Every finding on record at Carlyle Senior Care of Williston

Based on facility policy review, observation, and interview, the facility failed to ensure residents' right to reside in a safe, clean, comfortable, and homelike environment, related to routine cleaning of resident rooms and bathrooms. The deficient practice affected 8 (Rooms 1, 2, 7, 8, 9, 10, 11, and 12) of 9 resident rooms reviewed for environmental concerns. Findings included: Review of an undated facility policy titled, Routine Bathroom Cleaning indicated, It is the policy of this facility to establish policies, procedures and guidelines to provide a clean and sanitary environment for residents, staff and visitors in order to prevent cross contamination and transmission of healthcare associated infection (HAI). The policy's Procedure included 1. Working from clean areas to dirty areas, which included d. Clean inside and outside the sink, sink faucets and mirror. Wipe plumbing under the sink. Apply disinfectants to interior of sink and allow sufficient contact time with disinfectant according to manufacturer's recommendations. Rinse sink and dry fixtures; e. Clean all dispensers and frames; and i. Clean entire toilet including handle and underside of flush rim. Apply disinfectant and allow sufficient contact time according to manufacturer's recommendations. During an initial tour of the facility on 04/17/26 at 9:10 AM, the following was observed: - room [ROOM NUMBER]'s bathroom- A white, milky substance clouded the bottom third of the bathroom mirror. The soap dispenser did not have any soap in it. The soap dispenser appeared to have been replaced, but damage to the wall behind it was not repaired prior to hanging the new soap dispenser. - room [ROOM NUMBER]'s bathroom- A white, milky substance was observed on the mirror, the soap dispenser appeared to have been replaced, but damage to the wall behind it was not repaired prior to hanging the new soap dispenser, and a plastic bag was hanging over the toilet paper dispenser. - room [ROOM NUMBER]'s and room [ROOM NUMBER]'s shared bathroom- A broken toilet paper dispenser with sharp edges, rusted-colored stains inside the toilet bowl, the soap dispenser appeared to have been replaced, but damage to the wall behind it was not repaired prior to hanging the new soap dispenser. - room [ROOM NUMBER]'s and room [ROOM NUMBER]'s shared bathroom- There were rust-colored stains in the toilet bowl, a brown smudged substance about the size of a quarter on the back of the toilet, the soap dispenser appeared to have been replaced, but damage to the wall behind it was not repaired prior to hanging the new soap dispenser. - room [ROOM NUMBER]'s bathroom- Both the sink and toilet had rust colored stains, and there was resident equipment being stored in the bathroom. The mirror in the bathroom had milky residue obscuring the bottom third of the mirror. The soap dispenser appeared to have been replaced, but damage to the wall behind it was not repaired prior to hanging the new soap dispenser. - room [ROOM NUMBER]'s bathroom- A white, milky substance was observed on the mirror, the soap dispenser appeared to have been replaced, but damage to the wall behind it was not repaired prior to hanging the new soap dispenser, and a roll of toilet paper was inside the toilet bowl. During a follow-up observation on 04/17/26 beginning at 8:45 AM, the following was observed: - room [ROOM NUMBER]'s bathroom- The damage to the wall behind the soap dispenser remained. - room [ROOM NUMBER]'s bathroom- The same milky substance was observed on the mirror, the damage to the wall behind the soap dispenser remained, and a plastic bag was hanging over the toilet paper dispenser. - room [ROOM NUMBER]'s and room [ROOM NUMBER]'s shared bathroom- The broken toilet paper dispenser with sharp edges, rusted-colored stains inside the toilet bowl, and the damage to the wall behind the soap dispenser remained. - room [ROOM NUMBER]'s and room [ROOM NUMBER]'s shared bathroom- Rust colored stains in the toilet bowl, brown smudged substance about the size of a quarter on the back of the toilet, and the damage to the wall behind the soap dispenser remained. - room [ROOM NUMBER]'s bathroom- The rust-colored stains in the toilet and sink, resident equipment being stored in the bathroom, the mirror in the bathroom had the same milky residue obscuring the bottom third of the mirror, and the damage to the wall behind the soap dispenser remained. - room [ROOM NUMBER]'s bathroom- The same milky substance on the mirror, the damage to the wall behind the soap dispenser, and a roll of toilet paper inside the toilet bowl remained. During an interview on 04/17/26 at 11:35 AM, the Maintenance Director stated that the expectation was that every resident room and bathroom was to be cleaned at least once a day and more often if needed. He stated that even if the room was empty, it was still an expectation that the bathroom was to be cleaned. The Maintenance Director stated that there was a maintenance logbook for anything that needed to be fixed, and he expected any staff to report items that needed attention in the maintenance logbook. The Maintenance Director revealed that every couple of months he conducted facility rounds with the Administrator (ADM) and identified areas needing cleaning or fixed, which they called Angel Rounds. The Maintenance Director stated that each resident's room was their own apartment, and it should feel like home. He stated that all residents allowed housekeeping staff into their rooms to clean both the room and the bathroom. An observation of Rooms 1 through 12 on 04/17/26, beginning at 11:45 AM, was completed with the Maintenance Director and the ADM and revealed the following: - room [ROOM NUMBER]'s bathroom- The Maintenance Director stated that the mirror was dirty and the toilet had stains. He stated that the bathroom did not appear to have been cleaned in a while. - room [ROOM NUMBER]'s and room [ROOM NUMBER]'s shared bathroom- Per the Maintenance Director and the ADM, no one had reported the broken toilet paper dispenser, and it was stated that at least two of the four residents who shared the bathroom were capable of using the toilet on their own. The damage to the wall behind the soap dispenser remained, and the bottom third of the bathroom mirror was clouded by a white, milky substance. In regard to how often the Maintenance Director made round of the resident rooms, he stated, Not enough. - room [ROOM NUMBER]'s and room [ROOM NUMBER]'s shared bathroom- A brown substance smeared on the back of the toilet and rust-colored stains were observed. The Maintenance Director stated that if staff could not remove the stains, then the toilet should be replaced. - room [ROOM NUMBER]'s bathroom- The damaged wall behind the soap dispenser remained, and the mirror had the same white milky residue. A toilet paper roll remained in the toilet. The main part of the resident room had scuff marks along the lower part of the wall and paint chips about the size of half a dollar. The Maintenance Director stated that the wall behind the soap dispenser should have been repaired prior to the new soap dispenser being hung up. The ADM stated he expected the room to be in better condition if it was his own loved one moving in. - room [ROOM NUMBER]'s bathroom- The resident's equipment being stored in the bathroom remained. The Maintenance Director observed the rust-colored stains in the sink and toilet and stated, It is obvious that it has not been cleaned. During an interview on 04/17/26 at 4:06 PM, Housekeeper #5 revealed being aware of the broken toilet paper dispenser in room [ROOM NUMBER]'s and room [ROOM NUMBER]'s shared bathroom but could not recall when she had reported it; and stated having written it in the maintenance book. Housekeeper #5 stated that if something was broken, she reported it to maintenance staff or her supervisor. During an interview on 04/17/26 at 3:47 PM, the Maintenance Director stated that he had met with the housekeepers, who denied not cleaning the restrooms. He revealed he had conducted education with the housekeepers on room cleaning back in January of 2026. During an interview on 04/17/26 at 12:17 PM, the ADM stated his expectation was that they would get everything fixed and to come up with a system to increase rounds; maybe develop some type of check-off list for rooms.

Based on observation, interview, record review, and facility policy review, the facility failed to ensure treatment in accordance with professional standards of practice for 1 (Resident (R)25) of 2 sampled residents reviewed for wound dressing changes. Specifically, R25's wound dressing was not changed on 04/13/26 as ordered. Findings included: Review of the facility policy titled, Documentation of Wound Treatments, dated 08/01/2025, indicated, Wound treatments are documented at the time of each treatment. Review of the facility policy titled, Clean Dressing Change, dated 11/30/2025, indicated, Physician's orders will specify type of dressing and frequency of changes. An admission Record indicated the facility admitted R25 on 10/24/25. According to the admission Record, the resident had a medical history that included a diagnosis of a chronic non-pressure ulcer of the right lower leg with unspecified severity (a persistent sore or wound not caused by pressure). A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 01/23/26, revealed R25 had a Brief Interview for Mental Status (BIMS) score of 11, which indicated the resident had moderate cognitive impairment. R25's Care Plan Report included a focus area, initiated 10/27/25 and resolved 12/22/25, that indicated the resident had a non-pressure wound to the right lower shin. Interventions directed staff to refer R25 to a wound care doctor, to follow the facility's and doctor's orders, to avoid friction/shearing, and to offer appropriate wound healing supplements. R25's Order Summary Report, with active orders as of 04/16/26, included: Clean area to right lower shin with wound cleanser, apply xerofoam [a medicated gauze dressing] and cover with bordered gauze dressing and change daily and PRN [pro re nata, as-needed] until healed, every day shift for stasis ulcer, dated 04/12/2026. R25's Treatment Administration Record [TAR], dated 04/26, included the transcription of a physician's order that indicated, Clean area to right lower shin with wound cleanser, apply xerofoam and cover with bordered gauze dressing. Change daily and PRN until healed. [sic] every day shift for stasis ulcer - Start Date - 04/13/2026 0700. The TAR revealed the entry space for R25's dressing change on 04/13/2025 was blank which indicated the dressing change had not been done. During an interview on 04/14/26 at 11:16 AM, R25 stated the resident had a sore on their right leg, it had been an ongoing problem, and they had the wound before being admitted into the facility. R25 stated the dressing was supposed to be changed daily, but the nurses did not change the wound dressing daily. During a concurrent observation and interview on 04/14/26 at 11:34 AM, Licensed Practical Nurse (LPN)1 stated R25 had a vascular wound (an open sore related to poor circulation) on the right leg. The observation revealed R25's right lower leg shin dressing was dated 04/12/26, and LPN1 confirmed the date on the dressing was 04/12/26. LPN1 stated R25's dressing changes were supposed to be performed daily. During an interview on 04/17/26 at 11:54 AM, the Director of Nursing (DON) stated she expected nurses to adhere to and follow the physician's orders exactly to ensure the best care was provided to the residents. The DON stated R25's dressings should have been changed on 04/13/26. During an interview on 04/17/26 at 11:56 AM, the Corporate Clinical Consultant (CCC) stated she expected physician's orders to be followed. The CCC stated it was a standard of practice to follow physician's orders. The CCC stated if physician's orders were not followed, it should have been documented as to why they were not followed. The CCC stated not following orders could have resulted in the worsening of the wound that could have potentially led to an amputation. During an interview on 04/17/26 at 12:09 PM, the Administrator (ADM) stated he expected physician's orders to be followed, and R25's dressing should have been changed daily.

