gov/ency/article/000739.htm. (2) A type of broken hip. The hip is made up of two bones: the femur (thigh bone) and the pelvis (socket). This information was obtained from the website: https://ota.org/for-patients/find-info-body-part/3720#/+/0?score/desc/

Based on clinical record review and staff interview, facility staff failed to notify the physician of a need to alter treatment for one of 14 residents in the survey sample, Resident #8 (R8). The findings include:For R8, facility staff failed to notify the physician of X-ray results in a timely manner. R8 was admitted with diagnosis that included but not limited to dementia (1). On the most recent comprehensive MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 09/21/2025, R8 scored 0 (zero) out of 15 on the BIMS (brief interview for mental status), indicating R8 was severely impaired for making daily decisions. The facility's incident report dated 11/19/2024 documented in part, Incident date: 11/18/2024. Resident involved: (Name of R8). Incident type: Injury of unknown injury. Resident noticed w/ (with) bruise on left leg. Resident was in her bed. The facility's nursing notes for R8 dated 11/18/2024 at 6:42 a.m. documented Note Text: Staff reported bruise on resident left front leg, pain to touch, MD (medical doctor) notified, MD stated, called (Name of After-Hours Provider Organization). (Name of After-Hours Provider Organization) was contacted via (by) iPad, response is pending. POA (power of attorney) was notified. Morning will follow up. The facility's nursing notes for R8 dated 11/18/2024 at 6:50 a.m. documented Note Text: Received a call from (Name of After-Hours Provider Organization) (Name of Representative) to use ice for pain as needed. The facility's nursing notes for R8 dated 11/18/2024 at 2:45 p.m. documented Note Text: Writer was informed this morning about a bruise on the left leg. The resident was monitored for any signs of pain. The resident reported 0 (zero) pain, and no discomfort was noted during morning shift. The facility's nursing notes for R8 dated 11/18/2024 at 11:05 p.m. documented Note Text: New orders given X-ray for left hip and left lower leg 2 (two) views. The physician's order for R8 dated 11/18/2024 documented in part, Left lower leg xray (X-ray) 2 (two) view. For bruise. The report from (Name of X-ray Company) for R8 documented in part, Exam date: 11/19/2024. Impression: Comminuted, angulated, intertrochanteric (2) fracture of the left femur (thigh bone). The facility's nursing notes for R8 dated 11/20/2024 at 9:41 a.m. documented Note Text: X-ray of left hip received at 0845 (8:45 a.m.). (Name of Nurse Practitioner) notified of results immediately. No new orders received at this time. Plan of [sic]is ongoing. The facility's nursing notes for R8 dated 11/20/2024 at 10:56 a.m. documented Note Text: Order recvd (sic)(received) from (Name of Nurse Practitioner) to send resident to (Name of Hospital) for evaluation and treatment Fracture of left femur. R/P (responsible party) (Name of Responsible Party) notified of xray (X-ray) results and transfer to (Name of Hospital) via (by) EMS (emergency medical services). The (Name of Hospital) Emergency Department Visit Note for R8 dated 11/20/2024 documented in part, The patient is a [AGE] year-old female who is seen in the Emergency Department for hip fracture. General Appearance: no apparent distress, normally reactive to environment 'Baseline according to nursing. On 10/21/2025 at approximately 10:27 a.m. a telephone interview was conducted with OSM (other staff member) #2, workflow coordinator for (Name of X-ray Company). When asked to describe the procedure for contacting a nursing home for X-ray results he stated that if the results have a positive finding (fracture) they call the facility the same day with the results. When asked about notifying the facility with the findings of the X-ray taken on 11/19/2024 OSM #2 stated that (Name of X-ray Company) records indicated that the facility was notified of R8's fracture on 11/19/2024 and that they spoke to (Name of Registered Nurse #5). Review of R8's clinical record failed to evidence documentation on 11/19/2024 that the physician was notified of the X-ray results. On 10/21/2025 at approximately 12:47 p.m. an interview was conducted with LPN (licensed practical nurse) #1. When asked about receiving the results of a resident's X-ray she stated that the X-ray company calls the facility if the results indicate a broken bone or fracture. When asked what a nurse should do if a phone call has not been received from the X-ray company by the end of the day that the X-ray was obtained she stated that the nurse should call the X-ray company for the results. She further stated that after receiving the X-ray results the nurse should immediately notify the physician of the results. After reviewing the nurse's notes and X-ray report for R8 LPN #1 stated that there was no evidence of the physician being notified on 11/19/2024 of R8's X-ray results. On 10/21/2025 at approximately 1:25 p.m. an interview was conducted with RN (registered nurse) #5. When asked if she recalled receiving a telephone call from (Name of X-ray Company) on 11/19/2024 with the results of R8's X-ray, RN #5 stated she did not recall receiving a call. After reviewing the nurse's notes and X-ray report for R8, RN #5 stated that there was no evidence of the physician being notified on 11/19/2024 of R8's X-ray results. On 10/21/2025 at approximately 3:05 p.m. ASM (administrative staff member) #1, administrator, ASM #2, director of nursing, ASM #3, regional director of clinical operations and ASM #4 risk nurse, were made aware of the above findings. No further information was provided prior to exit. References:(1) A loss of brain function that occurs with certain diseases. It affects memory, thinking, language, judgment, and behavior. This information was obtained from the website: https://medlineplus.gov/ency/article/000739.htm. (2) A type of broken hip. The hip is made up of two bones: the femur (thigh bone) and the pelvis (socket). This information was obtained from the website: https://ota.org/for-patients/find-info-body-part/3720#/+/0?score/desc/

Based on staff interview, facility document review, and clinical record review, the facility staff failed to maintain residents' highest level of well-being for two of 52 residents in the survey sample, Residents #44 and #51. The findings include: 1. For Resident #44 (R44), RN (registered nurse) #8 failed to assess and treat the resident in a timely manner. R44 sustained a fall during the day shift on 7/20/24. During the evening shift on 7/20/24, CNAs (certified nursing assistants) reported R44 was screaming in pain and RN #8 failed to assess the resident. On 7/21/24, R44 was screaming and could not be moved in the bed. X-rays were obtained, R44 was diagnosed with a left intertrochanteric fracture of the left femur, and the resident was transferred to the hospital for surgical repair. A nurse's note dated 7/20/24 documented, Resident fell down on floor in dining room, hit her head with the wall but did not get any injury. This nurse checks [sic] her vitals and skin assessment. This nurse also notified to NP (nurse practitioner) (name) and called to family member (name). He did not pick up the call. Will continue to monitor. A nurse's note dated 7/21/24 documented, Resident unable to tolerate rolling from side to side in bed with out [sic] severe pain to bilateral hip area. Left inner knee swollen, unable to move left leg without severe pain. RP (responsible party) and NP notified, new orders noted. An x-ray of the bilateral hips and pelvis with an examination and report date of 7/21/24 documented, There is an intertrochanteric fracture of the left femur which is acute. Acute fracture of the left proximal femur. Another nurse's note dated 7/21/24 documented, X-Ray result came back. There is intertrochanteric fracture of the femur which is acute. Called 911, resident was transported to the hospital for further evaluation. An initial facility synopsis of events with a report date of 7/22/24 and an incident date of 7/21/24 documented, Resident noted with pain on bilateral hip. X-ray ordered and fracture of the left hip noted. Immediately, resident sent to ER (emergency room). A witness statement signed by LPN (licensed practical nurse) #1 on 7/23/24 and referring to 7/20/24 documented, After breakfast I was sitting behind nurses station chart. I hear a dull thud coming from dining room. I immediately enter dining room observed resident (R44) sitting upright on buttock with back against wall were [sic] television is mounted on wall. There were no other residents in close proximity. I performed physical assessment prior to moving resident with RN (name). I saw no discoloration or swelling to any part of resident body. Resident was able to move all extremities with no indication of pain verbal and nonverbal. We assisted to dining room chair. Vital signs were taken. Vital signs within normal limit. Resident was witness [sic] ambulating without difficulty prior to me departing shift at 2pm. A witness statement by CNA #9 and referring to the 3:00 p.m. to 11:00 p.m. shift on 7/20/24 documented, I was walking with (R44) to her room to assist with getting her ready for bed. While walking with resident the resident sat in the floor. She did not appear to be in any distress. The other cna came to help me get (R44) off the floor. (R44) walked to her room. Myself and (CNA #10) attempted to assist resident to bed when attempting to transfer resident in bed she screamed. (CNA #10) left the room to inform the nurse. About 2 minutes later I left the room and went up to the desk and informed (RN #8) the RN that resident had sat on the floor. Also inform [sic] the nurse when we were transferring resident in bed she scream [sic]. (RN #8) was behind the nurse [sic] on his Ipad. (RN #8) got up and left the nurses station but I don't know where he went to. A witness statement by CNA #10 on 7/23/24 and referring to the 3:00 p.m. to 11:00 p.m. shift on 7/20/24 documented, After dinner around 7:30pm I observed (CNA #9) walking with resident down the hallway. I saw the resident sat on the floor in the hallway outside of her room. I assisted (CNA #9) with getting resident off floor. We walked with resident to her room and attempted to transfer resident to bed. (R44) screamed we [sic] then I realized she was in pain. I walked up to the nurses station and informed (RN #8) the nurse. The nurse said ok and continued to looked [sic] at his ipad. The nurse did not go down to the resident room. A witness statement signed by RN #8 on 7/23/24 and referring to 7/20/24 documented, No one told me about the resident (R44). I was working with different cart. A witness statement signed by CNA #8 on 7/23/24 and referring to 7/21/24 documented, On 7/21 helped aide and nurse with (R44) and while changing her and she was screaming in pain and hip looked deformed and warm to touch. Care was done after breakfast and pain was reported to nurse. Another witness statement signed by LPN #1 on 7/23/24 and referring to 7/21/24 documented, 7/21/24 Around 8:30A or 9A (name of CNA) asked me to come assessed [sic] (R44) regarding severe pain. I assessed resident immediately was apparent the pelvis/hip section unable to move with extreme pain and screaming. Resident was unable to move her left lower extremity. I immediately contacted NP (nurse practitioner) (name) regarding assessment. I received order for stat x-ray of pelvis and bilateral hip and left knee. Oxycodone (pain medication) 5 mg (milligrams) now X1. Orders were completed. X-ray on lt (left) knee was negative other result pending. I then contacted NP to update of x-ray. Follow up assessment the left upper leg was red swollen, hot to touch with vein distention. The left lower leg was cool to touch with no swelling. NP gave no new order. Prior to leaving my shift, I reported to (name of another nurse) who also assessed resident with me. A final facility synopsis of events with a report date of 7/24/24 and an incident date of 7/21/24 and submitted by ASM (administrative staff member) #1 (the administrator) documented, Summary of incident: (R44) had an unwitnessed fall on 7/20/24. Post fall assessment show [sic] no visible injury and no verbalize pain. The nurse sits her back to the chair, check [sic] her vitals and was noted to ambulate during the rest of the morning shift. On 7/21/24, resident unable to roll from side to side in bed without pain to bilateral hip area. RP (Responsible Party) and NP notified, new orders for Xray of left knee, and pelvis ordered. X-ray report shows fracture of the left femur and resident was sent to the ER. Actions taken by facility: Residents assessed. Nurse Practitioner and DON (director of nursing) notified. Responsible party notified. Staff interviewed and written report obtained. Investigation in progress. Investigation: After breakfast on 7/20/24, a loud sound coming from the dining room. (LPN #1) and (CNA #9) entered the dining room and found (R44) on the floor with upper body back against the wall. After dinner on 7/20/24, at around 7:30pm, (CNA #9) walked with resident down the hallway to the room. Later, resident was observed sitting on the floor in the hallway outside of her room. (CNA #10) assisted (CNA #9) with getting resident off floor, walked her back to the room and attempted to transfer resident to bed, and she screamed from pain. Staff walked up to the nursing station and informed Nurse (RN #8). The nurse said OK and continued to look at his iPad. The nurse did not go down to the resident room. Conclusion: Staff conduct was unprofessional and disciplinary action taken. All staff will get re-education on care and safety of residents under their care. Residents [sic] care plan will be updated upon return from hospital. A form titled, Suspension Pending Investigation documented RN #8 was suspended on 7/23/24, Pending investigation related to resident (R44) not being assess [sic]- for pain related to previous fall. A hospital Discharge summary dated [DATE] documented R44 was transferred to the hospital on 7/21/24 after an unwitnessed fall and a complaint of left hip pain. R44 was administered 0.5 mg of Dilaudid (pain medication) in the emergency department and the resident's hip was surgically repaired. CNA #9, CNA #10, and RN #8 were not available for interview during the survey. On 8/7/24 at 3:16 p.m., an interview was conducted with LPN #1. LPN #1 stated another nurse was caring for R44 during the day shift on 7/20/24 but while sitting at the nurses' station, she heard a bump and went over to the dining room. LPN #1 stated R44 was sitting under the television with her back against the wall. LPN #1 stated she and the nurse caring for R44 assessed the resident and at that time, the resident did not appear to be in pain or have any injuries, so the staff assisted R44 to a chair and encouraged her to sit in the chair. LPN #1 stated that during the morning on 7/21/24, a CNA came to her right after breakfast and said she needed to look at R44 because the resident was in a lot of pain and the CNA could not even touch the resident. LPN #1 stated she immediately went to R44 and was unable to move the resident without the resident screaming in pain. LPN #1 stated R44 said, Please don't touch me. Don't move me. Don't do that, it hurts. LPN #1 stated she notified the nurse practitioner and x-rays were ordered. ASM #2 (the director of nursing) was on vacation when R44 fell and when R44 was transferred to the hospital. On 8/7/24 at 4:04 p.m., an interview was conducted with ASM #1. ASM #1 stated he received a call on 7/21/24 and was made aware R44 sustained a fracture and was sent to the emergency room, so he began an investigation on 7/22/24. ASM #1 stated R44 fell on 7/20/24 but at the time of the fall, the resident did not appear to have an injury and the resident was able to ambulate. ASM #1 stated that during his investigation, he talked to CNAs who worked with R44 during the evening/night on 7/21/24. ASM #1 stated one or two of the CNAs said they tried to put R44 to bed on Saturday (7/21/24) night and the resident presented with pain. ASM #1 stated the CNAs said they informed the nurse (RN #8), but nothing was done at that time. ASM #1 stated he spoke to RN #8 who said the CNAs did not report anything regarding R44 to him and there was nothing wrong with R44. On 8/7/24 at 5:20 p.m., ASM #1 and ASM #2 were made aware of the concern for harm. The facility policy titled, Change in a Resident's Condition documented, 1. The nurse will notify the resident's Attending Physician/ practitioner or physician on call when there has been a (an): a. accident or incident involving the resident; b. discovery of injuries of an unknown source .d. significant change in the resident's physical, mental, or psychosocial status (that is, a deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complications); e. need to alter the resident's medical treatment significantly .2. Prior to notifying the physician/practitioner, the nurse will make detailed observations and gather relevant and pertinent information for the provider. 2. For Resident #51(R51), the facility staff failed to obtain a physician ordered laboratory test in a timely manner. The physician order dated, 3/18/24, documented, BMP (basic metabolic panel)(1), CBC (complete blood count)(2). The physician order dated, 3/20/24, documented, BMP, CBC. The laboratory test results dated 3/27/24, documented the results of the above test results. An interview was conducted with ASM (administrative staff member) #8, the nurse practitioner, on 8/8/24 at 11:02 a.m. When asked why she ordered the same laboratory tests on 3/18/24 and then again on 3/20/24, ASM #8 stated she didn't see the results from the ones I ordered on 3/18/24 so she reordered them again. ASM #8 was asked if she had any knowledge as to why the tests were not done until 3/27/24, ASM #8 stated she didn't know why there was a delay. An interview was conducted with ASM #2, the director of nursing, on 8/8/24 at 4:00 p.m. When asked why there was a delay in getting the laboratory tests ordered by the nurse practitioner on 3/18/24 and then reordered on 3/20/24, ASM #2 stated she looked into this and didn't see any documentation as to why they were not done. ASM #2 further stated they were having trouble with the laboratory company at that time. ASM #2 was asked if there was a delay in obtaining the physician ordered laboratory tests, ASM #2 stated, yes. When asked if not obtaining the laboratory tests for seven to nine days following the physician orders, ASM #2 stated, no. ASM #1, the administrator, ASM #2, the director of nursing, ASM #3, the regional director of clinical operations, ASM #4, the regional director of clinical operations, and ASM #6, the regional senior administrator, were made aware of the above findings on 8/8/24 at 4:30 p.m. No further information was provided prior to exit. References: (1) The basic metabolic panel (BMP) is a group of blood tests that provides information about your body's metabolism. This information was obtained from the following website: http://www.nlm.nih.gov/medlineplus/ency/article/003462.htm (2) A complete blood count (CBC) test measures the following: The number of red blood cells (RBC count) The number of white blood cells (WBC count). This information was obtained from the following website: http://vsearch.nlm.nih.gov/vivisimo/cgi-bin/query-meta?v%3Aproject=medlineplus&query=CBC&x=24&y=17

Based on observation, staff interview and facility document review, it was determined the facility staff failed to store food and maintain a kitchen in a sanitary manner for one of one kitchens. The findings include: Observation was made of the kitchen on 8/5/24 at 11:03 a.m. accompanied by OSM (other staff member) #7, the dietary manager. In the walk-in freezer a carton containing hashbrowns was open and the bag was open to the air. A carton with frozen biscuits was observed open and the bag was open to the air. A carton containing frozen chocolate chip cookies was observed to be open with the bag open to air. When asked how the boxes in the freezer are to be stored, OSM #7 stated the bag is supposed to be tied and the box secured. The griddle was observed and found to have food crumbs and debris on the sides and front of it. When asked when it was last used, OSM #9, the cook, stated, it's been a while since he has used it. The stove was observed to have dried, black, built-up food debris and burned food on the side of the stove and the wells of the burners. The stand-alone oven had brown on the rack and doors. There was burned food debris in the bottom of the ovens. When asked about the conditions of the stove and oven, OSM #7 stated, I'll be sure to make a cleaning schedule. The rack of pans ready for use was observed. There were three sheet pans found to be wet nesting and three hotel pans also noted to be wet nesting. OSM #7 stated the pans are dried on the racks, pointing to racks in the back of the kitchen, and not stored until dried. The facility policy, Food Storage documented in part, 13. Frozen Foods: c. All food should be covered. The facility policy, Cleaning Instructions: Ranges/Griddles documented in part, The cook/chef on each shift is responsible for keeping the range and/or griddle as clean as possible during the preparation of the meal. The range/griddle will be cleaned after each use. Spills and food particles will be wiped up as they occur. The facility policy, Cleaning and Sanitation of Dining and Food Service Areas documented in part, Procedure: 1. The director food and nutrition services will determine all cleaning and sanitation tasks needed for the department. 2. Tasks shall be designated to be the responsibility of specific positions in the department. 3. Staff will be trained on the frequency of cleaning as necessary. 4. The methods and guideline to be used and agents used for cleaning shall be developed for each task or piece of equipment to be cleaned. 5. A cleaning schedule will be posted for all cleaning tasks, and staff will initial the tasks as completed. 6. Staff will be held accountable for cleaning assignments. ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing, ASM #3, the regional director of clinical operations, ASM #4, the regional director of clinical operations, ASM #5, the regional risk nurse, and ASM #6, the regional senior administrator, were made aware of the above findings on 8/6/24 at 5:15 p.m. No further information was obtained prior to exit.

