Every finding on record at Cascadia of Nampa

Based on record review, staff interviews, review of the neglect investigation and clinical guidance, the facility failed to ensure resident's were provided treatment and care in accordance with professional standards of practice, and the residents goals and preferences when they did not identify and act upon Resident #60's physical and cognitive deterioration. This failure resulted in Immediate Jeopardy to Resident #60's health and safety when Resident #60 was not promptly assessed and treated for acute changes in condition, leading to hospitalization of sepsis (a life-threatening condition where the body's immune system has a severe and overwhelming response to an infection, causing damage to its own tissues and organs) and Stevens-Johnson Syndrome/Toxic Epidermal Necrolysis (a rare, severe, life-threatening skin disorder, often triggered by medications, causing widespread blistering and peeling of the skin and mucous membranes, resembling a severe burn, leading to fluid loss, infection risk, and intense pain).Immediate Jeopardy was identified on 12/4/25 at 12:31 PM and was determined to exist since 11/21/25, when the facility failed to ensure appropriate nursing response to Resident #60 when she displayed signs of sepsis. On 12/4/25 at 12:31 PM, the facility's Administrator was notified of the Immediate Jeopardy at F684 Quality of Care. On 12/5/25 at 6:10 PM, after the Survey Team verified implementation of the IJ removal plan, the facility Administrator was notified the Immediacy was removed on 12/5/25. The noncompliance remained at a scope and severity level of G (isolated actual harm) following the removal of the immediate jeopardy.Findings include:Review of the facility's policy titled, Resident Change of Condition revised 8/31/25, defined a change in condition as, A deviation from the resident's baseline health status, including but not limited to changes in: Functional ability, cognition, continence, significant weight fluctuations, behavior, or chronic disease status.The policy directed the nursing staff to notify the provider if any of the following occurred:Significant change or a trending change in vital signs (temperature, pulse, blood pressure, heart rate, and/or oxygen saturation.)Significant change in level of consciousness etc.It also directed Nursing staff to:Monitor and reassess the Resident until resolved, stable or transferred. Place the Resident on alert charting for additional observation, documentation, and response to any interventions. Documentation in the clinical record includes the following, but is not limited to: a. Date and time of discovery of the change in condition.b. Resident assessment (evaluation) of overall condition. c. Interventions completed and resident response, including any emergency care provided.d. Notification attempts and responses. The American Association of Post-Acute Care Nursing website, titled Nurse Assessment - Acute Changes in Condition, accessed 12/4/25, documented: The nurse must assess subtle changes and work with the medical team to differentiate normal changes of aging from acute changes in condition. Recognize symptoms and changes in vital signs, physical function, mental function, and body condition that could indicate acute conditions.Resident #60 was admitted to the facility on [DATE], with multiple diagnoses including aftercare following joint replacement surgery.Resident #60's MDS dated [DATE], documented she was cognitively intact. An admission progress note dated 11/13/25 at 2:33 PM, documented Resident #60 was alert and oriented on admission. The admission notes also documented Resident #60 complained of an itchy back.A physician's order dated 11/13/25, directed staff to apply hydrocortisone to Resident #60's rash two times a day.A Skin Inspection Evaluation dated 11/13/25, documented Resident #60 had a surgical incision on her right hip and bilateral bruising on both arms.The Skin Inspection Evaluation dated 11/13/25 did not include documentation of Resident #60's rash on her back.A Physician's Note dated 11/14/25, documented she was alert, awake, and able to follow commands. On 11/19/25, a Physical Therapy Progress note documented Resident #60 was disoriented and struggling with simple directions.Resident #60's record did not include documentation of notification to the provider of her cognitive change on 11/19/25.A Nursing Progress Note dated 11/19/25 at 04:01 AM, documented Resident #60 continued with a significant rash on her back. The progress note documented hydrocortisone cream was applied with no improvement to rash or itchy feeling. Resident #60 reported having changed her shirt due to moisture and her entire back feeling raw and sore.A Skilled Daily Progress Note dated 11/19/25 at 8:52 PM, documented Resident #60 was alert and oriented with the following respiratory issues: Shortness of breath or trouble breathing with activity and when lying flat. As well as a rash to upper back that was managed with hydrocortisone. The note also documented Resident #60 complained of increased itching to back and a non-urgent referral for dermatology was made.On 11/20/25, a Physical Therapy Progress note documented Resident #60 continues to present with increased confusion and nausea at baseline. The note also documented Resident #60 was found lying in bed and reported continued symptoms of nausea and feeling hot then cold and high confusion with simple directions.Resident #60's record dated 11/20/25, did not include documentation the provider was notified of the continued changes in her cognition and health status.On 11/21/25 at 5:20 AM, a Nursing Progress Note documented Resident #60 was observed shivering, with the following vital signs: blood pressure 139/63, temperature 101.9 F, heart rate 80. The note also documented an as needed Tylenol was administered.On 11/21/25 at 9:45 AM, a Physician Note documented Resident #60 stated, I was here all night? I thought I was somewhere else. The note further documented, she was able to correctly identify orientation questions; however, Resident #60's comment indicated some change in her mentation.On 11/21/25 the following physician orders were received:Sodium Chloride Solution 0.9% give 2 liters intravenously one time for mild hypotension/acute kidney injury for 1 day at 100 ml/hr.Complete blood count and a basic metabolic panel lab to be done 11/24/25.Vital Signs every 4 hours for 24 hours.Hold Aspirin, Celecoxib, Acyclovir for 3 days related to acute kidney injury.Zofran 4 mg by mouth every 6 hours as needed for nausea/vomiting. Ceftriaxone 10 grams reconstituted solution give 1 gram intravenously for empiric sepsis-like symptoms.Monitor right hip incision every shift for signs and symptoms of infection for 3 days.Prednisone 50 mg give 1 tablet by mouth at bedtime for rash to back until 11/24/25.A Skin Inspection Evaluation dated 11/21/25 at 8:56 PM, documented Resident #60 had generalized dry skin with, Extensive rash on entire back. Reddish sores with crusted dry sores. The evaluation documented the rash was located on the right and left rear shoulders, both shoulder blades, and vertebrae; it also documented no signs of infection to her right hip incision. Resident #60's MAR dated 11/21/25, documented she had increased confusion/poor concentration, and a mental status change that morning.Resident #60's MAR documented she began receiving sodium chloride solution via IV at 12:45 PM on 11/21/25. Resident #60's record documented on 11/21/25 at 1:39 PM, her vitals as follows: blood pressure 88/47, temperature 97.3 F, respirations of 16, heart rate 109.The facility's Abuse/Neglect investigation report dated 11/24/25, documented Resident #60's representative became upset when she was notified of Resident #60's change in condition. The representative was informed the DON would contact her with further information. Shortly after Resident #60's representative arrived at the facility and informed the DON she did not believe the skilled nursing facility was equipped to manage Resident #60's medical condition. The DON agreed with Resident #60's representative and following the representative's insistence, Resident #60 was sent to the emergency department due to cognitive deterioration and irregular vital signs.At the hospital, Resident #60 was diagnosed with sepsis and Stevens-Johnson Syndrome/Toxic Epidermal Necrosis. Resident #60 was immediately airlifted to a burn unit in another state for treatment after obtaining burns on 18% of her body.On 12/3/25 at 2:25 PM, during an interview with the CRN, DON, and Administrator, the CRN and DON confirmed Resident #60 did not have appropriate monitoring to ensure effective treatment was implemented. On review of Resident #60's care plan, the DON stated the care plan did not include monitoring, assessments or interventions pertaining to her rash. When asked if Physical therapy notified nursing or the provider of the change in Resident #60's mentation, the CRN reviewed Resident #60' record and stated there was no documentation the physician was notified of her change in mentation.On 12/3/25 at 3:45 PM, The Medical Director stated he was not informed of Resident #60's change in cognition. The Medical Director stated resident's change in condition should have been reported as soon as a nursing assessment was completed.The facility's failure to recognize Resident #60's change of condition placed her in Immediate Jeopardy. The lack of timely physician notification and intervention resulted in Resident #60 experiencing life-threatening sepsis and Stevens-Johnson Syndrome, requiring her to be transferred to a specialized burn unit.

Based on observation, the FDA Food Code, and staff interview, it was determined the facility failed to ensure ice machines were cleaned, and resident freezers were not contaminated by non-food items, or undated, opened food. These deficiencies had the potential to affect all facility residents who consumed food or ice prepared by the facility. This placed residents at risk for potential contamination of food and adverse health outcomes, including food-borne illnesses. Findings include:1. The FDA Food Code Section 2-301.14 documented food employees shall clean their hands and exposed portions of their arms immediately before engaging in food preparation including working with exposed food, clean equipment and utensils, and unwrapped single-service and single-use articles; as well as during food preparation, as often as necessary to remove soil and contamination and to prevent cross contamination when changing tasks; before donning gloves to initiate a task that involves working with food; and after engaging in other activities that contaminate the hands.On 12/3/25 from 11:00 AM to 11:30 AM, [NAME] #1 was observed preparing food for residents while wearing gloves, taking food temperatures, and cleaning the thermometer with a sani-wipe. [NAME] #1 was not observed performing hand hygiene by washing hands before donning gloves. At 11:36 AM, [NAME] #1 was observed grabbing an unwrapped hotdog bun with the original gloves from before serving resident food.On 12/3/25 at 11:37 AM, the Kitchen Manager stated the proper use of gloves includes hand hygiene by appropriate washing methods before and after glove use and whenever changing tasks. She acknowledged [NAME] #1 should have changed her gloves with appropriate hand hygiene after preparing food and taking food temperatures and before starting tray line. [NAME] #1 should also have used tongs or clean gloves when handling the hot dog buns. 2. The FDA Food Code Section 3-501.17 Ready-to-Eat, TCS food, date marking, documented marking the date or day the original container is opened in a food establishment, with a procedure to discard the food on or before the last date or day by which the food must be consumed on the premises, sold, or discarded.On 12/1/25 at 8:23 AM, the following items were observed opened and undated:Tray line refrigerator and freezer: cheese, salsa, French fries. Walk-in freezer: breaded chicken pieces, breaded steak fries, and hoagie bread rolls. Large plastic bins in the main kitchen area containing dried mashed potatoes, flour, oatmeal, and sugar. On 12/1/25 at 8:40 AM, the Kitchen Manager stated food items should be stored with labels indicating date open and/or use by date, and the plastic bins should have been labeled appropriately.3. The FDA Food Code Section 4-602.11 Equipment Food-Contact Surfaces and Utensils documented surfaces of utensils and equipment contacting food that is not time/temperature control for food shall be cleaned in equipment such as ice bins and enclosed components of equipment such as ice makers, at a frequency specified by the manufacturer, or absent manufacturer specifications, at a frequency necessary to preclude accumulation of soil or mold.On 12/3/25 at 2:50 PM, it was observed in the Hall A Ice Room, the blue plastic scooper bucket had black residue on the bottom of the bucket where the ice scooper was stored. On Hall A and Hall B, the ice machines were observed to have a thin shiny pink layer on the interior plastic separator plate where the ice accumulates.On 12/3/25 at 3:03 PM, the Kitchen Manager stated the ice bucket should not have black residue and the interior plastic plates of the ice machines should not have a thin shiny pink layer. 4. FDA Food Code Section 6-403.11 documented areas designated for employees to eat, drink, and use tobacco products shall be located so that food, equipment, and linens single-service and single use articles are protected from contamination.On 12/5/25 at 11:10 AM, it was observed in Hall A, the resident freezer had multiple food items (ice cream, stir fry meals, frozen shake) which were open and undated, and had visible layers of ice indicating the food had been defrosted and refrozen.On 12/5/25 at 11:13 AM, it was observed in Hall B of the resident's nourishment refrigerator food belonging to staff (open drink, iced coffee, whipped cream) was stored alongside resident nourishments. On 12/5/25 at 11:14 PM, the Kitchen Manager stated staff food is not supposed to be stored with resident food, and all resident food should be dated, labeled, and sealed (not visibly open.)