Based on observation, interview, record review, and facility policy review, the facility failed to ensure enhanced barrier precautions (EBP) were implemented for 2 (Resident (R)25 and R40) of 4 residents reviewed for EBP. Specifically, staff failed to don gowns prior to high contact resident care activities for R25 and R40. Additionally, Licensed Practical Nurse (LPN)2 failed to dispose of worn gloves prior to leaving R40's room. Findings included: 1. Review of the facility policy titled, Enhanced Barrier Precautions, dated 05/30/2024, indicated, It is the policy of this facility to implement enhanced barrier precautions for the prevention of transmission of multidrug-resistant organisms [MDRO]. The policy also indicated, 'Enhanced barrier precautions [EBP] refer to an infection control intervention designed to reduce transmission of multidrug resistant organisms that employs targeted gown and gloves use during high contact resident care activities. The policy also indicated, Wounds (e.g. [exempli gratia, for example], chronic wounds such as pressure ulcers, diabetic foot ulcers, unhealed surgical wounds, and chronic venous stasis ulcers) and/or indwelling medical devices (e.g., central lines, urinary catheters, feeding tubes, tracheostomy/ventilator tubes, hemodialysis catheters, PICC [peripherally inserted venous catheter] lines, midline catheters) even if the resident is not known to be infected or colonized with a MDRO. The policy also indicated, PPE [personal protective equipment] for enhanced barrier precautions is only necessary when performing high-contact care activities and may not need to be donned prior to entering the resident's room. It continued, Position a trash can inside the resident room and near the exit for discarding PPE after removal, prior to exit of the room or before providing care for another resident in the same room. The policy also indicated, High-contact resident care activities include, and h. Wound care: any skin opening requiring a dressing. Review of the facility policy titled, Standard Precautions Infection Control, dated 06/30/2025, indicated, All staff are to assume that all residents are potentially infected or colonized with an organism that could be transmitted during the course of providing resident care services. Therefore, all staff shall adhere to Standard Precautions to prevent the spread of infection to residents, staff and visitors. The policy also indicated, Standard Precautions refers to the infection prevention practices that apply to all residents, regardless of suspected or confirmed diagnosis or presumed infection status. This includes hand hygiene, selection and use of PPE (e.g., gloves, gowns, facemask, respirators, eye protection), respiratory hygiene and cough etiquette, safe injection practices, environmental cleaning and disinfection, and reprocessing of reusable resident medical equipment. The policy also indicated, All staff who have contact with residents and/or their environments must wear personal protective equipment as appropriate during resident care activities and at other times in which exposure to blood, body fluids, or potentially infectious materials is likely. Review of the facility policy titled, Standard Precautions Infection Control Protocol, dated 2025, indicated in the section Personal Protective Equipment that gloves were for the practices of, touching blood, body fluids, secretion, excretions, contaminated items; for touching mucous membranes, non-intact and intact resident skin, and gowns were for practices, During the procedures and resident-care activities when contact of clothing/exposed skin with blood/body fluids, secretions, and excretions is anticipated. Review of an admission Record indicated the facility admitted R25 on 10/24/25. According to the admission Record, the resident had a medical history that included a diagnosis of a chronic non-pressure ulcer of the right lower leg with unspecified severity (a persistent sore or wound not caused by pressure). Review of a quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 01/23/26, revealed R25 had a Brief Interview for Mental Status (BIMS) score of 11, which indicated the resident had moderate cognitive impairment. The MDS indicated R25 had no venous ulcers present. Review of R25's Care Plan Report included a focus area, initiated 10/27/25 and resolved 12/22/25, that indicated the resident had a non-pressure wound to the right lower shin. R25's Care Plan Report also included a focus area, initiated 12/01/25 and resolved 12/08/25, that indicated the resident had a non-pressure wound to the left shin. Interventions directed staff to refer R25 to a wound care doctor, to follow the facility's and doctor's orders, to avoid friction/shearing, and to offer appropriate wound healing supplements. Review of R25's Order Summary Report, with active orders as of 04/16/2026, included: Clean area to right lower shin with wound cleanser, apply xerofoam [a medicated gauze dressing] and cover with bordered gauze dressing. Change daily and PRN [pro re nata, as-needed] until healed, every day shift for stasis ulcer, dated 04/12/2026 and- Enhanced barrier precautions every shift for chronic wound, dated 04/15/2026. An observation, on 04/14/26 at 11:16 AM, revealed R25's room had EBP signage on the door, and a supply cart filled with gowns and gloves was outside the door. During a concurrent interview, R25 stated the resident had a wound on their right leg. An observation, on 04/14/26 at 11:34 AM, revealed Licensed Practical Nurse (LPN)1 removed R25's right lower leg shin dressing while wearing gloves. During a concurrent interview, LPN1 stated she did not wear a gown but should have worn one. During an interview on 04/16/26 at 2:56 PM, the Infection Preventionist (IP) stated that if a resident had an open wound, whether acute or chronic, the resident had to be placed on EBPs, and gowns and gloves were required when performing patient care. The IP stated LPN1 should have worn a gown while caring for R25's wound dressing. The IP stated it was important that gowns had to be worn to prevent any spread of pathogens. During an interview on 04/17/26 at 11:32 AM, the Director of Nursing (DON) stated it was her expectation for staff to adhere to EBP guidelines. The DON stated that when nurses had direct patient care such as wound care, they had to wear gowns and gloves. The DON stated it was important to follow EBP guidelines so as not to spread infections. During an interview on 04/17/26 at 11:41 AM, the Administrator (ADM) stated he expected staff to follow standards of practice. During an interview on 04/17/26 at 3:54 PM, LPN3 stated residents who had open wounds had to be placed on EBPs. LPN3 stated staff had to wear gowns and gloves whenever direct patient care was done. 2. An admission Record indicated the facility originally admitted R40 on 08/14/23, with the most recent admission date on 02/17/25. According to the admission Record, the resident had a medical history that included a diagnosis of lymphedema. Review of a quarterly MDS, with an ARD of 02/21/26, revealed R40 had a BIMS score of 14, which indicated the resident had intact cognition. Review of R40's Care Plan Report included a focus area, initiated 01/06/2026, that indicated the resident had wounds to the right leg and foot due to lymphedema. Interventions directed staff to provide wound care to the right leg and foot as ordered until resolved. Review of R40's Order Summary Report with active orders as of 04/16/2026, included: - Enhanced barrier precautions, dated 02/18/2026; - dorzolamide HCL (hydrochloride) - timolol ophthalmic solution, 2%/- 0.5%, one drop in both eyes two times a day for glaucoma, started 11/11/2025; - Cleanse wounds to right lateral calf, right lateral thigh, right lateral foot, right distal calf with wound cleanser, apply calcium alginate (a wound dressing) to the wound bed only, cover with rolled gauze, two times a day for wound care, as needed, dated 04/15/2026; - Cleanse wounds to right distal thigh, apply calcium alginate to the wound bed only, cover with rolled gauze, two times a day for lymphedema, dated 04/16/2026; - Cleanse wounds to right lateral foot, apply calcium alginate to the wound bed only, cover with rolled gauze, as needed dated 04/16/2026; and - Cleanse wounds to right lateral foot, apply calcium alginate to the wound bed only, cover with rolled gauze, two times a day for wound care, dated 04/16/2026. An observation on 04/15/26 at 8:25 AM revealed LPN2 went into R40's room to administer morning medications. The observation revealed R40 was in a room that required enhanced barrier precautions (EBPs). The observation revealed LPN2 performed hand hygiene and donned gloves. The observation revealed LPN2 pulled down R40's conjunctiva (a thin, transparent mucous membrane that lines the inside of the eyelids) and instilled one eye drop in each eye and wiped away an extra drop. The observation revealed LPN2 exited the room without removing gloves and performing hand hygiene. The observation revealed LPN2 returned to the medication cart and removed her gloves there. During an interview on 04/15/26 at 8:25 AM, LPN2 stated she should have worn a gown when administering R40's eye drops. LPN2 stated she should not have worn gloves in the hallway after providing care to R40. LPN2 stated she should have removed the gloves and performed hand hygiene before leaving the room. During an interview on 04/16/26 at 2:56 PM, the Infection Preventionist (IP) stated that if a resident had an open wound, whether acute or chronic, they had to be placed on EBPs, and gowns and gloves were required when performing patient care. The IP stated hand hygiene had to be performed before and after patient care. The IP stated LPN2 should not have worn gloves in the hallway and should have removed them inside R40's room. The IP stated wearing gloves in the hallway posed a contamination risk. The IP stated they did not think a gown needed to be worn when administering eye drops to residents on EBP who did not have a wound near their eyes, but that gloves were necessary. During an interview on 04/17/26 at 11:32 AM, the DON stated it was her expectation for staff to adhere to EBP guidelines. The DON stated LPN2 should not have been walking in the hallway while wearing gloves. The DON stated PPE should have been disposed inside the room before exiting. The DON stated it was important to follow EBP guidelines so as not to spread infections. During an interview on 04/17/26 at 11:41 AM, the ADM stated he expected staff to follow standards of practice. During an interview on 04/17/26 at 3:54 PM, LPN3 stated residents who had open wounds had to be placed on EBPs. LPN3 stated staff had to wear gowns and gloves whenever direct patient care was done.

Based on facility policy review, facility document review, observation, and interview, the facility failed to ensure drugs and biologicals were labeled in accordance with professional principles. Specifically, the facility failed to date a multi-dose vial of tuberculin purified protein derivative (PPD) (a solution used to detect tuberculosis infection) with an opened date and a discard date and failed to discard an expired multi-dose vial of tuberculin PPD. The facility also failed to date a semaglutide (an antidiabetic) injection pen with an opened date and discard date. The deficiencies were identified in 1 of 2 medication storage refrigerators observed. Findings included: Review of a facility policy titled, Medication Management, dated 04/10/2019, indicated, All medications and biologicals used in the facility will be labeled in accordance with current state and federal regulations to facilitate consideration of precautions and safe administration of medications. The policy indicated, 4. Labels for individual drug containers must include, which included f. The date the drug was dispensed; and h. The expiration date when applicable. The policy further indicated, 6. Labels for each floor/unit's stock medications must include, which included c. The expiration date when applicable. The policy revealed, 8. Labels for multi-use vials must include, which included a. The date the vial was initially opened or accessed (needle-punctured); b. All opened or accessed vials should be discarded within 28 days unless the manufacturer specifies a different (shorter or longer) date for that opened vial; and c. Unopened or unaccessed (needle-punctured) vials should be discarded according to the manufacturer's instructions. Review of a facility policy titled, Medication Administration, dated 10/22/2022, indicated, Medications are administered by licensed nurses, or other staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice, in a manger to prevent contamination or infection. The policy revealed, 12. Identify expiration date. If expired, notify nurse manager. Review of a facility document titled, Medication with shortened expiration dates, dated 2025-2026, included Tuberculin PPD, diluted injection, which instructed to Discard vial 30 days after opening. The document revealed, Semaglutide injection, which instructed Keep refrigerated until dose given OR each multi-dose pen can be stored at 59-86 F [degrees Fahrenheit] or refrigerated for up to 56 days after first use. The document revealed, How to use, which included 1. Pick the month you first opened (punctured/used) the vial/medication; and 4. Write on auxiliary sticker/product (not Rx label) 'Date opened' and 'Date Expired' (Do not use medication beyond this date). Review of a quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 04/07/26, revealed the facility admitted R1 on 09/22/23. According to the MDS, the resident had active diagnoses that included diabetes mellitus. The MDS indicated the resident had a Brief Interview for Mental Status (BIMS) score of 13, which indicated the resident had intact cognition. An observation with the Director of Nursing (DON) on 04/16/26 at 1:14 PM in the facility's medication storage room revealed that in a medications storage refrigerator there was an opened and used vial of a tuberculin PPD was observed that did not have an opened or date expired written on the bottle or vial. Another tuberculin PPD vial was observed that had a discard date of 04/15/25 written on the bottle. An opened and used semaglutide injection pen that belonged to R1 was observed without an opened or discard date written on the box. During an interview at the time of the observation, the DON stated she expected used medications to have an opened date and discard date on all the medications. The DON stated it was important to have medications dated so residents did not receive expired medications. The DON stated expired medications were not effective and had the potential to cause severe side effects. During an interview on 04/16/26 at 3:42 PM, the Corporate Clinical Consultant stated that the dates on the multi-dose vials had to have dates when it was opened along with the expiration dates. During an interview on 04/16/26 at 2:19 PM, the Infection Preventionist (IP) stated that once medications were opened, nurses should label them with an opened date and discard-by date. The IP stated that the medication in Resident #1's injector pen only lasted a month and should have been discarded after a month. The IP stated residents should not be given expired medications. She added that expired medications had the potential to cause adverse reactions and would not be therapeutic. During an interview on 04/16/26 at 3:41 PM, the Administrator (ADM) stated he deferred to the nurse and nurse consultant regarding the labeling of dates of medications.

Based on facility policy review, record review, and interview, the facility failed to ensure Minimum Data Set (MDS) assessments were accurately coded to reflect residents' status, which affected 1 (Resident (R)32) of 2 residents reviewed for tube feeding and R40, 1 of 1 resident reviewed for edema. Findings included: An undated facility policy titled, MDS [Minimum Data Set] 3.0 Completion, revealed Residents are assessed, using a comprehensive assessment process, in order to identify care needs and to develop an interdisciplinary care plan. The policy revealed, 1. According to federal regulations, the facility conducts initially and periodically a comprehensive, accurate and standardized assessment of each resident's functional capacity, using the RAI [Resident Assessment Instrument] specified by the State. The policy revealed, 4. Care Plan Team Responsibility for Assessment Completion included a. Interdisciplinary Responsibility for Completion of MDS Sections, which included i. The responsibility of all sections of the MDS will be clearly assigned; ii. Persons completing part of the assessment must attest to the accuracy of the section they completed by signature and indication of the relevant sections; and iii. The R.N. (Registered Nurse) Coordinator signs, dates, and attests (in section Z0500A) to timely completion of the RAI, once all other disciplines have completed their sections. The policy revealed, d. Care Area Assessment (CAA's) included iii. Based on the CAA review, key findings regarding a resident's status are documented, including the nature of the condition, complications and risk factors that affect the care planning decision, factors that must be considered in developing care plan interventions, and the need for referrals or evaluation by appropriate health professionals. The policy revealed, 5. Corrections of Errors on the Assessment included i. Modification, which included i. A Modification Request is used when an MDS record (assessment, entry tracking record, or death in facility tracking record) is in the QIES [Quality Improvement and Evaluation System] ASAP [Assessment and Submission and Processing] system (already transmitted and accepted by CMS [Centers for Medicare and Medicaid Services]), but the information in the record contains clinical or demographic errors. It must be corrected within 14 days after identifying errors. 1. An admission Record revealed the facility admitted R32 on 01/11/24. According to the admission Record, the resident had a medical history that included diagnoses of adult failure to thrive, unspecified protein-calorie malnutrition, Alzheimer's Disease, dysphagia, and gastrostomy status. An annual Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 01/16/26, revealed R32 had a Brief Interview for Mental Status (BIMS) score of 3, which indicated the resident had severe cognitive impairment. The MDS further indicated the resident had a feeding tube (nasogastric or abdominal) while a resident of the facility and within the last seven days of the look-back period. The MDS also indicated R32's received 51 percent (%) or more of their total calories through parenteral or tube feeding and 501 cubic centimeter (cc)/day or more of their average fluid intake by intravenous (IV) or tube feeding within the last seven days of the look-back period. R32's Care Plan Report included a focus area initiated 10/08/24, that indicated the resident required tube feeding. Per the Care Plan Report, the focus area revealed, 12/4/25 RESIDENT TUBE D/C. R32's Order Recap [Recapitulation] Report, for the timeframe from 12/01/25 through 04/16/26, revealed the enteral feed order for Jevity (a liquid supplement that provides nutrition) 1.5 at 55 milliliters (ml)/hour (hr) for 12 hrs was discontinued on 12/04/25. The reason indicated dc'd [discontinued] feeding tube. During an interview on 04/16/26 at 8:35 AM, the MDS Nurse stated she was responsible for checking the entire MDS for accuracy and department directors were responsible for their individual sections. She stated that the Certified Dietary Manager (CDM) was responsible for Section K of the MDS, that documented dietary needs. The MDS Nurse stated the R32's annual MDS was incorrect because the resident's tube feeding was discontinued on 12/04/25. The MDS Nurse stated that she should have double checked the MDS and caught the error. During an interview on 04/16/26 at 9:08 AM, the CDM stated that Section K of the MDS was her responsibility. The CDM confirmed R32's tube feeding was discontinued on 12/04/25, and she had marked that the resident was still receiving tube feeding on their 01/16/26 annual MDS. The CDM said she did not know how she missed that. During an interview on 04/16/26 at 1:33 PM, the Corporate Clinical Consultant (CCC) stated that the MDS assessment should accurately reflect the resident's status. During an interview on 04/16/26 at 1:51 PM, the Administrator (ADM) stated his expectation was for the MDS to be correct, and that it mirror the residents and their care needs. 2. An admission Record indicated the facility admitted R40 on 02/17/25. According to the admission Record, the resident had a medical history that included a diagnosis of lymphedema. A quarterly MDS, with an ARD of 02/21/26, revealed R40 had a BIMS score of 14, which indicated the resident had intact cognition. The MDS further revealed the resident's diagnosis of lymphedema was not included under the section titled, Section I- Active Diagnoses. R40's Care Plan Report included a focus area initiated 02/19/25, that indicated the resident had edema related to a history of lymphedema. Interventions directed staff to elevate extremities as needed, position to aid in reducing edema, and follow diet as ordered. R40's Order Summary Report with active orders as of 04/16/26, contained an order dated 02/18/26 to apply lymphatic boot to the resident's right leg for one hour twice a day for lymphedema.During an interview on 04/16/26 at 4:15 PM, the MDS Nurse stated she was responsible for updating residents' MDS assessments. The MDS Nurse stated R40 had a diagnosis of lymphedema and it should have been represented in the resident's 02/21/2026 MDS. She stated she must have missed it, but that it should have been there. During an interview on 04/17/26 at 11:43 AM, the Director of Nursing (DON) stated she expected the MDS to be accurately coded. The DON stated that an inaccurate MDS had the potential to affect resident care as it could result in inaccurate care plans. CCDuring an interview on 04/17/26 at 11:46 AM, the CCC stated she expected the MDS to be accurate.