Based on observation, staff interview, and facility document review, it was determined the facility staff failed to serve pureed food in a palatable temperature. The findings include: Observation of the kitchen was made on 8/6/24 at 11:20 a.m. The temperature of the pureed food was as followed: Pureed Brussel sprouts - 160 degrees Mashed potatoes - 170 degrees Pureed orange chicken and rice - 161 degrees. The test tray left the kitchen at 12:06 p.m. sitting on top of the food cart. The last resident tray served was at 12:24 p.m. The test tray was then tested. The temperature of the pureed food was as followed: Pureed Brussel sprouts - 110 - a 50 degree drop in temperature. Mashed potatoes - 113.5 - a 56.5 degree drop in temperature. Pureed orange chicken and rice - 108.1 - a 52.9 degree drop in temperature. The test tray was tasted by OSM (other staff member) #7, the dietary manager, and OSM #8, the regional dietary manager and the surveyors. When asked how the chicken and rice tasted regarding its temperature, OSM #7 stated, mediocre. OSM #8 stated the meat was cooler to taste. The facility policy, Food Temperatures, documented in part, 4. Food should be transported as quickly as possible to maintain temperatures for delivery and service .5. a. Hold foods at or below 41 degrees F (Fahrenheit) for cold foods and at or above 135 degrees F for hot foods .6. Foods sent to the units for distribution (such as meals, snacks, nourishments, oral supplements) will be transported and delivered to unit storage areas maintaining temperatures at or below 41 degrees F for cold foods and at or above 135 degrees F for hot foods. ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing, ASM #3, the regional director of clinical operations, ASM #4, the regional director of clinical operations, ASM #5, the regional risk nurse, and ASM #6, the regional senior administrator, were made aware of the above findings on 8/6/24 at 5:15 p.m. No further information was obtained prior to exit.

2. For Resident #60 (R60), the facility staff failed to act upon pharmacy recommendations in a timely manner. A review of the monthly pharmacy medication regimen reviews for R60 documented reviews completed by the pharmacist on 10/15/23, 11/25/23, 12/19/23, 1/15/24, 2/13/24, 3/23/24, 4/29/24, 5/31/24, 6/30/24, and 7/31/24. On 8/7/24 at 12:00 p.m., a request was made to ASM (administrative staff member) #3, the regional director of clinical operations for evidence of any pharmacy recommendations from the monthly medication regimen reviews with evidence of facility and physician response from 10/1/23 to the present. On 8/8/24 at 3:15 p.m., an interview was conducted with ASM #2, the director of nursing. ASM #2 stated that the pharmacist came in monthly to complete the monthly reviews and provided her with a list of residents that stated whether or not they gave any recommendations or not. She stated that for R60, the pharmacist had made recommendations but they were not addressed and she would be able to provide the blank copies. On 8/8/24 at approximately 3:20 p.m., ASM #3 provided pharmacy recommendations for R60 dated 12/19/23, 2/13/24 and 3/23/24. The response and physician signature areas were blank. The Consultant Pharmacist Recommendation to Physician dated 12/19/2023 documented in part, .This resident is currently receiving the following Non Antipsychotic medication on a PRN (as needed) Benadryl. Per regulatory guidelines, the duration of treatment with such medications on a PRN basis should be limited to 14 days, however, a new order may be written to extend the duration beyond 14 days if the prescriber believes it is appropriate. Please evaluate the continued need for this medication. If it is to be extended, please document the rationale for the extended time period in the medical record and indicate a specific duration . The Consultant Pharmacist Recommendation to Physician dated 2/13/2024 documented in part, .The resident has been treated with Sliding Scale Insulin therapy since 12/2023. Upon review, this resident routinely receives 2-10 units at meals. To better stabilize glucose control, reduce the change of medication error and to reduce the need for this additional coverage, may I suggest increasing the basal dose by 2 units once weekly until sliding scale is no longer required . The Consultant Pharmacist Recommendation to Physician dated 3/23/2024 documented in part, .Federal guidelines state antidepressant drugs should have an attempt at a gradual dose reduction (GDR) twice per year for the first year in 2 different quarters with 1 month between attempts, then annually thereafter, when used to manage behavior, stabilize mood or treat psych disorder. The resident has been taking Zoloft 100mg (milligram) HS (at bedtime) since (9/2023) without a GDR. Could we attempt a dose reduction at this time to 75mg hs to verify this resident is on the lowest possible dose? If not please indicate response below . On 8/8/24 at 3:53 p.m., an interview was conducted with ASM #2. ASM #2 stated that their process was to print out any pharmacy recommendations each month and provide them to either the psychiatric nurse practitioner or the medical nurse practitioner. She stated that she had started a binder at the beginning of 2024 to track the medication regimen reviews and kept a duplicate copy of them in there to track that they were addressed. She stated that she would check to see if the 2024 recommendations for R60 were addressed or not. On 8/8/24 at 4:12 p.m., ASM #2 stated that they were unable to find any evidence that the pharmacy recommendations were addressed for R60. On 8/8/24 at 5:00 p.m., ASM #1, the administrator, ASM #2, the director of nursing, ASM #3, the regional director of clinical operations, ASM #4, the regional director of clinical operations, ASM #5, the regional risk nurse and ASM #6, the regional senior administrator were made aware of the concern. No further information was provided prior to exit. Based on staff interview, facility document review and clinical record review, it was determined that the facility staff failed to ensure the physician responded to a pharmacy recommendation for three of five residents reviewed for unnecessary medications; Residents #74, #60 and #51. The findings include: 1. For Resident #74, the facility staff failed to ensure the physician acted on a pharmacy recommendation in a timely manner. A review of the clinical record revealed a Pharmacist Recommendations form dated 11/25/23, for Antipsychotic Reduction Therapy The resident has been taking RISPERDAL (1) 0.5 MG HS (milligrams at bedtime) since (5/2023) without a GDR (gradual dose reduction). Could we attempt a dose reduction at this time to perhaps 0.25 MG HS to verify this resident is on the lowest possible dose? If not, please indicate response below . Further review failed to reveal any evidence that the physician reviewed and signed this form, and chose to or not to reduce the medication dose related to this review. On 8/7/24 at 9:33 AM, ASM #4 (Administrative Staff Member) a Regional Director of Clinical Operations, stated, when providing the above form, The November GDR was not addressed by the physician. We recognize that is an issue. A review of the comprehensive care plan revealed one dated 4/20/22 for (Resident #74) uses psychotropic medications This care plan included an intervention dated 4/20/22 for Consult with pharmacy, MD (medical doctor) to consider dosage reduction when clinically appropriate at least quarterly. The facility document, Medication Regimen Review documented, The consulting pharmacist will provide copy of recommendations to the attending physician, medical director, and director of nursing within 5 working days of completion of the review If the attending physician does not respond within 30 days, the medical director will be asked to review the recommendations and/or contact the attending physician On 8/8/24 at 4:00 PM, ASM #1 the Administrator and ASM #4 were made aware of the findings. No further information was provided by the end of the survey. References: 1. Risperdal is an antipsychotic used to treat symptoms of schizophrenia. Information obtained from https://medlineplus.gov/druginfo/meds/a694015.html 3. For Resident #51, the facility staff failed to act upon a pharmacist recommendation in December 2024 for the use of Hydroxyzine. The pharmacy recommendation dated, 12/20/23, documented in part, The resident received Hydroxyzine (1) 25 MG (milligrams) Q (every) 12H (hours) which has significant anticholinergic properties. It is generally not recommended therapy for the elderly. The elderly are ore susceptible to the anticholinergic effects of drugs such as urinary retention and falls. Suggest evaluating the use of this drug in the resident, and consider the use of an alternative agent, such as Claritin or Zyrtec, to reduce the risk of side effects. If hydroxyzine is necessary for this resident, please respond as follow to help keep this facility OBRA compliant. An interview was conducted with ASM (administrative staff member) 2, the director of nursing on 8/8/24 at 3:45 p.m. ASM #2 stated they did not have any pharmacy reviews for the past 12 months. There were recommendations but they were not addressed. ASM #2 then provided one recommendation for December 2023 that was given to the nurse practitioner but was not addressed. When asked her process for ensuring the pharmacy recommendations were being addressed, ASM #2 stated, at the end of the month, she prints out the recommendations from the pharmacist, she separates them for the psychiatrist and the nurse practitioner to address. She started a binder for the new year. When asked how she is tracking the ones that have been given out to the doctors/nurse practitioners, ASM #2 stated they just give them back to me. She looks through them and put them in medical records. When asked if she documents or keeps a copy of the recommendations so she can follow up on them, ASM #2 stated, no. ASM #1, the administrator, ASM #2, ASM #3, regional director of clinical operations, ASM #4, regional director of clinical operations, and ASM #6, the regional senior administrator, were made aware of the above findings on 8/8/24 at 4:30 p.m. No further information was provided prior to exit. (1) Hydroxyzine is used in adults and children to relieve itching caused by allergic skin reactions. It is also used alone or with other medications in adults and children to relieve anxiety and tension. Hydroxyzine is also used along with other medications in adults and children as a sedative before and after general anesthesia for surgery. Hydroxyzine is in a class of medications called antihistamines. It works by blocking the action of histamine a substance in the body that causes allergic symptoms. It also works by decreasing activity in the brain. This information was obtained from the following website: Hydroxyzine: MedlinePlus Drug Information.

2. For Resident #10 (R10), the facility staff failed to evidence treatment to a pressure injury (1) on dates in May, June and July of 2024. On the most recent MDS (minimum data set), a significant change assessment with an ARD (assessment reference date) of 6/1/2024, the resident scored 10 out of 15 on the BIMS (brief interview for mental status), indicating the resident was moderately impaired for making daily decisions. Section M documented R10 having one unstageable pressure injury that was not present on admission. On 8/6/2024 at 11:26 a.m., an observation was made of LPN (licensed practical nurse) #4, wound nurse, providing wound care to R10's pressure injury to the left heel. There were no concerns with the pressure injury treatment observation. The physician orders for R10 documented in part, - Cleanse left heel wound with wound cleanser and apply foam silicone border dressing QD (every day). every day. shift for skin impairment. Order Date: 07/09/2024. The comprehensive care plan for R10 documented in part, [Name of R10] has potential for impairment to skin integrity r/t (related to) decrease mobility and incontinent bowel and bladder and has stage 4 (1) to left heel. Date Initiated: 07/24/2024. Under Interventions it documented in part, Administer medications, supplements and treatments as ordered. Monitor/document for side effects and effectiveness. Date Initiated: 07/24/2024 . The eTAR (electronic treatment administration record) for R10 dated 5/1/24-5/31/24 failed to evidence the treatment to the left heel wound on 5/13/24, 5/17/24 and 5/22/24. The eTAR for R10 dated 6/1/24-6/30/24 failed to evidence the treatment to the left heel wound on 6/2/24. The eTAR for R10 dated 7/1/24-7/31/24 failed to evidence the treatment to the left heel wound on 7/11/24. On 8/7/24 at 3:35 p.m., an interview was conducted with RN (registered nurse) #4. RN #4 stated that when the wound nurse was not there the nurse assigned to the resident completed the wound care treatments. She stated that wound care was evidenced as completed by documenting it on the eTAR and a note was made if there was any change to the wound or the treatment was not completed. On 8/8/24 at 11:06 a.m., an interview was conducted with LPN (licensed practical nurse) #4, wound nurse. LPN #4 stated that they worked Monday through Friday and completed wound care of the days that they were there. She stated when they were off the nurses completed the wound care. She stated that the wound care was evidenced by the staff signing off on the eTAR and if it was not signed off it could not be evidenced that it was done. She stated that if the treatment was not done there should be a note documenting the reason. The facility policy, Pressure Injury Prevention and Management documented in part, .Treatments, including preventative interventions, will be documented in the resident's medical record .A resident centered care plan will be developed and implemented to address the resident's risk for development of a pressure ulcer/injury and to promote healing if the resident has a pressure ulcer/injury . On 8/8/24 at 5:00 p.m., ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing, ASM #3, the regional director of clinical operations, ASM #4, the regional director of clinical operations, ASM #5, the regional risk nurse and ASM #6, the regional senior administrator were made aware of the concern. No further information was provided prior to exit. Reference: (1) Pressure injury A pressure sore is an area of the skin that breaks down when something keeps rubbing or pressing against the skin. Pressure sores are grouped by the severity of symptoms. Stage I is the mildest stage. Stage IV is the worst. Stage I: A reddened, painful area on the skin that does not turn white when pressed. This is a sign that a pressure ulcer is forming. The skin may be warm or cool, firm or soft. Stage II: The skin blisters or forms an open sore. The area around the sore may be red and irritated. Stage III: The skin now develops an open, sunken hole called a crater. The tissue below the skin is damaged. You may be able to see body fat in the crater. Stage IV: The pressure ulcer has become so deep that there is damage to the muscle and bone, and sometimes to tendons and joints. This information was obtained from the website: https://medlineplus.gov/ency/patientinstructions/000740.htm. 2. For Resident #362 (R362), the facility staff failed to evidence treatment to a pressure injury (1) on dates in November 2023 and December 2023. On the most recent MDS (minimum data set), a significant change assessment with an ARD (assessment reference date) of 1/15/2024, the resident was assessed as having one unstageable pressure injury that was not present on admission. The physician orders for R362 documented in part, - Skin prep to bilateral heel and apply foam heel protector as tolerated every shift. every shift for skin impairment. Order Date: 09/27/2023. - Cleanse sacrum with wound cleanser and apply calcium alginate and cover with foam dressing every day. every day shift for skin impairment. Order Date: 11/29/2023. The comprehensive care plan for R362 documented in part, [Name of R362] has unstageable to sacrum, bilateral heel and DTI (deep tissue injury) to both inner knee r/t (related to) decline and decrease mobilty. Date Initiated: 12/26/2023. Under Interventions it documented in part, Treatments per wound doctor orders. Date Initiated: 12/26/2023. The eTAR (electronic treatment administration record) for R362 dated 11/1/23-11/30/23 failed to evidence the treatment to the bilateral heels on 11/12/23 evening shift and 11/25/23 night shift. The eTAR for R362 dated 12/1/23-12/31/23 failed to evidence the treatment to the sacrum on 12/12/23. It further failed to evidence the treatment to the bilateral heels on 12/25/23 night shift and 12/28/23 evening shift. On 8/7/24 at 3:35 p.m., an interview was conducted with RN (registered nurse) #4. RN #4 stated that when the wound nurse was not there the nurse assigned to the resident completed the wound care treatments. She stated that wound care was evidenced as completed by documenting it on the eTAR and a note was made if there was any change to the wound or the treatment was not completed. On 8/8/24 at 11:06 a.m., an interview was conducted with LPN (licensed practical nurse) #4, wound nurse. LPN #4 stated that they worked Monday through Friday and completed wound care of the days that they were there. She stated when they were off the nurses completed the wound care. She stated that the wound care was evidenced by the staff signing off on the eTAR and if it was not signed off it could not be evidenced that it was done. She stated that if the treatment was not done there should be a note documenting the reason. On 8/8/24 at 5:00 p.m., ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing, ASM #3, the regional director of clinical operations, ASM #4, the regional director of clinical operations, ASM #5, the regional risk nurse and ASM #6, the regional senior administrator were made aware of the concern. No further information was provided prior to exit. Reference: (1) Pressure injury A pressure sore is an area of the skin that breaks down when something keeps rubbing or pressing against the skin. Pressure sores are grouped by the severity of symptoms. Stage I is the mildest stage. Stage IV is the worst. Stage I: A reddened, painful area on the skin that does not turn white when pressed. This is a sign that a pressure ulcer is forming. The skin may be warm or cool, firm or soft. Stage II: The skin blisters or forms an open sore. The area around the sore may be red and irritated. Stage III: The skin now develops an open, sunken hole called a crater. The tissue below the skin is damaged. You may be able to see body fat in the crater. Stage IV: The pressure ulcer has become so deep that there is damage to the muscle and bone, and sometimes to tendons and joints. This information was obtained from the website: https://medlineplus.gov/ency/patientinstructions/000740.htm. Based on staff interview, facility document review, and clinical record review, the facility staff failed to provide care and services for the treatment of a pressure injury for three of 52 residents in the survey sample, Residents #87, #10, and #362. The findings include: 1. For Resident #87 (R87), the facility staff failed to provide physician ordered treatments to the resident's sacral pressure injury on 7/20/24, and 7/30/24. A review of R87's clinical record revealed a wound care physician note dated 7/15/24 that documented an area on R87's sacrum as an unstageable pressure injury (1) measuring 3.5 cm (centimeters) (length) by 2 cm (width) by 0.2 cm (depth). A physician's order dated 7/16/24 documented to cleanse the sacrum with wound cleanser, apply hydrogel and cover with a gauze island dressing every day. A review of R87's July 2024 TAR (treatment administration record) revealed the same 7/16/24 physician's treatment order. Further review of R87's July 2024 TAR failed to reveal treatment was administered on 7/20/24 and 7/30/24 (as evidenced by blank spaces on the TAR). Nurses' notes dated 7/20/24 and 7/30/24 failed to reveal documentation that the treatment was done on those dates. On 8/6/24 at 2:48 p.m., an interview was conducted with LPN (licensed practical nurse) #1. LPN #1 stated physician's orders for pressure injury treatments are documented on the MAR (medication administration record) or TAR and nurses evidence the treatments are completed by checking and signing off on the MAR or TAR. On 8/7/24 at 5:20 p.m., ASM (administrative staff member) #1 (the administrator), and ASM #2 (the director of nursing) were made aware of the above concern. The facility policy titled, Pressure Injury Prevention and Management documented, The intent of this organization is to develop and maintain systems and processes to ensure that the resident does not develop pressure ulcers/injuries unless clinically unavoidable and that the facility provides care and services consistent with professional standards of practice .Treatment Protocols: 5. Treatments, including preventive interventions, will be documented in the resident's medical record. No further information was presented prior to exit. Reference: (1) A pressure injury is localized damage to the skin and underlying soft tissue usually over a bony prominence or related to a medical or other device. The injury can present as intact skin or an open ulcer and may be painful . Unstageable Pressure Injury: Obscured full-thickness skin and tissue loss Full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough or eschar (dead skin tissue). This information was obtained from the website: https://cdn.ymaws.com/npiap.com/resource/resmgr/online_store/npiap_pressure_injury_stages.pdf