Based on the review of the Facility's Arbitration agreement and staff interview, it was determined the facility failed to ensure the facility's arbitration agreement provides the selection of a venue that is convenient to both parties. This was true for all residents who reside in the facility. This failure created the potential for residents to be inconvenienced or the inability to participate during the arbitration process. Findings include:The facility's Voluntary Agreement for Arbitration undated, documented an arbitration hearing arising under the Arbitration Agreement shall be held in the county where the facility is located before a board of three arbitrators.On 12/3/25 at 10:55 AM, after review of the arbitration agreement and the federal regulation requirement the Administrator stated the arbitration agreement was missing the regulatory requirement of a convenient location of arbitration for both parties.

Based on observation, interview, and policy review, it was determined the facility failed to ensure infection control measures were consistently implemented. This was true for 5 of 5 residents (#2, #16, #39, #49, and #61) when staff failed to perform effective hand hygiene during medication preparation, and for all resident's using the facility's laundry services. The facility failed to practice standard based precautions when preparing medications and handle, store, process, and transport linens to prevent the spread of infection. These failures created the potential for the spread of infection among all residents. Findings include: The CDC recommended the following procedure for hand hygiene with soap and water: Wet hands first with water, Apply the recommended amount of antibacterial soap, Rub hands together vigorously for at least 15 seconds, covering all surfaces of the hands and fingers, Rinse hands with water and use disposable towels to dry, and Use towel to turn off the faucet. The CDC guidelines also documented other entities had recommended cleaning hands with soap and water for approximately 20 seconds and documented either amount of time was acceptable. The facility's Hand Hygiene - Infection Control Policies and Procedures, revised 9/15/25, documented staff should perform hand hygiene: Before and after resident care; Before an aseptic procedure; Before moving from one soiled body site to a clean body site on the same resident; After contact with objects in resident's environment; Before and After assisting a resident with a meal; After any contact with blood or other body fluids, even if gloves are worn; Immediately after removal of PPE. 1. On 12/3/25 at 8:45 AM, RN #2 was observed preparing Resident #16's morning medications at the medication cart. RN #2 used hand sanitizer to clean her hands, removed a pill from house stock, and used the pill cutter to split the pill in half. During this process she dropped the two halves on the tabletop, she then picked 1/2 pill up with her fingers and placed it in the cup with the residents' other medications. RN #2 then picked up the remaining 1/2 of the pill with her fingers and returned 1/2 pill into the pill container. On 12/3/25 at 10:50 AM, the IP stated the observations described above were inappropriate forms of hand hygiene regarding medication administration. He stated during medication preparation; the nurse should never touch medications with an ungloved hand. The IP stated gloves should be donned, or a spoon or other tool should have been used to pick up the dropped medications and disposed of due to them being contaminated by the countertop. 2. RN #3 was observed without performing hand hygiene as follows: 12/8/25 at 9:14 AM, when she entered Resident #3's room to administer her insulin. RN #3 then removed her gloves, donned new gloves without performing hand hygiene, and administered Resident #3's Brimonidine eye drops. 12/3/25 at 9:33 AM, when she entered Resident #3's room to administer her oral medications. RN#3 then left to get Resident #3's Dorzolamide eye drops and came back without performing hand hygiene upon entering Resident #3's room. On 12/3/25 at 2:38 PM, the IP stated hand hygiene should be performed before entering and after exiting residents' room, and prior to administering medications. 3. On 12/3/25 at 8:58 AM, RN #1 prepared Resident #61's medications. RN #1 then entered Resident #61's room and administered medications. On Resident #61's overbed table was his upper and lower dentures. The dentures were not in a container and there was no barrier between the dentures and overbed table. On 12/3/25 at 9:02 AM, when asked about Resident #61's dentures not being in a container, RN #1 stated she could have educated Resident #61 better regarding the potential for infection. 4. Resident #2 was admitted to the facility on [DATE], with multiple diagnoses including anxiety, depression, and malnutrition. Resident #2's MDS comprehensive assessment dated [DATE], documented yes under the question indicating the use of a CPAP (a non-invasive mechanical ventilator.) On 12/1/25 at 10:28 AM, and on 12/2/25 at 10:05 AM, Resident #2's CPAP mask was observed uncovered, laying on the machines hose, on top of her nightstand. On 12/2/25 at 10:08 AM, Resident #2 confirmed the face mask is often sitting out with no cover. On 12/2/25 at 10:24 AM, RN #1 stated the CPAP mask was not stored in a sanitary condition and should be placed in a bag to ensure cleanliness. 5. Resident #39 was admitted to the facility on [DATE], with multiple diagnoses including respiratory disorder, cough, and need for assistance with personal care. A physician's order dated 7/11/24, documented Fluticasone Propionate Nasal Suspension 50 mcg/ACT give 1 spray in each nostril two times a day for nasal congestion. On 12/1/25 at 8:55 AM, RN #2 was observed approaching Resident #39 with a vital cart. Inside the vital cart basket was a cup with a nasal spray. RN #2 proceeded to take the spray and administer one spray into each nostril. RN #2 was not observed performing hand hygiene prior to the administration of medication without gloves. On 12/1/25 at 9:06 AM, RN #2 stated she would normally don gloves prior to administration, but she did not today because it's the residents' home like environment. She also stated she did not feel she had breached infection control and confirmed she was not worried about infection control or cross contamination. 6. The facility's Laundry Services policy dated 10/8/25, documented nursing and laundry staff would follow procedures for handling, storing, processing and transporting linens to prevent contamination. It also documented wet linens are not to be left in laundry equipment overnight to prevent mildew and ensure timely processing. a. On 12/5/25 at 7:20 AM, during a laundry room inspection, two washers were observed to be full of wet clothing. The laundry staff stated the clothing in the washer at the time had been left from the night before, and she would be moving it into the dryer. On 12/5/25 at 7:30 AM, the laundry staff stated they often leave resident clothing in the washer and rewash it if it gets stinky. b. On 12/5/25 at 7: 25 AM, the laundry staff explained that after drying the residents clothing, if clothing needed to be labeled, she would take the clean laundry back to the dirty side of the laundry room to label it before delivering it to resident rooms. On 12/5/25 at 7:30 AM, the laundry staff confirmed the label maker was on the dirty side of the laundry room and if clothing was being labeled it should be rewashed before being taken to the resident's room. 12/5/25 at 8:10 AM, the Administrator stated laundry gets washed then labeled and then sent out to the resident's room. Upon visiting the laundry room, the Administrator confirmed the label machine was on the dirty side of the laundry room.

Based on policy review, observation, record review, and resident and staff interview, it was determined the facility failed to serve palatable food to facility residents who were interviewed about food temperature and taste. This was true for all residents who consumed food and coffee prepared by the kitchen and facility staff. This had the potential to create dissatisfaction with meals and decrease residents' quality of life. Findings include:The facility's Meal Service policy dated 9/15/25, documented the facility will ensure each resident receives a minimum of three nourishing, palatable, and well-balanced meals daily, consistent with their clinical needs, dietary orders, and care plan directives.1. During the survey, residents reported the food was not at the right temperature when it was served, the food was not consistently palatable, and the coffee tasted burnt, as follows:a. On 12/2/25 at 9:49 AM, Resident #1 stated, The food is awful. b. On 12/2/25 at 11:05 AM, Resident #6 stated the food was okay, but the portions are small and the temperature is not always right.c. During a State-Surveyor led Resident Council meeting on 12/2/25 at 3:45 PM, with 9 residents in attendance, there were various concerns about the food and coffee as follows: The food is always cold because the food cart sits [in the hallway], and the meals are cold before residents are served. The butter does not melt, and the coffee creamer does not mix because the food and coffee are too cold. The food is too salty, the vegetables are watery and overcooked, the meat is overdone, dry and tough, and the new coffee machines make the coffee taste burnt.2. On 12/3/25 at 12:25 PM, two lunch meal test trays, consisting of a regular diet on two different serving plates were loaded last onto the uncovered B-hall room tray food cart. Observations during tray line meal service showed hot food was dished onto cold plates. Some plate bottoms were placed onto a warmed insulated bottom and covered with an insulated top, while adaptable plates were covered with a metal lid containing a hole in the center, without a heated bottom.On 12/3/25 at 12:37 PM, the test trays were evaluated after all the resident meal trays had been delivered. Condiments (salt, pepper, butter) were not added to the tray to flavor the food. Food temperatures were measured by surveyors with the following results:a. Scoop Plate, no insulated bottom or top, showed temperatures were out of range for some foods, and the overall meal was bland without seasoning or flavor, as follows: Turkey- 111 F; Sweet potatoes- 124 F; Spinach -135 F, Cranberry juice- 48 F.b. Regular Plate, insulated top with heated insulated base, showed temperatures were out of range for some foods, and some foods were found to be bland without seasoning or flavor, as follows: Turkey- 109 F; Sweet potatoes- 144 F; Spinach 136 F, Apple juice - 47 F; Milk - 45 F; Pumpkin Cake-61 F.3. On 12/1/25, 12/2/25, and 12/3/25 surveyors were provided the same coffee residents received throughout the facility with the following results: the coffee was not palatable and had a burnt taste.On 5/5/25 at 10:39 AM, the Kitchen Manager confirmed the facility coffee had tasted burnt since facility staff were not familiar with working the new coffee machines and made the coffee too strong by not adjusting the boldness of the brew. The Kitchen Manager confirmed based on the results of the test trays and the quality of the coffee, the facility had not provided resident's food and coffee that was palatable, and at a safe and appetizing temperature.