Based on record review, interview, and facility policy review, the facility failed to provide written information regarding the facility's bed hold policy to the resident's responsible party (RP) at the time of transfer or within 24 hours of the transfer for three residents (Resident (R) 4, R23 and R33) of three reviewed for hospitalization out of a total sample of 17 residents. This failure has the potential to negatively impact any resident transferred to the hospital due to the RP not being aware of the bed hold options. Findings include: Review of the facility's policy titled, Bed Hold Notice Upon Transfer dated 02/01/23 indicated, Policy: At the time of transfer for hospitalization or therapeutic leave, the facility will provide the resident and/or the resident's representative written notice which specifies the duration of the bed-hold policy and addresses the information explaining the return of the resident to the next available bed .Bed Hold Notice Upon Transfer 1. Before a resident is transferred to the hospital .the facility will provide to the resident and/or the resident representative written information that specifies, a. The duration of the state bed-hold policy .during which the resident is permitted to return and resume residence in the nursing facility; b. The reserve bed payment in the state plan policy, if any. c. The facility policies regarding bed-hold periods to include allowing residents to return to the next available bed. d. Conditions upon which the resident would return to the facility: The resident requires the services which the facility provides .2. In the event of an emergency transfer of a resident, the facility will provide within 24 hours written notice of the facility's bed hold policies . Review of the facility's admission packet under the section titled, Bed Holds and Discharges undated indicated, 1. Bed Hold Procedure The Resident may need to be absent from the Facility temporarily for hospitalization . The Resident may request that the Facility hold open the Resident's bed during this time. This is known as a bed hold. The Resident shall be given notice the bed hold option at the time of the hospitalization . If the Resident's care is paid under the Medicaid program .Medicaid allows for 10 bed hold days. If the Resident's care is not paid under the Medicaid program the Resident requesting a bed hold must pay the Facility's private daily rate for the bed being held during the bed hold period . 1.Review of the electronic medical record (EMR) under the Face Sheet tab revealed R4 was initially admitted to the facility on [DATE]. Review of R4's EMR under the Notes tab revealed R4 was admitted to the hospital on 09/04/24 due to hyperkalemia. There was no documentation, located in the EMR, confirming that written information regarding the facility's bed hold policy was provided to R4's RP at the time of the transfer. 2.Review of the EMR under the Face Sheet tab revealed R23 was initially admitted to the facility on [DATE]. Review of R23's EMR under the Notes tab revealed R23 was admitted to the hospital on 01/06/25 due to sepsis. There was no documentation, located in the EMR, confirming that written information regarding the facility's bed hold policy was provided to R23's RP at the time of the transfer. 3.Review of the EMR under the Face Sheet tab revealed R33 was admitted to the facility on [DATE]. Review of R33's EMR under the Notes tab revealed R33 was admitted to the hospital on 02/17/25 due to the diagnosis of sepsis. There was no documentation, located in the EMR, confirming that written information regarding the facility's bed hold policy was provided to R23's RP at the time of the transfer. During an interview on 03/06/25 at 1:30 PM with the Director of Nursing (DON) explained that upon transfer of a resident nursing places a copy of the facility's bed hold policy with the information that was sent with a resident to the hospital. The DON said that all residents and RPs are provided a copy of the facility's bed hold policy upon admission. The DON was not aware that written information needed to also be provided to the resident's RP.

Based on record review and interview, the facility failed to notify in writing the resident's responsible party (RP) of three of three Residents (R4, R23, and R33) transfer to the hospital out of a sample of 17 residents. This had the potential for the resident's RP not to be informed of the resident's transfer to the hospital and the reasons why. Findings include: 1.Review of the electronic medical record (EMR) under the Face Sheet tab revealed R4 was initially admitted to the facility on [DATE]. Review of R4's EMR under the Notes tab revealed R4 was admitted to the hospital on 09/04/24 due to hyperkalemia. There was no documentation, located in the EMR, of written notification regarding R4's transfer to R4's RP. 2.Review of the EMR under the Face Sheet tab revealed R23 was initially admitted to the facility on [DATE]. Review of R23's EMR under the Notes tab revealed R23 was admitted to the hospital on 01/06/25 due to sepsis. There was no documentation located in the EMR, of written notification regarding R23's transfer to R23's RP. 3.Review of the EMR under the Face Sheet tab revealed R33 was admitted to the facility on [DATE]. Review of R33's EMR under the Notes tab revealed R33 was admitted to the hospital on 02/17/25 due to the diagnosis of sepsis. There was no documentation, located in the EMR, of written notification regarding R33's transfer to R33's RP. During an interview on 03/06/25 at 1:30 PM with the Director of Nursing (DON) explained that upon transfer of a resident to the hospital the nurse involved in the transfer made verbal contact with the RP to notify them of the change in the resident's condition and need to go to the hospital for evaluation. The DON stated this communication was documented in the resident's medical record. The DON was not aware written notification of the transfer needed to be sent to the RP.

Based on interview, observation, and record review, the facility failed to protect 1 of 3 residents from physical abuse. On 04/02/23 at approximately lunchtime, Resident (R)24 was slapped by Certified Nursing Aide (CNA)2 after a combative incident. This was witnessed by CNA3 and the Activities Director. Because a wheelchair-bound resident was struck by a nursing aide, the resident was placed at increased risk for severe harm and mental anguish. On 06/13/23 at approximately 3 PM, the State Agency (SA) determined that the facility's non-compliance with one or more federal health, safety, and/or quality regulations has caused or was likely to cause serious injury, serious harm, serious impairment, or death. On 06/13/23 at 5:30 PM the Administrator was notified that the physical abuse of R24 by CNA2 constituted immediate jeopardy at F600. The facility presented an acceptable plan of removal of the immediate jeopardy on 06/14/23 at 10 AM. The survey team validated that the immediate jeopardy was removed on 06/14/23 at 12 PM following the facility's implementation of the plan of removal of the immediate jeopardy. The facility's presented plan revealed the facility had identified its own deficiencies and corrected prior to the start date, warranting F600 at past noncompliance. The IJ began on 04/02/23 and was removed on 04/09/23. Findings include: Review of the facility policy titled, Resident Abuse and Neglect and revised on 09/27/22 revealed that It is the policy of [NAME] Healthcare and Rehab to ensure that residents are free from any form of abuse or neglect. The policy defined physical abuse as hitting, slapping, pinching, kicking, and includes controlling resident behavior through corporal punishment. R24 was admitted to the facility on [DATE] with diagnoses including, but not limited to, hemiplegia and hemiparesis following cerebral brain infarction affecting left nondominant side, frontal lobe and executive function deficit following cerebral infarction. She scored 04/15 on her Brief Interview for Mental Status (BIMS) during her admission Minimum Data Set (MDS) with Assessment Reference Date (ARD) 03/03/23 indicating severe cognitive impairment. Review of CNA3's statement written to the facility on [DATE] revealed R24 knocked a phone out of the possession of CNA2. After the incident, CNA2 slapped the resident and continued to pick up her phone. CNA2 also said that the resident knocked her new phone from her and that's the reason she slapped the resident. Interview with CNA3 on 06/13/23 at approximately 2:42 PM revealed that she and three other CNAs were standing by the nurse's station. R24 tried to stand from her chair. CNA2 went to the resident to seat her down when R24 pushed the phone from CNA2's hand. CNA2 picked it up and slapped the resident. This happened after lunch. Review of Activities Director statement to the facility written on 04/02/23 revealed that she witnessed CNA2 slap R24. The Activities Director was trying to help the resident in the wheelchair, but the resident was resistant. She called CNA2 to assist. During the struggle, the resident knocked CNA2's phone from her possession. The CNA gave the resident a slap across the face and stated, she slapped my new phone out of my hand. Afterward the resident was quiet. Activities reported the incident to Licensed Practicing Nurse (LPN)3. Multiple unsuccessful attempts were made to contact the Activities Director for interview during the course of the survey. Review of LPN3's statement to the facility, written on 04/02/23, revealed she was informed of the abuse incident by the Activities Director. She notified LPN2, who was the nurse for R24. Multiple unsuccessful attempts were made to contact LPN3 for interview during the course of the survey. Review of LPN2's statement to the facility, written on 04/02/23, revealed she was in her car during her lunch break when LPN3 informed her of the abuse incident. She performed a body audit for R24 and found no abnormal findings or apparent injury. She notified the abuse coordinator. Multiple unsuccessful attempts were made to contact LPN2 for interview during the course of the survey. Review of CNA2's undated statement to the facility, and her follow-up statement conducted by phone by Registered Nurse (RN)1 on 04/04/23 revealed she denied slapping R24. Interview with CNA2 on 06/13/23 at approximately 11:27 AM revealed she denied the abuse allegation. Interview with daughter of R24 on 06/13/23 at approximately 4:30 PM revealed, when asked regarding changes in the resident after the abuse incident, that R24 gets scared. The facility followed up on the resident for psychosocial harm. Review of R24 progress notes revealed a 04/03/23 social services note indicating that the resident was calm with no signs or symptoms of distress. Review of R24's Care Plan revealed that the facility care planned for Alleged incident occurring 04/02/23, and that interventions included 14-day monitoring for victim for mental and physical signs of distress or anger as well as psychosocial support. Interview with the Director of Nursing (DON) on 06/13/23 at 4:40 PM revealed that she had repeatedly instructed CNA2 to not have their phones out in resident care areas. The DON had educated staff on this over and over. Interview with the Social Services Director (SSD) on 06/13/23 at approximately 5:30 PM revealed she monitored R24 in the days after the incident as well as updating the care plan for the resident. There were no psychosocial or behavioral changes or concerns in the days following the incident or the months since the investigation. Multiple observations of R24 during the course of the survey revealed no concerns, physical or psychosocial, regarding the abuse incident that occurred on 04/02/23. The facility's removal plan included: R24 was assessed by the charge nurse and found to be without injury. The resident has continued to receive body audits for a total of 2 more days to monitor for any signs of injury. These were completed on 04/03/23 and 04/04/23 with no injuries noted. Social Services began following R24 for any negative psychosocial outcomes related to the incident and none had been observed. Nurses monitored R24 for 14 days for any negative effects regarding the incident and none have been noted. R24 was assessed by the facility Nurse Practitioner on 04/03/23 with no negative outcomes noted. R24's medical doctor was notified of the incident on 04/02/23. The Administrator and Director of Nursing were notified of the incident on 04/02/23. The alleged perpetrator was suspended pending outcome of investigation on 04/02/23 and was terminated on 04/05/23. All interviewable residents in the facility were interviewed / assessed to identify if they felt safe and if they had ever experienced abuse while living at the facility. There were no further allegations or issues noted. Abuse policies were reviewed, and no revisions were made. All staff received education on facility abuse policies by the administrator starting on 04/03/23. All staff will receive abuse training, reporting and protecting residents, including agency staff prior to their assigned duties. All newly hired staff will receive proper abuse training, reporting, and protecting residents during orientation. New agency staff will be in-serviced by the DON or charge nurse prior to working regarding resident abuse, reporting, protecting the residents, and abuse policy. All staff received training regarding how to deal with residents who are resistive or combative during care provided by the Administrator starting 04/06/23. All newly hired staff will receive this training during orientation. All new agency staff will be in-serviced by the DON or charge nurse prior to starting work regarding dealing with resistant or combative residents. Abuse investigation procedures and documentation process were reviewed and revised. The Administrator implemented a new reportable incident procedure to ensure investigations were initiated and completed thoroughly on 04/06/23. The IDT staff were educated on changes starting on 04/06/23. The Administrator, DON, and Social Services Director will conduct random interviews and observations of residents and staff regarding any signs, complaints of abuse, timely reporting, and timely protection of resident and following policy and providing proper care of residents who are aggressive and resistive to care. This will be done weekly x 4, then monthly x 3, then quarterly. Root cause analysis was conducted and presented to IDT on 04/06/23 by the nurse consultant.

Based on observations, interviews, and facility policy reviews, the facility failed to protect the confidential health information of residents on 2 of 2 halls. Specifically, the facility posted the username and password to the electronic health record (EHR) on the wall. This had the potential to affect all residents. Findings include: Review of a policy titled Confidentiality of Personal and Medical Records, dated 10/24/2022, revealed, this facility honors the resident's right to secure, and confidentiality of all information contained in a resident's records, regardless of the form of storage or location of the record. 1. Personal and medical records include all types of records the facility might keep on a resident, whether they are medical, social, fund accounts, automated, or other. On 06/12/2023 at 12:17 PM, an activities of daily living (ADL) coding poster was observed hanging on the wall, located on A-hall, next to an electronic touch screen kiosk, next to resident room [ROOM NUMBER]. There was a yellow piece of paper taped to the poster that had a handwritten username and password for agency certified nursing assistants to login into the resident's EHR. On 06/13/2023 at 9:01 AM, an ADL coding poster was observed hanging on the wall located on A-hall, next to an electronic touch screen kiosk, next to resident room [ROOM NUMBER]. There was a yellow piece of paper taped to the poster that had a handwritten username and password for agency certified nursing assistants to login the residents EHR. On 06/13/2023 at 9:02 AM, an ADL coding poster was observed hanging on the wall located on A-hall, next to an electronic touch screen kiosk, next to resident room [ROOM NUMBER]. There was a yellow piece of paper taped to the poster that had a handwritten username and password for agency certified nursing assistants to login the residents EHR. On 06/13/2023 at 9:04 AM, an ADL coding poster was observed hanging on the wall located next to the nurse's station between A-hall and B-hall, next to an electronic touch screen kiosk, with a yellow piece of paper taped to the electronic kiosk that had a handwritten username and password for agency certified nursing assistants to login the residents EHR. On 06/14/2023 at 9:27 AM, Certified Nursing Assistant (CNA) #5-stated that she had been employed by the facility for a few months. She stated that CNAs and nurses had access to resident medical records by using the electronic touch screen kiosk that was located on the halls and by the nurses' station with the posted username and password. She stated that CNAs charted ADLs, and care provided to the residents on the kiosk. She stated that anyone could access the resident's charts with the username and password that was posted on the wall by the kiosk. She stated the privacy and confidentiality of all residents should be maintained. She stated by posting the username and password to the EHR on the hall, the resident's right to privacy and confidentiality of their medical records could be breached. On 06/14/2023 at 10:13 AM, CNA #6 demonstrated how to login to the kiosk, and access resident medical records with the posted username and password. She stated she had access to all the residents, ADLs, and skin care observations. She stated the username and passwords were located at all kiosks in the facility. She stated that anyone could access the residents record by using the kiosk with the username and password posted next to the kiosk. She stated she expected resident's rights to privacy and confidentiality to always be maintained. On 06/14/2023 at 10:23 AM, the Director of Nursing (DON) stated the kiosks are used by the CNAs to document the care and assistance provided to the residents. She stated a former human resource posted the username and password on the posters. She stated it was possible for anyone to access the kiosk with the username and password posted next to kiosk. She stated she expected a resident's right to privacy and confidentiality to be always maintained. On 06/14/2023 at 10:39 AM, Human Resource Director (HRD) stated both facility and agency CNA's access the kiosk located in the facility. She stated that she was aware the username and password were posted next to kiosk. She stated the username and password posted are used for agency employees only. She stated she expected the privacy and confidentiality of resident's medical records always be maintained. She stated that by having the username and password posted to the resident EHR, it could be accessed by hackers and other people who visited the facility. On 06/14/2023 at 10:51 AM, the Administrator stated the kiosk were used by CNAs to document resident's daily ADL status. She stated she was aware that a previous human resource director posted the username and passwords next to kiosk. She stated she did not think that visitors would know how to navigate the EHR but could login with the username and password posted. She stated she expected a resident's right to privacy and confidentiality of their medical records to be protected.

Based on review of the facility policy, observation and interviews, the facility failed to complete ensure appropriate infection control and hand hygiene protocols were followed during an observation of the laundry for 1 of 1 laundry facility reviewed. Findings include: Record review of facility policy titled, Linen and Personal Laundry revealed All contaminated linen and personal laundry will be handled appropriately to prevent cross-contamination. Laundry will be hygienically cleaned and handled to prevent recontamination from dust and dirt during loading and transport. When moving from the soiled area to the clean area (drying, folding, and storage), staff will remove the gown and gloves, and wash their hands with antibacterial soap. An observation and interview on 6/14/23 at 8:54 AM revealed Housekeeping Staff (HK)1 with appropriate PPE and handling linen to be put in the washing machine. After putting the linen in the machine, HK1 was observed walking into the dirty linen room and doffing PPE appropriately. Observation revealed HK1 exiting the dirty linen area without sanitizing the washing machine and no hand sanitization prior to exiting the dirty linen area. Interview with HK1 revealed that they last sanitized the washing machine on Monday, two days prior, and does not sanitize the machine after each use. An interview with the Maintenance Director on 6/14/23 at 9:05 AM revealed that the dirty linen area has a hand sanitizer machine located on the wall outside of the the dirty linen storage room, that housekeeping staff could use prior to exiting the dirty linen room to wash their hands in the sink in the nearby area. An interview on 6/14/23 at 1:50 PM with the Director of Nursing (DON) revealed that they expect staff to complete hand hygiene prior to exiting the soiled linen area and that the machines should be sanitized after each use.