Based on clinical record review, staff interview and facility document review, it was determined the facility staff failed to provide ADL (activities of daily living) care to a dependent resident for one of 52 residents in the survey sample, Resident #362. The findings include: For Resident #362 (R362), the facility staff failed to evidence assistance with turning and repositioning on multiple dates in November 2023, December 2023 and January 2024. On the most recent MDS (minimum data set) a significant change assessment with an ARD (assessment reference date) of 1/15/2024, the resident was assessed as being dependent for rolling left and right and transfers. Review of the ADL documentation for R362 from 11/1/2023-11/30/2023 documented the resident requiring extensive to total assistance from one to two persons for bed mobility. It failed to evidence assistance with bed mobility provided on day shift 11/5/23, 11/6/23, 11/7/23, 11/18/23, 11/19/23, 11/26/23 and on evening shift on 11/5/23, 11/13/23, 11/18/23 and 11/23/23. It further failed to evidence assistance with bed mobility provided on night shift on 11/5/23, 11/12/23, 11/20/23, 11/22/23, and 11/23/23. The shifts on the dates listed above were observed to be blank. Review of the ADL documentation for R362 from 12/1/2023-12/31/2023 documented the resident requiring extensive to total assistance from one to two persons for bed mobility. It failed to evidence assistance with bed mobility provided on day shift 12/10/23, 12/26/23, on evening shift on 12/22/23, 12/31/23 and on night shift on 12/3/23, 12/5/23, 12/9/23, 12/14/23, 12/15/23, 12/16/23 and 12/27/23. The shifts on the dates listed above were observed to be blank. Review of the ADL documentation for R362 from 1/1/2024-1/31/2024 documented the resident requiring extensive to total assistance from one person for bed mobility. It failed to evidence assistance with bed mobility provided on day shift 1/7/24, 1/14/24, on evening shift on 1/7/24, 1/10/24, 1/13/24, 1/14/24 and on night shift on 1/1/24, 1/2/24, 1/7/24, and 1/13/24. The shifts on the dates listed above were observed to be blank. The comprehensive care plan for R362 documented in part, The resident has an ADL self-care performance deficit AEB (as evidenced by) Date Initiated: 09/15/2023. Under Interventions it documented in part, Physical assist as needed with adls. Date Initiated: 09/15/2023. Revision on: 10/24/2023 .Bed Mobility: The resident requires by (X) staff to turn and reposition in bed and as necessary. Date Initiated: 09/15/2023. Revision on: 10/24/2023. On 8/8/24 at 12:46 p.m., an interview was conducted with CNA (certified nursing assistant) #5. CNA #5 stated that residents who could not turn themselves were turned and repositioned every two hours when they were in the bed. CNA #5 stated that they evidenced the care that they provided to the residents by their documentation in the electronic medical record in the ADL documentation by documenting the bed mobility every shift. CNA #5 stated that they did not document every two hours but they documented every shift that bed mobility assistance was provided and if the resident was not in the bed during the shift they documented that. The facility policy, Activities of Daily Living (ADLs) documented in part, Residents will be provided with care, treatment, and services as appropriate to maintain or improve their ability to carry out activities of daily living (ADLs). Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene . 4. Appropriate care and services will be provided for residents who are unable to carry out ADLs independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with: .b. Mobility (transfer and ambulation, including walking); i. Residents will be assisted with transfer and mobility as ordered by the physician/practitioner and/or as instructed in the resident's care plan . On 8/8/24 at 5:00 p.m., ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing, ASM #3, the regional director of clinical operations, ASM #4, the regional director of clinical operations, ASM #5, the regional risk nurse and ASM #6, the regional senior administrator were made aware of the concern. No further information was provided prior to exit.