Based on observation, record review, policy review, and interviews, it was determined the facility failed to ensure residents were assessed for safety to self-administer medication. This was true for 3 of 19 residents (#49, #52 and #87) whose medications were observed at bedside. This failure created the potential for adverse outcome if residents were to administer their medication inappropriately. Findings include: The facility's Self-Administration of Medication policy revised 9/16/25, documented residents may self-administer medications when it is determined to be safe and appropriate. The facility will assess each request using a team-based approach. The assessment will consider the resident's ability to manage medications independently and safely, including bedside storage as appropriate.1. Resident #49 was admitted to the facility on [DATE], with multiple diagnoses including stroke and diabetes.On 12/3/25 at 9:14 AM, RN #3 entered Resident #49's room with a medication cup containing the resident's oral medication mixed with pudding. Resident #49 asked for her Dorzolamide (eye drops) to be administered first before her oral medications. RN #3 placed the medication cup on top of Resident #49's table and stated she brought the Brimonidine eye drops instead of the Dorzolamide eye drops. RN #3 then left the room, leaving the cup of medication, and came back with Dorzolamide eye drops and administered it to Resident #3's eyes. RN #3 then administered Resident #49's oral medications.On 12/3/25 at 9:45 AM, RN #3 was asked why she left the medication cup on Resident #49's overbed table to get the Dorzolamide eye drops. RN #3 stated she left the medication cup on the overbed table because she did not want to spill the medications. RN #3 added she would not leave the medications at resident's bedside if she knew the resident was confused.On 12/3/25 at 3:15 PM, CRN together with the RCM stated the medications should not have been left at Resident #49's overbed table.2. Resident #52 was admitted to the facility on [DATE], with multiple diagnoses including traumatic subdural (brain) hemorrhage with loss of consciousness and heart failure.A Comprehensive MDS assessment dated [DATE], documented Resident #52 had severely impaired-no vision or sees only light, colors or shapes; eyes do not appear to follow objects.On 12/1/25 at 8:53 AM, a medication cup containing white powder was observed on Resident #52's bedside table.On 12/1/25 at 3:20 PM, the RCM stated she had no idea what the white powder inside the medication cup was. When asked if the medication cup containing the white powder should be left at Resident #52's bedside table, the RCM stated No it should not be left at Resident #52's bedside table. The RCM stated if a medication was at Resident #52's bedside table she should have an assessment to self-administer the medication.On 12/3/25 at 2:18 PM, the RCM stated Resident #52 did not have an assessment to self-administer her medications.3. Resident #87 was admitted to the facility on [DATE], with multiple diagnoses including osteoarthritis and diabetes.On 12/1/25 at 8:48 AM, a ketoconazole (anti-fungal) cream was observed on Resident #87's overbed table. Resident #87 stated the ketoconazole cream was prescribed by his dermatologist and he applied it to his skin once or twice a day.On 12/1/25 at 3:14 PM, the RCM stated the ketoconazole should not be left in Resident #87's room. The RCM stated if a medication was at Resident #87's bedside table he should have an assessment to self-administer the medication.On 12/3/25 at 2:18 PM, the RCM stated Resident #87 did not have an assessment to self-administer his medications.

Based on record review, observation and interview, it was determined the facility failed to ensure residents received services in the facility with reasonable accommodation of resident needs and preferences when they were denied access to the call light system while left alone in their room. This was true for 2 of 19 residents (#28 and #89) whose call lights were observed. This deficient practice had the potential for harm if residents could not alert staff for assistance when needed. Findings include:1. Resident #28 was admitted to the facility on [DATE], with multiple diagnoses including muscle spasms, age related physical debility and fall from one level to another.An admission MDS, dated [DATE], documented Resident #28 was cognitively intact and she required extensive assistance of one to two persons for activities of daily living.Resident #28's care plan, initiated on 10/22/25, documented she had an ADL deficit with progressive weakness and staff were to encourage her to use a standard call light to ring for assistance and validate placement upon leaving the resident.On 12/1/25 at 4:00 PM, Resident #28 was sitting in her wheelchair in her room. Resident #28 asked if the Surveyor could hand her the call light which was observed to be on the bedside table on the opposite side of the bed from where her wheelchair was placed. Resident #28 stated the staff did not give it to her when they left her room about 20 minutes earlier, and she was unable to move her wheelchair by herself. 12/1/25 at 4:05 PM, CNA #1 entered Resident #28's room and confirmed the call light was out of reach and should have been given to the resident prior to staff leaving her alone. 2. Resident #89 was admitted to the facility on [DATE], with multiple diagnoses including muscle weakness and surgical aftercare following right artificial shoulder joint replacement.An admission MDS, dated [DATE], documented Resident #89 was moderately cognitively impaired and she required extensive assistance of one to two persons for ADLs.Resident #89's care plan, initiated on 10/20/25, documented she had an ADL self-care deficit with impaired mobility, impaired cognition, weakness and non-weight bearing to upper right extremity and staff were to encourage her to use a standard call light to ring for assistance and validate placement upon leaving resident.On 12/1/25 at 4:10 PM, Resident #89's call light was observed laying across the bed on her right side. She was sitting in a wheelchair positioned with the bed on her right and the wall on her left. Resident #89 was wearing an arm sling on the right side. She stated she could not reach her call light and due to her arm sling she could not propel her wheelchair. On 12/1/25 at 4:15 PM, CNA #1 entered Resident #89's room and confirmed the resident could not reach call light and said PT must have left it on the bed when they returned the resident to her room. She stated call light should have been placed where Resident #89 could easily reach it. On 12/5/25 at 4:45 PM, the DON stated her expectation was that all staff ensure residents are left with their call light within reach before leaving them alone in their room.

Based on observation, record review, and staff interview it was determined the facility failed to ensure accurate MDS Assessments. This was true for 1 of 5 residents (Resident #1) reviewed for accuracy of assessments. This deficient practice had the potential to create harm if residents did not have an accurate MDS assessment. Findings include:Resident #1 was admitted to the facility on [DATE], with multiple diagnoses including hypertensive heart disease with heart failure and acute and chronic respiratory failure with hypoxia (low levels of oxygen in the body tissues).A Quarterly MDS assessment dated [DATE], documented Resident #1 was not receiving oxygen therapy.A care plan initiated 5/27/25, documented Resident #1 was to receive oxygen as ordered by the physician.On 12/1/25 at 12:03 PM, Resident #1 was observed in the dining room receiving oxygen via nasal cannula.On 12/2/25 at 3:44 PM, the MDS Coordinator reviewed Resident #1's MDS assessment dated [DATE]. The MDS Coordinator stated Resident #1's MDS assessment should have been coded Yes for oxygen.

Based on record review and staff interviews, the facility failed to ensure coordination of assessments with the PASARR program for 1 of 2 residents (Resident #9) reviewed for PASARR coordination. This failure created the potential for residents with a mental disorders or intellectual disabilities to miss care and services in the most integrated care setting appropriate to their needs. Findings include:Resident #9 was admitted to the facility on [DATE] with multiple diagnoses including schizoaffective disorder, dementia, and lack of expected physiological development.Resident #9's record included an abbreviated PASARR Level II dated 10/1/25, which documented the admitting facility must complete a PASARR when it appears the resident's stay will exceed 30 days, and no later than the 40th calendar day after admission.On 12/5/25 at 10:46 AM, the LSW stated Resident #9's PASARR should have been submitted by 11/9/25. A review of Resident #9's record showed the PASARR was not submitted until 12/4/25, 26 days late.

Based on policy review, record review, and staff interview, it was determined the facility failed to ensure a PASARR was accurately completed for 1 of 2 residents (Resident #44) reviewed for PASARR screenings. This deficient practice created the potential for harm if Resident #44 required, but did not receive, specialized services for mental health while residing in the facility. Findings include:The facility's PASARR policy revised 8/29/25, documented the facility would ensure that potential admissions were to be screened for possible serious mental disorders or intellectual disabilities and related conditionsResident #44 was admitted to the facility on [DATE], with multiple diagnoses including post-traumatic stress disorder.Resident #44's PASARR evaluation dated 10/2/23, documented on section 1. Does the individual have any of the following Major Mental Illnesses (MMI)? The Post-Traumatic Stress Disorder was not checked off for Resident #44.On 12/3/22 at 2:18 PM, the LSW reviewed Resident #44's PASARR. The LSW stated Resident #44 had diagnosis of PTSD and his PASARR Level I was not accurately completed. Resident #44 should have PASARR Level II assessment completed.

Based on observation, record review, and staff interview, it was determined the facility failed to provide accurate and quarterly smoking evaluations and did not follow the care plan. This was true for 1 of 2 residents (Resident #90) reviewed for smoking. This deficient practice had the potential for harm if smoking assessment evaluation safety procedures were not followed. Findings include: Resident #90 was admitted to the facility on [DATE] and 12/26/23, with multiple diagnoses including Alzheimer's, schizoid personality disorder, dementia, depression, and muscle weakness.A Comprehensive MDS assessment dated [DATE], documented Resident #90 was cognitively intact.a. The facility's Resident Assessment policy, revised 10/15/22, documented assessments are completed to analyze or evaluate the resident's physical and mental condition or abilities which may include smoking habits. Assessment accuracy is necessary to provide documentation of medical, functional, and psychosocial problems; assisting to identify resident strengths to maintain or improve. The care plan is reviewed and revised in conjunction with the updates.A Smoking Evaluation Report, dated 11/30/25, documented Resident #90 was an independent smoker, but was required to store his smoking paraphernalia at the nursing station.On 12/4/25 at 3:35 PM, Resident #90 was observed leaving the facility to smoke in the designated area. He was not observed stopping by the nursing station to get his smoking paraphernalia.On 12/5/25 at 7:44 AM, LPN #1 stated Resident #90 keeps his smoking paraphernalia with him, and it is not kept in the nursing cart. He keeps his smoking materials on his person to use when he wants to. On 12/5/25 at 8:34 AM, the DON, with the CRN present, stated Resident #90 is an independent smoker and keeps his smoking items locked up in his room. When asked if Resident #90's Smoking Evaluation Report from 11/30/25 was accurate, they confirmed it was not. The DON stated, Resident #90's smoking assessment should have identified he was able to keep his smoking paraphernalia locked in his room.b. The facility's Person-Centered Care Planning dated 9/10/25, documented each resident will have a person-centered, comprehensive care plan developed and implemented to reflect their individual preferences. The interdisciplinary team will ensure the plan is based on current assessments, supporting the residents' highest practicable level of well-being, and that is it reviewed and revised as needed.Resident #90's care plan, revised 11/30/25 informed staff Resident #90 was an independent smoker, but smoking paraphernalia should be stored at the nursing station.On 12/5/25 at 8:37 AM, the DON with the CRN in attendance, confirmed Resident #90's care plan was not accurate as it did not identify Resident #90 was able to keep his smoking paraphernalia locked in his room.c. Resident #90's care plan initiated 4/2/25, documented smoking evaluations should be completed quarterly, and with a change of condition which may affect the ability to manage smoking materials.A review of Resident #90's smoking assessments documented smoking evaluations were completed on 11/27/24 and 11/30/25.On 12/5/25 at 8:42 AM, the DON and CRN stated Resident #90 did not have quarterly smoking assessments from 11/27/24 through 11/30/25, and he should have had at least two additional smoking assessments in 2025.