Based on review of the facility policy, record review, observations, and interviews, the facility failed to implement interventions to prevent/mitigate a fall with injury for Resident (R)24. Findings include: Review of the facility policy titled, Fall Prevention Program last revised 10/24/22 revealed Each resident will be assessed for fall risk and will receive care and services in accordance with their individualized level of risk to minimize the likelihood of falls. The facility utilizes a standard risk assessment for determining a resident ' s fall risk. For program identification purposes, the facility utilizes high risk and low/moderate risk, using the coring method designated on the risk assessment. High Risk Protocols include: the resident will be placed on the facilities Fall Prevention program; indicate fall risk on care plan; provide interventions that address unique risk factors measured by the risk assessment tool: medications, psychological, cognitive status, or recent changes in functional status; additional interventions as directed by the resident ' s assessment, including but not limited to: assistive devices, increased frequency of rounds, sitter if indicated, medication regime review, low bed, alternate call system access, scheduled ambulation or toileting assistance, family/caregiver or resident education, or therapy services referral. Each resident ' s risk factors, and environmental hazards will be evaluated when developing the resident's comprehensive plan of care. R24 was admitted to the facility on [DATE] with diagnoses including but not limited to type 2 diabetes without complications, fracture of part of neck of left femur, encounter for closed fracture with routine healing, aphasia, muscle weakness, repeated falls, dysphagia, mild cognitive impairment, and hypertension. Review of the Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 6/1/23 revealed R24 has a Brief Interview of Mental Status (BIMS) score of 02 out of 15 which indicates she is not cognitively intact. Further review of R24's Quarterly MDS revealed she needs limited assistance with bed mobility, transfers, and walking. An observation and interview on 6/12/23 at 3:47 PM with R24 and her Resident Representatives revealed R24 lying in a high bed with no observation of a side-rail or fall mats near the bedside. Interview with R24 Resident Representatives revealed R24 had a fall last week (6/4/23) trying to get out the bed to use the restroom but tripped over the trash can near her bed and broke her hip. She has had several falls over the last few months, but this is the first time she has had an injury from a fall. Since her fall on last week, I staff have not put any anything into place to prevent her from falling and hurting herself again. Before she moved into this room she had side-rails so she could pull herself up in bed. An observation on 6/13/23 at 9:24 AM of R24 and her room revealed a fall mat added on the right side of the bed, no observation for the side rail during observation. Review of R24's Physician Orders revealed an order for 1/2 side rails to promote bed mobility with an order date of 2/24/23 and an order for a fall mat for safety on the right side of the bed with an order date of 6/13/23. Record review of R24's Side Rail assessment dated [DATE] reviewed on 6/14/23 at 9:31 AM revealed bed and side rail equipment are appropriate for this resident. Record review of R24's Fall assessment dated [DATE] reviewed on 6/14/23 at 9:32 AM revealed R24 was a High-Risk for falling. Review of R24's Care Plan last revised on 6/13/23 reviewed on 6/14/23 at 9:33 AM revealed Resident is at risk for falls related to weakness, unsteadiness, related to history of stroke. On 5/13/23 resident had a fall, on 6/4/23 R24 tripped over a trashcan resulting in a fracture. Fall on 5/12/23 R24 was attempting to ambulate from bed, no injuries noted from this fall. Inventions include: 1/2 side rails up on both sides of the bed to aid resident in bed mobility to encourage independence in bed mobility for safety; anticipate the needs of the residents; be sure call light is within reach and encourage the resident to use for assistance as needed; bed mat on right side of bed (initiated on 6/13/23); follow facility fall protocol; keep bed in the low position when care not being provided; review information on falls and attempt to determine cause of falls. Record possible root causes and alter/move any potential causes if possible. Review of R24's Nurses Note dated 6/5/23 revealed Resident had an apparent fall on yesterday 6/4/23 around 10 AM. Resident has left leg and arm pain and now unable to move limbs or walk. Made a call to the Director of Nursing (DON) to report incident. Call made to Nurse Practitioner (NP), Resident Representative, and Emergency Medical Services (EMS) for transportation. Review of R24's Nurses Note dated 6/8/23 revealed Resident returned from hospital with a left hip fracture. Review of R24's Nurses Note dated 6/12/23 revealed Resident had an unwitnessed fall around 8pm. Resident stated she got up out of bed and slid on the floor trying to go to the bathroom. Resident was laying on the left side when found by the CNA. I assessed resident for injury and pain and there is no apparent injury or pain. Resident stated she is not having any pain. Resident was lifted off floor and placed back into the bed. The bed is in the lowest position with the call light within reach. Sent a text message to the DON to notify her of the incident. Bed rails will be placed onto resident's bed in the morning. Made call to NP and Resident Representative to notify them of the fall. An interview with Licensed Practical Nurse (LPN)1 on 6/13/23 at 10:59 AM revealed I was not working on the days when the resident had her most recent falls (6/4/23 and 6/12/23) but is familiar with this resident. Interventions that the facility has put into place to help prevent the resident from having falls include more frequent checks on the resident and a fall mat on the side of her bed. Nursing staff and the Integrated Multi-Disciplinary Team (IDT) team are currently reviewing if the resident is appropriate for a side rail. The resident has a hip fracture and was ordered at the hospital to be on bed rest for a few days but now the facility is looking into beginning physical therapy for this resident. Further stated that the resident is very active and will often attempt to walk or stand without assistance, and previously attempted to exit seek from the facility. When I spoke with the resident's daughter she told me the resident likes to do things with her hands such as crocheting and gardening but think the resident gets bored and that causes her to have behaviors. Finally stated that the facility currently does not have an Activity Director at this time. An interview with Certified Nursing Assistant (CNA)1 on 6/13/23 at 2:21 PM revealed On the morning on 6/4/23, R24 fell at 10:00 AM while leaning over the trash can. Her CNA asked if I could help the nurse get her up, I assisted the nurse and helped R24 on her bed, the resident had no complaints of pain. An interview with the DON on 6/13/23 at 2:53 PM revealed that the facility has a falling program for residents that are at a high risk of falls. R24 had had repeated falls; one last week on 6/4/23 and another on 6/12/23, but they were not in the building during the times the resident had fallen. Interventions that are now in place for R24 include a fall protection mat on the side of her bed and the maintenance director will a side rail to the resident's bed. R24 previously had a side rail in her old room, but staff must have not transferred it over into her new room.

Based on observation, interviews, facility document review, and facility policy review, the facility failed to provide services to a resident who was unable to carry out activities of daily living (ADL) necessary to maintain good grooming and personal hygiene for 1 (Resident (R)24) of 6 sampled residents reviewed for assistance ADL care. Specifically, R24 had toenails that were long, thick, and jagged. Findings include: Review of the facility policy titled, Nail Care, dated 11/27/2017, revealed, the purpose of this procedure guidelines for the provision of care to a resident's nails for good grooming and health. 1. Assessments of resident nails will be conducted on admission and readmission to determine the resident nail condition, needs, and preferences for nail care. 6. Principles of nail care: a. Nails should be kept smooth to avoid skin injury. c. If a resident had a toe infection, diabetes mellitus, neurologic disorders, renal failure, or peripheral vascular disease (PVD), toenail trimming should be performed by a physician or practitioner. Review of the facility policy titled, Activities of Daily Living (ADLs), dated 11/27/2017, revealed, Policy Explanation and Compliance Guidelines 3. A resident who is unable to carry out activities of daily living will receive the necessary services to maintain good nutrition, grooming, and personal and oral hygiene. Review of Admission Records indicated the facility admitted R24 on 09/26/2019 with diagnoses that included type two diabetes mellitus without complications, hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, and frontal lobe and executive function deficit following cerebral infarction. The quarterly Minimum Data Sheet (MDS) with an Assessment Reference Data (ARD) of 06/03/2023, revealed R24 had a Brief Interview for Mental Status (BIMS) score of 02, which indicated the resident had severe cognitive impairment. The resident required limited assistance with bed mobility, and transfers, extensive assistance with personal hygiene and total dependence on staff for bathing. Review of R24's Care Plan, initiated on 03/10/2023, and revised on 03/28/2023, revealed R24 had an ADL self-care performance deficit and required extensive staff assistance for bed mobility, transfers, grooming, toileting and bathing due to Cerebral Vascular Accident (CVA), hemiparesis, hemiplegia, and weakness. Interventions included to provide total assistance with bathing and showering. R24 required staff to provide extensive assistance with personal hygiene. Interventions included to keep feet dry and clean between toes and refer to podiatrist as needed. R24 had diabetes mellitus with interventions to refer to podiatrist/foot care. Review of R24's Physician Orders for the month of 06/2023, revealed an order, dated 02/24/2023, for podiatry care as needed. Also, revealed an order dated 06/08/2023, for 500 milligrams (mg) metformin hydrochloride (HCI) (a diabetic medicine)- give one tablet by mouth one time a day for elevated blood sugars. Review of nursing Progress Note, dated 02/24/2023 at 11:57 AM, revealed R24 arrived at the facility with a head-to-toe assessment performed. R24 had toenails that were very long and thick. Review of the Podiatry Vendor Appointment Add-on List, dated 03/20/2023, revealed R24 was added to podiatry services for the next visit. Review of the Podiatry Vendor Appointment List, dated 03/22/2023, revealed a list of residents to receive foot care by podiatrist on 03/22/2023. R24 was not included on the list to be seen by the podiatrist. On 06/12/2023 at 2:39 PM, R24 was observed laying in bed with toenails, on both feet, which extended over the tip of the toe about 1/2 inches in length to 3/4 inches in length. The toenails were thick, uneven, twisted, and jagged. The toenail of the small toe of the right foot was bending towards the underside of toe with skin intact. During an interview on 06/12/2023 at 2:39 PM, Family Member (FM)1 was at the bedside of R24. FM1 stated they asked staff about taking R24 to see a podiatrist to get R24's toenails cut and were told they had an in-house podiatrist that would see R24. On 06/14/2023 at 11:32 AM, the Admissions/Social Worker (Adm/SW) stated that she was aware of the nurse's note on 02/24/2023 that stated R24 toenails were long and thick. She stated she was responsible for maintaining the list of residents who needed to see the podiatrist and any residents that needed added on before the next scheduled podiatry visit. She stated she received a list of residents the podiatrist would see about a month in advance of residents but could add residents onto the list if needed. She stated the day before the podiatrist was scheduled to visit, she posted the list of residents to be seen at the nurse's station. She stated for residents not on the list, and need podiatry care, staff could add the residents to the posted list. She stated when the podiatrist visits, the beauty shop was used for their visits. She stated R24 should have been on the list to be seen by the podiatrist when they visited on 03/22/2023. She stated she did not know why R24 was not on the list and did not see the podiatrist. She stated she expected a resident's toenails to be trimmed and maintained. On 06/14/2023 at 11:48 AM, Licensed Practical Nurse (LPN)4 stated that she went to R24's room and filed some of their toenails down. LPN4 stated the toenails were 1/4 inches in length to 1/2 inches in length, and thick, and the right big toe was thick, curled and backwards. She stated the nurses inspected all residents' feet a week or two prior to the scheduled podiatry visit, and when a resident needed to be seen by podiatry, she told the ADM/SW so they could be added to the next podiatry visit. She stated the list of residents to be seen by the podiatrist were posted at the nurse's station one day prior to the podiatrist visit. She stated she was aware that R24 was added to the list in March 2023 but did not see the podiatrist when they visited on 03/22/2023. LPN4 stated she expected residents to be seen by the podiatrist as needed and for a resident's toenails to be trimmed and maintained. On 06/14/2023 at 1:03 PM, the Director of Nursing (DON) stated FM1 indicated R24's toenails needed to be cut a few months ago and FM1 would take them to the podiatrist. The DON stated she told FM1 they had a podiatrist come to the facility to cut residents toenails and she would be put on the list to be seen by the podiatrist. She stated she told ADM/SW that R24's toenails needed cut and to add them to the next scheduled visit. She stated the list of residents to be seen by the podiatrist was posted at the nurse's station a day before they visited the facility. She indicated residents could also be written in on the list to be seen, if staff noticed their nails needed cut. She stated R24 should have been seen when podiatry visited on 03/22/2023. She stated the ADM/SW was responsible for scheduling appointments and maintaining the list of residents to be seen by dental, vision, and podiatry. She stated that she expected R24 toenails to be trimmed and clean and for appointments to be followed. On 06/14/2023 at 2:32 PM, the Administrator stated the ADM/SW was responsible for the list of residents that need podiatry appointments and any residents added on to the list as needed. She stated that R24 was added to the list dated 03/20/2023 and should have been seen by the podiatrist on 03/22/2023. She stated she expected residents to receive care in a timely manner and for resident's toenails to be trimmed and maintained.