Based on observation, resident interview, clinical record review, staff interview and facility document review it was determined that the facility staff failed to develop and/or implement the comprehensive care plan for eight of 52 residents in the survey sample, Residents #4, #362, #10, #81, #3, #11, #9 and #74. The findings include: 1. For Resident #4 (R4), the facility staff failed to implement the comprehensive care plan for the use of fall mats. On the most recent MDS (minimum data set), a significant change assessment with an ARD (assessment reference date) of 6/10/24, the resident scored nine out of 15 on the BIMS (brief interview for mental status) assessment, indicating the resident was moderately impaired for making daily decisions. The resident was assessed as requiring substantial/maximal assistance with bed mobility and sitting on the side of the bed. Section J documented R4 having no falls since the previous assessment. On 8/5/24 at 12:33 p.m., an observation was made of R4 in their room. R4 was observed in bed with upper bed rails in place. No fall mat was observed. An interview was attempted with R4 but due to their cognitive status they were unable to answer the questions appropriately. Additional observations of R4 on 8/6/24 at 8:53 a.m., 11:34 a.m., and 4:04 p.m. revealed R4 in bed without a fall mat in place. The comprehensive care plan for R4 documented in part, The resident has had an actual fall. Resident had recent hospitalization and compromised functional ability. Date Initiated: 05/29/2024. Under Interventions it documented in part, Floor mat. Date Initiated: 05/29/2024 . The fall risk assessment dated [DATE] documented R4 being a moderate risk for falling. On 8/7/24 at 12:08 p.m., an interview was conducted with CNA (certified nursing assistant) #4. CNA #4 stated that if a resident required the use of fall mats the nurses let them know and if the resident was a high fall risk there was a fall risk tag on the residents bed. She stated that the fall mats were also on the residents medical record so they could see it when they were documenting and know that they needed to make sure they were down when the resident was in the bed. On 8/7/24 at 3:35 p.m., an interview was conducted with RN (registered nurse) #4. RN #4 stated that the purpose of the care plan was to have an individualized plan for each resident that was a carbon copy of the things that the resident needed to have in place to take care of them. She stated that the care plan should be implemented because it was a guideline to show how to meet the residents needs. RN #4 stated that residents that were a high fall risk had interventions documented on their care plan and the staff were able to refer to that to see what needed to be in place. She stated that fall mats were documented there and there normally were orders in for them also. She stated that the CNA staff did not have access to the full care plan but could look at the Kardex which documented any fall interventions that needed to be in place for a specific resident. The facility policy, Falls and Fall Risk Management documented in part, .The staff, with the input of the attending physician/practitioner, will implement a resident-centered fall prevention plan to reduce the specific risk factor(s) of falls for each resident at risk or with a history of falls . The facility policy, Care planning- Comprehensive Person-Centered documented in part, .The facility will develop and implement a comprehensive person-centered care plan for each resident, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and metal and psychosocial needs as identified throughout the comprehensive Resident Assessment Instrument (RAI) process . On 8/7/24 at 5:20 p.m., ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing, ASM #3, the regional director of clinical operations, ASM #4, the regional director of clinical operations, ASM #5, the regional risk nurse and ASM #6, the regional senior administrator were made aware of the concern. No further information was provided prior to exit. 2. For Resident #362 (R362), the facility staff failed to implement the comprehensive care plan for assisting with ADL (activities of daily living) care including turning and repositioning on multiple dates in November 2023, December 2023 and January 2024. On the most recent MDS (minimum data set) a significant change assessment with an ARD (assessment reference date) of 1/15/2024, the resident was assessed as being dependent for rolling left and right and transfers. The comprehensive care plan for R362 documented in part, The resident has an ADL self-care performance deficit AEB (as evidenced by) Date Initiated: 09/15/2023. Under Interventions it documented in part, Physical assist as needed with adls. Date Initiated: 09/15/2023. Revision on: 10/24/2023 .Bed Mobility: The resident requires by (X) staff to turn and reposition in bed and as necessary. Date Initiated: 09/15/2023. Revision on: 10/24/2023. Review of the ADL documentation for R362 from 11/1/2023-11/30/2023 documented the resident requiring extensive to total assistance from one to two persons for bed mobility. It failed to evidence assistance with bed mobility provided on day shift 11/5/23, 11/6/23, 11/7/23, 11/18/23, 11/19/23, 11/26/23 and on evening shift on 11/5/23, 11/13/23, 11/18/23 and 11/23/23. It further failed to evidence assistance with bed mobility provided on night shift on 11/5/23, 11/12/23, 11/20/23, 11/22/23, and 11/23/23. The shifts on the dates listed above were observed to be blank. Review of the ADL documentation for R362 from 12/1/2023-12/31/2023 documented the resident requiring extensive to total assistance from one to two persons for bed mobility. It failed to evidence assistance with bed mobility provided on day shift 12/10/23, 12/26/23, on evening shift on 12/22/23, 12/31/23 and on night shift on 12/3/23, 12/5/23, 12/9/23, 12/14/23, 12/15/23, 12/16/23 and 12/27/23. The shifts on the dates listed above were observed to be blank. Review of the ADL documentation for R362 from 1/1/2024-1/31/2024 documented the resident requiring extensive to total assistance from one person for bed mobility. It failed to evidence assistance with bed mobility provided on day shift 1/7/24, 1/14/24, on evening shift on 1/7/24, 1/10/24, 1/13/24, 1/14/24 and on night shift on 1/1/24, 1/2/24, 1/7/24, and 1/13/24. The shifts on the dates listed above were observed to be blank. On 8/7/24 at 3:35 p.m., an interview was conducted with RN (registered nurse) #4. RN #4 stated that the purpose of the care plan was to have an individualized plan for each resident that was a carbon copy of the things that the resident needed to have in place to take care of them. She stated that the care plan should be implemented because it was a guideline to show how to meet the residents needs. On 8/8/24 at 12:46 p.m., an interview was conducted with CNA (certified nursing assistant) #5. CNA #5 stated that residents who could not turn themselves were turned and repositioned every two hours when they were in the bed. CNA #5 stated that they evidenced the care that they provided to the residents by their documentation in the electronic medical record in the ADL documentation by documenting the bed mobility every shift. CNA #5 stated that they did not document every two hours but they documented every shift that bed mobility assistance was provided and if the resident was not in the bed during the shift they documented that. On 8/8/24 at 5:00 p.m., ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing, ASM #3, the regional director of clinical operations, ASM #4, the regional director of clinical operations, ASM #5, the regional risk nurse and ASM #6, the regional senior administrator were made aware of the concern. No further information was provided prior to exit. 3. For Resident #10 (R10), the facility staff failed to implement the comprehensive care plan to provide treatment to a pressure injury (1) on dates in May, June and July of 2024. On the most recent MDS (minimum data set), a significant change assessment with an ARD (assessment reference date) of 6/1/2024, the resident scored 10 out of 15 on the BIMS (brief interview for mental status), indicating the resident was moderately impaired for making daily decisions. Section M documented R10 having one unstageable pressure injury that was not present on admission. The comprehensive care plan for R10 documented in part, [Name of R10] has potential for impairment to skin integrity r/t (related to) decrease mobility and incontinent bowel and bladder and has stage 4 (1) to left heel. Date Initiated: 07/24/2024. Under Interventions it documented in part, Administer medications, supplements and treatments as ordered. Monitor/document for side effects and effectiveness. Date Initiated: 07/24/2024 . The physician orders for R10 documented in part, - Cleanse left heel wound with wound cleanser and apply foam silicone border dressing QD (every day). every day. shift for skin impairment. Order Date: 07/09/2024. The eTAR (electronic treatment administration record) for R10 dated 5/1/24-5/31/24 failed to evidence the treatment to the left heel wound on 5/13/24, 5/17/24 and 5/22/24. The eTAR for R10 dated 6/1/24-6/30/24 failed to evidence the treatment to the left heel wound on 6/2/24. The eTAR for R10 dated 7/1/24-7/31/24 failed to evidence the treatment to the left heel wound on 7/11/24. On 8/7/24 at 3:35 p.m., an interview was conducted with RN (registered nurse) #4. On 8/7/24 at 3:35 p.m., an interview was conducted with RN (registered nurse) #4. RN #4 stated that the purpose of the care plan was to have an individualized plan for each resident that was a carbon copy of the things that the resident needed to have in place to take care of them. She stated that the care plan should be implemented because it was a guideline to show how to meet the residents needs. RN #4 stated that when the wound nurse was not there the nurse assigned to the resident completed the wound care treatments. She stated that wound care was evidenced as completed by documenting it on the eTAR and a note was made if there was any change to the wound or the treatment was not completed. On 8/8/24 at 11:06 a.m., an interview was conducted with LPN (licensed practical nurse) #4, wound nurse. LPN #4 stated that they worked Monday through Friday and completed wound care of the days that they were there. She stated when they were off the nurses completed the wound care. She stated that the wound care was evidenced by the staff signing off on the eTAR and if it was not signed off it could not be evidenced that it was done. She stated that if the treatment was not done there should be a note documenting the reason. The facility policy, Pressure Injury Prevention and Management documented in part, .A resident centered care plan will be developed and implemented to address the resident's risk for development of a pressure ulcer/injury and to promote healing if the resident has a pressure ulcer/injury . On 8/8/24 at 5:00 p.m., ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing, ASM #3, the regional director of clinical operations, ASM #4, the regional director of clinical operations, ASM #5, the regional risk nurse and ASM #6, the regional senior administrator were made aware of the concern. No further information was provided prior to exit. Reference: (1) Pressure injury A pressure sore is an area of the skin that breaks down when something keeps rubbing or pressing against the skin. Pressure sores are grouped by the severity of symptoms. Stage I is the mildest stage. Stage IV is the worst. Stage I: A reddened, painful area on the skin that does not turn white when pressed. This is a sign that a pressure ulcer is forming. The skin may be warm or cool, firm or soft. Stage II: The skin blisters or forms an open sore. The area around the sore may be red and irritated. Stage III: The skin now develops an open, sunken hole called a crater. The tissue below the skin is damaged. You may be able to see body fat in the crater. Stage IV: The pressure ulcer has become so deep that there is damage to the muscle and bone, and sometimes to tendons and joints. This information was obtained from the website: https://medlineplus.gov/ency/patientinstructions/000740.htm. 4. For Resident #81 (R81), the facility staff failed to develop the comprehensive care plan to include the use of A) an anticoagulant medication and B) an antidepressant medication. On the most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 7/10/24, the resident was assessed as taking an antidepressant and an anticoagulant medication while a resident at the facility. The comprehensive care plan for R81 failed to evidence documentation of the use of an anticoagulant medication or monitoring for the use of an anticoagulant medication, an antidepressant medication or behaviors. The physician orders for R81 documented in part, - Order Date: 04/01/2024. Xarelto Oral Tablet 20 MG (Rivaroxaban) Give 1 tablet by mouth at bedtime for CVA (cerebrovascular accident). - Order Date: 07/13/2024 Lexapro Oral Tablet 10 MG (milligram) (Escitalopram Oxalate) Give 2 tablet by mouth one time a day for Depression/Anxiety Give 20mg (2 tablet) daily for anxiety/depression. - Order Date: 07/12/2024 Valproic Acid Oral Solution 250 MG/5ML (Valproate Sodium) Give 5 ml by mouth every 8 hours for MDD (major depressive disorder). Hold if lethargic. Review of the eMARs (electronic medication administration records) for R81 dated 6/1/24-6/30/24, 7/1/24-7/31/24, and 8/1/24-8/30/24 documented R81 receiving the Xarelto, Valproic Acid and Lexapro as ordered. The physician/NP progress notes for R81 documented in part, 07/12/2024 06:48 (6:48 a.m.) Psychiatric Progress note .Patient seen to evaluate for depression, Patient seen to evaluate for anxiety . He was observed in his room, appearing irritated and repeatedly screaming for help to use the bathroom. After being assisted by this writer, he continued to yell for help to be placed back in his chair, and this behavior occurred intermittently throughout the day, as reported by staff. He seemed frustrated with his care and admitted to feeling restless, with fluctuations in his sleep and appetite. Staff and chart reviews indicate that his mood remains at baseline. He is currently on Lexapro 10mg daily and Valproic acid 250mg/5ml daily. This writer plans to decrease Depakote to 250mg TID, raise Lexapro to 20mg daily and prescribe Xanax every 12 hours as needed for breakthrough anxiety . On 8/7/24 at 3:35 p.m., an interview was conducted with RN (registered nurse) #4. RN #4 stated that the purpose of the care plan was to have an individualized plan for each resident that was a carbon copy of the things that the resident needed to have in place to take care of them. She stated that the care plan should reflect residents that take anticoagulant and antidepressant medications because the care plan showed them how to meet the residents needs. On 8/7/24 at 3:53 p.m., an interview was conducted with LPN (licensed practical nurse) #2. LPN #2 stated that the managers developed and updated the care plan as needed and that she would expect to see anticoagulants and antidepressants on the care plan because they should be monitoring them. On 8/7/24 at 4:00 p.m., an interview was conducted with ASM (administrative staff member) #2, the director of nursing. ASM #2 stated that they would expect the comprehensive care plan to reflect anticoagulant and antidepressant use so that the staff caring for the resident were aware of the medication usage and to make sure that they were meeting the needs of the residents. On 8/8/24 at 5:00 p.m., ASM #1, the administrator, ASM #2, the director of nursing, ASM #3, the regional director of clinical operations, ASM #4, the regional director of clinical operations, ASM #5, the regional risk nurse and ASM #6, the regional senior administrator were made aware of the concern. No further information was provided prior to exit. 8. For Resident #74, the facility staff failed to implement the comprehensive care plan to consult with the pharmacy to consider dosage reduction when clinically appropriate, upon a pharmacy recommendation dated 11/25/23 A review of the comprehensive care plan revealed one dated 4/20/22 for (Resident #74) uses psychotropic medications This care plan included an intervention dated 4/20/22 for Consult with pharmacy, MD (medical doctor) to consider dosage reduction when clinically appropriate at least quarterly. A review of the clinical record revealed a Pharmacist Recommendations form dated 11/25/23, for Antipsychotic Reduction Therapy The resident has been taking RISPERDAL (1) 0.5 MG HS (milligrams at bedtime) since (5/2023) without a GDR (gradual dose reduction). Could we attempt a dose reduction at this time to perhaps 0.25 MG HS to verify this resident is on the lowest possible dose? If not, please indicate response below . Further review failed to reveal any evidence that the physician reviewed and signed this form, and chose to or not to reduce the medication dose related to this review. On 8/7/24 at 9:33 AM, ASM #4 (Administrative Staff Member) the Regional Director stated, when providing the above form, The November GDR was not addressed by the physician. We recognize that is an issue. On 8/8/24 at 1:44 PM, an interview was conducted with RN #6. She stated that the care plan provides a road map on how the resident should be treated and goals for the resident to achieve. When asked if the care plan documented to consult with the pharmacy and for the physician to consider a dosage reduction, and the pharmacy recommendation was not addressed by the physician, then was the care plan followed, she stated that it was not. On 8/8/24 at 4:00 PM, ASM #1 the Administrator and ASM #4 were made aware of the findings. No further information was provided by the end of the survey. References: 1. Risperdal is an antipsychotic used to treat symptoms of schizophrenia. Information obtained from https://medlineplus.gov/druginfo/meds/a694015.html 5.a. For Resident #3 (R3), the facility staff failed to develop a comprehensive care for the resident receiving hospice care. Review of the comprehensive care plan dated, 7/17/24, failed to evidence documentation related to R3 receiving hospice care services. On the most recent MDS (minimum data set) assessment, an admission assessment, with an assessment reference date of 7/24/24, the resident scored a three out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was severely, cognitively impaired for making daily decisions. In Section O - Special Treatments, Procedures and Programs, the resident was not coded as receiving hospice services. The physician orders documented, Admit to (Name of Hospice) effective 7/17/24, Dx (diagnosis) malignant neoplasm of unspecified part of left bronchus or lung (cancer). An interview was conducted with RN (registered nurse) #5, the MDS coordinator, on 8/6/24 at 4:51 p.m. When asked who develops the comprehensive care plans, RN #5 stated everyone had the ability to do it. The care plan for R3 was reviewed with RN #5. When asked if she saw a care plan to address the resident being on hospice, RN #5 stated, no, the resident has been on hospice care since admission. When asked the purpose of the care plan, RN #5 stated it is your guide to how to plan for the care of that patient. ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing, ASM #3, the regional director of clinical operations, ASM #4, the regional director of clinical operations, ASM # 5, the regional risk nurse, and ASM #6, the regional senior administrator, were made aware of the above concern on 8/6/24 at 5:15 p.m. No further information was provided prior to exit. 5.b. For Resident #3, the facility staff failed to implement the comprehensive care plan. The comprehensive care plan dated, 7/17/24, documented in part, Focus: Oxygen in use for comfort measure, The Interventions documented in part, Oxygen therapy continuous. Observation was made of R3 on 8/5/24 at approximately 12:45 p.m. in bed. The oxygen was in use via a nasal cannula. The oxygen concentrator was set with the bottom of the ball on the 1 LPM (liter per minute) line. A second observation was made of R3 on 8/6/24 at 8:26 a.m. The resident had the oxygen on, and the concentrator was set with the top of the ball under the 3 LPM line. The physician order dated, 7/17/24, documented, Oxygen at 6/liters continuous. The physician order dated, 7/17/24, documented, Hospice Care. The oxygen concentrator in use with R3 does not go above 5 LPM setting. The August 2024 Treatment Administration Record documented the above order for oxygen. It was signed off as having been administered as ordered for all shifts since 8/1/24 through 8/6/24, day shift. An interview was conducted with RN (registered nurse) #5, the MDS coordinator, on 8/6/24 at 4:51 p.m. When asked who develops the comprehensive care plans, RN #5 stated everyone had the ability to do it. When asked the purpose of the care plan, RN #5 stated is your guide to how to plan for the care of that patient. When asked if it should be followed, RN #5 stated, yes. ASM #1, the administrator, ASM #2, the director of nursing, ASM #3, the regional director of clinical operations, ASM #4, the regional director of clinical operations, ASM # 5, the regional risk nurse, and ASM #6, the regional senior administrator, were made aware of the above concern on 8/6/24 at 5:15 p.m. No further information was provided prior to exit. 6. For Resident #11, the facility staff failed to develop a comprehensive care for the resident receiving hospice care. The most recent MDS (minimum data set) assessment, a significant change assessment, with an assessment reference date of 5/14/24, coded the resident in Section O - Special Treatments, Procedures and Programs as being on hospice care. The physician order dated 5/7/24 documented, Admit to (Name of Hospice) for Dx (diagnosis) Senile degeneration of the brain. The comprehensive care plan, last revised on 5/17/24, failed to evidence documentation related to the resident receiving hospice care services. An interview was conducted with RN #5, the MDS coordinator, on 8/6/24 at 4:56 p.m. RN #5 was asked to review the care plan to determine if there was documentation of the resident being on hospice care, RN #5 reviewed the care plan and stated, no, and she's been on hospice for a long time. ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing, ASM #3, the regional director of clinical operations, ASM #4, the regional director of clinical operations, ASM # 5, the regional risk nurse, and ASM #6, the regional senior administrator, were made aware of the above concern on 8/6/24 at 5:15 p.m. No further information was provided prior to exit. 7. For Resident #9, the facility staff failed to implement the comprehensive care plan for the use of oxygen. On the most recent MDS (minimum data set) assessment, a quarterly assessment, with an assessment reference date of 6/21/24, the resident scored a 15 out of 15, indicating the resident was not cognitively impaired for making daily decisions. In Section O - Special Treatment, Procedure & Programs, coded the resident as using oxygen during the look back period. The comprehensive care plan dated, 1/24/24, documented in part, Focus: Respiratory Therapy: (R9) is on oxygen therapy r/t (related to) COPD (chronic obstructive pulmonary disease), respiratory failure, CHF (congestive heart failure). The Interventions documented in part, Oxygen Settings: O2 via nasal cannula @ 3L continuous. Observation was made of R9 on 8/5/24 at 1:06 p.m. sitting in the dining room. The resident had her oxygen on and there was no humidification in use, the humidification bottle was sitting on top of the concentrator. A second observation was made of R9 on 8/5/24 at 2:25 p.m. The resident was in the dining room with her oxygen in use. No humidification was in use. The bottle for humidification was sitting on top of the oxygen concentrator. The oxygen was set with the ball sitting between the 2 and 2.5 line. On 8/6/24 at 8:37 a.m. R9 was observed in the dining room, the oxygen concentrator was on, but the resident didn't have it on. The oxygen concentrator was set with the top of the ball sitting on the 3 line. An observation was made of R9 on 8/6/24 at 4:41 p.m. The resident had her oxygen in use and there was no humidification bottle attached to her oxygen tubing. On 8/8/24 at 9:26 a.m. R9 was observed in the dining room, her oxygen was in use and there was no humidification bottle attached or on the oxygen concentrator. The physician order dated, 9/3/21, documented, Oxygen therapy at 3 liters per minute via nasal cannula every shift related to dependence on supplemental oxygen - continuous O2 (oxygen). The physician order dated, 5/23/24 documented, Humidifier with oxygen concentrator every shift for Oxygen use at 3 L (liters). The August 2024 Medication Administration Record documented the order for the humidifier with oxygen concentrator every shift. It was signed off as completed for every shift from 8/1/24 through day shift on 8/8/24. The Treatment Administration Record for August 2024 documented the above order for oxygen. It was signed off as completed for every shift from 8/1/24 through 8/7/24. An interview was conducted with RN (registered nurse) #5, the MDS coordinator, on 8/6/24 at 4:51 p.m. When asked who develops the comprehensive care plans, RN #5 stated everyone had the ability to do it. When asked the purpose of the care plan, RN #5 stated is your guide to how to plan for the care of that patient. When asked if it should be followed, RN #5 stated, yes. ASM #1, the administrator, ASM #2, the director of nursing, ASM #3, the regional director of clinical operations, ASM #4, and ASM #6, the regional senior administrator, were made aware of the above findings on 8/8/24 at 4:30 p.m. No further information was provided prior to exit.

2. For Resident #81 (R81), the facility staff failed to promote dignity during lunch on 8/5/24. The resident was observed eating lunch on an overbed tray with a urinal containing urine inside beside the lunch tray. On the most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 7/10/2024, the resident scored 14 out of 15 on the BIMS (brief interview for mental status) assessment, indicating that they were cognitively intact for making daily decisions. The assessment documented R81 having impairment on one side in the upper and lower extremities, requiring supervision or touching assistance with toileting hygiene and being frequently incontinent of urine. On 8/5/24 at 12:38 p.m., an observation was made of R81 in their room. R81 was observed sitting on the side of their bed eating lunch placed on the overbed table. A urinal was observed sitting on the overbed table with approximately 300ml (milliliters) of yellow contents sitting beside the lunch tray. At that time an interview was conducted with R81. When asked about the urinal, R81 stated that they kept the urinal on the table or the bed rail to have it nearby when they needed to urinate. When asked about the contents of the urinal, R81 stated that they hoped they did not knock it over on the lunch tray. The comprehensive care plan for R81 documented in part, The resident has an ADL (activities of daily living) self-care performance deficit AEB (as evidenced by), resident uses urinal. Date Initiated: 04/01/2024. Revision on: 06/03/2024. Under Interventions it documented in part, Resident prefers to store urinal on bedside table and floor. Date Initiated: 06/03/2024 . On 8/7/24 at 12:08 p.m., an interview was conducted with CNA (certified nursing assistant) #4. CNA #4 stated that urinals were normally stored in the bathroom when not in use although there were some residents who preferred to keep them close to them. She stated that the urinal should not be left on the table with urine inside it during meals because it was unsanitary and it could be knocked over and spill onto the food. On 8/7/24 at 5:20 p.m., ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing, ASM #3, the regional director of clinical operations, ASM #4, the regional director of clinical operations, ASM #5, the regional risk nurse and ASM #6, the regional senior administrator were made aware of the concern. No further information was provided prior to exit. Based on resident interview, staff interview, facility document review, and clinical record review, the facility staff failed to provide care and services in a dignified manner, to include retaining personal property, for four of 52 residents in the survey sample, Residents #94, #81, #162, and #102. The findings include: 1. For Resident #94 (R94), the facility staff failed to allow the resident to retain toiletries in the resident's room. On the most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 7/14/24, the resident scored 15 out of 15 on the BIMS (brief interview for mental status), indicating the resident was cognitively intact for making daily decisions. A review of R94's clinical record revealed a nurse's note dated 7/24/24 that documented, Resident becoming increasingly more anxious and agitated after toiletries were removed from her room and placed in shower room per protocol. Attempted to explain to resident with no success. No answer from residents [sic] mother when attempting phone call. Resident behavior continued to escalate approaching and grabbing all disciplines of staff. Interrupting phone calls to unit and ability of staff to pass trays at lunch time. Call made to geri psych to update on behaviors. Another nurse's note dated 7/24/24 documented, Resident continues with crying, pleading for toiletries to be returned to her room. Grabbing staff and disruptive in dining room. Refused lunch, refusing to return to room. Geri psych arrived to assess resident. New order for Ativan (1) 0.5 mg (milligrams) PO (by mouth) Q (every) 12 hours prn (as needed) anxiety, agitation. Unable to redirect resident. Rx (Prescription) faxed to pharmacy. A nurse's note dated 7/25/24 documented, Resident's spouse came to visit resident during the evening shift. RP (Responsible Party)/Spouse asked what had happened earlier during the day shift about resident's personal toiletries being removed from her room. Informed RP that it is company policy that all resident's [sic] personal toiletries are to be kept in the shower room. RP would like to know if they can be kept in her closet secured. Will inform social services. On 8/6/24 at 1:13 p.m., an interview was conducted with CNA (certified nursing assistant) #1. CNA #1 stated staff was told that residents cannot have liquid toiletries in their rooms on that unit because some residents on that unit wander and someone must have drunk body wash. CNA #1 stated staff is supposed to place residents' toiletries in plastic bags and place them in the shower room. CNA #1 stated R94 does not allow anyone in her room, and it is safe for R94 to keep her own toiletries. CNA #1 stated R94's toiletries could be kept locked up in her closet so she would have access to them, but other residents would not. On 8/6/24 at 2:48 p.m., an interview was conducted with LPN (licensed practical nurse) #1. LPN #1 stated the facility rule on the unit where R94 resides is to keep residents' toiletries in cubbies in the shower room because some residents wander, take other residents' belongings, and eat objects. LPN #1 stated it would be safe for R94 to keep her belongings locked in an area in her room and R94 was capable of this. On 8/7/24 at 1:38 p.m., an interview was conducted with ASM (administrative staff member) #2 (the director of nursing). ASM #2 stated R94 resides on a dementia unit and residents on that unit are not allowed to keep toiletries in their room because staff does not want residents to consume or use those items inappropriately. ASM #2 stated she thought R94 is capable of retaining and using her toiletries safely, but this would not be safe for other residents. ASM #2 stated she could offer R94 options such as keeping her toiletries in a locked drawer in the room or offering the resident a room change on another unit. On 8/7/24 at 5:20 p.m., ASM #1 (the administrator), and ASM #2 were made aware of the above concern. The facility policy titled, Personal Property documented, Residents are permitted to retain and use personal possessions and appropriate clothing, as space and safety permits. No further information was presented prior to exit. Reference: (1) Ativan is used to treat anxiety. This information was obtained from the website: https://medlineplus.gov/druginfo/meds/a682053.html. 3. For Resident #162 (R162), the facility staff failed to knock on the closed door prior to entering the room. On the most recent MDS (minimum data set) assessment, an admission assessment, with an assessment reference date of 8/5/24, the resident scored a 15 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was not cognitively impaired for making daily decisions. On 8/6/24 at 1:32 p.m., an interview was being conducted with R162 in his room, with the door closed. CNA (certified nursing assistant) #4, opened the door, without knocking to enter the room. R162 stated they just walk in all the time. An interview was conducted with CNA #4 on 8/7/24 at 12:09 p.m. When asked what she does when entering a resident's room, CNA #4 stated she greets the resident, checks on how the resident is doing, and start care. CNA #4 was asked what she should do before entering the room, CNA #4 stated, knock on the door. When asked why we should knock on the door, CNA #4 stated, privacy and it's a person and we need to respect their rights. CNA #4 was asked if she knocked when she entered the room with the surveyors in the room, CNA #4 stated she couldn't remember. ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing, ASM #3, the regional director of clinical operations, ASM #4, the regional director of clinical operations, ASM # 5, the regional risk nurse, and ASM #6, the regional senior administrator, were made aware of the above concern on 8/7/24 at 4:54 p.m. No further information was provided prior to exit. 4. For Resident #102 (R102), the facility staff failed to ensure the resident's shoes were not soiled with a brown substance. On the most recent MDS assessment, an admission assessment, with an assessment reference date of 6/6/24, the resident scored a five out of 15 on the BIMS score, indicating the resident was severely cognitively impaired for making daily decisions. R102 resided on a secured dementia unit. R102 was observed on 8/5/24 at 2:28 p.m. in his bed. His right croc style shoe had a large amount of brown substance on it. A second observation was made of R102 on 8/6/24 at 8:33 a.m. The right croc style shoe continued to have a brown substance on it. R102 was observed on 8/6/24 at 11:51 a.m., the brown substance remained on his right shoe. An interview was conducted with CNA (certified nursing assistant) #3 on 8/7/24 at 11:23 a.m. When asked if she sees a resident with a brown substance on their shoes, what should you do, CNA #3 stated you take the shoes off and offer the resident new shoes and socks. We should try to clean it off and take it to the laundry if needed. CNA #3 was asked if a resident has stool on their shoes, is that living in a dignified manner, CNA #3 stated, no. R102 was ambulating towards CNA #3 and this writer and CNA #3 was asked to observe the shoes, CNA #3 stated, It's definitely poop, and I need to try to get that off. CNA #3 proceeded to talk to the resident and guided him to his room to clean his shoes. CNA #3 returned to this writer and stated, It was definitely poop. An interview was conducted with LPN (licensed practical nurse) #1 on 8/7/24 at 11:29 a.m. When asked if a resident has a brown substance on their shoes, what should be done, LPN #1 stated, she would check to see if it could be chocolate pudding or chocolate milk shake or stool. LPN #1 was asked if it was stool, what should be done, LPN #1 stated, clean it up. When asked if a resident s walking around the unit with stool on their shoes, is that living a dignified life, LPN #1 stated, no. ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing, ASM #3, the regional director of clinical operations, ASM #4, the regional director of clinical operations, ASM # 5, the regional risk nurse, and ASM #6, the regional senior administrator, were made aware of the above concern on 8/7/24 at 4:54 p.m. No further information was provided prior to exit.