Based on observation, record review, and staff interview, it was determined the facility failed to ensure residents received respiratory services consistent with physician's order and/or their care plan. This was true for 1 of 3 residents (Resident #1) reviewed for oxygen use. This deficient practice created the potential for harm if Resident #1's respiratory needs were not met. Findings include:Resident #1 was admitted to the facility on [DATE], with multiple diagnoses including hypertensive heart disease with heart failure and acute and chronic respiratory failure with hypoxia (low levels of oxygen in the body tissues) and overactive bladder.A physician's order dated 11/30/25, documented Resident #1 was to receive oxygen 1 liter per minute per nasal cannula to maintain her oxygen saturation greater than 90% every shiftA care plan initiated 5/27/25, documented Resident #1 was to receive oxygen as ordered by the physician.Resident #1 was observed without using her oxygen via nasal cannula on:12/2/25 at 9:11 AM, in the dining room.12/2/25 at 9:20 AM, in her room.On 12/2/25 at 9:46 AM, CNA #2 stated Resident #1 was to have oxygen all day and night. CNA #2 stated she did not notice Resident #1 was not using her oxygen when she wheeled her to her room.On 12/2/25 at 4:15 PM, the RCM stated Resident #1 should have used her oxygen continuously.

Based on policy review, review of McGeer's Criteria Surveillance for Infection, and staff interviews, it was determined the facility failed to ensure antibiotic stewardship was implemented and residents had appropriate clinical indications for the use of antibiotic. This was true for 1 of 1 resident (Resident #1) whose record was reviewed for antibiotic use. This deficient practice created the potential for Resident #1 to receive unnecessary treatment for a suspected urinary tract infection and/or develop multi-drug-resistant organism. Findings include:The facility's Antibiotic Stewardship policy revised 10/15/22, documented the facility focused on improving antibiotic use through an Antibiotic Stewardship program to ensure appropriate antibiotic usage are in place, to promote therapeutic and cost-effective care for the residents, and ultimately reduce the likelihood of developing multi-drug-resistant organism. The policy also documented the facility utilized McGeer's criteria to validate the infection, and to review culture and sensitivity reports routinely as part of the surveillance of the infection.The Revised MCGeer's Criteria for urinary tract infection with indwelling catheter documented both 1 and 2 must be fulfilled:1. At least one of the following sign or symptoms:Fever, rigors, or new-onset hypotension, with no alternate site of infection.Either acute change in mental status or acute functional decline with no alternate diagnosis and leukocytosis.New-onset suprapubic pain or costovertebral angle pain or tenderness.Purulent discharge from around the catheter or acute pain, swelling, or tenderness of the testes, epididymis, or prostate.2. Urinary catheter specimen culture with greater than 105 CFU/ml of any organism(s). Resident #1 was admitted to the facility on [DATE], with multiple diagnoses including hypertensive heart disease with heart failure and acute and chronic respiratory failure with hypoxia (low levels of oxygen in the body tissues).Resident #1's progress notes documented the following:11/11/25 at 9:30 AM, an NP progress note documented Resident #1 had significant leaking from her urinary catheter. Resident #1 denied pain other than annoyance of being wet. The NP ordered urinalysis with culture and sensitivity.11/11/25 at 6:15 PM, a Nursing Progress note documented Resident #1 urine was hazy and straw yellow colored. Resident #1 was afebrile (no fever) and denied flank pain, suprapubic pain or burning sensation.11/14/25 at 9:00 AM, an NP progress note documented Resident #1's result suggested improper specimen collection or delay in delivery. The laboratory suggested to do a repeat specimen if the condition warrants it. 11/17/25 at 8:30 AM, an NP progress note documented Resident #1 continued to have significant leaking of urine from her urinary catheter and repeat urinalysis with culture and sensitivity was requested.11/18/25 at 4:49 AM, a Nursing progress note documented Resident #1's urinary catheter was changed, and urine specimen was collected. Resident #1 was afebrile and no complaints of flank pain or dysuria (painful urination).11/18/25 at 6:02 PM, a Nursing Progress note documented Resident #1's urine sample was picked up by the laboratory.11/19/25 at 12:41 AM, a Nursing Progress note documented Resident #1 denied dysuria/urgency, no leakage noted from her urinary catheter.11/23/25 at 1:42 PM, a Nursing Progress note documented Resident #1's urinary catheter drained a straw-colored urine with trace sediments noted.11/24/25 at 7:45 AM, an NP progress note documented repeat urinalysis was pending as the previous sample was not picked up by the laboratory in time. The NP also requested CBC and CMP for further follow-up on the concern with the foley/UTI as well as weakness that was reported at the end of last week. The NP also documented Resident #1 was not currently having an altered mental status, and the nurse had not reported Resident #1 as having altered mental status over the last couple of days.11/24/25 at 6:47 PM, a Nursing Progress note documented Resident #1's urine was noted to have a strong odor. She denied suprapubic pain, burning or flank pain. The urine specimen was picked up by the laboratory. Resident #1 was noted to be falling asleep more during the day in activities.11/25/25 at 9:53 PM, a Nursing Progress note documented Resident #1 was slightly weaker and drowsy during activities and in-between meals. She was afebrile and denied flank pain or suprapubic pain.11/26/25 at 10:20 PM, a Nursing progress note documented Resident #1's urine was noted to be cloudy and amber with blood tinge. A call was made to the laboratory to follow-up the urinalysis result. The laboratory reported they made a mistake, even though the test was abnormal they threw the sample [out] and did not perform a culture and sensitivity test. The NP was informed of Resident #1's increase in weakness and sleeping more than usual and her urinary catheter leaking urine with strong odor. An order was received to collect Resident #1's urine for urinalysis and culture and sensitivity test. The NP also gave an order to start Resident #1 with Augmentin (antibiotic) 875/125 mg two times a day for 14 days after her urine was collected.11/30/25 at 3:01 PM, an IP Progress note documented Resident #1 had not complained of any urinary symptoms.12/2/25 at 1:13 PM, a Nursing progress note documented a new order was received from the NP to discontinue the antibiotic and urinalysis, issue resolved.Resident #1's progress notes documented she was afebrile and had no complained of flank pain or suprapubic pain, and culture and sensitivity test were not done. On 12/2/25 at 3:34 PM, the RCM with the CRN present when asked about the urinalysis result, the RCM stated the laboratory reported the urine sample was contaminated and another urine sample was collected, but the laboratory did not pick up the specimen during the holiday (Thanksgiving). When asked when did the facility find out Resident #1's urine sample was not collected, the RCM stated, yesterday. The RCM stated, Yes Resident #1's urinalysis and culture result should have been followed up. When asked why the antibiotic was discontinued when it was ordered for 14 days. The RCM stated Resident #1's symptoms had been resolved.On 12/5/25 at 8:01 AM, the IP stated a urine having a foul odor is not a criterion for infection. When asked what the signs and symptoms for UTI would be, the IP stated the facility follows the McGeer's criteria for UTI, if the resident had a urinary catheter, it would be new onset of hypotension, fever, change in mental status or functional decline.

Based on observation, policy review, and staff interview, it was determined the facility failed to ensure waste was properly contained with lids or otherwise covered. This created the potential for insect and pest infestation of the facility's premises and had the potential to adversely affect all 90 residents residing in the facility. Findings include: The facility's Pest Control policy, dated 10/18/23, documented routine inspections were conducted at the facility for evidence of pests. The policy documented staff were to keep the facility grounds free of trash and brush and to keep the dumpster area clean and the lid closed. On 6/18/24 at 10:20 AM, with the Dietary Manager the area in the parking lot behind the kitchen where the trash dumpster was located was observed. One dumpster used to contain the facility trash and recycling material was open and the lid was flipped back exposing boxes and bags of trash. During an interview on 6/18/24 at 10:20 AM, the Dietary Manager stated, The dumpster should be closed and not left open.