Based on record review and interview the facility failed to ensure the most recent Minimum Data Set (MDS) assessments were coded accurately in the area of falls for three (3) of three (3) residents reviewed for falls (Residents #3, #5 and #6). The findings include: 1. Review of the Face Sheet for Resident #3 revealed he/she was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Resident #3 expired on [DATE]. Review of the Nursing Progress Notes dated [DATE] for Resident #3 revealed he/she had a fall with a laceration to the right forehead. The Nursing Progress Notes dated [DATE] revealed Resident #3 had a fall with a laceration to the left forehead which required stitches. A care plan for falls initiated on [DATE] identified Resident #3 to be at risk for falls due to Poor Safety Awareness, Impaired Mobility, Arthritis, Lack of Coordination and History of Falls. Interventions included Geri-chair when out of bed, keep bed in low position, keep call light in reach, keep pathways clear of obstacles, non-skid footwear, neurochecks per protocol, remind resident to call for assistance with transfers and/or ambulation. The quarterly MDS dated [DATE] did not include documentation of the all the falls Resident #3 had since the previous MDS assessment. The [DATE] MDS assessment documented one (1) fall with injury instead of two (2) falls with injuries. It did not include the fall with major injury on that occurred [DATE]. Prior MDS assessments for Resident #3 included a quarterly on [DATE], a discharge on [DATE], and an entry on [DATE]. The two (2) falls Resident #3 had on [DATE] and [DATE] were not documented correctly on the quarterly assessment completed [DATE]. The entry assessment completed on [DATE] did not require documentation for falls; therefore, both falls should have been coded on the [DATE] quarterly MDS. 2. Review of the Face Sheet for Resident #5 revealed he/she was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Review of the Nursing Progress Notes dated [DATE] for Resident #5 revealed he/she had a fall without injury on [DATE]. The Nursing Progress Notes dated [DATE] revealed Resident #5 had a fall with no injury on [DATE]. A care plan for falls initiated [DATE] identified Resident #5 to be at risk for falls due to poor safety awareness and impaired mobility with confusion related to Dementia. Interventions included bed in low position, keep frequently used items in reach, call light in reach, keep pathways clean of obstacles, floor mat beside bed, and non-skid shoes. These interventions were observed in place on [DATE] at 9:30 a.m. The care plan was updated on [DATE] and [DATE] after Resident #5 had a fall without injury. The annual MDS dated [DATE] was reviewed. This assessment did not include documentation of the falls Resident #5 had on [DATE] and [DATE]. The MDS was coded for no falls having occurred during the assessment period. 3. Review of the Face Sheet for Resident #6 revealed he/she was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Review of the Nursing Progress Notes dated [DATE] for Resident #6 revealed he/she had a fall without injury on [DATE]. A care plan for falls identified Resident #6 to be at risk for falls due to Impaired Mobility, [MEDICAL CONDITION], Dementia and Muscle Weakness. Interventions included ensure bed is locked at all times, keep bed in low position at all times, keep call light within reach, keep pathways clear of obstacles, non-skid footwear, and remind resident to call for assistance with transfers and/or ambulation. These interventions were observed in place on [DATE] at 9:30 a.m. The care plan was updated [DATE] after Resident #6 had a fall without injury. The quarterly MDS dated [DATE] was reviewed. This assessment did not include documentation of the fall Resident #6 had on [DATE]. On [DATE] at 8:45 a.m., during an interview with the Administrator, he/she stated the nurse who was assigned to complete the MDS assessments had recently changed. He/She stated the previous MDS Coordinator left on [DATE]. He/She stated the facility had an interim MDS Coordinator who worked at the facility two (2) days a week and a new MDS Coordinator had been hired and would be starting the first of February 2021. On [DATE] at 10:15 a.m., an interview with the interim MDS Coordinator revealed he/she was responsible for completing MDS assessments. He/she stated he/she was at the facility two - three (,[DATE]) days per week as needed. He/she stated the facility was aware of the inaccuracies on the assessments from the previous MDS Coordinator and they were working on correcting them. When reviewing the MDS assessments for Resident #3, he/she stated only one (1) of the falls fell within the assessment period. He/she stated the fall on [DATE] would have been in the previous assessment period. Therefore, the documentation of one (1) fall would have been correct on the quarterly MDS dated [DATE]. He/she did not review the previous MDS and to realize the prior assessment was an entry assessment and would not have been coded for falls. When asked about the MDS for Resident #5 which was completed on [DATE], after the previous MDS Coordinator left, he/she confirmed the assessment was inaccurate for falls and stated a correction should be submitted. He/she also confirmed the MDS assessment completed on [DATE] for Resident #6 was also inaccurate for falls and a correction should also be submitted. He/she acknowledged two (2) of the three (3) assessments reviewed were completed after the previous MDS Coordinator left.

Based on interviews, observations, record review and policy review, the facility failed to follow the Dietician's recommendation and a Physician's order for one (1) out of 12 sampled residents (Resident #29) to address weight loss. Resident #29 had a history of [REDACTED]. Findings Include: Review of a policy titled, Nursing Policy Manual no date, revealed the Physician retained control of the resident's medical plan of care, and was consulted when changes in condition occurred requiring an alteration to prescribe treatments. Such orders were often received by telephone. Physician's orders could be transmitted by facsimile machine or received by telephone, by a licensed nurse, or by another licensed or registered health care specialist in their own area of specialty. Further review of the Policy titled Nursing Policy Manual no date, revealed staff were to write the orders verbally given by the Physician on the orders sheet, read the order back to the Physician to ensure accuracy, then date and sign. The Physician should sign the order on his/her next visit to the facility. Staff should follow through with orders by contacting the pharmacy, lab, etc., and revise medication and treatments sheets as appropriate. Review of Resident #29's Quarterly Minimum Data Set ((MDS) dated [DATE] revealed an admission date of [DATE], under Section C - Cognition, the resident had a Brief Interview Mental Status (BIMS) score of two (2) indicating severe cognitive deficits. Review of Section G - Functional Status, revealed the resident was independent with meals but required staff supervision. Review of Section I - Active Diagnoses, revealed the resident was coded with [DIAGNOSES REDACTED]. Review of Section K- Nutrition, revealed Resident #29 weighed 153 pounds (lbs) with a height 68 inches and experienced a significant unplanned weight loss of five (5)% or more in the last month or 10% or more in the last six (6) months. Review of Resident #29's Dietary Notes dated 8/10/2020 revealed: Note Text: Current Body Weight (CBW): 151 pounds (lbs) (8/7/20). Resident with significant weight loss x (times) 80 days (-17.0%). Body Mass Index (BMI): 23, Within Normal Limits (WNL). Resident receives Consistent Carbohydrate Diet (CCD), Regular diet with finger foods with meals, strawberry Glucerna three times per day (TID) between meals, night time (HS) snack, and chocolate provided if resident consumes 50% or less of meal. Resident is also on the red napkin program to assist with increasing PO (oral) intakes. Current PO intakes are 50-75% mostly. Reviewed meds (medications). Reviewed progress notes. Resident's weight has been stable x 30 x 90 days. Current nutrition appropriate at this time. Review of Resident #29's weights from April 2020 -August 2020 revealed, the resident's weights remained between 151 lbs to 159 lbs with a Body Mass Index (BMI) of 23 (resident within a normal body weight range). Further review of the residents weights on a monthly basis from November 2019 - March 2020 revealed Resident #29 experienced a 37 pound weight loss during this timeframe. 8/7/2020 - 151.0 lbs 7/2/2020 - 152.6 lbs 6/1/2020 - 151.8 lbs 5/5/2020 - 153.0 lbs 4/7/2020 - 159.0 lbs 3/24/2020 - 165.0 lbs 2/6/2020 - 182.0 lbs 1/9/2020 - 177.2 lbs 12/14/2019 - 183.2 lbs 11/10/2019 - 188.0 lbs Review of the Physician's order dated 5/5/2020 for Resident #29, revealed the Physician prescribed a Consistent Carbohydrate Diet (CCD), regular texture with thin liquids, with finger foods added to the meal, and a Red Napkin program to help increase fluid intake. Review of Resident #29's lunch meal ticket for 8/25/2020, revealed the resident would be served, turkey and brown gravy, mashed potatoes and brown gravy, broccoli, peach cobbler and two (2) glasses of lemonade. Review of the breakfast meal ticket for 8/26/2020 revealed the resident was served scrambled eggs, grits, toast, cereal, banana, coffee and juice. Observation on 8/25/2020 at approximately 12:30 p.m. revealed Resident #29 was observed in his/her room with his/her lunch tray consisting of turkey with brown gravy, mashed potatoes with brown gravy, broccoli, peach cobbler and two (2) glasses of lemonade. The resident was observed eating the peach cobbler and then drinking one (1) of the glass of lemonade. The remaining meal sat on his/her tray. There were no finger foods observed on the tray. Observation of breakfast on 8/26/2020 at approximately 8:30 a.m. revealed Resident #29 was sitting up in his/her room with the breakfast tray in front of him/her. The meal consisted of grits, cereal, toast, scrambled eggs, a banana, coffee, milk and juice. The resident was observed eating the toast but did not finish the rest of the meal. During an interview on 8/25/2020 at 12:42 p.m. the Director of Nursing (DON) revealed Resident #29 preferred sweets over everything else, stating, We offered alternatives and he/she receives Glucerna several times during the shift; and will drink propel water which helps . I expect dietary to follow the Medical Director/Attending physician orders . I received the orders via e-mail from the Dietician; we discussed what's best for Resident #29, then the Medical Director is contacted and writes the order . Dietary is given the order right away via e-mail. During an interview on 8/25/2020 at 12:45 p.m. the Dietary Manager (DM) revealed Resident #29 did not get his/her finger foods for lunch on this date because the ham wasn't thawed out. The DM stated, I received the order from the Dietician via e-mail for finger foods a few months ago . I could have given him/her a Pimento cheese sandwich, but I didn't want him/her to get tired of eating them. During an on 8/25/20 at 2:24 p.m. the Registered Dietician (RD) revealed finger foods were recommended for Resident #29 on 5/13/2020. The RD stated, I spoke with the DON and we agreed that he/she would benefit weight wise if given finger foods . We wanted the weight to remain stable because he/she loves sweet stuff. The RD stated once the recommendation was made it was sent to the DON, then to the Medical Director who wrote the order; a copy was also sent to the Dietary Manager (DM). The RD stated, I expect the kitchen to follow my recommendations to ensure Resident #29 eats his/her meals and to prevent weight loss which has remain stable for the last several months. During an interview on 8/26/20 at 1:00 p.m. the Administrator stated, I expect dietary to follow any meal orders given for the residents. When the Certified Nursing Assistants (CNAs) look at the tray card and see the resident is not getting the meal ordered, they are expected to notify the kitchen immediately. The Facility failed to follow the Registered Dietician's recommendations and Physician orders for Finger Foods to prevent weight loss.

Based on observation, interview, record review, and review of the facility's policy, it was determined the facility failed to ensure interventions such as non-skid footwear and removal of mats on the floor that reduced maneuverability were implemented to prevent falls for one (1) of 3 (three) sampled residents who experienced falls (Resident #12). Resident #12 fell on [DATE] trying to get back in his/her wheelchair unassisted. Although the resident was non-compliant regarding asking for assistance, he/she was wearing sandals instead of non-skid footwear he/she should have been wearing. Observations during the survey revealed Resident #12 sitting his/her wheelchair wearing sandals instead of non-skid footwear and floor mats in place on the floor after they were discontinued. The findings include: Review of the facility's policy titled, Falls Management Program, not dated, revealed the purpose was to reduce falls and risk of injury from falls. First, a falls risk assessment would be completed on each resident upon admission, readmission, with a significant change, and at least quarterly. Second, a resident would be placed on the fall management program when the fall risk assessment score was 10 or higher. The fall management committee was an interdisciplinary committee which functioned as part of the Patient at Risk (PAR) meeting. During the weekly PAR meeting, the committee would do the following: review incident reports and investigations; review all new admits, readmits, and any significant changes; determine which residents should be placed on the fall management program; discuss each resident's risk factors based on history and declines; incidents, investigations and any other pertinent factors; develop interventions to decrease the risk for a fall or risk of reoccurrence; complete the fall management communication form and place with the resident's activities of daily living form and medication administration form to ensure the certified nursing assistants and nurses were aware of new interventions; review each resident on the program on a weekly basis during the PAR meeting; revise interventions as needed; institute a new intervention immediately if the resident has another incident; update the care plan to reflect each new intervention; and the resident would stay on the fall management program either without a fall in 30 days or longer if deemed necessary by the team. Review of Resident #12's clinical record, revealed the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #12's Quarterly Minimum Data Set (MDS) assessment, dated 6/14/2020, revealed Resident #12's cognition was intact with a Brief Interview for Mental Status (BIMS) score of 13 out of 15. Continued review of the MDS revealed the resident required the assistance of one (1) person for bed mobility, transfers, toileting, walking in room and corridor. Further review of the MDS revealed Resident #12 was assessed as occasionally incontinent of bladder. The MDS revealed Resident #12 used the wheelchair for mobility. Continued review of the MDS revealed Resident #12 had no falls prior to admission, since admission, or since the prior assessment. Review of Resident #12's comprehensive care plan, no date, revealed the resident was at high risk for falls related to deconditioning, gait, balance problems, [DIAGNOSES REDACTED]. The goal was for the resident to remain free of falls, free of minor injury and not to sustain serious injury related to falls. The approaches directed staff to be sure the resident's call light was within reach and encourage the resident to use it for assistance as needed, c-collar (cervical collar) to neck at all times, consult pharmacist for medication review, fall mats to both sides of the bed, not place items on top of the refrigerator, new signage in room to remind the resident to call for assistance, the Reacher placed within the resident's reach as tolerated, physical and occupational therapy as ordered, follow facility fall protocol, follow up with neurosurgeon as ordered, and ensure the resident participated in activities that promoted exercise, physical activity for strengthening, improved mobility and ensure the resident wore non-skid footwear when ambulating or mobilizing in the wheelchair. Review of the Certified Nurse Assistant (CNA) care plan, dated 8/20/2020, revealed Resident #12 used a wheelchair for mobility, had a pressure reducing cushion in the wheelchair, was at risk for falls, transfer assist of one-person was needed, and tumbler mats (floor mats) were discontinued. However, the fall intervention for non-skid footwear when Resident #12 was ambulating in the wheelchair was not listed. Review of the Fall Incident Report, dated 6/15/2020, revealed Licensed Practical Nurse (LPN) #4 responded to Resident #12's call for help from his/her room and found him/her lying on the floor at 10:35 a.m. The nurse assessed the resident for injuries. Resident #12 complained of left knee, right shoulder and right side of his/her face pain. The report stated Resident #12's Physician and family were notified of the fall. The Physician ordered an x-ray of the left knee and right shoulder. Resident #12 stated that he/she fell trying to get back to his/her wheelchair and forgot to use the call light for assistance. The report revealed the resident was wearing improper footwear and ambulating without assistance. Continued review of the report revealed the intervention to prevent future falls and to ensure the resident's safety was for staff to reinforce use of the call light with the resident and move the resident to a room closer to the nurses' desk for frequent monitoring. Review of the radiology report, dated 6/15/2020, revealed a 22 millimeter (mm) of inferior displacement of the acromion and a [MEDICAL CONDITION] patella. Review of the physician's orders [REDACTED]. Observation of Resident #12 on 8/25/2020 at 11:10 a.m., revealed he/she was sitting in his/her wheelchair in his/her room and fall mats were on the floor next to both sides of the bed. Observation of Resident #12 on 8/25/2020 at 11:31 a.m., revealed he/she was propelling down the hallway in his/her wheelchair with sandals on. Interview with Resident #12 on 8/25/2020 at 11:31 a.m., revealed he/she had fallen a lot because he/she forgot to call for assistance. Resident #12 stated he/she doesn't have any other shoes to wear except the sandals and wore them while in the wheelchair, stating it was difficult to propel the wheelchair when he/she wore them. Interview with Resident #12 on 8/26/2020 at 9:00 a.m. revealed the staff removed the fall mats by his/her bed that morning and he/she was happy about it because he/she couldn't move around in his/her room with the mats on the floor. Interview with Certified Nursing Assistant (CNA) #2 on 8/26/2020 at 9:47 a.m., revealed the CNA assisted Resident #12 back to bed after his/her fall on 6/15/2020. Continued interview with CNA #2 revealed Resident #12 had sandals on and the fall mats were on the floor by the bed when he/she responded to the fall. The CNA stated Resident #12 was moved to a room closer to the nurses' station after the fall and the CNA was not educated to ensure he/she wore non-skid footwear when he/she was in the wheelchair. The CNA stated the nursing assistants rounded on him/her more frequently because he/she had fallen a lot in the last three (3) months trying to do things in his/her wheelchair in his/her room without requesting assistance. Interview with Licensed Practical Nurse (LPN) #4 on 8/26/2020 at 11:28 a.m., revealed he/she found Resident #12 on the floor by his/her wheelchair in his/her room on 6/15/2020. LPN #4 stated he/she assisted Resident #12 back to bed, assessed the resident for injuries and notified the Physician and family of the fall and complaint of pain. Continued interview revealed Resident #12 would not use her call light for assistance because he/she was confused at times and was progressively getting worse. LPN #4 stated the fall interventions in place now were not appropriate for Resident #12 because staff could not supervise him/her all the time and he/she wouldn't use her call light. Interview with the Director of Nursing (DON) on 8/26/2020 at 10:27 a.m., revealed fall interventions for Resident #12 were to remind him/her to call staff for assistance, signs posted in his/her room to remind to call staff for assistance and use of a low bed. Continued interview revealed Resident #12 was moved to a room closer to the nurses' station, staff removed clutter in his/her room and he/she removed the fall mats next to his/her bed today. The DON stated the Interdisciplinary Team (IDT) had discussed placing a different type of cushion in his/her wheelchair seat but didn't implement it because Resident #12 wanted to get up out of the wheelchair. Further interview revealed Resident #12 wanted to wear the sandals; however, didn't have any other shoes.