Based on staff interview, facility document review, and clinical record review, the facility staff failed to inform a resident/resident representative of the risks and benefits of psychotropic medication treatment for one of 52 residents in the survey sample, Resident #87. The findings include: For Resident #87 (R87), the facility staff failed to inform the resident/resident representative of the risks and benefits for the use of multiple psychotropic medications: olanzapine (1)- ordered on 3/11/24, trazodone (2)- ordered on 3/11/24, Depakote (3)- ordered on 3/30/24, and Risperdal (4)- ordered on 4/4/24. R87 was admitted to the facility on [DATE] with a diagnosis of dementia with psychotic disturbance. A review of R87's clinical record revealed the following physician's orders: 3/11/24- olanzapine 2.5 mg (milligrams)- one tablet two times a day for acute psychosis dementia. 3/11/24- trazodone 50 mg- one tablet every night for anxiety. 3/30/24- Depakote 250 mg- one tablet every 12 hours for dementia with behavioral disturbance. 4/4/24- Risperdal 2 mg at bedtime for dementia with behavioral disturbance. Further review of R87's clinical record failed to reveal the facility staff informed the resident or the resident's representative of the risks and benefits for the use of the above medications. On 8/7/24 at 3:16 p.m., an interview was conducted with LPN (licensed practical nurse) #1. LPN #1 stated nurses should notify a resident's representative any time a new medication is ordered. LPN #1 stated nurses should inform a resident's representative of the risks and benefits of the medication, including why the medication has been ordered, and the side effects of the medication. On 8/7/24 at 5:20 p.m., ASM (administrative staff member) #1 (the administrator), and ASM #2 (the director of nursing) were made aware of the above concern. The facility policy titled, Informing Residents of Health, Medical Condition and Treatment Options documented, Each resident and/or resident representative will be informed of his or her total health status, medical condition, and options for treatment and/or care. No further information was presented prior to exit. References: (1) Olanzapine is used to treat schizophrenia and bipolar disorder. This information was obtained from the website: https://medlineplus.gov/druginfo/meds/a601213.html (2) Trazodone is used to treat depression. This information was obtained from the website: https://medlineplus.gov/druginfo/meds/a681038.html (3) Depakote is used to treat seizures and mania. This information was obtained from the website: https://medlineplus.gov/druginfo/meds/a682412.html (4) Risperdal is used to treat schizophrenia and mania. This information was obtained from the website: https://medlineplus.gov/druginfo/meds/a694015.html

2. For Resident #88 (R88), the facility staff failed to maintain a homelike environment. On the most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 7/9/24, the resident scored 15 out of 15 on the BIMS (brief interview for mental status), indicating the resident was cognitively intact for making daily decisions. On 8/5/24 at 12:49 p.m., an observation of R88's room was conducted. R88 was observed in bed with their foot of the bed facing the window in a semi-private room. A window air condition unit was observed in the window of R88's room with black tape around the sides of the unit. At this time, an interview was conducted with R88 who stated that the air conditioner had been placed there since they had been in that room because there were problems with the facility air condition system and there were issues with moths and small spiders getting in around the window unit. Further observation of R88's room revealed a dead moth and dead insect beside the air condition unit on the window sill. An additional dead beetle was observed on the floor beside the wall near the window. R88 stated that they had reported the bugs getting inside to the nurses and the aides in the facility and that nothing had been done that they knew of. On 8/6/24 at 8:20 a.m., an observation was made of R88 in their room. R88 stated that the bugs were still coming in around the air condition unit and bothering them. A small black bug and moth were observed beside the air condition unit on the window sill and a dead beetle was observed on the floor beside the wall near the window. On 8/7/24 at 10:37 a.m., an interview was conducted with OSM (other staff member) #5, the maintenance director. OSM #7 stated that they had put in the window air condition units as a temporary fix and left them in due to a chiller being replaced. He stated that they set them up the best that they could and when he received a complaint he went in and resealed them. He stated that he had not heard any complaints about bugs until 8/6/24. He stated that the facility had a pest control program with an outside vendor who came in monthly and as needed. He stated that any maintenance needs were communicated in their computerized system which went directly to his phone so that he could look them up. He stated that the residents should not have to have bugs coming in their rooms. OSM #5 observed R88's room and observed a dead moth on the window sill and one in the floor. OSM #5 stated that he would take care of resealing the unit or fix the issue as soon as possible. On 8/7/24 at 11:40 a.m., an interview was conducted with ASM (administrative staff member) #7, the long term care ombudsman. ASM #7 stated that they had been receiving complaints from residents for a few months about bugs getting in their rooms since the facility installed the window air condition units. Review of the facility work orders revealed none entered by staff for complaints of bugs coming in R88's room. Review of the facility pest control logs revealed regular pest control visits at the facility for ants, roaches, mice and other bugs. On 8/7/24 at 5:20 p.m., ASM #1, the administrator, ASM #2, the director of nursing, ASM #3, the regional director of clinical operations, ASM #4, the regional director of clinical operations, ASM #5, the regional risk nurse and ASM #6, the regional senior administrator were made aware of the concern. No further information was presented prior to exit. 3. For Resident #90 (R90), the facility staff failed to maintain a homelike environment. On the most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 7/6/24, the resident scored 14 out of 15 on the BIMS (brief interview for mental status), indicating the resident was cognitively intact for making daily decisions. On 8/5/24 at 2:22 p.m., an observation of R90's room was conducted. R90 was observed in a manual wheelchair in their room. R90 resided on the window side of a semi-private room with their foot of the bed facing the window. Between the foot of the bed and the wall along the window, multiple plastic bags of clothing and personal belongings were observed stacked on top of each other on the floor beside an oxygen concentrator and a bedside commode. A window air condition unit was observed in the window of R90's room. At this time, an interview was conducted with R90 who stated that the air conditioner was there because the other one was broken and there was a problem with bugs getting in because there was a gap underneath the unit that let them in. Observation underneath the air condition unit revealed a gap approximately 1/4 inch high vertically between the bottom of the unit and the window sill which ran the length of the bottom of the air condition unit. R90 stated that they had seen moths and lightening bugs in the room and they mostly came in at night when the lights were on. R90 stated that they had just gotten the bags of clothing from their family over the weekend and were waiting on the staff to help them hang them up and put them in their dresser. On 8/6/24 at 8:58 a.m., an observation was made of R90's room. The multiple plastic bags of clothing and personal belongings were observed stacked on top of each other on the floor and the gap approximately 1/4 inch remained. On 8/7/24 at 10:37 a.m., an interview was conducted with OSM (other staff member) #5, the maintenance director. OSM #7 stated that they had put in the window air condition units as a temporary fix and left them in due to a chiller being replaced. He stated that they set them up the best that they could and when he received a complaint he went in and resealed them. He stated that he had not heard any complaints about bugs until 8/6/24. He stated that the facility had a pest control program with an outside vendor who came in monthly and as needed. He stated that any maintenance needs were communicated in their computerized system which went directly to his phone so that he could look them up. He stated that the residents should not have to have bugs coming in their rooms. OSM #5 observed R90's room and observed the multiple plastic bags of clothing and personal belongings that were observed stacked on top of each other on the floor and the gap approximately 1/4 inch wide, running the length of the bottom of the air condition unit and stated that nursing was responsible for the bags of clothing but they would take care of the gap underneath the unit as soon as possible. On 8/7/24 at 11:40 a.m., an interview was conducted with ASM (administrative staff member) #7, the long term care ombudsman. ASM #7 stated that they had been receiving complaints from residents from residents for a few months about bugs getting in their rooms since the facility installed the window air condition units. On 8/7/24 at 12:08 p.m., an interview was conducted with CNA (certified nursing assistant) #4. CNA #4 stated that the CNA staff were responsible for assisting residents with keeping rooms tidy and organized. She stated that they assisted residents in putting away their clothing and getting bags up off of the floor. She stated that they did this to prevent falls and also for infection control purposes unless the resident refused. She stated that if the resident refused to allow them to assist it was reported to the nurse and should be documented. Review of the facility work orders revealed none entered by staff for complaints of bugs coming in R90's room. Review of the facility pest control logs revealed regular pest control visits at the facility for ants, roaches, mice and other bugs. The clinical record for R90 failed to evidence documentation of refusal to allow staff to assist in getting the bags off of the floor and put the clothing away. On 8/7/24 at 5:20 p.m., ASM #1, the administrator, ASM #2, the director of nursing, ASM #3, the regional director of clinical operations, ASM #4, the regional director of clinical operations, ASM #5, the regional risk nurse and ASM #6, the regional senior administrator were made aware of the concern. No further information was presented prior to exit. 4. For Resident #81 (R81), the facility staff failed to maintain a homelike environment. On the most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 7/10/24, the resident scored 14 out of 15 on the BIMS (brief interview for mental status), indicating the resident was cognitively intact for making daily decisions. On 8/5/24 at 12:38 p.m., an observation of R81's room was conducted. R81 was observed sitting on the side of the bed eating lunch. R81 resided on the window side of a semi-private room with their foot of the bed facing the window. A window air condition unit was observed in the window of R81's room. At this time, an interview was conducted with R81 who stated that for about the past two months there had been moths coming in around the air condition unit. R81 stated that they had reported it to the nurses and anyone that came in the room but no one did anything about it. R81 stated that they had seen a mouse come in the room a few weeks back and it ran out of the room. Observation of R81's room revealed a dead moth behind R81's nightstand, a gnat flying in the room and a dead moth on the window sill beside the air condition unit. On 8/6/24 at 8:26 a.m., an observation was made of R81's room. The dead moth was observed behind the nightstand and dead moth on the window sill were observed. On 8/7/24 at 10:37 a.m., an interview was conducted with OSM (other staff member) #5, the maintenance director. OSM #7 stated that they had put in the window air condition units as a temporary fix and left them in due to a chiller being replaced. He stated that they set them up the best that they could and when he received a complaint he went in and resealed them. He stated that he had not heard any complaints about bugs until 8/6/24. He stated that the facility had a pest control program with an outside vendor who came in monthly and as needed. He stated that any maintenance needs were communicated in their computerized system which went directly to his phone so that he could look them up. He stated that the residents should not have to have bugs coming in their rooms. OSM #5 observed R81's room and spoke with R81 who complained about the bugs coming in and stated that he would take care of it as soon as possible. On 8/7/24 at 11:40 a.m., an interview was conducted with ASM (administrative staff member) #7, the long term care ombudsman. ASM #7 stated that they had been receiving complaints from residents from residents for a few months about bugs getting in their rooms since the facility installed the window air condition units. Review of the facility work orders revealed none entered by staff for complaints of bugs coming in R81's room. Review of the facility pest control logs revealed regular pest control visits at the facility for ants, roaches, mice and other bugs. On 8/7/24 at 5:20 p.m., ASM #1, the administrator, ASM #2, the director of nursing, ASM #3, the regional director of clinical operations, ASM #4, the regional director of clinical operations, ASM #5, the regional risk nurse and ASM #6, the regional senior administrator were made aware of the concern. No further information was presented prior to exit. Based on observation, staff interview, and facility document review, the facility staff failed to maintain a clean and homelike environment for one of two units, the north unit, and for three of 52 residents in the survey sample, Residents #88, #90, and #81. The findings include: 1. The facility staff failed to maintain the north unit in a clean and homelike manner. A persistent urine odor was observed on 8/5/24 and 8/6/24. A persistent urine odor was observed throughout the north unit on the following dates and times: 8/5/24 at 12:10 p.m. 8/5/24 at 2:24 p.m. 8/5/24 at 4:04 p.m. 8/6/24 at 8:26 a.m. 8/6/24 at 10:33 a.m. 8/6/24 at 1:10 p.m. On 8/6/24 at 1:13 p.m., an interview was conducted with CNA (certified nursing assistant) #1. CNA #1 stated she does notice the urine odor on the north unit and some residents urinate and defecate on the floor. On 8/6/24 at 3:20 p.m., an interview was conducted with OSM (other staff member) #1 (the director of environmental services) and OSM #2 (the regional director of environmental services). OSM #2 stated there has been lingering odors on the north unit for some time and the environmental services staff uses an enzymatic chemical to break down odors in addition to regular chemicals and disinfectants. OSM #2 stated the environmental staff mops the floors, and recently stripped and waxed the floors in the hallway but they continue to troubleshoot to try to figure out the root cause of the odors. On 8/7/24 at 5:20 p.m., ASM (administrative staff member) #1 (the administrator), and ASM #2 (the director of nursing) were made aware of the above concern. The facility policy titled, Homelike Environment documented, Residents will be provided with a safe, clean, comfortable and homelike environment . No further information was presented prior to exit.