Based on facility document review, record review, observation, and resident and staff interview, it was determined the facility failed to ensure residents' rights for self-determination was honored. This was true for 3 of 3 residents (#5, #35, and #49) reviewed for choices. This deficient practice had the potential for Resident #5, #35, and #49 to experience a decreased sense of well-being, lack of self-worth, and frustration when their preference for having the television (TV) on in the dining room during meals was not accommodated. Findings include: Review of the facility document, Resident Rights 2017, documented .The Resident has the right to make choices about the aspects of his/her life in the facility that are significant to the resident . - Resident #5 was admitted to the facility on [DATE] with multiple diagnoses including spina bifida (a condition that occurs when the spine and spinal cord do not form properly which can range from being mild to causing serious disabilities) and muscle weakness. An annual MDS assessment, dated 3/22/24, documented Resident #5 was moderately cognitively impaired. Resident #5's care plan for activities, revised 12/27/23, documented Resident #5 has engaged in bingo, coloring, watching TV . - Resident #35 was initially admitted to the facility on [DATE], with multiple diagnoses including diabetes and depression. A quarterly MDS assessment, dated 5/3/24, documented Resident #35 was moderately cognitively impaired. Resident #35's care plan for activities, revised 2/5/24, documented Resident #35 .Will watch TV in dining room at mealtimes only . - Resident #49 was initially admitted to the facility on [DATE] with multiple diagnoses including diabetes and muscle weakness. A quarterly MDS assessment, dated 3/25/24, documented Resident #49 was cognitively intact. Resident #35's care plan for activities, revised 2/5/24, documented staff were to .Provide a program of activities that is of interest and empowers the resident by encouraging/allowing choice, self-expression, and responsibility . 1. On 6/19/24 at 12:15 PM, Resident #5, Resident #35, and Resident #49 were observed in the B-Hall independent dining room watching TV while waiting for lunch to be served. When the lunch trays arrived at 12:30 PM, CNA #3 was observed turning the TV off, in the middle of a program that Resident #5, Resident #35, and Resident #49 were watching. Resident #5, Resident #35, and Resident #49 stated to CNA #3 their dislike of the TV being turned off and CNA #3 stated .I know, but I have to . and walked away. During an interview on 6/19/24 at 12:45 PM, Resident #35 and Resident #49 stated they liked the TV on during their meal and did not like it being turned off. Resident #49 stated he was told the TV was to be turned off during meals to .avoid distractions . during the meal. Resident #49 also stated some staff turned the TV off and some did not, and he ate all his meals in the dining room. Resident #35 agreed with Resident #49 that some staff would turn it off and others did not, but he also preferred to watch TV while eating. Resident #5 agreed with Resident #35 and Resident #49 that she preferred to have the TV on while eating. The TV was turned back on at 1:00 PM by CNA #4. Resident #35 and Resident #49 had finished eating and left the dining room, however Resident #5 was still eating and was observed actively watching the TV. 2. On 6/20/24 at 11:30 AM, in the B-Hall independent dining room, Resident #5, Resident #35, and Resident #49 were observed watching TV while waiting for the lunch meal to be served. Lunch was served at 12:15 PM and the TV was not turned off, or the volume turned down, while the residents ate. During an interview on 6/20/24 at 12:45 PM, Resident #35, Resident #5, and Resident #49 stated they were happy the TV was not turned off while they ate their meal. During an interview on 6/22/24 at 9:15 AM, Resident #6, who was the current Resident Council President, stated some staff would turn off the TV during meals in the dining room and others did not. She stated she was unsure why some turned it off and stated .I think they want us to talk to each other . She also stated this concern had not been brought up at resident council meetings. 3. On 6/22/24 at 11:15 AM, the TV was observed on and Resident #49 and Resident #35 were in the dining room actively watching TV while waiting for lunch. Lunch was served at 12:05 PM and the TV was not turned off, or the volume turned down, during the meal. Resident #5, Resident #35, and Resident #49 were actively watching TV while eating. During an interview on 6/22/24 at 12:20 PM, LPN #1 for B-Hall stated the TV could be left on during mealtimes, especially if the residents requested it. LPN #1 stated the volume could be lowered if needed, but if the residents requested the TV to be left on it should be on as it was their choice as this was their home. LPN #1 also stated that CNA #3 would turn the TV off and was educated by LPN #1 if the residents want the TV left on, it could be, but there was no policy that stated that the TV had to be turned off. During an interview on 6/22/24 at 12:30 PM, the Administrator and DON stated the TV could be left on during meals, as this was the residents' home and their choice. The Administrator stated the volume could be adjusted so the staff could be aware of any potential choking concerns, but if they wanted the TV on, it should be left on. The Administrator also stated the facility did not have a specific policy regarding this but referred to the facility Resident Rights 2017 document provided to all residents.

Based on observation, record review, policy review, and staff interview, it was determined the facility failed to ensure a fall prevention intervention was implemented following a fall. This was true for 1 of 3 residents (Resident #10) whose records were reviewed. This had the potential for harm if the resident sustained an injury from a fall. Findings include: The facility's Accidents and Supervision to Prevent Accidents policy, dated 10/15/22, documented .The facility provides an environment that is free from accident hazards over which the facility has control and provides supervision and assistance devices to each resident to prevent avoidable accidents . Resident #10 was admitted to the facility on [DATE], with multiple diagnoses including abnormalities of gait and mobility. A fall risk evaluation, dated 8/8/23, documented Resident #10 was a fall risk. A quarterly MDS assessment, dated 8/10/23, documented Resident #10 was moderately cognitively impaired. The assessment further documented she required extensive assistance of one staff for bed mobility and extensive assistance of two staff for transfers and was dependent on staff for bathing. An incident progress note, dated 10/22/23, documented a post fall investigation was completed for Resident #10. The note documented Resident #10 sustained a fall from her bed and was found on the floor near the bed. The progress note further documented Resident #10 was assessed for injuries she hit her head and had possible bruising to the posterior scalp. An interdisciplinary team (IDT) progress note, dated 10/23/23, documented Resident #10's fall was reviewed and Resident #10 said she was going to prepare lunch for her mother. The IDT note documented Resident #10 was on comfort measures and refused to get out of bed. The IDT recommended a low bed and to have a fall mat placed next to her bed. Resident #10's care plan, dated 10/23/23, documented the facility implemented an impact floor mat to increase the Resident #10's safety. A fall risk evaluation, dated 2/5/24, documented Resident #10 continued to be a fall risk. A health status progress note, dated 2/5/24, documented a NA found Resident #10 on the floor face down adjacent to her bed with her feet at the head of the bed. The note documented Resident #10 stated she had a dream she could walk. Another progress note, dated 2/5/24, documented Resident #10 sustained a bruise on her right cheek and was sent to the local emergency room for evaluation and treatment. An emergency room progress note, dated 2/5/24, documented Resident #10 presented to the hospital due to a recent fall and the resident struck the right side of her face. Tests were run and there were no injuries. The resident was later returned to the facility on the same day. On 6/18/24 at 10:16 AM, two NAs were observed conducting a mechanical lift transfer of Resident #10. There was no impact floor mat next to Resident #10's bed during this observation. On 6/19/24 at 1:26 PM, Resident #10 was in bed and stated she felt safe. There was no impact floor mat next to her bed. During an interview on 6/19/24 in Resident #10's room at 4:25 PM, NA #2 confirmed she worked with Resident #10 a great deal and she confirmed Resident #10 did not have a fall mat on the floor, next to her bed. NA #1 was also present and confirmed there was no floor mat on the floor next to Resident #10's bed and there was none located in her room. During an interview on 6/20/24 at 2:20 PM, the DON stated the floor mat was to be placed on the floor next to Resident 10's bed since this would reduce the likelihood of injury if the resident fell on the floor.

Based on policy review, record review and staff interview, it was determined the facility failed to ensure residents were offered a pneumococcal vaccine they were eligible to receive. This was true for 2 of 5 residents (#31 and #52) whose records were reviewed for pneumococcal vaccinations. This failure created the potential for residents to have an increased risk of pneumococcal (bacterial) pneumonia and the potential for severe illness or death. Findings include: The Centers for Disease Control and Prevention (CDC) Pneumococcal Vaccine Timing for Adults, dated 3/15/23, located at https://www.cdc.gov/vaccines/vpd/pneumo/downloads/pneumo-vaccine-timing.pdf, included recommendations for pneumococcal vaccinations for all adults [AGE] years or older as follows: - For those who have never received any pneumococcal vaccine, the CDC recommends receiving one dose of PCV20 or PCV15. - For those who have previously received PCV13 at any age and PPSV23 at less than [AGE] years of age, the CDC recommends receiving PCV20 at least five years after administration of PCV13 or PPSV23. The CDC also stated these adults can talk with their doctor and decide, together, whether to get the PCV20 vaccine. The facility's Pneumococcal Program policy, dated 5/31/23, documented for routine vaccination for those who are age 65 or older who have not previously received a dose of PCV13, PCV15, or PCV20, or whose previous vaccination history is unknown, 1 dose of PCV15 or 1 dose of PCV20 should be offered. For those who have previously received only the PCV13, 1 dose of PCV20 at least 1 year after the PCV13 was administered or to complete the recommended PPSV23 series should be offered. The following residents who were eligible for the PCV20 vaccine did not have documentation in their record they were offered or received the PCV20 vaccination: a. Resident #31 was admitted to the facility on [DATE], with multiple diagnoses including stroke and muscle weakness. Resident #31's immunization record documented he received the PPSV23 on 10/14/13 and the PCV13 on 4/6/15. Resident #31's record did not include documentation of shared decision-making between Resident #32 and/or his representative and his primary care physician on the possible administration of the PCV20 vaccination. b. Resident #52 was admitted to the facility on [DATE], with multiple diagnoses including end stage renal disease and muscle weakness. Resident #52's immunization record documented he received PCV13 on 11/1/11 and the PPSV23 on 11/1/12. The PCV13 and PPSV23 were administered to the resident before he turned [AGE] years old. Resident #52's record did not include documentation of shared decision-making between Resident #52 and/or his representative and his primary care physician on the possible administration of the PCV20 vaccination. During an interview on 6/20/24 at 10:02 AM, the Infection Preventionist stated the facility did not have a process between the resident and the physician which would reflect a shared decision making on PVC20 vaccination.