Based on interview, record review. observation, and facility policy review, it was determined the facility failed to revise the care plan to reflect current falls interventions for one (1) of 12 sampled residents (Resident #12). Use of a cervical collar and floor mats were discontinued by the Physician; however, both interventions remained on the care plan. The findings include: Review of facility's policy titled, Care Plans, dated 6/2013, revealed care plans were developed by the Interdisciplinary Team to coordinate and communicate care approaches and goals for the resident. Review of the care plan process revealed the Minimum Data Set (MDS) Coordinator should oversee the committee and offer assistance in problem solving, as needed. The team should attempt to make care plans goals measurable, attainable, resident specific and easy to understand. Disciplines responsible for actions should be documented. Target dates for the accomplishment of goals may vary dependent on the nature of the problem. When a new approach is or goal is identified, the entry should be dated using the date the goal/approach is entered on the care plan. When problems, goals, or approaches identified in the care plan are resolved they should be discontinued from the care plan. Review of Resident #12's clinical record, revealed the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #12's Comprehensive Care Plan, no date, revealed the resident was at high risk for falls related to deconditioning, gait, balance problems, [DIAGNOSES REDACTED]. The goal was for the resident to remain free of falls, free of minor injury and would not sustain serious injury related to falls. The approaches directed staff to ensure the resident's call light was within reach and encourage the resident to use it for assistance as needed, c-collar (cervical collar) to neck at all times, consult pharmacist for medication review, fall mats to both sides of the bed, new signage in room to remind resident to call for assistance, Reacher within reach as tolerated, physical and occupational therapy as ordered, follow facility fall protocol, follow up with neurosurgeon as ordered, and ensure that the resident participates in activities that promote exercise, physical activity for strengthening and improved mobility and ensure the resident wore non-skid footwear when ambulating or mobilizing in wheelchair. The care plan intervention dated 6/10/2020 stated not to place items on top of the refrigerator. Review of Resident #12's physician's orders [REDACTED].>Review of the physician's orders [REDACTED]. The care plan had not been updated to discontinue the cervical collar and fall mats in accordance with physician's orders [REDACTED]. Observation of Resident #12 on 8/23/2020 at 3:50 p.m., revealed he/she was lying in bed with fall mats on both sides of the bed. Observation on 8/24/2020 at 8/25/2020 at 11:10 a.m., revealed Resident #12 was sitting in his/her wheelchair; and fall mats were on the floor next to both sides of the bed. Interview with the Director of Nursing (DON) on 8/26/2020 at 10:27 a.m. revealed the nursing assistants were educated on the fall care planned interventions during the daily shift report and the nursing assistants' care plans were placed in the resident's closet The DON stated that he/she should have revised the falls interventions on Resident #12's care plan but he/she missed it. Interview on 8/26/2020 at 11:02 a.m. with the MDS Coordinator revealed he/she attended the interdisciplinary team (IDT) meetings in which incident reports were reviewed to determine the root cause of the fall and specific interventions were determined to prevent the resident's falls. The MDS Coordinator stated he/she updated the resident's care plan based on the decisions made in the IDT meetings. Further interview revealed he/she was in the process of reviewing and revising the care plans but was not responsible for the incorrect information on the care plans for Resident #12 and #18. Interview on 8/26/2020 at 1:01 p.m. with the Administrator, revealed he/she expected the MDS Coordinator to develop an individualized care plan and revise the care plans timely per the regulations. The Administrator also stated that the care plan for Resident #12 was not revised to the reflect the falls care planned interventions. Further interview revealed he/she had oversight of the care plans and reviewed care plan audits completed by the DON.

Based on interview, record review, and review of the Centers for Medicare and Medicaid Services (CMS) Resident Assessment Instrument (RAI) 3.0 User's Manual, it was determined the facility failed to ensure staff accurately coded the Minimum Data Set (MDS) assessment for two (2) of twelve (12) sampled residents (Resident #12 and Resident #9) related to falls. Resident #9's Quarterly MDS dated [DATE] was coded incorrectly in three separate data fields under the Falls Section. Resident #12 sustained one (1) fall in the facility on 6/10/2020; however, the fall was not coded on the Quarterly MDS dated [DATE]. The findings include: Interview with MDS Coordinator #1, on 8/26/2020 at 11:02 a.m., revealed the facility did not have a policy to ensure MDS assessments were accurately coded. MDS Coordinator #1 stated the facility followed the RAI User's Manual to code assessments. Review of the CMS RAI 3.0 User's Manual, Version 1.17.1, dated October 2019, Chapter 3, pages J-27 through J-35, revealed the facility should code: -Item J1700A, Fall History on Admission/Entry or Reentry, as 1-Yes if the resident or family report, or transfer records or medical records documented a fall in the month preceding the resident's admission (A1600). -Item J1800, Any Falls since Admission/Entry or Reentry or Prior Assessment (OBRA) or Scheduled PPS, whichever was more recent, as 1-Yes if the resident had fallen since the last assessment then continue to item J1900, Number of Falls Since Admission/Entry or Reentry or Prior Assessment (OBRA or Scheduled PPS), whichever was more recent. -Item J1900A, No Injury, the facility should code 0 for none, 1 for one and 2 for two or more falls. 1. Record review revealed the facility admitted Resident #9 on 2/1/19 with multiple diagnoses, which included hypertension, anxiety, constipation, type 2 diabetes, dementia, [MEDICAL CONDITIONS], abnormalities of gait and mobility, muscle weakness, [MEDICAL CONDITION], history of falling, gout, and [MEDICAL CONDITION]. Further record review of Nurse's Progress Notes, dated February 2020-August 2020, revealed the resident had only one fall during this period. Review of the Fall Incident Report, dated 8/15/2020, revealed Resident #9 stated he/she was pulling the privacy curtain and he/she fell to the floor. The resident was unable to elaborate further. Upon entering the room, Resident #9 was observed on his/her right lateral side in front of the closet after attempting to stand from wheelchair unassisted to pull the privacy curtain. Review of Nursing Progress Notes, dated 8/15/2020, revealed Resident #9 had a fall in her room on this date. Review of Resident #9's Quarterly MDS assessment, dated 6/1/2020, revealed item J1700 - Fall History on Entry or Reentry was blank; it should have been coded Yes or No; J -Did the resident have a fall in the last month prior to admission entry/or reentry or the prior assessment was coded 1 for yes and since the resident had no previous falls it should have been coded No; and J1900A - Number of falls since admission/entry or reentry or prior Assessment (OBRA or Scheduled PPS) whichever is more recent was coded as Yes and should have been coded No since the resident had no previous falls before the assessment. Interview with the Director of Nursing (DON) on 8/25/2020 at 1:53 p.m., revealed Resident #9 had no falls prior to 8/15/2020. The DON stated, I am not sure why it is coded on the MDS as such, it was coded wrong. 2. Review of Resident #12's clinical record, revealed the resident was admitted on [DATE] with [DIAGNOSES REDACTED]. Review of the Fall Incident Report, dated 6/10/2020, revealed the nurse found Resident #12 on the floor by the refrigerator and wheelchair in his/her room. The nurse assisted Resident #12 in his/her wheelchair, assessed for injuries, performed vital signs and notified the physician and family of the fall. The report stated that no injuries were noted, and that Resident #12 stated he/she tried to grab something off the top of the refrigerator and fell out of his/her wheelchair. Review of Resident #12's Quarterly Minimum Data Set (MDS) assessment, dated 6/14/2020, revealed item J1800 - Any Falls since Admission/Entry or Prior Assessment (OBRA or Scheduled PPS), whichever was more recent, was coded as No. The coding on J1800 should have been coded Yes since a fall occurred on 6/10/2020. Item J1900A- No Injury, was blank. The coding on J1900A should have been coded 1 since the fall on 6/10/2020 resulted in no injuries. Interview with the MDS Coordinator on 8/26/2020 at 11:02 a.m., revealed he/she has been employed with the facility for two (2) months and was hired after two (2) previous MDS Coordinators resigned. The MDS Coordinator stated that he/she was in the process of reviewing and correcting the errors on the previously submitted MDS assessments. Interview on 8/26/2020 at 11:22 a.m. with the Director of Nursing (DON) revealed that he/she began auditing the MDS assessments for accuracy in May or June 2020 with the assistance of a DON from a sister facility. Continued interview revealed that two (2) MDS Coordinators resigned. The MDS Coordinator that was completing the assessments during that time coded them incorrectly. Interview with the Administrator, on 8/26/2020 at 1:01 p.m., revealed he/she expected the MDS assessments to be submitted timely and coded accurately by the MDS Coordinator and to be audited for accurate coding and submission by the DON. Continued interview revealed that he/she would review the MDS assessment audits performed by the DON to ensure they were accurately coded. The Administrator verified Resident #9's and Resident #12's MDS assessments were not coded correctly for falls.

Based on record review and interview, the facility failed to update the Care Plan for 1 of 5 residents reviewed for hospitalization s. The Care Plan for Resident #18 was not updated to include a history of [MEDICAL CONDITION]-Resistant Staphylococcus Aureus (MRSA). The facility also failed to ensure that required staff were included on the interdisciplinary team for Care Plan development for 6 of 13 residents reviewed for Care Plans (Residents #12, #13, #14, #18, #24, and #37). The findings included: The facility admitted Resident #18 with [DIAGNOSES REDACTED]. Record review on 01-29-18 at 04:20 PM revealed that Resident #18 returned from the hospital after treatment for [REDACTED]. During an interview on 01-30-19 at 10:40 AM, Licensed Practical Nurse (LPN) #1 reviewed the record and confirmed that the Care Plan had not been updated to [MEDICAL CONDITION]. S/he also verified there was no signature to indicate RN participation in the Care Plan. The facility admitted Resident #12 on 10-12-18 with [DIAGNOSES REDACTED]. Record review on 01-29-19 at 12:10 PM revealed that a RN had not documented participation in the Care Plan. During an interview on 01-29-19 at 07:02 PM, LPN #1 reviewed the Care Plan and confirmed there was no signature to indicate RN participation in the Care Plan. The facility admitted Resident #13 with [DIAGNOSES REDACTED]. Review of the 8/8/18 Care Plan Attendance Record on 1/30/19 at 11:38 AM revealed no RN participation in care plan development. The facility admitted Resident #14 with [DIAGNOSES REDACTED]. Review of 8/15/18 and 11/28/18 Care Plan Attendance Records on 1/29/19 at 6:15 PM revealed no RN participation in care plan development. The facility admitted Resident #24 with [DIAGNOSES REDACTED]. Review of the 11/28/18 Care Plan Attendance Record on 1/30/19 at 1:24 PM revealed no RN participation in care plan development. The facility admitted Resident #37 with [DIAGNOSES REDACTED]. Review of the 8/7/18 Care Plan Attendance Record on 1/29/19 at 12:17 PM revealed no RN participation in care plan development. During an interview on 1/30/19 at 3:48 PM, both the Administrator and Corporate Director of Operations stated they were not aware an RN had to participate in the care plan.

Based on record review and interview, the facility failed to notify the physician and/or the resident representative of changes in condition potentially requiring medical intervention for 3 of 3 residents reviewed for notification. Resident #14 had respiratory changes and Resident #31 was given [MEDICATION NAME] for a low blood sugar without evidence of representative notification. Resident #37 had multiple omissions of routinely ordered insulin and multiple finger-stick blood sugar (FSBS) results outside established parameters without physician or representative notification. The findings included: The facility admitted Resident #14 with [DIAGNOSES REDACTED]. Review of Nurses Notes on 1/29/19 at 8:53 AM revealed that the resident developed respiratory symptoms including a productive cough, wheezing, and chest congestion on 12/3/18. The physician/extender was notified and ordered medication for the cough. The physician/extender ordered a chest X-ray which was completed on 12/5/18. There was no evidence in the record that the family/resident representative was notified of the resident's change in condition. During an interview on 1/29/19 at 4:39 PM, the Director of Nursing (DON) reviewed the medical record, verified the documentation as noted, and confirmed there was no record of representative notification. The facility admitted Resident #31 with [DIAGNOSES REDACTED]. Record review on 1/29/19 at 6:50 PM revealed a 12/17/18 physician's orders [REDACTED]. Review of the record on 1/30/19 at 12:33 PM revealed the BS had not been recorded on the Medication Administration Record (MAR) or in the Nurses Notes. Further review revealed no Nurses Note for that date. There was no evidence that the family/resident representative was notified of the resident's change in condition. During interviews on 1/29/19 at 7:54 PM and on 1/30/19 at 12:33 PM, the DON reviewed the record and verified there were no Nurses Notes between 12-13-18 and 12-26-18 and that the weekly summary also did not address the change in condition. The facility admitted Resident #37 with [DIAGNOSES REDACTED]. Record review on 1/29/19 at 11:13 AM revealed physician's orders [REDACTED]. Review of the 11/18 MAR on 01/29/19 at 12:18 PM revealed that the 6:30 AM insulin had nurses' initials circled indicating that the medication had not been administered as ordered with the blood sugar results noted as follows: 11/2/18 = 87 11/3/18 = 89 11/4/18 = 91 11/6/18 = 96 11/7/18 = 119 11/12/18 = 103 11/13/18 = 117 11/20/18 = 111 Further record review revealed no evidence of physician notification of the BS results or orders to hold the medication. Standing orders used by the facility failed to address this issue. Further record review on 1/29/19 at 11:13 AM revealed physician's orders [REDACTED]. Record results. Notify MD if BS > 300 and [MEDICATION NAME] 5 units subcut twice daily as needed if BS > 300. Review of the MARs and Nurses Notes on 01/29/19 at 12:18 PM revealed that the physician was not notified and the as needed insulin was not administered as ordered for BS >300 on the following dates: -11/12/18 = 306, -11/13/18 = 356, -11/23/18 = 355, -11/24/18 = 369, -12/1/18 = 336, -12/2/18 = 314, -12/7/18 = 400, -12/10/18 = 495, -12/12/18 = 352 -12/17/18 = 395, -12/19/18 = 586 During an interview on 1/29/19 at 2:35 PM, the DON reviewed physician's orders [REDACTED]. S/he verified that there was no evidence in the record of physician notification of morning BS results with insulin held as noted. The DON also confirmed that the physician had not been notified of BS results greater than 300 and that the as needed insulin had not been administered as ordered.