2. For Resident #60 (R60), the facility staff failed to code the annual MDS (minimum data set) assessment with an ARD (assessment reference date) of 6/28/24 for tobacco use. On the most recent MDS assessment, an annual assessment, with an ARD of 6/28/24, Section J documented no current tobacco use. The smoking-resident safety evaluation for R60 dated 6/6/24 documented in part, .Does the resident use tobacco products? Yes .Tobacco products utilized. Cigarettes/Cigars . Is the resident a safe smoker? Safe to smoke without supervision . The comprehensive care plan for R60 documented in part, [Name of R60] is a smoker. Date Initiated: 10/05/2023. Revision on: 03/07/2024 . On 8/7/24 at 10:15 a.m., an interview was conducted with RN (registered nurse) #5, MDS coordinator. RN #5 stated that they used the RAI (resident assessment instrument) manual when completing the MDS assessments. She stated that when completing Section J regarding tobacco use she reviewed the facility smoker list and the clinical record for the smoking assessment. She stated that she would review R60's annual MDS with the ARD of 6/28/24. On 8/7/24 at 11:01 a.m., RN #5 stated that R60 was an active smoker and the annual MDS should have been coded for smoking because there was a smoking assessment for them and they smoked. According to the RAI Manual, Version 1.16, dated October 2018, section J1300 documented in the steps for assessment, 1. Ask the resident if they used tobacco in any form during the 7-day look-back period. 2. If the resident states that they used tobacco in some form during the 7-day look-back period, code 1, yes . On 8/7/24 at 5:20 p.m., ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing, ASM #3, the regional director of clinical operations, ASM #4, the regional director of clinical operations, ASM #5, the regional risk nurse and ASM #6, the regional senior administrator were made aware of the concern. No further information was provided prior to exit. 3. For Resident #26 (R26), the facility staff failed to accurately code the quarterly MDS (minimum data set) assessment regarding insulin use. On the most recent MDS assessment, a quarterly assessment, with an ARD (assessment reference date) of 6/9/24, Section N documented insulin injections received one day during the 7 day look-back period. Review of the clinical record for R26 failed to evidence orders for insulin. The eMAR (electronic medication administration record) for R26 dated 6/1-6/30/24 failed to evidence insulin administered to R26. On 8/7/24 at 10:15 a.m., an interview was conducted with RN (registered nurse) #5, MDS coordinator. RN #5 stated that they used the RAI (resident assessment instrument) manual when completing the MDS assessments. She stated that when completing Section N they looked at the physician orders, diagnoses and the eMAR's following the 7 day look-back period. She stated that she would review R26's quarterly MDS with the ARD of 6/9/24 and the clinical record regarding insulin. On 8/7/24 at 11:01 a.m., RN #5 stated that R26 did not receive insulin and that it was a coding error and should not have been coded for insulin use. According to the RAI Manual, Version 1.16, dated October 2018, section N0350 documented in the steps for assessment, 1. Review the resident ' s medication administration records for the 7-day look-back period (or since admission/entry or reentry if less than 7 days). 2. Determine if the resident received insulin injections during the look-back period. 3. Determine if the physician (or nurse practitioner, physician assistant, or clinical nurse specialist if allowable under state licensure laws) changed the resident's insulin orders during the look-back period. 4. Count the number of days insulin injections were received and/or insulin orders changed . On 8/7/24 at 5:20 p.m., ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing, ASM #3, the regional director of clinical operations, ASM #4, the regional director of clinical operations, ASM #5, the regional risk nurse and ASM #6, the regional senior administrator were made aware of the concern. No further information was provided prior to exit. Based on staff interview, facility document review and clinical record review, it was determined the facility staff failed to maintain an accurate MDS (minimum data set) assessment for three of 52 residents in the survey sample, Residents #3, #60 and #26. The findings include: 1. For Resident #3, the facility staff failed to code the resident as receiving hospice care services on the admission MDS. On the most recent MDS assessment, an admission assessment, with an assessment reference date of 7/24/24, the resident scored a three out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was severely, cognitively impaired for making daily decisions. In Section O - Special Treatments, Procedures and Programs, the resident was not coded as receiving hospice services. The physician orders documented, Admit to (Name of Hospice) effective 7/17/24, Dx (diagnosis) malignant neoplasm of unspecified part of left bronchus or lung (cancer). An interview was conducted on 8/6/24 at 4:51 p.m. with RN (registered nurse) #5, the MDS coordinator. The above admission MDS assessment was reviewed with RN #5. When asked if the resident was coded for hospice care, RN #5 stated, no, she's been on hospice since admission. The facility provided a policy, MDS Error Correction, that did not address the accuracy of the MDS, only how to correct an error on the MDS. ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing, ASM #3, the regional director of clinical operations, ASM #4, the regional director of clinical operations, ASM # 5, the regional risk nurse, and ASM #6, the regional senior administrator, were made aware of the above concern on 8/6/24 at 5:15 p.m. No further information was provided prior to exit.

Based on staff interview, facility document review and clinical record review, it was determined that the facility staff failed to report an allegation of abuse to the required state agency in a timely manner for one of 52 residents in the survey sample; Resident #212. The findings include: For Resident #212, the facility staff failed to report an allegation of abuse in a timely manner. On 3/7/24 at 7:50 AM, a nurse's note documented the incident of abuse. The facility did not report the incident to the required state agency until 3/7/24 at 5:19 PM. The facility policy, Abuse documented, Abuse - is the willful infliction of injury, unreasonable confinement, intimidation, or punishment resulting in physical harm, pain or mental anguish Willful, as used in this definition of abuse, means the individual must have acted deliberately Prevention: a. The facility will not use verbal, mental, sexual or physical abuse .g. The organization will maintain protocols and procedures to identify, correct and intervene in situations in which abuse, neglect, mistreatment and/or misappropriation of resident property is more likely to occur. This includes analysis of: .The supervision of staff to identify inappropriate behaviors, such as using derogatory language Reporting: a. The organization will maintain systems to ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse to the administrator of the facility, or his or her designee, and to other officials (including to the State Survey Agency Resident #212 was admitted to the facility on [DATE] and discharged on 4/9/24. The admission MDS dated [DATE] coded Resident #212 as being cognitively intact in ability to make daily life decisions. A review of the clinical record revealed a nurse's note dated 3/7/24 at 7:50 AM that documented, writer observed resident and another staff member engaged in an argument. both parties threw insults and profanity at each other. after a few minutes resident was wheeled to his room and staff member walked down the hallway. A review of a facility synopsis of event form dated 3/7/24 and received by the state agency on 3/7/24 at 5:19 PM, documented, Staff alleged that one of our nurses was engaged in an argument with the resident and both parties insulted each other. Staff immediately suspended pending investigation The final report attached to this incident documented, On 3/7/24, it was alleged that (Resident #212) and one of our nurses (LPN #7) (Licensed Practical Nurse), engaged in an argument and both parties threw insults and profanity at each other. Investigation revealed that around 7:45am, a resident (not Resident #212) was redirected from juice due to elevated blood sugar by (LPN #7). (Resident #212) interrupted the Nurse by asking her if she knows the blood sugar of the resident asking for the juice. The Nurse told (Resident #212) she knew but she won't tell him because of HIPPA. (Resident #212) started cursing the Nurse out by calling her bi*** and telling her she knows nothing. According to the Nurse, she responded by saying you too. Witnesses said they heard resident using cursed words such as wh*** and your mother is a $10 wh***. Other witnesses also said they heard the nurse saying, fu** you and called him (Resident #212) a drug dealer when (Resident #212) was using profanity and cursing her out. The Unit Manager and the 2 (two) other nurses redirected (Resident #212) from the nurses' station Conclusion: Based on the investigation and after interviewing residents and staff, the allegation of abuse/Mistreatment is unsubstantiated. (Resident #212) said he was not in any way abused by the staff. Staff has been terminated for unprofessional conduct. A witness statement from the above investigation was reviewed. This statement was written by RN #6 (Registered Nurse). This statement documented, At approximately 7:45 AM, I observed Resident (#212) and LPN (#7) engaged in an argument. Resident stated to (LPN #7) you don't know her blood sugar. (LPN #7) said, yes I do. Resident (#212) stated, what is it. (LPN #7) stated, I can't share a resident's medical information with you. Both parties repeated the same thing several times. (LPN #7) then called resident (#212) a drug addict. Resident (#212) stated, I've been clean for 2 years. (LPN #7) called resident (#212) a drug dealer. Resident (#212) stated, you're profiling me, why, because I have tattoos. Resident (#212) then called (LPN #7) bi***, (LPN #7) said, your mother is a bi***. Resident (#212) stated, your mother is a $10 wh***. Both parties then stated back and forth fu** you. (LPN #6), supervisor and (another identified nurse) told resident (#212) to stop. I also told resident (#212) to stop and wheeled resident to his room. A review of the time sheet for LPN #7 for 3/7/24 revealed that LPN #7 was clocked in at 7:22 AM and clocked out at 3:27 PM, having worked the entire shift after verbally abusing a resident and was not removed from duty immediately after the incident. On 8/8/24 at 1:44 PM an interview was conducted with RN #6, who wrote the above witness statement. She stated that everything happened as she wrote it. She stated that this constituted as resident abuse by a staff member. She stated that she was preparing for morning med pass when she observed the above scenario as it happened. She stated that it was not appropriate for a nurse to say such things to a resident. When asked about reporting the abuse, she stated that the supervisor was aware and that at some point during the shift she was asked to speak to the DON (Director of Nursing) and write a witness statement. On 8/8/24 at 2:23 PM an interview was conducted with LPN #6, who was the unit manager/supervisor. He stated that he arrived at the end of the incident and heard the resident being verbally abusive to the nurse. He stated that he did not hear the nurse say anything. He stated that the incident was discussed in the morning meeting with the Administrator, Director of Nursing, Assistant Director of Nursing. He stated that the Director of Nursing was aware of the incident in the morning meeting, which he said was held daily at about 9:00 AM. On 8/8/24 at 2:46 PM, an interview was conducted with ASM #2 (Administrative Staff Member) the Director of Nursing. She stated that she did not feel the incident was abuse. When asked when is an allegation of abuse supposed to be reported to the state agency, she stated within two hours. It was noted that the incident was at approximately 7:45 AM and that a nurse wrote a note about it at 7:50 AM, however, the fax stamp on the incident report indicated the state agency received the report on 3/7/24 at 5:19 PM. She stated that it was reported within two hours of her learning about it. However, per the above interview with LPN #6, she had been aware of it since the morning meeting at approximately 9:00 AM. On 8/8/24 at 4:00 PM, ASM #1 the Administrator and ASM #4 a Regional Director of Clinical Operations, were made aware of the findings. ASM #4 stated that this was considered as resident abuse and that he did not agree with the former Administrator's findings that abuse was unsubstantiated, and he expressed concern that ASM #2 the Director of Nursing, did not recognize this incident as abuse.

Based on resident interview, staff interview, facility document review and clinical record review, it was determined that the facility staff failed to implement the facility abuse policy for three of 52 residents in the survey sample; Residents #212, #96 and #98. The findings include: 1. For Resident #212, the facility staff failed to implement the abuse policy to ensure the resident was free from abuse by a staff member (LPN #7) on 3/7/2 and failed to correctly identify the incident as abuse upon investigation in the facility's report to the required state agency. The facility policy, Abuse documented, Abuse - is the willful infliction of injury, unreasonable confinement, intimidation, or punishment resulting in physical harm, pain or mental anguish Willful, as used in this definition of abuse, means the individual must have acted deliberately Prevention: a. The facility will not use verbal, mental, sexual or physical abuse .g. The organization will maintain protocols and procedures to identify, correct and intervene in situations in which abuse, neglect, mistreatment and/or misappropriation of resident property is more likely to occur. This includes analysis of: .The supervision of staff to identify inappropriate behaviors, such as using derogatory language Resident #212 was admitted to the facility on [DATE] and discharged on 4/9/24. The admission MDS dated [DATE] coded Resident #212 as being cognitively intact in ability to make daily life decisions. A review of the clinical record revealed a nurse's note dated 3/7/24 at 7:50 AM that documented, writer observed resident and another staff member engaged in an argument. both parties threw insults and profanity at each other. after a few minutes resident was wheeled to his room and staff member walked down the hallway. A review of a facility synopsis of event form dated 3/7/24 and received by the state agency on 3/7/24 at 5:19 PM, documented, Staff alleged that one of our nurses was engaged in an argument with the resident and both parties insulted each other. Staff immediately suspended pending investigation The final report attached to this incident documented, On 3/7/24, it was alleged that (Resident #212) and one of our nurses (LPN #7) (Licensed Practical Nurse), engaged in an argument and both parties threw insults and profanity at each other. Investigation revealed that around 7:45am, a resident (not Resident #212) was redirected from juice due to elevated blood sugar by (LPN #7). (Resident #212) interrupted the Nurse by asking her if she knows the blood sugar of the resident asking for the juice. The Nurse told (Resident #212) she knew but she won't tell him because of HIPPA. (Resident #212) started cursing the Nurse out by calling her bi*** and telling her she knows nothing. According to the Nurse, she responded by saying you too. Witnesses said they heard resident using cursed words such as wh*** and your mother is a $10 wh***. Other witnesses also said they heard the nurse saying, fu** you and called him (Resident #212) a drug dealer when (Resident #212) was using profanity and cursing her out. The Unit Manager and the 2 (two) other nurses redirected (Resident #212) from the nurses' station Conclusion: Based on the investigation and after interviewing residents and staff, the allegation of abuse/Mistreatment is unsubstantiated. (Resident #212) said he was not in any way abused by the staff. Staff has been terminated for unprofessional conduct. A witness statement from the above investigation was reviewed. This statement was written by RN #6 (Registered Nurse). This statement documented, At approximately 7:45 AM, I observed Resident (#212) and LPN (#7) engaged in an argument. Resident stated to (LPN #7) you don't know her blood sugar. (LPN #7) said, yes I do. Resident (#212) stated, what is it. (LPN #7) stated, I can't share a resident's medical information with you. Both parties repeated the same thing several times. (LPN #7) then called resident (#212) a drug addict. Resident (#212) stated, I've been clean for 2 years. (LPN #7) called resident (#212) a drug dealer. Resident (#212) stated, you're profiling me, why, because I have tattoos. Resident (#212) then called (LPN #7) bi***, (LPN #7) said, your mother is a bi***. Resident (#212) stated, your mother is a $10 wh***. Both parties then stated back and forth fu** you. (LPN #6), supervisor and (another identified nurse) told resident (#212) to stop. I also told resident (#212) to stop and wheeled resident to his room. A review of the time sheet for LPN #7 for 3/7/24 revealed that LPN #7 was clocked in at 7:22 AM and clocked out at 3:27 PM, having worked the entire shift after verbally abusing a resident and was not removed from duty immediately after the incident. On 8/8/24 at 1:44 PM an interview was conducted with RN #6, who wrote the above witness statement. She stated that everything happened as she wrote it. She stated that this constituted as resident abuse by a staff member. She stated that she was preparing for morning med pass when she observed the above scenario as it happened. She stated that it was not appropriate for a nurse to say such things to a resident. When asked about reporting the abuse, she stated that the supervisor was aware and that at some point during the shift she was asked to speak to the DON (Director of Nursing) and write a witness statement. On 8/8/24 at 2:23 PM an interview was conducted with LPN #6, who was the unit manager/supervisor. He stated that he arrived at the end of the incident and heard the resident being verbally abusive to the nurse. He stated that he did not hear the nurse say anything. He stated that the incident was discussed in the morning meeting with the Administrator, Director of Nursing, Assistant Director of Nursing. He stated that the Director of Nursing was aware of the incident in the morning meeting, which he said was held daily at about 9:00 AM. On 8/8/24 at 2:46 PM, an interview was conducted with ASM #2 (Administrative Staff Member) the Director of Nursing. She stated that she did not feel the incident was abuse. She stated that the resident did not say he was abused and that the resident started the altercation, and therefore, she did not feel that the nurse cursing at the resident was considered verbal abuse. On 8/8/24 at 4:00 PM, ASM #1 the Administrator and ASM #4 a Regional Director of Clinical Operations, were made aware of the findings. ASM #4 stated that this was considered as resident abuse and that he did not agree with the former Administrator's findings that abuse was unsubstantiated, and he expressed concern that ASM #2 the Director of Nursing, did not recognize this incident as abuse. 2. For Residents #98 and #96, the facility staff failed to pimplement the abuse policy to ensure the residents were free from abuse in a resident to resident altercation on 7/11/24. Resident #98 was admitted to the facility on [DATE] and on the quarterly MDS (Minimum Data Set) dated 6/6/24 was coded as being cognitively intact in ability to make daily life decisions. Resident #96 was admitted to the facility on [DATE] and on the quarterly MDS dated [DATE] was coded as being cognitively intact in ability to make daily life decisions. On 8/5/24 at 2:56 PM an interview was conducted with Resident #98. He stated that about a month or so ago another resident, which he identified as Resident #96, had head butted him for no reason. He stated that the incident was reported to the police and APS (adult protective services). He stated that Resident #96 acts like a [AGE] year old and mocks people the way a kid would do. A review of the facility synopsis of the event dated 7/11/24 documented, Physical Altercation - upon rounding the corner toward (a room number) - nurse observed two residents punching and hitting and kicking each other while laying on the floor. IDT (Interdisciplinary team) met to review incident. Police were called to the facility. Psych consult to see both residents. Discharge plan to be enforced. The follow up to the above report, dated 7/15/24, documented, Summary of incident: (Resident #98) and (Resident #96) were observed around (room number) engaged in physical altercation - both residents on the floor kicking, hitting, and punching each other. Staff nurse separated the residents and directed them back to their rooms. (Resident #98) claimed (Resident #96) head-butted him to the floor. This writer observed a small knot on the bridge of his nose and another on the right side of his left eye. The patient claimed he did nothing to provoke his former roommate before the incident. He expressed his intention to press charges against the former roommate. (Resident #96) explained that he had gone to sit in the hallway by himself and felt disrespected. He stated that he did not care and became belligerent toward other staff Conclusion: This physical altercation between the two residents constitutes an abuse. This writer advised both residents to always report their concerns to the appropriate authorities and to avoid fighting each other. Failure to comply with facility rules and regulations will result in administrative discharge. A review of the clinical record for Resident #98 revealed a nurse's note dated 7/11/24 that documented, Upon rounding the corner heading toward (a room number), observed two residents on the floor kicking, hitting, and punching each other. Additional nurse notified offered assistance. Separated residents, Police, MD (Medical Doctor), DON (Director of Nursing), ED (Executive Director), Resident is self-responsible party. All notified. A second nurse's note dated 7/11/24 documented, Area above tip of nose reddened no drainage noted, area below the right nare also with redness, no drainage noted related to the altercation. A review of the clinical record for Resident #96 revealed a nurse's note dated 7/11/24 that documented, Upon rounding the corner heading toward (a room number), observed two residents on the floor kicking, hitting, and punching each other. Additional nurse notified offered assistance. Residents were separated, police notified, RP's (responsible party) aware, DON (Director of Nursing), ED (Executive Director) aware no apparent injury currently. A second nurse's note dated 7/11/24 documented, As of this moment resident without any injuries. The staff member who wrote the above nurses notes was not available for interview. On 8/8/24 at 2:33 PM an interview was conducted with LPN #6 (Licensed Practical Nurse). He stated that the supervisor called for help regarding the residents fighting. He stated that they were separated and assessed and that Resident #98 had a mark on his nose. He stated that the resident did not require going to the emergency room. He stated that when the police came, they spoke to the residents. He stated that he did not know about anything else that was said. On 8/8.24 at 2:46 PM, an interview was conducted with ASM #2 (Administrative Staff Member) the Director of Nursing. She stated that she did not know anything about the incident other than that the residents were separated and that the police were called and that the psych provider followed up with both residents. On 8/8/24 at 4:00 PM, ASM #1 the Administrator and ASM #4 a Regional Director of Clinical Operations, were made aware of the findings. No further information was provided by the end of the survey.