Based on observation, policy review, record review, and staff interview, it was determined the facility failed to ensure infection control prevention practices were consistently implemented to prevent the spread of COVID-19 infection. COVID-19 is an infectious disease by a new virus causing respiratory illness with symptoms including cough, fever, new or worsening malaise, headache, or new dizziness, nausea, vomiting, diarrhea, loss of taste or smell, and in severe cases difficulty breathing that could result in severe impairment or death. This failure created the potential for negative outcomes by placing the 59 residents in the facility who were negative for COVID-19 and all staff in the facility who were negative for COVID-19, to the risk of COVID-19 infection. Findings include: The facility's policy for Screening and Management of Coronavirus COVID-19, revised 9/1/20, documented the following: * Staff who enter rooms with positive COVID-19 residents utilize Enhanced Droplet Precautions-Red with an N95 mask. * Use of Personal Protective Devices-COVID-19 Unit-Red: Wear gown, N95/respirator, eye protection, and gloves when in (the resident's) room. On 12/7/20 at 3:35 PM, the surveyors entered the facility's COVID-19 positive unit. A red sign was posted on the outside of the door to the unit. The sign stated Enhanced Droplet Precautions were in place, and full PPE was required for entry to the unit. The sign stated and illustrated that a gown, N95 mask/respirator, eye protection (goggles or face shield), and gloves were required. The above policy and directions were not followed. 1. On 12/7/20 at 3:45 PM, LPN #1 entered Resident #5's room, which was in the COVID-19 positive unit. LPN #1 was carrying a plastic cup of water and a plastic medication cup which contained several pills. LPN #1 was wearing a gown, face shield, N95 mask, and yellow procedure mask over the N95 mask. LPN #1 was not wearing gloves when she entered the room. LPN #1 walked to Resident #5's bedside and handed him the cup of pills and water. After he swallowed the pills, Resident #5 tossed the medication cup towards the trash can, and it landed on the floor. Resident #5 handed the empty water cup to LPN #1, and she disposed of it in the trash and picked up the medication cup from the floor and disposed of it in the trash. LPN #1 then sanitized her hands and exited Resident #5's room. LPN #1 did not wear gloves in Resident #5's room as she administered medication to him and as she disposed of cups that were handled by Resident #5. LPN #1 said Resident #5 was on airborne or droplet precautions, and he had recovered from COVID-19. LPN #1 said she would wear gloves in the room if she was providing direct care to residents. She said she was not wearing gloves when she touched the cups that were used by Resident #5. 2. On 12/7/20 at 4:02 PM, the Physical Therapist (PT) entered Resident #6's room, which was in the COVID-19 positive unit. The PT was wearing a face shield, N95 mask, and gown when he entered the room, and he was not wearing gloves. The PT closed the door, and he exited the room a short time later. The PT said Resident #6 was on standard COVID precautions, and he said he did not wear gloves when he was in her room. The PT said Resident #6 was recovering from COVID-19, and staff were to wear PPE to prevent the spread of COVID-19. The PT said he would wear gloves if he was working directly with a resident, and he went into Resident #6's room to return a pillow to her bed and he did not touch anything else but the pillow. 3. On 12/7/20 at 4:30 PM, Nursing Assistant #1 (NA #1) entered Resident #5's room, which was in the COVID-19 positive unit. NA #1 was wearing a face shield, N95 mask, and gown when she entered the room, and she was not wearing gloves. Approximately one minute later, NA #1 exited the room carrying Resident #5's empty water cup with her bare hands, and she walked down the hall with the water cup. Approximately five minutes later, NA #1 returned to the room with a full water cup and re-entered the room carrying the water cup with her bare hands. NA #1 was wearing a face shield, N95 mask, and gown when she entered the room, and she was not wearing gloves. Approximately one minute later, NA #1 exited the room, and she said staff were to wear PPE in the COVID-19 unit, including a gown, face shield, N95 mask, and gloves when working with the residents. NA #1 said gloves should be worn when in a COVID-19 positive resident's room. NA #1 said she carried Resident #5's water cup with her bare hands after he had touched it, and she should have kept her gloves on. 4. On 12/7/20 at 4:45 PM, RN #1 was assisting Resident #7 to ambulate in the hall near the nurse's station in the COVID-19 positive unit. RN #1 was holding onto a gait belt, which was in place around Resident #7's waist. RN #1 was wearing a face shield, N95 mask, and gown as he assisted Resident #7, and he was not wearing gloves. RN #1 assisted Resident #7 to walk back to her wheelchair and helped her sit down in the wheelchair. RN #1 leaned down and tied Resident #7's shoe and helped adjust her in the wheelchair, and he was not wearing gloves. RN #1 said the residents in the unit were under quarantine precautions, and staff were to wear a gown, N95 mask, and face shield in the unit. Resident #7 then stood up from her wheelchair, and RN #1 assisted her to sit back down in the wheelchair, removed a cup of soda from the table in front of her, and handed a cup of water to her. RN #1 was not wearing gloves. RN #1 said Resident #7 recently had COVID-19 and she was beyond the 14-day window, and he said staff should wear gloves when providing resident care. RN #1 said if a resident came in with signs or symptoms of COVID-19, then they should wear gloves when in contact with the resident for the first 14 days. 5. On 12/7/20 at 4:25 PM, on the COVID-19 positive unit, RN #2 assisted Resident #7 by touching Resident #7's waist and the gait belt around her waist, without gloves, cuing Resident #7 to sit down, then returned to the COVID-19 positive unit medication cart and continued to place medications into a plastic cup. RN #2 then entered and exited the Nourishment Room with the cup in her hand, went to the Alpine Unit medication cart with the cup and got a spoon. RN #2 then approached Resident #8 in the dining area, placed an oximeter on his finger, touched the front of his face mask with her non-gloved hands, and spoon fed him his medications. She then again grabbed the front of Resident #8's face mask and pulled it up over his nose. RN #2 then returned to the medication cart. RN #2 said she touched the cup and went to the nourishment room looking for pudding for Resident #8's medications, then went to the Alpine Unit medication cart before providing Resident #8 his medications. RN #2 said she did not need to wear gloves, and she only needed to if she was providing resident cares. 6. On 12/7/20 at 4:45 PM, RN #2 entered Resident #9's room without gloves. Resident #9 was admitted to the facility on [DATE] and was positive for COVID-19. She placed the blood pressure cuff on Resident #9's arm and the oximeter on Resident #9's finger. RN #2 removed the cuff and oximeter and exited the room. RN #2 said the whole unit was on droplet precautions, and she sanitized everything that went into and out of the room, and herself. She said she was not aware of a requirement to wear gloves into the resident's room when staff provided cares. On 12/7/20 at 5:35 PM, the DON said staff should wear an N95 mask, face shield, gown, and gloves when providing resident care in the COVID-19 positive unit. The DON said it was not good to wear gloves in the hall, such as wearing gloves to carry dishes or glasses used by the resident, because it would spread the germs in the hall.

Based on record review and staff interview, it was determined the facility failed to ensure residents with unplanned weight loss were provided interventions to prevent further weight loss. This was true for 1 of 1 resident (Resident #7) reviewed for weight loss. This failure created the potential for harm if residents experienced adverse health outcomes due to unplanned weight loss. Findings include: Resident #7 was initially admitted to the facility on [DATE], and readmitted on [DATE], with [DIAGNOSES REDACTED]. Resident #7's care plan, revised 6/16/20, directed staff to provide meals per physician diet orders and to weigh her monthly and record the weight. The care plan also documented weight loss was beneficial for Resident #7. The care plan did not identify the desired weight for Resident #7 and the acceptable amount weight loss per week/month. Resident #7's Weight Summary documented she weighed 155.4 pounds on 6/2/20 and was 5 feet 4 inches tall (64 inches). Resident #7's care plan area addressing nutrition interventions, revised 8/14/20, documented Resident #7 required a consistent carbohydrate diet with regular (non-modified) textures, to cut all meats, and liquids were to be of thin (non-restrictive) consistency. Resident #7's care plan did not include a pre-determined weight loss plan. Resident #7's care plan, revised 8/27/20, directed staff to assist with and set up her meals and that at times Resident #7 was able to feed herself and at other times required verbal cues and physical assistance. On 9/6/20, Resident #7's Dietary Evaluation documented she had a good appetite and had no difficulty swallowing. Resident #7's Weight Summary documented she weighed 154.8 pounds on 9/16/20. The Weight Summary did not include documentation of Resident #7's weight the month of October. A Progress Note, dated 10/23/20, documented Resident #7 tested positive for COVID-19. Symptoms of COVID 19 were not documented in Resident #7's record throughout the course of her illness. Resident #7's Clinical Evaluation Summaries, dated 10/23/20, 10/28/20, and 10/29/20, documented Resident #7's appetite was low (less than half of baseline/typical). No interventions were documented to address her low appetite. Resident #7's Intervention/Task Documentation Survey Reports, from 10/1/20 through 10/31/20, documented Resident #7 declined replacement meals/snacks 48 of 180 (26%) eating opportunities. The Report from 11/1/20 through 11/30/20 documented she declined to eat on 47 of 174 (27%) eating opportunities, and in the first week of December, Resident #7 declined to eat 18 of 42 (42%) eating opportunities. Interventions to promote Resident #7's nutritional intake were not documented. A Clinical Evaluation Summary, dated 11/3/20, documented Resident #7 now required assistance with eating, was less verbal and did not often respond to attempts at communication, and required increased cueing. Resident #7's Behavior Management IDT note, dated 11/3/20, documented she required assistance with eating and increased cueing. On 11/5/20, Resident #7's Weight Summary documented she weighed 150.2 pounds. New or revised interventions to address Resident #7's reduced eating ability and decreased weight were not documented. A Health Status Note, dated 11/15/20, documented Resident #7 had difficulty eating meals without propelling around in her wheelchair and standing up and down. Alternative meal delivery interventions were not documented in Resident #7's care plan. Resident #7's Intervention/Task Documentation Survey Report, from 11/9/20 to 12/6/20, documented Resident #7 consumed, on average each day, less than or equal to 50% of her meals 21 of 28 days. No new interventions regarding intake were documented in Resident #7's care plan. Resident #7's care plan addressing diet interventions, revised 11/25/20, documented Resident #7 often sat and ate at a table near the nurse's station with less stimulation from television and other residents where staff could provide cueing and assistance if needed. No new meal assistance interventions were documented in the care plan. Resident #7's Weight Summary documented she weighed 138.9 pounds on 12/6/20, a loss of 11.3 pounds in one month, a 7.5% unplanned weight loss. A Health Status Note, dated 12/6/20, documented Resident #7 was having difficulty sitting down to eat and kept standing up during meal time. The Note stated much of lunch was eaten while standing. The Note documented Resident #7 had an 11-pound weight loss in the last month. The MD was made aware. A Dietary Note was documented in Resident #7's record on 5/4/20 and she had a Dietary Evaluation on 9/6/20, which documented she had a good appetite. The next dietary note was documented on 12/8/20 after the significant weight loss. On 12/9/20 at 9:00 AM, the DON said Resident #7 re-weighed that day and her weight was 139 pounds. This was consistent with Resident 7's weight of 138.9 pounds on 12/6/20. On 12/9/20 at 9:53 AM, the Dietitian said that he determined the caloric intake a resident should have upon admission. He said an evaluation was done and a typical intake is around 2000 calories, or more if required to maintain a large person. The Dietitian said Lucerne, a low sugar high calorie supplement for persons with diabetes, was discussed for Resident #7 at a meeting on 12/8/20. Resident #7 experienced a unplanned significant weight loss in one month. No dietary interventions were documented in the care plan and implemented to address Resident #7's weight loss.