Based on record review and interview, the facility failed to administer medications as ordered for 1 of 1 residents reviewed for [MEDICAL TREATMENT]. Staff failed to give [MEDICATION NAME] multiple times as ordered in (MONTH) (YEAR) and failed to start medications in a timely manner upon admission for Resident #31. The findings included: The facility admitted Resident #31 on 12/13/18 with [DIAGNOSES REDACTED]. Record review on 1/29/19 at 6:50 PM revealed 12/13/18 admission physician's orders [REDACTED]. Review of the Medication Administration Record [REDACTED]. The Linaclotide, Apixaban, and Atorvastatin were not documented as started until 12/20/18. During an interview on 1/29/19 at 8:00 PM, the Director of Nursing reviewed the record and confirmed the medication had not been documented as given as ordered.

Based on record review and interview, the facility failed to provide oxygen for respiratory distress to Resident #91, 1 of 1 resident reviewed for respiratory distress. The findings included: The facility admitted Resident #91 with [DIAGNOSES REDACTED]. Review of the Physicians Orders at 12:07 PM on [DATE] revealed untimed orders dated [DATE] for oxygen at 3 liters per minute via mask, transfer to the hospital emergency room for evaluation, and admitted to the hospital in patient Hospice all signed by Registered Nurse #5. On [DATE] at 3:00 PM, review of the Nurse's Note revealed a note timed and dated 7:15 AM on [DATE] by Registered Nurse #5 that the resident ' s breathing could be heard at the nurses station. S/he had wet breath sounds bilaterally and was using ancillary muscles to breathe . The O2 SAT was 62% on room air and s/he was placed on oxygen at 3 liters per minute via a mask. Vital signs were obtained after placing the resident on oxygen with an axillary temperature of 99.4 degrees, pulse of 86, respiratory rate of 30, blood pressure of ,[DATE] and the O2 SAT was up to 68%. The physician was notified and an order obtained to transport Resident #91 to the hospital. The facility was notified at 12:45 that the resident was admitted to inpatient hospice and at 6:30 PM on [DATE] the facility was notified by the hospital that the resident had expired. During an interview on [DATE] at 10:46 AM, the Director of Nursing (DON) confirmed there was no documentation of the resident's change in status by the night shift nurse. The DON further confirmed that s/he would have expected the nurse to have documented the resident's change in respiratory status, to check the resident's oxygen saturation level due to labored breathing and apply oxygen, When asked if s/he would have expected the nurse to discontinue the tube feeding, the DON stated I would have. Review of the facility-obtained statement dated [DATE] from LPN #5 indicated that upon arrival at the nurses' station (for the 7:00 AM-7:00 PM shift) s/he asked Who is breathing like that? and another nurse stated it was resident #91. At that time, LPN #8, the night shift nurse, confirmed it was Resident #91 and stated the resident sounds bad. LPN #5 asked if the resident was being sent to the hospital and LPN #8 stated s/he thought the resident was on hospice. The statement indicated at that time LPN #5 went to the resident's room, assessed the resident, found the tube feeding infusing and the resident clearly in respiratory distress, mouth breathing (and) using ancillary muscles to breathe. LPN #5 stopped the tube feeding, instructed the Certified Nursing Assistant (CNA) to obtain vital signs, obtained an O2 SAT (62%), and started the resident on oxygen at 3 liters per minute via mask. LPN #5 then notified the physician and received an order to send the resident to the emergency room for evaluation. The facility obtained statement from LPN #9 dated [DATE] indicated that while conducting the narcotic count, LPN #8 stated there is someone on the hall that I believe is about to pass. The CNA came to the nurses' station and informed the 2 nurses that Resident #91's oxygen saturation was 62% and that at this point (no) oxygen was placed on the resident. The statement indicated the other day nurse overheard and asked why wasn't the resident being sent to the hospital (sic) night nurse states I don't know why. The statement further indicated the day nurse began to address the issue and the night nurse completed (her/his) stuff to leave, after stating that (s/he) tried suctioning resident (without) success. Upon observation it does not look as if the suction machine was used. The statement further indicated the resident's oxygen saturation did not improve much even (with) oxygen and that the night nurse had left by that time. CNA (Certified Nursing Assistant) #16's facility-obtained statement dated [DATE] indicated that s/he heard a noise and found that Resident #91 sounded like something was rattling in (her/him) (and) (s/he) wasn't responding to me when I called out to (her/him). The statement also indicated the night shift CNA told her the resident was like that all night. Review of the facility's Five-Day Follow-Up Report dated [DATE] indicated that there was conflicting information related to how long the resident was in respiratory distress. During a verbal statement, the night shift nurse stated to the Director of Nursing that the resident had been in distress since 5:30 AM but her written statement indicated 6:20 AM. According to the summary in the 5- Day report the Certified Nursing Assistant stated s/he informed the night shift nurse that the resident was not as responsive as usual at 1:00 AM. The report stated it appears that the resident went into respiratory distress sometime after 5:30 AM to 6:20 AM and that the nurse failed to assess resident change in condition and did not provide appropriate plan of care for a resident in respiratory distress. The report further indicated the facility substantiated the allegation of neglect, terminated the nurse and reported the nurse to the State Board of Nursing. On [DATE] at 6:00 p.m. the facility was notified that the failure to provide care to Resident #91 while experiencing respiratory distress was identified as Immediate Jeopardy and Substandard Quality of Care at 42 CFR 483.25(i) (F695). The Immediate Jeopardy was identified to have existed since [DATE] when Resident #91 developed respiratory distress. The nurse did not adequately monitor the resident per the care plan, assess the resident's vital signs or oxygen level, notify the physician of the change, or administer oxygen. On [DATE] at 11:56 a.m. the facility provided an allegation of compliance to remove the immediacy of the jeopardy. Measures put into place or system changes made to ensure that the immediate jeopardy will not recur were put in place by the facility as follows: 1. The nurse involved in the incident was terminated on [DATE] and reported to the State Board of Nursing. 2. On [DATE] the Administrator and the Corporate Compliance Officer completed a review of records of residents who had been transferred from the facility or who expired since [DATE] to assure that change of condition was identified and treated appropriately and timely. There were no other incidents noted. 3. The Administrator and Corporate Compliance Officer reviewed the 24-hour reports and clinical stand-up minutes from [DATE] to [DATE] to identify any change of condition to assure they were treated in a timely and appropriate manner. There were no additional incidents noted. 4. On [DATE] nurses were in-serviced by the Director of Nursing on resident change in condition, notification of changes to physician and the management of residents with change of condition. An Independent Clinical Nurse Consultant and the Director of Nursing will provide education to all nursing staff (CNA's/LPN's/RN's (Certified Nursing Assistants/ Licensed Practical Nurses/ Registered Nurses)) on change of condition, notification of changes to physician and the management of residents with change of condition beginning [DATE]. Any staff who has not received this training by [DATE] will not be allowed to work until the training is completed. 5. Any PRN (as needed), agency staff or new hires (CNA's/LPN's/RN's) will be educated by the Director of Nursing or Administrator prior to working in the facility. On [DATE] the State Agency accepted and ensured implementation of the facility's written plan of action presented on [DATE] at 11:56 a.m. that removed the Immediate Jeopardy. The citation at F695 will continue at a lower scope and severity level of D.

Based on record review and interview, the facility failed to follow the care plan to monitor/ observe for shortness of breath for Resident #91, 1 of 12 residents reviewed for care plans. The findings included: The facility admitted Resident #91 with [DIAGNOSES REDACTED]. On [DATE] at 4:00 PM, review of the record revealed a comprehensive care plan dated [DATE] that identified potential for complications related to receiving tube feedings, potential for cardio/resp (cardiac/ respiratory) dysfunction related to Hypertension and mild [DIAGNOSES REDACTED], and potential for complications related to the [DIAGNOSES REDACTED]. All 3 care plans included the intervention to assess/ observe/ monitor for shortness of breath. Notification of the MD (Medical Doctor) as indicated was included on the care plan for potential for complications related to receiving tube feedings. On [DATE] at 3:00 PM, review of the Nurse's Notes revealed a note timed and dated at 7:15 AM on [DATE], that the resident ' s breathing could be heard at the nurses station. She had wet breath sounds bilaterally and was using ancillary muscles to breathe . The oxygen saturation was 62% on room air. There was no documentation of shortness of breath or respiratory distress in the nurse's notes by the night shift nurse. During an interview on [DATE] at 10:46 AM, the Director of Nursing (DON) confirmed there was no documentation that the night shift nurse identified the resident's shortness of breath as a change in status or that the physician was notified of the resident's respiratory distress. The DON further confirmed there was no documentation by the night shift nurse on 0 [DATE] and that s/he would have expected the nurse to have documented the resident's change in respiratory status and to notify the physician. The DON also confirmed that s/he would have expected the nurse to check the resident's oxygen saturation level due to labored breathing and apply oxygen. The failure to follow the care plan at CFR 483.21(b)(1) was identified as Immediate Jeopardy. On [DATE] at 6:00 p.m. the facility was notified that the failure to provide care to Resident #91 while experiencing respiratory distress was identified as Immediate Jeopardy. The Immediate Jeopardy was identified to have existed since [DATE] when Resident #91 developed respiratory distress. The nurse did not adequately monitor the resident per the care plan, assess the resident's vital signs or oxygen level, notify the physician of the change, or administer oxygen. On [DATE] at 11:56 a.m. the facility provided an allegation of compliance to remove the immediacy of the jeopardy. Measures put into place or system changes made to ensure that the immediate jeopardy will not recur were put in place by the facility as follows: 1. The nurse involved in the incident was terminated on [DATE] and reported to the State Board of Nursing. 2. On [DATE] the Administrator and the Corporate Compliance Officer completed a review of records of residents who had been transferred from the facility or who expired since [DATE] to assure that change of condition was identified and treated appropriately and timely. There were no other incidents noted. 3. The Administrator and Corporate Compliance Officer reviewed the 24-hour reports and clinical stand-up minutes from [DATE] to [DATE] to identify any change of condition to assure they were treated in a timely and appropriate manner. There were no additional incidents noted. 4. On [DATE] nurses were in-serviced by the Director of Nursing on resident change in condition, notification of changes to physician and the management of residents with change of condition. An Independent Clinical Nurse Consultant and the Director of Nursing will provide education to all nursing staff (CNA's/LPN's/RN's (Certified Nursing Assistants/ Licensed Practical Nurses/ Registered Nurses)) on change of condition, notification of changes to physician and the management of residents with change of condition beginning [DATE]. Any staff who has not received this training by [DATE] will not be allowed to work until the training is completed. 5. Any PRN (as needed), agency staff or new hires (CNA's/LPN's/RN's) will be educated by the Director of Nursing or Administrator prior to working in the facility. On [DATE] the State Agency accepted and ensured implementation of the facility's written plan of action presented on [DATE] at 11:56 a.m. that removed the Immediate Jeopardy. The citation at F656 will continue at a lower scope and severity level of D.

Based on record review and interview, the facility failed to adhere to professional standards as evidenced by the failure to provide oxygen for respiratory distress to Resident #91, 1 of 1 resident reviewed for respiratory distress. The findings included: The facility admitted Resident #91 with [DIAGNOSES REDACTED]. Review of the Physicians Orders at 12:07 PM on [DATE] revealed untimed orders dated [DATE] for oxygen at 3 liters per minute via mask, transfer to the hospital emergency room for evaluation, and admitted to the hospital in-patient Hospice, all signed by Licensed Practical Nurse (LPN) #5. On [DATE] at 3:00 PM, review of the Nurse's Note revealed a note timed and dated 7:15 AM on [DATE] by Licensed Practical Nurse #5 that the resident's breathing could be heard at the nurses station. S/he had wet breath sounds bilaterally and was using ancillary muscles to breathe. The oxygen saturation was 62% on room air and s/he was not receiving any oxygen at that time. The facility obtained statement from LPN #9 dated [DATE] indicated that while conducting the narcotic count, LPN #8 stated there is someone on the hall that I believe is about to pass. The CNA came to the nurses' station and informed the 2 nurses that Resident #91's oxygen saturation was 62% and that at this point (no) oxygen was placed on the resident. The statement indicated the other day nurse overheard and asked why wasn't the resident being sent to the hospital (sic) night nurse states I don't know why. The statement further indicated the day nurse began to address the issue and the night nurse completed (her/his) stuff to leave, after stating that (s/he) tried suctioning resident (without) success. Upon observation it does not look as if the suction machine was used. Review of the facility-obtained statement dated [DATE] from LPN #5 indicated that upon arrival at the nurses' station (for the 7:00 AM-7:00 PM shift) s/he asked Who is breathing like that? and another nurse stated it was resident #91. At that time, LPN #8, the night shift nurse, confirmed it was Resident #91 and stated the resident sounds bad. LPN #5 asked if the resident was being sent to the hospital and LPN #8 stated s/he thought the resident was on hospice. There was no documentation that LPN #8 had contacted the family or attempted to notify a hospice nurse that s/he though the resident was about to pass. CNA (Certified Nursing Assistant) #16's facility-obtained statement dated [DATE] indicated that s/he heard a noise and found that Resident #91 sounded like something was rattling in (her/him) (and) (s/he) wasn't responding to me when I called out to (her/him). The statement also indicated the night shift CNA said the resident was like that all night. Review of the facility's Five-Day Follow-Up Report dated [DATE]) indicated that there was conflicting information related to how long the resident was in respiratory distress. During a verbal statement, the night shift nurse stated to the Director of Nursing that the resident had been in distress since 5:30 AM but her written statement indicated 6:20 AM. According to the summary in the 5- Day report the Certified Nursing Assistant stated s/he informed the night shift nurse that the resident was not as responsive as usual at 1:00 AM. The report stated it appears that the resident went into respiratory distress sometime after 5:30 AM to 6:20 AM and that the nurse failed to assess resident change in condition and did not provide appropriate plan of care for a resident in respiratory distress. Review of the facility's policy, Oxygen Administration, revealed In an emergency situation oxygen may be administered without a physician's orders [REDACTED].>During an interview on [DATE] at 10:46 AM, the Director of Nursing (DON) confirmed there was no documentation of the resident's change in status by the night shift nurse. The DON further confirmed that s/he would have expected the nurse to have documented the resident's change in respiratory status, to check the resident's oxygen saturation level due to labored breathing and apply oxygen, When asked if s/he would have expected the nurse to discontinue the tube feeding, the DON stated I would have. The failure to ensure that services provided met professional standards of care at CFR 483.21(b)(3)(i) were identified as Immediate Jeopardy. On [DATE] at 6:00 p.m. the facility was notified that the failure to provide care to Resident #91 while experiencing respiratory distress was identified as Immediate Jeopardy. The Immediate Jeopardy was identified to have existed since [DATE] when Resident #91 developed respiratory distress. The nurse did not adequately monitor the resident per the care plan, assess the resident's vital signs or oxygen level, notify the physician of the change, or administer oxygen. On [DATE] at 11:56 a.m. the facility provided an allegation of compliance to remove the immediacy of the jeopardy. Measures put into place or system changes made to ensure that the immediate jeopardy will not recur were put in place by the facility as follows: 1. The nurse involved in the incident was terminated on [DATE] and reported to the State Board of Nursing. 2. On [DATE] the Administrator and the Corporate Compliance Officer completed a review of records of residents who had been transferred from the facility or who expired since [DATE] to assure that change of condition was identified and treated appropriately and timely. There were no other incidents noted. 3. The Administrator and Corporate Compliance Officer reviewed the 24-hour reports and clinical stand-up minutes from [DATE] to [DATE] to identify any change of condition to assure they were treated in a timely and appropriate manner. There were no additional incidents noted. 4. On [DATE] nurses were in-serviced by the Director of Nursing on resident change in condition, notification of changes to physician and the management of residents with change of condition. An Independent Clinical Nurse Consultant and the Director of Nursing will provide education to all nursing staff (CNA's/LPN's/RN's (Certified Nursing Assistants/ Licensed Practical Nurses/ Registered Nurses)) on change of condition, notification of changes to physician and the management of residents with change of condition beginning [DATE]. Any staff who has not received this training by [DATE] will not be allowed to work until the training is completed. 5. Any PRN (as needed), agency staff or new hires (CNA's/LPN's/RN's) will be educated by the Director of Nursing or Administrator prior to working in the facility. On [DATE] the State Agency accepted and ensured implementation of the facility's written plan of action presented on [DATE] at 11:56 a.m. that removed the Immediate Jeopardy. The citation at F658 will continue at a lower scope and severity level of D.