Based on resident interview, staff interview, facility document review and clinical record review, it was determined that the facility staff failed to ensure 3 of 52 residents in the survey sample were free from abuse; Residents #212, #98 and #96. The findings include: 1. For Resident #212, the facility staff failed to ensure the resident was free from abuse by a staff member (LPN #7) on 3/7/24. Resident #212 was admitted to the facility on [DATE] and discharged on 4/9/24. The admission MDS dated [DATE] coded Resident #212 as being cognitively intact in ability to make daily life decisions. A review of the clinical record revealed a nurse's note dated 3/7/24 at 7:50 AM that documented, writer observed resident and another staff member engaged in an argument. both parties threw insults and profanity at each other. after a few minutes resident was wheeled to his room and staff member walked down the hallway. A review of a facility synopsis of event form dated 3/7/24 and received by the state agency on 3/7/24 at 5:19 PM, documented, Staff alleged that one of our nurses was engaged in an argument with the resident and both parties insulted each other. Staff immediately suspended pending investigation The final report attached to this incident documented, On 3/7/24, it was alleged that (Resident #212) and one of our nurses (LPN #7) (Licensed Practical Nurse), engaged in an argument and both parties threw insults and profanity at each other. Investigation revealed that around 7:45am, a resident (not Resident #212) was redirected from juice due to elevated blood sugar by (LPN #7). (Resident #212) interrupted the Nurse by asking her if she knows the blood sugar of the resident asking for the juice. The Nurse told (Resident #212) she knew but she won't tell him because of HIPPA. (Resident #212) started cursing the Nurse out by calling her bi*** and telling her she knows nothing. According to the Nurse, she responded by saying you too. Witnesses said they heard resident using cursed words such as wh*** and your mother is a $10 wh***. Other witnesses also said they heard the nurse saying, fu** you and called him (Resident #212) a drug dealer when (Resident #212) was using profanity and cursing her out. The Unit Manager and the 2 (two) other nurses redirected (Resident #212) from the nurses' station Conclusion: Based on the investigation and after interviewing residents and staff, the allegation of abuse/Mistreatment is unsubstantiated. (Resident #212) said he was not in any way abused by the staff. Staff has been terminated for unprofessional conduct. A witness statement from the above investigation was reviewed. This statement was written by RN #6 (Registered Nurse). This statement documented, At approximately 7:45 AM, I observed Resident (#212) and LPN (#7) engaged in an argument. Resident stated to (LPN #7) you don't know her blood sugar. (LPN #7) said, yes I do. Resident (#212) stated, what is it. (LPN #7) stated, I can't share a resident's medical information with you. Both parties repeated the same thing several times. (LPN #7) then called resident (#212) a drug addict. Resident (#212) stated, I've been clean for 2 years. (LPN #7) called resident (#212) a drug dealer. Resident (#212) stated, you're profiling me, why, because I have tattoos. Resident (#212) then called (LPN #7) bi***, (LPN #7) said, your mother is a bi***. Resident (#212) stated, your mother is a $10 wh***. Both parties then stated back and forth fu** you. (LPN #6), supervisor and (another identified nurse) told resident (#212) to stop. I also told resident (#212) to stop and wheeled resident to his room. A review of the time sheet for LPN #7 for 3/7/24 revealed that LPN #7 was clocked in at 7:22 AM and clocked out at 3:27 PM, having worked the entire shift after verbally abusing a resident and was not removed from duty immediately after the incident. On 8/8/24 at 1:44 PM an interview was conducted with RN #6, who wrote the above witness statement. She stated that everything happened as she wrote it. She stated that this constituted as resident abuse by a staff member. She stated that she was preparing for morning med pass when she observed the above scenario as it happened. She stated that it was not appropriate for a nurse to say such things to a resident. When asked about reporting the abuse, she stated that the supervisor was aware and that at some point during the shift she was asked to speak to the DON (Director of Nursing) and write a witness statement. On 8/8/24 at 2:23 PM an interview was conducted with LPN #6, who was the unit manager/supervisor. He stated that he arrived at the end of the incident and heard the resident being verbally abusive to the nurse. He stated that he did not hear the nurse say anything. He stated that the incident was discussed in the morning meeting with the Administrator, Director of Nursing, Assistant Director of Nursing. He stated that the Director of Nursing was aware of the incident in the morning meeting, which he said was held daily at about 9:00 AM. On 8/8/24 at 2:46 PM, an interview was conducted with ASM #2 (Administrative Staff Member) the Director of Nursing. She stated that she did not feel the incident was abuse. When asked when is an allegation of abuse supposed to be reported to the state agency, she stated within two hours. It was noted that the incident was at approximately 7:45 AM and that a nurse wrote a note about it at 7:50 AM, however, the fax stamp on the incident report indicated the state agency received the report on 3/7/24 at 5:19 PM. She stated that it was reported within two hours of her learning about it. However, per the above interview with LPN #6, she had been aware of it since the morning meeting. The facility policy, Abuse documented, Abuse - is the willful infliction of injury, unreasonable confinement, intimidation, or punishment resulting in physical harm, pain or mental anguish Willful, as used in this definition of abuse, means the individual must have acted deliberately Prevention: a. The facility will not use verbal, mental, sexual or physical abuse .g. The organization will maintain protocols and procedures to identify, correct and intervene in situations in which abuse, neglect, mistreatment and/or misappropriation of resident property is more likely to occur. This includes analysis of: .The supervision of staff to identify inappropriate behaviors, such as using derogatory language Reporting: a. The organization will maintain systems to ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse to the administrator of the facility, or his or her designee, and to other officials (including to the State Survey Agency On 8/8/24 at 4:00 PM, ASM #1 the Administrator and ASM #4 a Regional Director of Clinical Operations, were made aware of the findings. ASM #4 stated that this was considered as resident abuse and that he did not agree with the former Administrator's findings that abuse was unsubstantiated, and he expressed concern that ASM #2 the Director of Nursing, did not recognize this incident as abuse. 2. For Residents #98 and #96, the facility staff failed to ensure the residents were free from abuse in a resident to resident altercation on 7/11/24. Resident #98 was admitted to the facility on [DATE] and on the quarterly MDS (Minimum Data Set) dated 6/6/24 was coded as being cognitively intact in ability to make daily life decisions. Resident #96 was admitted to the facility on [DATE] and on the quarterly MDS dated [DATE] was coded as being cognitively intact in ability to make daily life decisions. On 8/5/24 at 2:56 PM an interview was conducted with Resident #98. He stated that about a month or so ago another resident, which he identified as Resident #96, had head butted him for no reason. He stated that the incident was reported to the police and APS (adult protective services). He stated that Resident #96 acts like a [AGE] year old and mocks people the way a kid would do. A review of the clinical record for Resident #98 revealed a nurse's note dated 7/11/24 that documented, Upon rounding the corner heading toward (a room number), observed two residents on the floor kicking, hitting, and punching each other. Additional nurse notified offered assistance. Separated residents, Police, MD (Medical Doctor), DON (Director of Nursing), ED (Executive Director), Resident is self-responsible party. All notified. A second nurse's note dated 7/11/24 documented, Area above tip of nose reddened no drainage noted, area below the right nare also with redness, no drainage noted related to the altercation. A review of the clinical record for Resident #96 revealed a nurse's note dated 7/11/24 that documented, Upon rounding the corner heading toward (a room number), observed two residents on the floor kicking, hitting, and punching each other. Additional nurse notified offered assistance. Residents were separated, police notified, RP's (responsible party) aware, DON (Director of Nursing), ED (Executive Director) aware no apparent injury currently. A second nurse's note dated 7/11/24 documented, As of this moment resident without any injuries. A review of the facility synopsis of the event dated 7/11/24 documented, Physical Altercation - upon rounding the corner toward (a room number) - nurse observed two residents punching and hitting and kicking each other while laying on the floor. IDT (Interdisciplinary team) met to review incident. Police were called to the facility. Psych consult to see both residents. Discharge plan to be enforced. The follow up to the above report, dated 7/15/24, documented, Summary of incident: (Resident #98) and (Resident #96) were observed around (room number) engaged in physical altercation - both residents on the floor kicking, hitting, and punching each other. Staff nurse separated the residents and directed them back to their rooms. (Resident #98) claimed (Resident #96) head-butted him to the floor. This writer observed a small knot on the bridge of his nose and another on the right side of his left eye. The patient claimed he did nothing to provoke his former roommate before the incident. He expressed his intention to press charges against the former roommate. (Resident #96) explained that he had gone to sit in the hallway by himself and felt disrespected. He stated that he did not care and became belligerent toward other staff Conclusion: This physical altercation between the two residents constitutes an abuse. This writer advised both residents to always report their concerns to the appropriate authorities and to avoid fighting each other. Failure to comply with facility rules and regulations will result in administrative discharge. The staff member who wrote the above nurses notes was not available for interview. On 8/8/24 at 2:33 PM an interview was conducted with LPN #6 (Licensed Practical Nurse). He stated that the supervisor called for help regarding the residents fighting. He stated that they were separated and assessed and that Resident #98 had a mark on his nose. He stated that the resident did not require going to the emergency room. He stated that when the police came, they spoke to the residents. He stated that he did not know about anything else that was said. On 8/8.24 at 2:46 PM, an interview was conducted with ASM #2 (Administrative Staff Member) the Director of Nursing. She stated that she did not know anything about the incident other than that the residents were separated and that the police were called and that the psych provider followed up with both residents. On 8/8/24 at 4:00 PM, ASM #1 the Administrator and ASM #4 a Regional Director of Clinical Operations, were made aware of the findings. No further information was provided by the end of the survey.

Based on observation, staff interview, facility document review, and clinical record review, the facility staff failed to ensure a resident was safe to self-administer a medication for one of 52 residents in the survey sample, Resident #98. The findings include: For Resident #98 (R98), the facility staff failed to complete an assessment to determine if the resident was safe to self-administer a nebulizer medication. A review of R98's clinical record revealed a physician's order dated 6/14/24 for ipratropium-albuterol inhalation solution (1) 0.5-2.5 MG (milligram)/3ML (milliliters) three times a day for chronic obstructive pulmonary disease. Further review of R98's clinical record failed to reveal an assessment to determine it was safe for the resident to self-administer the medication. On 8/6/24 at 9:31 a.m., RN (registered nurse) #1 poured the ipratropium-albuterol solution into R98's nebulizer machine, turned on the machine, and handed the mouthpiece to R98. RN #1 exited the room while R98 continued to self-administer the medication. On 8/6/24 at 3:11 p.m., an interview was conducted with RN #1. RN #1 stated it takes 15 minutes for R98 to complete the nebulizer medication breathing treatment. RN #1 stated R98 wants to complete the medication treatment by himself and does not want staff to stand there and wait. RN #1 stated an assessment should be completed to determine if a resident can safely administer a medication breathing treatment, but he had no idea if an assessment had been completed for R98. On 8/7/24 at 5:20 p.m., ASM (administrative staff member) #1 (the administrator) and ASM #2 (the director of nursing) were made aware of the above concern. The facility policy titled, Self-Administration of Medications and Treatments documented, POLICY: Residents have the right to self-administer medications / treatments if the interdisciplinary team has determined that it is clinically appropriate and safe for the resident to do so. SPECIFIC PROCEDURES / GUIDANCE 1. As part of their overall evaluation, the staff and practitioner will assess each resident's mental and physical abilities and choice to determine whether self-administering medications and/or treatments is clinically appropriate for the resident. No further information was presented prior to exit. Reference: (1) Ipratropium-albuterol inhalation solution is used to treat lung diseases. This information was obtained from the website: https://medlineplus.gov/ency/patientinstructions/000006.htm.

Based on observation, family interview, staff interview, facility document review, and clinical record review, the facility staff failed to assess and/or monitor a change in a resident's condition for one of 45 residents in the survey sample, Residents #254. For Resident #254, the facility staff failed to assess and monitor a diabetic resident's right great toe after identifying a skin tear. Three days after identifying the skin tear, the resident was transferred to the hospital with a necrotic right great toe and received treatment with antibiotics. The lack of assessment and monitoring resulted in harm to Resident #254. The findings include: For Resident #254 (R254), the facility staff identified a skin tear on her right great toe on 8/26/23. The facility staff failed to evidence further assessment or monitoring of the skin tear until the resident was sent to the hospital in the late afternoon of 8/29/23 with a necrotic (1) right great toe. The lack of assessment and monitoring resulted in harm to the resident. On the most recent MDS (minimum data set), an admission assessment with an ARD (assessment reference date) of 8/11/23, R254 was coded as being severely cognitively impaired for making daily decisions, having scored one out of 15 on the BIMS (brief interview for mental status). R254 was admitted to the facility with diagnoses including diabetes, dementia, and polyneuropathy (2). On 8/29/23 at 12:08 p.m., R254 was observed sitting in a wheelchair beside her bed. R254's daughter was seated beside the resident. R254's right leg was elevated, and a blanket covered the leg down to the ankle. R254's right great toe was red/purple/black, and toe was shiny with fluid on it. There was no dressing on the toes. R254's daughter stated: [R254] had a bloody sock over the weekend and I showed it to a nurse. She stated the weekend nurse told her that the nurse would put R254 on the list to be seen by the nurse practitioner on Monday, 8/28/23. She stated she visits R254 every day, and there has never been any type of dressing on the toe. R254's daughter stated she was waiting for the nurse to come in and look at the toe. On 8/29/23 at 3:28 p.m., R254 was lying in her bed. Her right great toe was visible, and was still red/purple/black, and wet. A review of R254's clinical record revealed the following progress notes: 8/26/2023 14:18 (2:18 p.m. Nursing Note Text: Skin tear found on Resident's great toe on right foot. Tear measures <0.5cm (centimeters) x <0.5cm x <0.5cm. Resident stated that she does not remember how skin tear happened. Cleansed w/ (with) wound cleanser and applied bacitracin. NP(nurse practitioner) .and [name of primary physician] informed. Will continue to monitor. This note was written by RN (registered nurse) #2. 8/26/2023 15:21 (3:21 p.m.) Nursing Note Text: skin assessment documented. weekly wound assessment triggered. 8/29/2023 1635 (4:35 p.m.) Transfer to hospital. 8/29/2023 22:11 (10:11 p.m.) eINTERACT .Summary for Providers Situation: The Change In Condition/s reported on this .Evaluation are/were: Tired, Weak, Confused, or Drowsy Change in skin color or condition .Outcomes of Physical Assessment: Positive findings reported on the resident/patient evaluation for this change in condition were: Mental Status Evaluation: Increased confusion (e.g. disorientation) .Skin Status Evaluation: Discoloration .Primary Care Provider Feedback: Primary Care Provider responded with the following feedback: A. Recommendations: to send the resident to the emergency [room]. 8/29/2023 22:41 (10:41 p.m.) Nursing Note Text: Nursing assistant was giving the resident shower and noticed changes on her toe. upon assessment necrotic toe was observed. physician was notified instructions was given to send the resident to the ER (emergency room ). RP (responsible party) was in the building and escorted the resident. phone call follow-up was made, resident admitted for hypernatremia (high sodium level), narcotic [sic] toe, dehydration, UTI (urinary tract infection). A review of R254's Weekly Skin Observation dated 8/26/23 revealed, in part: Are there any bruises, open wounds, surgical incisions, skin tears, reddened areas or other skin conditions noted? Yes. Skin Tear. Skin Tear Location: Right Toes. Is this a new skin condition? Yes. A review of R254's clinical record (orders, provider notes, MAR [medication administration record] and TAR [treatment administration record]) revealed no evidence of an order for care of the skin tear, and no evidence of any assessment or monitoring of the resident's right great toe between 8/26/23 and when she was sent to the hospital with a necrotic right great toe on 8/29/23. A review of the emergency room records from the local hospital where R254 was admitted on [DATE] revealed, in part: The patient .who is seen in the Emergency Department for concerns of black toes on her right foot, unsure how long it has been going on. Daughter first noticed it four days prior Physical Examination .MSK (musculoskeletal): Black first and second right toes .The patient presents with altered mental status, concerning for acute infection, possibly sepsis, although ongoing for three weeks per daughter. Concerns for foot ulceration vs. gangrenous changes on right toes .Presentation most consistent with foot infection, UTI. On 8/31/23 at 10:43 a.m., LPN (licensed practical nurse) #11 was interviewed. She stated if she identifies that a resident has a skin tear, she assess the injury and notifies the NP to obtain treatment orders. She completes a skin assessment form, and enters the treatment order so it will show up on the TAR for follow up. She stated skin tears should be monitored by the facility staff until they are resolved. She stated this is especially important for resident who have diabetes and neuropathy. On 8/31/23 at 11:11 a.m., ASM (administrative staff member) #5, a nurse practitioner, was interviewed. She stated RN #2 texted her about the skin tear by way of the facility's electronic medical record software on Saturday, 8/26/23. She stated: I don't respond to those routine notifications. She stated she did not see the resident on 8/28/23 or 8/29/23. She stated: I never looked at [R254's] toes. On 8/31/23 at 12:36 p.m., ASM #1, the administrator, ASM #2, the director of nursing, and ASM #3, the regional nurse consultant, were informed of these concerns, and of the concern for harm to R254. ASM #2 stated the facility does not have standing orders for skin tears. On 8/31/23 at 4:13 p.m., RN #2 was interviewed. She stated R254's daughter notified her on Saturday, 8/26/23, that the resident's right sock was bloody. She stated the daughter assisted her in removing the resident's sock. There was a skin tear on the top of the right great toe, extending around toward the side of the toe. The toenail was still intact, but there was dried blood on the toe. She stated she cleaned the dried blood with wound cleanser and applied an antibiotic ointment but no bandage. She put a clean sock on the resident and made the required notes in the clinical record. She stated she notified ASM #5 by a routine text. She stated it is her understanding that the electronic medical record software triggers a formal wound assessment for follow up, and the wound nurse would look at the injury and determine a proper treatment. She stated there is no list of residents for the NP to see on the NP's next visit to the facility. She stated: I figured with me notifying the NP, that would trigger a visit. On 9/1/23 at 8:14 a.m., ASM #2, the director of nursing, was asked if the facility had additional evidence to present regarding R254. She stated the hospital had determined the resident had peripheral vascular disease, of which the facility was not previously aware. When asked if the facility staff was aware that R254 had diabetes and peripheral neuropathy, she stated: Yes, we were aware of that. When asked what was put in place to monitor this diabetic resident, who had a skin tear on her toe, ASM #2 did not answer. A review of the facility policy, Skin Tears, Abrasions, and Bruises Management, revealed, in part: Skin Tear .is a traumatic wound caused by mechanical forces .Severity may vary by depth .Staff will be encouraged to promptly report any observation of a change in the resident's skin integrity including presence of a skin tear, abrasion, or bruise .Observations of new areas of impaired skin integrity will be reported to the physician/practitioner for further evaluation and treatment .Treatments will be ordered by the physician/practitioner .Resident centered interventions and treatments will be prescribed by the physician/practitioner and administration of the treatments will be documented in the resident's medical record .Treatments, including preventive interventions, will be documented in the resident's medical record. No further information was provided prior to exit. References: (1) Necrosis is the death of body tissue. It occurs when too little blood flows to the tissue. This can be from injury, radiation, or chemicals. Necrosis cannot be reversed. This information is taken from the website https://medlineplus.gov/ency/article/002266.htm (2) Peripheral neuropathies are diseases of the peripheral nervous system that can be divided into mononeuropathies, multifocal neuropathies, and polyneuropathies. Symptoms usually include numbness and paresthesia. These symptoms are often accompanied by weakness and can be painful. This information is taken from the website https://pubmed.ncbi.nlm.nih.gov/27637963/.