Based on observation, policy review, and staff interview, it was determined the facility failed to ensure infection control prevention practices were implemented and maintained to provide a safe and sanitary environment. This failure created the potential for negative outcomes by exposing residents to the risk of infection and cross-contamination including COVID-19. Findings include: 1. The facility's Transmission-Based Precautions policy, dated 9/10/20, documented a gown and gloves were required upon entry into a resident's room to complete cares. The policy also documented staff were to use an N95 facemask or follow the indications of specific zones and other droplet precaution directives. The facility's COVID-19 Exposure - Asymptomatic, Enhanced Droplet Precautions sign, informed staff full Personal Protective Equipment (PPE) was required for entry into the room. The sign directed staff the required PPE included a gown, an N95 facemask, eye protection (goggles or face shield), and gloves. On 10/27/20 at 11:15 AM, the DNS said Area A was the COVID-19 positive unit, and Area B was the COVID-19 negative unit which included some residents who were being observed for symptoms of COVID-19 and were under Enhanced Droplet Precautions. On 10/27/20 at 12:28 PM, The door to Resident #1's room had a sign that stated, Stop - COVID-19 Exposure - Asymptomatic, Enhanced Droplet Precautions near the door. CNA #1 entered Resident #1's room, in Area B, with a lunch tray. CNA #1 was not wearing gloves or a gown. CNA #1 said he entered the room wearing a face shield and an N95 facemask and did not put on a gown and gloves as the sign directed. On 10/27/20 at 3:00 PM, the IP said staff were to follow the guidance on the enhanced precaution sign, and to wear a KN95 or N95 facemask, face shield, a gown, and gloves when entering the room. The IP said staff were to put on the gown and gloves before entering the room and remove them before exiting the room. 2. The facility's Screening and Management of Coronavirus COVID-19 policy, revised 7/21/20, directed staff to assist residents to wash their hands when potentially soiled, before eating, after toileting, after coughing/sneezing, when leaving their rooms, and as indicated. This policy was not followed. Examples include: a. On 10/27/20 from 12:05 PM to 12:21 PM, food trays were being served to residents in the Cascade unit. The following was observed: -At 12:05 PM, CNA #3 and CNA #5, delivered and set up Resident #3 and Resident #4's food trays on their overbed table in their room. CNA #3 and CNA #5 did not offer hand hygiene to Resident #3 and Resident #4 before serving their meal. -At 12:08 PM, the AD delivered and set up Resident #5's food tray on his overbed table in his room. The AD did not offer hand hygiene to Resident #5 before serving his meal. -At 12:21 PM, the AD delivered and set up Resident #6's food tray on her overbed table in her room. The AD did not offer hand hygiene to Resident #6 before serving her meal. On 10/27/20 at 1:08 PM, the AD said she did not offer hand hygiene to the residents when she delivered their meal trays. The AD said she should have offered hand hygiene to the residents before serving their meals. On 10/27/20 at 1:14 PM, CNA #3 said she did not offer hand hygiene to Resident #4 when she delivered her food tray. On 10/27/20 at 1:25 PM, CNA #5 said she did not offer hand hygiene to residents when she delivered their food trays. b. On 10/27/20 from 5:20 PM to 5:26 PM, food trays were being served to residents in the Alpine unit (COVID-19 positive unit). The following was observed: -At 5:20 PM, CNA #4 delivered and set up Resident #8's food tray on his overbed table in his room. CNA #4 did not offer hand hygiene to Resident #8 before serving his meal. -At 5:24 PM, CNA #7 delivered and set up Resident #9's food tray on her overbed table in her room. CNA #7 said he did not offer hand hygiene to Resident #9 before serving her meal. -At 5:25 PM, CNA #4 delivered and set up Resident #10's food tray on her table in her room. CNA #4 did not offer hand hygiene to Resident #10 before serving her meal. -At 5:26 PM, CNA #4 delivered and set up Resident #11's food tray on her overbed table in her room. CNA #4 did not offer hand hygiene to Resident #11 before serving her meal. On 10/27/20 at 5:28 PM, CNA #4 said she did not offer hand hygiene to the residents when she delivered their food trays. -At 5:16 PM, CNA #2 delivered a meal tray to Resident #13 in room A12 and she placed it on a bedside table. CNA #2 assisted Resident #13 with a transfer from bed to the wheelchair, then she placed the table in front of Resident #13. CNA #2 did not offer or remind Resident #13 to perform hand hygiene before eating. The CNA said she did not offer the resident hand hygiene. On 10/27/20 at 3:10 PM, the IP said residents should be offered hand hygiene before meals. The IP said if a resident was independent the staff should remind them to perform hand hygiene or ask the resident if they wanted to wash their hands prior to eating. 3. The facility's Blood Glucose Monitoring policy, dated 12/20/17, directed staff to do the following: * Place a cleaned glucometer on a barrier. * Assemble blood glucose test strip, alcohol wipe, lancet, gauze pad, and clean barrier. * Approach the resident and place items on overbed table with clean barrier protection. This policy was not followed. Examples include: a. On 10/27/20 at 11:45 AM, RN #2 prepared to perform a blood glucose test for Resident #1. RN #2 placed the glucometer on top of Resident #1's overbed table. There was no barrier between the glucometer and the overbed table. When RN #2 checked Resident #1's blood glucose, she said the glucometer was not reading Resident #1's blood glucose. RN #2 then removed the glucose test strip from the glucometer and reinserted it, and repeated the process. During the process of removing and reinserting the glucose test strip, RN #2's gloved hand touched the tip of the glucose test strip. RN #2 then attempted to repeat Resident #1's blood glucose test but the glucometer would not turn on. RN #2 left the room and returned with another glucometer, she placed the glucometer on top of the overbed table with no barrier between the glucometer and the overbed table. RN #2 then checked Resident #1's blood glucose, removed her gloves, performed hand hygiene and exited Resident #1's room. On 10/27/20 at 1:35 PM, RN #2 said she placed the glucometer on top of Resident #1's overbed table without a barrier. RN #2 said she removed and inserted the glucose test strip twice, and during the process she touched the tip of the glucose test strip. RN #2 said she should have put a barrier between the glucometer and Resident #1's overbed table. RN #2 said she should have changed the glucose test strip when her hand touched the tip. b. On 10/27/20 at 12:30 PM, RN #1 placed a glucometer on top of the medication cart. There was no barrier between the glucometer and the medication cart. RN #1 then gathered a 2 x 2 gauze pad, lancet device, alcohol swab, and glucose test strip. RN #1 then picked up the glucometer and testing supplies, and entered Resident #7's room. RN #1 also had an inhaler in her hand when she entered Resident #7's room. RN #1 placed the glucometer on top of Resident #7's overbed table. RN #1 did not put a barrier between the glucometer and the overbed table. RN #1 gave the inhaler to Resident #7 and asked her to take one puff orally. RN #1 then checked Resident #7's blood glucose. RN #1 then removed her gloves, performed hand hygiene, and exited the room. On 10/27/20 at 2:30 PM, RN #1 said she carried the supplies in her hand because she did not have anything to put them in. RN #1 said she placed the glucometer with the glucose test strip, lancet device, alcohol swab and 2 x 2 gauze pad on top of Resident #7's table because she wanted to administer the inhaler medication to her before she checked her blood glucose. RN #1 said she did not put a barrier on the table between the supplies and the glucometer. RN #1 said she did not know what kind of a barrier she should use. On 10/27/20 at 3:03 PM, the DNS said there should be a barrier when staff placed the glucometer on any surface. The DNS said the barrier could be a paper towel or an empty cup. 4. The facility's Transmission-Based Precautions policy, dated 9/10/20, documented Alcohol Based Hand Rub (ABHR) and/or hand washing with soap and water was to be performed before and after wearing gloves. On 10/27/20 at 12:55 PM, RN #1 doffed (took off) her gloves after disinfecting a glucometer, then she donned (put on) a new pair of gloves without performing hand hygiene. RN#1 did not perform hand hygiene between doffing and donning gloves. On 10/27/20 at 3:05 PM, the IP said staff were to perform hand hygiene before donning and after doffing gloves. 5. The CDC's website titled, Preparing for COVID-19 in Nursing Homes, updated 6/25/20, and accessed on 10/29/20, stated facilities were to provide necessary supplies to adhere to recommended infection prevention and control practices, and for environmental cleaning and disinfection. The facility was to ensure Environmental Protection Agency (EPA) registered disinfectants were available for frequent cleaning of high-touch surfaces and to use an EPA-registered disinfectant from List N on the EPA website to disinfect surfaces that might be contaminated with [DIAGNOSES REDACTED]-CoV-2 (COVID-19). On 10/27/20 at 1:41 PM, Housekeeper #1 was observed cleaning room B17 in Area B, which included residents under observation for COVID-19. Housekeeper #1 said she cleaned the resident floors daily with pH7 Ultra Neutral Cleaner. The United States EPA, List N Tool: COVID-19 Disinfectants website, accessed on 10/28/20, stated all products on the list met the EPA's criteria for use against [DIAGNOSES REDACTED]-CoV-2, [MEDICAL CONDITION] that caused COVID-19. The list did not include Betco, pH7 Ultra Neutral Cleaner that Housekeeper #1 used in rooms under observation for COVID-19. On 10/27/20 at 3:10 PM, the IP said staff were to use cleaning products that killed [DIAGNOSES REDACTED]-CoV-2 and/or was EPA approved. On 10/28/20 at 1:48 PM, the Administrator said the facility did not have a manufacturer's product information sheet that stated the Betco pH7 Ultra Neutral Cleaner killed the [DIAGNOSES REDACTED]-CoV-2 (COVID-19) virus. 6. The facility's Laundry policy, dated 9/10/20, instructed staff to deliver the laundry to the appropriate area in a covered or closed container. Clean laundry and linens were to be kept covered in a bin or rack until ready to use. This policy was not followed. On 10/27/20 at 4:40 PM, clothes were observed hanging on a mobile rack near room A26 in Area A, the COVID-19 positive unit. The clothes were partially covered by a white linen sheet laid over the top of the clothes, leaving one quarter to one half of the length of the clothes exposed below the bottom of the sheet. On 10/27/20 at 4:49 PM, CNA #4 said clean laundry was brought in on a cart and distributed by the CNAs on the unit. On 10/27/20 at 5:00 PM, the IP said the clothes should have been fully covered.