Based on record review and interview, the facility failed to report an allegation of neglect within the mandated 2 hour timeframe for resident #91, 1 of 2 [MEDICATION NAME] reviewed. The findings included: The facility admitted Resident #91 with [DIAGNOSES REDACTED]. On 01/17/18 at 3:00 PM, review of the Nurse's Note revealed a note timed and dated 7:15 AM on 09/25/17 by Licensed Practical Nurse (LPN) #5 that the resident ' s breathing could be heard at the nurses station. The resident had wet breath sounds bilaterally and was using ancillary muscles to breathe . The oxygen (O2) saturation was 62% on room air and s/he was placed on oxygen at 3 liters per minute via a mask. Vital signs were obtained after placing the resident on oxygen with an axillary temperature of 99.4 degrees, pulse of 86, respiratory rate of 30, blood pressure of 103/44 and the O2 saturation was up to 68%. Review of the facility-obtained statement dated 09/25/17 at 7:05 AM from LPN #5 indicated that upon arrival at the nurses' station (for the 7:00 AM-7:00 PM shift) s/he asked Who is breathing like that? and another nurse stated it was resident #91. LPN #5 asked if the resident was being sent to the hospital and LPN #8, the night shift nurse, stated s/he thought the resident was on hospice. Review of the fax confirmation report revealed the 2-hour report was faxed to the State Agency at 11:48 AM. On 01/19/18 at 01:37 PM, The Director of Nursing (DON) confirmed the incident occurred on night shift and that the day shift nurse responded when she arrived. The DON confirmed the 2- Hour Report stated the incident occurred at 7:30 AM and stated that was the time s/he became aware of the incident. The DON confirmed the 2- hour report was sent to state agency at 11:48 AM and was not within the mandated timeframe.

Based on record review and interview, Licensed Practical Nurse (LPN) #8 neglected to provide necessary care for signs and symptoms of respiratory distress for Resident #91, 1 of 1 resident reviewed for neglect. The findings included: The facility admitted Resident #91 with [DIAGNOSES REDACTED]. Review of the Physicians Orders at 12:07 PM on [DATE] revealed untimed orders dated [DATE] for oxygen at 3 liters per minute via mask, transfer to the hospital emergency room for evaluation, and admitted to the hospital in patient Hospice. On [DATE] at 3:00 PM, review of the Nurse's Note dated [DATE] through [DATE] revealed the resident's oxygen (O2) saturation (SAT) was 95% on [DATE] and 97% on [DATE]. On [DATE] respirations were even and non-labored and the O2 SAT was 96%. Oxygen saturation on [DATE] appeared to be 96% and 95% on [DATE]. There was no documentation Resident #91 had a history of [REDACTED]. At 7:15 AM on [DATE], the on-coming day-shift nurse documented that the resident's breathing could be heard at the nurses station. The resident had wet breath sounds bilaterally and was using ancillary muscles to breathe. The O2 SAT was 62% on room air and the day shift nurse placed the resident on oxygen at 3 liters per minute via a mask. Vital signs were obtained after placing the resident on oxygen with an axillary temperature of 99.4 degrees, pulse of 86, respiratory rate of 30, blood pressure of ,[DATE] and the O2 SAT was up to 68%. The physician was notified by the day shift nurse and an order obtained to transport Resident #91 to the hospital. The Responsible Party was notified at 7:55 AM of the emergency transfer. The facility was notified at 12:45 that the resident was admitted to inpatient hospice and at 6:30 PM on [DATE] the facility was notified by the hospital that the resident had expired. Review of the facility-obtained statement dated [DATE] from LPN #5 revealed that upon arrival at the nurses' station (for the 7:00 AM-7:00 PM shift) s/he asked Who is breathing like that? and another nurse stated it was resident #91. At that time, LPN #8, the night shift nurse, confirmed it was Resident #91 and stated the resident sounds bad. LPN #5 asked if the resident was being sent to the hospital and LPN #8 stated s/he thought the resident was on hospice. The statement indicated at that time LPN #5 went to the resident's room, assessed the resident, found the tube feeding infusing and the resident clearly in respiratory distress, mouth breathing (and) using ancillary muscles to breathe. LPN #5 stopped the tube feeding, instructed the Certified Nursing Assistant (CNA) to obtain vital signs, obtained an O2 SAT (62%), and started the resident on oxygen at 3 liters per minute via mask. LPN #5 then notified the physician and received an order to send the resident to the emergency room for evaluation. The facility obtained statement from LPN #9 dated [DATE] indicated that while conducting the narcotic count, LPN #8 stated there is someone on the hall that I believe is about to pass. The CNA came to the nurses' station and informed the 2 nurses that Resident #91's oxygen saturation was 62% and that at this point (no) oxygen was placed on the resident. The statement indicated the other day nurse overheard and asked why wasn't the resident being sent to the hospital (sic) night nurse states I don't know why. The statement further indicated the day nurse began to address the issue and the night nurse completed (her/his) stuff to leave, after stating that (s/he) tried suctioning resident (without) success. Upon observation it does not look as if the suction machine was used. The statement further indicated the resident's oxygen saturation did not improve much even (with) oxygen and that the night nurse had left by that time. CNA (Certified Nursing Assistant) #16's facility-obtained statement dated [DATE] indicated that s/he heard a noise and found that Resident #91 sounded like something was rattling in (her/him) (and) (s/he) wasn't responding to me when I called out to (her/him). The statement also indicated the night shift CNA told her the resident was like that all night. Review of the facility's Five-Day Follow-Up Report dated [DATE] indicated that there was conflicting information related to how long the resident was in respiratory distress. During a verbal statement, the night shift nurse stated to the Director of Nursing that the resident had been in distress since 5:30 AM but his/her written statement indicated 6:20 AM. According to the summary in the 5- Day report the Certified Nursing Assistant stated s/he informed the night shift nurse that the resident was not as responsive as usual at 1:00 AM. The report stated it appears that the resident went into respiratory distress sometime after 5:30 AM to 6:20 AM and that the nurse failed to assess resident change in condition and did not provide appropriate plan of care for a resident in respiratory distress. The report further indicated the facility substantiated the allegation of neglect, terminated the nurse and reported the nurse to the State Board of Nursing. During an interview on [DATE] at 10:46 AM, the Director of Nursing (DON) confirmed there was no documentation of the resident's change in status or that the physician was notified of the resident's respiratory distress by the night shift nurse. The DON further confirmed that s/he would have expected the nurse to have documented the resident's change in respiratory status and to notify the physician. The DON also confirmed that s/he would have expected the nurse to check the resident's oxygen saturation level due to labored breathing and apply oxygen. When asked if she would have expected the nurse to discontinue the tube feeding, the DON stated I would have but stated s/he couldn't speak for anyone else. The failure to prevent neglect at CFR 42 483.12 (a)(1) (F600) constituted Immediate Jeopardy and Substandard Quality of Care. On [DATE] at 6:00 p.m. the facility was notified that the failure to provide care to Resident #91 while experiencing respiratory distress was identified as Immediate Jeopardy. The Immediate Jeopardy was identified to have existed since [DATE] when Resident #91 developed respiratory distress. The nurse did not adequately monitor the resident per the care plan, assess the resident's vital signs or oxygen level, notify the physician of the change, or administer oxygen. On [DATE] at 11:56 a.m. the facility provided an allegation of compliance to remove the immediacy of the jeopardy. Measures put into place or system changes made to ensure that the immediate jeopardy will not recur were put in place by the facility as follows: 1. The nurse involved in the incident was terminated on [DATE] and reported to the State Board of Nursing. 2. On [DATE] the Administrator and the Corporate Compliance Officer completed a review of records of residents who had been transferred from the facility or who expired since [DATE] to assure that change of condition was identified and treated appropriately and timely. There were no other incidents noted. 3. The Administrator and Corporate Compliance Officer reviewed the 24-hour reports and clinical stand-up minutes from [DATE] to [DATE] to identify any change of condition to assure they were treated in a timely and appropriate manner. There were no additional incidents noted. 4. On [DATE] nurses were in-serviced by the Director of Nursing on resident change in condition, notification of changes to physician and the management of residents with change of condition. An Independent Clinical Nurse Consultant and the Director of Nursing will provide education to all nursing staff (CNA's/LPN's/RN's (Certified Nursing Assistants/ Licensed Practical Nurses/ Registered Nurses)) on change of condition, notification of changes to physician and the management of residents with change of condition beginning [DATE]. Any staff who has not received this training by [DATE] will not be allowed to work until the training is completed. 5. Any PRN (as needed), agency staff or new hires (CNA's/LPN's/RN's) will be educated by the Director of Nursing or Administrator prior to working in the facility. On [DATE] the State Agency accepted and ensured implementation of the facility's written plan of action presented on [DATE] at 11:56 a.m. that removed the Immediate Jeopardy. The citation at F600 will continue at a lower scope and severity level of D.

Based on record review and interview, the facility failed to notify the physician of a change in condition involving respiratory distress for Resident #91, 1 of 3 residents reviewed with a change in condition. The findings included: Resident #91 was admitted to the facility with [DIAGNOSES REDACTED]. Additional [DIAGNOSES REDACTED]. On [DATE] at 3:00 PM, review of the Nurse's Notes revealed at 7:15 AM on [DATE] Licensed Practical Nurse (LPN) #5 indicated the resident's breathing could be heard at the nurses station. The resident had wet breath sounds bilaterally and was using ancillary muscles to breathe. The oxygen saturation was 62% on room air. There was no documentation in the record on [DATE] by Licensed Practical Nurse (LPN) #8, who was on duty until 7:00 AM, of the change in status or that the physician or family had been notified of the resident's condition. Review of the facility's Five-Day Follow-Up Report dated [DATE] indicated that there was conflicting information related to how long the resident was in respiratory distress. During a verbal statement, the night shift nurse stated to the Director of Nursing that the resident had been in distress since 5:30 AM but in a written statement indicated 6:20 AM. According to the summary in the 5- Day report, the Certified Nursing Assistant stated s/he informed the night shift nurse that the resident was not as responsive as usual at 1:00 AM. The report stated it appears that the resident went into respiratory distress sometime after 5:30 AM to 6:20 AM. In a facility obtained statement dated [DATE], LPN #9 indicated that while conducting the narcotic count, LPN #8 stated there is someone on the hall that I believe is about to pass. Review of a facility-obtained statement dated [DATE] revealed that, upon noting Resident #91 was in respiratory distress, LPN #5 asked if the resident was being sent to the hospital and LPN #8 stated s/he thought the resident was on hospice. There was no documentation that LPN #8 had notified the physician, contacted the family or attempted to notify a hospice nurse that s/he thought the resident was about to pass. In addition, review of the Medication and Treatment Administration Records revealed a Hemocult Stools form that indicated the resident had a positive stool for occult blood at 2:00 AM on [DATE]. There was no documentation the physician was notified of the positive result on [DATE]. During an interview on [DATE] at 10:46 AM, the Director of Nursing (DON) confirmed there was no documentation of the resident's change in status or that the physician was notified of the resident's respiratory distress by the night shift nurse. The DON further confirmed that she would have expected the nurse to have documented the resident's change in respiratory status and to notify the physician. On [DATE] at 01:46 PM, the DON also confirmed the physician was not notified of the first positive stool for hemocult on [DATE]. Review of the facility's policy, Change in Medical Condition of residents, revealed the purpose was To keep the physician and responsible party informed of the resident's medical condition so the plan of care can be directed as needed. The policy further stated The medical record should include documentation of the symptoms and observations associated with the change in condition and the date and time of contact with the physician and responsible party. The documentation should also include any orders and interventions that occurred. The failure to notify the physician of the change in the resident's status at 42 CFR 483.10 (g)(14)(B) (F580) was identified as an Immediate Jeopardy. On [DATE] at 6:00 p.m. the facility was notified that the failure to provide care to Resident #91 while experiencing respiratory distress was identified as Immediate Jeopardy. The Immediate Jeopardy was identified to have existed since [DATE] when Resident #91 developed respiratory distress. The nurse did not adequately monitor the resident per the care plan, assess the resident's vital signs or oxygen level, notify the physician of the change, or administer oxygen. On [DATE] at 11:56 a.m. the facility provided an allegation of compliance to remove the immediacy of the jeopardy. Measures put into place or system changes made to ensure that the immediate jeopardy will not recur were put in place by the facility as follows: 1. The nurse involved in the incident was terminated on [DATE] and reported to the State Board of Nursing. 2. On [DATE] the Administrator and the Corporate Compliance Officer completed a review of records of residents who had been transferred from the facility or who expired since [DATE] to assure that change of condition was identified and treated appropriately and timely. There were no other incidents noted. 3. The Administrator and Corporate Compliance Officer reviewed the 24-hour reports and clinical stand-up minutes from [DATE] to [DATE] to identify any change of condition to assure they were treated in a timely and appropriate manner. There were no additional incidents noted. 4. On [DATE] nurses were in-serviced by the Director of Nursing on resident change in condition, notification of changes to physician and the management of residents with change of condition. An Independent Clinical Nurse Consultant and the Director of Nursing will provide education to all nursing staff (CNA's/LPN's/RN's (Certified Nursing Assistants/ Licensed Practical Nurses/ Registered Nurses)) on change of condition, notification of changes to physician and the management of residents with change of condition beginning [DATE]. Any staff who has not received this training by [DATE] will not be allowed to work until the training is completed. 5. Any PRN (as needed), agency staff or new hires (CNA's/LPN's/RN's) will be educated by the Director of Nursing or Administrator prior to working in the facility. On [DATE] the State Agency accepted and ensured implementation of the facility's written plan of action presented on [DATE] at 11:56 a.m. that removed the Immediate Jeopardy. The citation at F580 will continue at a lower scope and severity level of D.