Based on observation, resident interviews and staff interviews it was determined the facility staff failed to cook unpasteurized eggs to proper temperatures and failed to properly sanitize food preparation equipment, store reusable cloths between use, and clean food service equipment and food service areas. On 10/12/11 at 8:45 AM, unpasteurized fried eggs were observed on the steam table in the dining room. Two residents were served unpasteurized fried eggs with runny yolks. On 10/14/11 at 6:50 AM, 24 unpasteurized fried eggs were prepared and put into pans for service on the tray line. The temperature of 2 eggs were 140 degrees, and 1 egg was 142 degrees. The yolks were not solid (i.e. were runny). This resulted in the identification of Immediate Jeopardy (Level 4-Isolated) on 10/14/11 at 7:50 AM. The facility staff identified 9 residents who ate fried eggs at breakfast. Three of the residents stated they have received eggs with runny yolks. The findings included: 1. On 10/11/11 at 12:00 noon the kitchen tour was conducted. Several cardboard trays of shell eggs were observed in the 3 door refrigerator near the food preparation area. The eggs were not marked with a "P" to indicate they were pasteurized. On its web site the University of Missouri Extension Division states: (http://missourifamilies.org/features/foodsafetyarticles/fdsftyfeature10.htm) "...The FDA requires that pasteurized shell eggs be individually marked or specially packaged to prevent intermingling with unpasteurized eggs..." On 10/12/11 at 8:45 AM, unpasteurized fried eggs were observed on the steam table in the dining room. Two residents were served unpasteurized fried eggs with runny yolks. On 10/13/11 at 6:40 AM, other staff member #10 (the cook) stated pancakes and scrambled eggs were on the menu for breakfast. At 8:50 AM, fried eggs were observed in the steam table. OSM #10 stated she made approximately 20 over medium fried eggs each morning. She said the over medium fried eggs were not hard in the middle. She said she usually started cooking the eggs between 6:55 AM and 7:00 AM and took them off at about 7:10 AM. On 10/14/11 at 7:33 AM, OSM #10 put 12 eggs on the grill. She flipped the eggs at 7:38 AM. The eggs were removed from the grill at 7:41 AM. The eggs were put in a steam table pan. Another batch of eggs were placed on the grill. OSM #10 did not take the temperature of the first batch of eggs. Other Staff Member (OSM) #4 (dietary manager) was asked to take the temperature of an egg. The temperature was 140 degrees and there was yolk on the thermometer. On 10/14/11 at 7:45 AM, the second batch of eggs was removed from the grill. OSM #4 was asked to take the temperature of 2 eggs. The temperatures were 142 degrees and 140 degrees. The yolks were runny. The fried eggs were put on the tray line for delivery to the residents. OSM #4 tested the thermometer accuracy by emerging it into an ice bath. The thermometer registered 32 degrees. OSM #4 was not sure if the eggs were pasteurized. He stated he had to find an invoice to see if the eggs were pasteurized. OSM #4 stated unpasteurized eggs should be cooked hard to 150 degrees. The USDA 2009 Food Code stated: http://www.fda.gov/Food/FoodSafety/RetailFoodProtection/FoodCode/FoodCode2009/ucm 4.htm "1 -2 Definitions...Highly susceptible population" means PERSONS who are more likely than other people in the general population to experience foodborne disease because they are: (1) Immunocompromised; preschool age children, or older adults; and (2) Obtaining FOOD at a facility that provides services such as custodial care, health care, or assisted living, such as a child or adult day care center, kidney [MEDICAL TREATMENT] center, hospital or nursing home, or nutritional or socialization services such as a senior center .... Cooking 3-401.11 Raw Animal Foods. (A) Except as specified under ? (B) and in ?? (C) and (D) of this section, raw animal FOODS such as EGGS, FISH, MEAT, POULTRY, and FOODS containing these raw animal FOODS, shall be cooked to heat all parts of the FOOD to a temperature and for a time that complies with one of the following methods based on the FOOD that is being cooked: (1) 63oC (145oF) or above for 15 seconds for: P (a) Raw EGGS that are broken and prepared in response to a CONSUMER'S order and for immediate service, ... 3-8 SPECIAL REQUIREMENTS FOR HIGHLY SUSCEPTIBLE POPULATIONS... 3-801.11 Pasteurized Foods, Prohibited Re-Service, and Prohibited Food. In a FOOD ESTABLISHMENT that serves a HIGHLY SUSCEPTIBLE POPULATION: ... (B) Pasteurized EGGS or EGG PRODUCTS shall be substituted for raw EGGS in the preparation of: ... (C) The following FOODS may not be served or offered for sale in a READY-TO-EAT form: ... (2) A partially cooked animal FOOD such as lightly cooked FISH, rare MEAT, soft-cooked EGGS that are made from raw EGGS, and meringue; ... (E) Time only, as the public health control as specified under ? 3-501.19(D), may not be used for raw EGGS. P (F) Subparagraph (B)(2) of this section does not apply if: (1) The raw EGGS are combined immediately before cooking for one CONSUMER ' S serving at a single meal, cooked as specified under Subparagraph 3-401.11(A)(1), and served immediately, such as an omelet, souffle, or scrambled EGGS; ..." On 10/14/11 at 7:50 AM, after consulting with supervisors at the state agency, the survey team determined that the residents at the facility were in immediate jeopardy due to the facility's failure to ensure unpasteurized shell eggs were cooked to the proper temperature and served promptly. On 10/14/11 at 8:05 AM, the administrator was notified of the immediate jeopardy status (scope/severity of Level 4 Isolated). On 10/14/11 at 8:10 AM, OSM #8 (the dietary supervisor) stated she knew the yolk had to be hard. She stated the eggs were cooked to the resident's preferences. She said by the time she saw the eggs they were hard. The raw shell eggs were observed. They were not in the box they were delivered in. They were not marked with a "P". An invoice, dated 10/13/11 was reviewed. The invoice did not state the eggs were pasteurized. OSM #8 stopped the service of fried eggs in the dining room. OSM #8 contacted the vendor. The vendor stated the eggs were not pasteurized. OSM #8 stated the administrator advised her not to serve any unpasteurized eggs. She discarded all the cooked and raw unpasteurized eggs. On 10/14/11 at 8:23 AM, the administrator stated the unpasteurized eggs were discarded and pasteurized scrambled eggs (at the proper temperature) were served to the residents. On 10/14/11 at 8:30 AM, OSM #4 stated he was going to the store to purchase pasteurized eggs. He noted he ordered pasteurized eggs from his regular vendor for delivery on Monday. On 10/14/11 at approximately 9:00 AM, OSM #4 and OSM #8 provided a policy titled Use of Fresh Eggs and dated 6/00. The policy stated "...Fresh eggs must be used in accordance with strict guidelines to prevent the contamination of food by the Salmonella bacteria. Procedure:...6. Fresh eggs may not be used in any product in which the eggs are not adequately cooked to assure that any Salmonella bacteria, if present, are killed by sufficient heat. In its place, pasteurized eggs must be used..." OSM #4 noted the policy was changed that day (10/14/11) to include the following: "8. Pasteurized eggs must be cooked to a temp(erature) of 140 (degrees) or higher. 9. No more unpasteurized eggs will be used in the dietary department...10. Before Breakfast (sic) lunch or dinner is served find a supervisor to double check temps on all food." OSM #4 noted the dietary staff would be inserviced on the new policy concerning eggs. On 10/14/11 at 9:30 AM, OSM #8 purchased 6 dozen shell eggs. Each egg shell was marked with a "P". On 10/14/11 at 9:45 AM, the director of nursing and the administrator presented the plan of removal for review by the survey team. The facility's plan of removal for the immediate jeopardy included the following: 1. Corrective action was immediately taken by serving scrambled eggs to replace the fried eggs. All non-pasteurized eggs have been disposed of. Food manager is obtaining fresh pasteurized eggs for current additional use. Residents who prefer and are served fried eggs include the following medical record numbers: 3857, 1782, 3803, 3809, 3905, 3749, 3220, 3736, and 3161. Administrator and Director of Nursing verified with Charge Nurse and Unit Manager no signs or symptoms related to Salmonella poisoning have been exhibited. (10/14/2011) 2. Scrambled eggs were served for all residents receiving egg products. Correct temperatures were verified by OSM #4. 3. OSM #4 has contacted food vendor to ensure that no non-pasteurized eggs will be purchased. A log to verify all eggs are pasteurized will be put into place. Administrator and OSM #4 will review the purchase orders to verify that no non-pasteurized eggs are ordered. Continue to check temperatures before each meal. An additional temperature check will be performed just prior to serving meals. Education on the potential hazards of serving non-pasteurized foods will be conducted by OSM #4 at 100 percent of employees within 24 hours. 4. Audits will be analyzed and results presented at monthly and quarterly Quality Assurance meeting for 3 months. The audits will be done daily for 3 months and then weekly for an additional 3 months and reported during facility Quality Assurance meetings. 5. Corrective action will be completed today 10-14-2011. Residents #2, #21, #29, #30, #31, #32, #33, #34 and #35 were identified in the plan of removal as preferring and receiving fried eggs. The survey team reviewed the clinical records of the residents identified above. There was no evidence in the clinical record, such GI symptoms that the residents had a Salmonella infection. Three residents (Residents #21, #31 and #32) stated they were served eggs with runny yolks in the past. The interviews were as follows: - Resident # 21 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The most recent MDS (minimum data set) assessment, a significant change assessment, with an ARD (assessment reference date) of 08/24/11 coded the resident as being moderately impaired to make daily decisions. The resident was coded as usually understanding others and usually being capable of being understood by others. An interview was conducted with Resident # 21 on 10/14/11 at 10:45 a.m. When asked how the resident's fried eggs were served the resident stated, "I kept getting them runny and I don't like them runny. " When asked how often she eats fried eggs, Resident # 21 stated, "I switch around, I'm now on a scrambled egg kick. " - Resident #31 was a [AGE] year old admitted to the facility with multiple [DIAGNOSES REDACTED]. He was identified by the facility staff as interviewable. An interview was conducted with Resident #31 on 10/14/11 at 10:50 a.m. Resident #31 stated " I like my eggs soft fried, the yokes run a little bit but it ' s soft. " - Resident #32 was a [AGE] year old admitted to the facility with multiple [DIAGNOSES REDACTED]. He was identified by the facility staff as interviewable. An interview was conducted with Resident #32 on 10/14/11 at 11:00 a.m. Resident #32 stated, "I like fried eggs, I like the middle runny. " On 10/14/11 at 10:30 AM, OSM #9 (the registered dietitian) stated under easy eggs and raw eggs should be pasteurized or a waiver (to serve undercooked unpasteurized eggs) should be obtained from the resident or family member. She noted serving undercooked unpasteurized eggs "goes against the health code". She noted she was not aware the facility served undercooked unpasteurized eggs. She said unpasteurized eggs should be cooked to temperature. On 10/14/11 at 11:00 AM, OSM #4 stated OSM #8 ordered the eggs. He noted they obtained them from a reputable supplier. He said he thought the eggs were pasteurized. OSM #8 stated she "just says eggs" when ordering. She noted she did not know how to check the eggs to ensure they were pasteurized. She said today was the first time the eggs had the letter "P" on them. On 10/14/11 at 11:10 AM, OSM #9 stated she told the administrator unpasteurized eggs had to be cooked to 160 degrees to kill any Salmonella if present. She noted pasteurized eggs could be served undercooked or raw. The survey team reviewed the plan of removal and accepted the plan with abatement of the immediate jeopardy status on 10/14/11 at 11:50 AM. The scope and severity level of the remaining deficient practice was reduced to a Level 2 widespread. 2. On 10/13/11 at 10:20 AM, other staff member (OSM) #15 (assistant food service manager) was washing food production equipment including the food processor bowl and blade in the 3-compartment sink. Water was dripping into the sinks from leaks on the spigot on the left faucet and both faucets. There were signs on the 3 sinks, which said to wash in the first sink, rinse in the second sink and sanitize in the third sink. OSM #15 was asked to test the sanitizer concentration. She put the test strip in the second sink (as noted above the sanitizer should be in the third sink). The test strip registered 200 ppm of sanitizer, which was the correct concentration. OSM #15 stated the first sink contained soapy water, the second sink contained sanitizer and the third sink contained rinse water. OSM #10 and #16 stated when washing equipment, they set up the 3-compartment sink the same way (wash, sanitize and rinse). OSM #8 (dietary supervisor) stated the sinks should be set up with the wash first, the rinse second and the sanitizer third. OSM #15 continued to wash the equipment. She dipped the equipment into the sanitizer last. OSM #4 stated for effective sanitization the equipment should be in the sanitizer for about 2 minutes. OSM #15 re-set the sinks correctly and finished washing the food production equipment. 3. On 10/13/11 at 11:15 AM, a reusable cleaning cloth was observed in a 1 gallon bucket. OSM #10 washed down a food preparation table with the cloth. OSM #10 stated the bucket contained soapy water. She emptied the soapy water and put bleach and sanitizer in the bucket. The USDA 2009 Food Code states " ...3-304.14 Wiping Cloths, Use Limitation. (B) Cloths in-use for wiping counters and other equipment surfaces shall be:...(1) Held between uses in a chemical sanitizer solution at a concentration specified under ? 4-501.114; ... " 4. On 10/11/11 at 12:00 noon, 10/13/11 at 10:20 AM, and 10/14/11 at 6:50 AM, large fans were observed in the food production and tray assembly areas. There was a large amount of greasy dust on the grills and blades of the fans. The fans were observed at various times to be blowing on prepared food and clean silverware. OSM #4 stated the fans need to be cleaned and they should not blow directly on the food. 5. On 10/11/11 at 12:00 noon and 10/13/11 at 6:40 AM and 10:20 AM, the 3 door reach-in refrigerator near the food preparation area was observed. There was a crack in the plastic on the floor of the left side compartment. The temperature was 40 degrees during all observations. 6. On 10/11/11 at 12:00 noon and 10/13/11 at 10:20 AM, there was red and black material on a plastic surface inside the ice maker storage compartment. OSM #4 stated the ice maker should be cleaned. 7. On 10/11/11 at 12:00 noon and 10/13/11 at 10:20 AM, visible debris was observed in the following areas: on the walls, floor and shelves of the 3 door reach-in refrigerator near the food production area, the pipe and the floor near the fryer, the lip of the stove top in front of the grill, the slicer, the floor and tables in the dish washing area, the sugar and flour bins, the floor of 3-door reach-in refrigerator #3, the door between the kitchen and the dining room, and the floors under equipment. OSM #4 stated the areas needed to be cleaned.