Based on observation, record review, staff interview, resident interview, and review of facility policies, it was determined the facility failed to implement interventions to prevent the worsening of pressure ulcers and ensure pressure ulcer prevention interventions were followed. This was true for 2 of 2 resident (Resident #1 and #318) reviewed for pressure ulcers. This deficient practice caused harm to Resident #318 when she developed Stage 2 pressure ulcers on her buttocks and placed Resident #1 at risk of developing pressure ulcers. Findings include: The facility's policy for Prevention and treatment of [REDACTED]. * A risk assessment would be completed upon the resident's admission. * Residents at risk for developing pressure ulcers would be identified by the Braden Scale assessment tool. * Pressure ulcer interventions would be developed with participation of the interdisciplinary team, and the interventions would be implemented in order to identify, prevent or reduce the risk of acquiring pressure and/or non-pressure related wounds or skin issues. * Basic or routine care could include interventions to redistribute pressure, minimize contact with moisture and keep skin clean, providing non-irritating surfaces, and maintaining/improving nutrition and hydration. The National Pressure Ulcer Advisory Panel website (www.npuap.org), accessed on 2/4/19, documented the following: * Deep tissue injuries appear as areas of intact or non-intact skin with persistent non-blanchable deep red, maroon, purple discoloration that result from acute and/or lengthy pressure. * A pressure injury is damage to an area of skin and underlying soft tissue, usually located over a bony prominence, and may be associated with a medical or other device. The pressure injury can appear as intact skin or an open ulcer. A pressure injury results from severe and/or prolonged pressure or pressure with shearing. * A Stage 2 pressure injury is partial-thickness loss of skin with exposed dermis. The wound bed is viable, pink or red, moist, and may also present as an intact or ruptured serum-filled blister. The Lippincott Manual of Nursing Practice, tenth edition, documented measures to prevent pressure ulcer development included repositioning every two hours, using special devices to cushion the specific area, and use an alternating pressure mattress or air fluidized bed for patients who are at high risk. Resident #318 was admitted to the facility on [DATE], with multiple [DIAGNOSES REDACTED]. A progress note, dated 1/26/19 at 9:51 PM, documented Resident #318 was admitted to the facility prior to the noon meal. Resident #318's Braden Scale for Predicting Pressure Sore Risk, dated 1/26/19 at 10:22 PM approximately 9 hours after her admission, documented she was at high risk for developing pressure ulcers. Her ability to change and control her body position was very limited, and she was not able to make frequent or significant changes without assistance. Resident #318's Weekly Skin Check, dated 1/26/19 at 10:22 PM, documented there were skin conditions, changes, ulcers, or injuries. The coccyx (tailbone area) had a dark purple area surrounding the entire coccyx that was non-blanchable (indicating blood flow was not returning to the area and damage had occurred). Resident #318's Progress Notes, documented the following: * On 1/26/19 at 9:51 PM, she arrived at the facility and her coccyx/sacrum was deep purple in color, which did not blanch. * On 1/27/19 at 3:11 AM, she was transferred to the hospital due to increased blood in the Foley (urinary) catheter, flank pain, and headache. * On 1/27/19 at 8:12 AM, she returned to the facility from the hospital. Her skin condition was not documented upon her return to the facility. Resident #318's Multidisciplinary Care Conference notes documented the meeting was held on 1/28/19 at 1:30 PM, and identified an effective date of 1/26/19 at 10:38 PM. The notes did not include documentation Resident #318's skin issues were addressed in the care conference. Resident #318's Weekly Skin Alteration Report, dated 1/28/19 at 3:43 PM, documented a large bruise that covered the buttocks and sacral area (the sacrum and coccyx are two bone located near the bottom of the spinal column/upper buttock). There was no skin loss, and there was discoloration with purple, pink, red, and yellow colors. There was no deterioration of the wound. The current treatment orders included barrier cream and monitoring. Resident #318's Weekly Pressure Ulcer Report, dated 1/28/19 at 3:45 PM, documented a new onset Stage 2 pressure ulcer on the coccyx that measured 0.3 cm by 0.3 cm by 0.1 cm and was first observed on 1/26/19. Resident #318's Weekly Pressure Ulcer Report, dated 1/28/19 at 3:48 PM, documented a new onset Stage 2 pressure ulcer on the right buttock that measured 2.5 cm by 3.5 cm by 0.1 cm and was first observed on 1/26/19. Resident #318's Weekly Pressure Ulcer Report, dated 1/28/19 at 3:50 PM, documented a Stage 2 pressure ulcer on the left buttock that measured 2 cm by 3 cm by 0.1 cm and was first observed on 1/26/19. The bruised, discolored area on Resident #318's coccyx and buttocks deteriorated into three Stage 2 pressure ulcers. Resident #318's (MONTH) 2019 physician orders [REDACTED]. * Cleanse Stage 2 pressure injury to coccyx with wound cleanser, apply barrier cream and apply dressing once daily and as needed, ordered on [DATE]. * Cleanse Stage 2 pressure injury to left buttock with wound cleanser, apply barrier cream and apply dressing once daily and as needed, ordered on [DATE]. * Cleanse Stage 2 pressure injury to right buttock with wound cleanser, apply barrier cream and apply dressing once daily and as needed, ordered on [DATE]. * Daily monitoring of Stage 2 pressure ulcers to coccyx, left buttock, and right buttock. Resident #318's care plan documented the following: * She had Stage 2 pressure injuries to the right and left buttock, and coccyx, initiated on 1/28/19. * Interventions to prevent new areas of breakdown or altered skin integrity were initiated on 1/28/19, including reposition 2-3 times every 8 hours, use care during transfers and bed mobility, and weekly skin assessments by licensed nurse. * She required 2 staff participation with transfers and bed mobility. * She was at risk for skin impairment/pressure ulcer related to significant bruises, chronic progressive disease, cognitive impairment, heart failure, and overactive bladder. * Staff were directed to use pressure reduction on her bed and chair. Treatment and medications were to be implemented per physician orders, and the nurse was to be notified of skin impairment, bruises, or rashes. Resident #318's Bed Mobility records for repositioning and turning, documented she was provided with extensive or total assistance at the following times and frequency: * 1/26/19 at 1:59 PM - one time * 1/27/19 at 2:12 AM, 1:59 PM, and 9:08 PM = 3 times Resident #318 was out of facility at the hospital for 5 hours (3:11 AM - 8:12 AM). * 1/28/19 at 4:05 AM, 11:13 AM, 8:11 PM - 8:13 PM, 9:59 PM, and 11:43 PM = 5 times * 1/29/19 at 4:14 AM 1:59 PM, 9:59 PM, and 10:56 PM = 4 times * 1/30/19 at 5:10 AM, 1:05 PM - 1:06 PM, and 9:38 PM - 9:48 PM = 3 times * 1/31/19 at 2:13 AM and 9:22 PM - 9:24 PM = 2 times The documentation showed Resident #318 was repositioned 1 - 5 times per day, instead of 2 - 3 times per 8 hour shift. On 1/29/19 at 2:31 PM, RN #5 said she had not observed Resident #318's wounds because she was up in her chair. RN #5 said Resident #318 had bilateral wounds on her coccyx and sacrum. Resident #318 was sitting in her wheelchair and there was no cushion (for pressure reduction) on her wheelchair. The mattress on her bed was not an alternating pressure or air fluidized mattress. On 1/29/19 at 2:34 PM, Resident #318 said she had sores on her bottom and she did not have them before being admitted to the facility. On 1/29/19 at 2:43 PM, LPN #3 said Resident #318 was admitted over the weekend and she saw her on 1/28/19. LPN #3 said she measured what she observed on Resident #318's buttock area and documented she had a Stage 2 pressure ulcer to the right buttock and a Stage 2 pressure ulcer on her bottom. LPN #3 said the current interventions for the pressure ulcers included barrier cream with a cover dressing and repositioning every 2-3 hours. On 1/30/19 at 10:18 AM, LPN #3 was observed providing wound care to Resident #3's buttocks. LPN #3 said Resident #318 had a right buttock pressure wound that was a Stage 2 with irregular margins and a red base. There was no redness or swelling. LPN #3 said Resident #318's left buttock had a pressure wound that was a Stage 2 with irregular margins and a red base with bloody drainage. There was no redness or swelling. On 1/30/19 at 10:54 AM, LPN #3 said she did not know when the open areas appeared on Resident #318's buttocks. LPN #3 said when she observed Resident #318 on 1/28/19, her buttocks were purple with yellow color and a very small open area on the coccyx. LPN #3 said the open skin areas looked better at the present time. LPN #3 said Resident #318's initial skin assessment was done by another nurse. She was notified on 1/28/19 she needed to observe Resident #318's skin needed to be monitored because of the purple area to her buttocks. On 1/30/19 at 11:11 AM, LPN #6 said she assessed Resident #318's skin on admission and her buttocks and sacrum were deep purple in color. LPN #6 said she did not see any open skin areas on her buttocks at that time. On 1/30/19 at 12:03 PM, RCM #1 said when Resident #318 was admitted to the facility, she would have started Resident #318 on a turning schedule and contacted the wound nurse or physician to ask for recommendations regarding the dark purple color on her bottom. On 1/31/19 at 9:49 AM, the DNS said it was documented on admission Resident #318 had bruising on her bottom and it was documented she was assisted with bed mobility for the first couple of days after admission. The DNS said she did not see anything documented Resident #318 was turned every 2 hours. The DNS said she expected staff to follow care plan interventions. 2. Resident #1 was admitted to the facility on [DATE] with multiple diagnoses, including difficulty in walking, generalized muscle weakness, history of falls, and unspecified dementia without behavioral disturbances. Resident #1's Admission MDS assessment, dated 9/20/18, and quarterly MDS assessment, dated 12/20/18, documented he was severely cognitively impaired. The assessment documented he required extensive assistance of staff for bed mobility, transfers, dressing, and toileting, and required limited assistance to walk in his room and to eat. The assessment stated Resident #1 was not steady or able to balance with transfers. Resident #1's care plan, revised on 12/17/18, documented he had moderate skin/tissue integrity risk due to [DIAGNOSES REDACTED]. The goal was for Resident #1 to have intact skin. The interventions included using a pressure relieving device while in a chair. Resident #1 was observed sitting in his wheelchair on 1/28/19 at 2:14 PM, 1/29/19 at 8:18 AM, 1/30/19 at 12:00 PM, 12:27 PM, 5:31 PM, and 6:16 PM, 1/31/19 at 12:00 PM, 2:07 PM, 3:26 PM, 3:34 PM, and 4:30 PM. He sat in his wheelchair directly on the seat portion of the wheelchair and had no pressure relieving device in place. On 1/31/19 at 3:26 PM, Resident #1 sat in his wheelchair in the activity room next to the activity director. He did not have a pressure relieving device in place. The Activity Director verified Resident #1 did not have a cushion or pressure relieving device in the seat of his wheelchair. On 1/31/19 at 3:34 PM, CNA #1 verified Resident #1 did not have a pressure relieving device in the seat of his wheelchair. She stated she routinely cared for him on the 2:00 PM to 10:00 PM shift and he generally did not have a cushion or pressure relieving device in the seat of his wheelchair. She stated Resident #1 sat directly on the seat of the wheelchair when he was in the wheelchair.

Based on staff and resident interview, review of narcotic count records and residents' clinical records, it was determined the facility failed to ensure a method for evaluating the effectiveness of residents' pain management plans was in place. This was true for 2 of 4 residents (#1 and #2) sampled for pain. Resident #1 and Resident #2 were harmed when they experienced increased pain and the facility did not identify and treat it timely. Findings include: 1. Resident #1 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The baseline care plan, dated 5/24/18, did not include Resident #1's pain management plan and documented she had a stage 4 pressure ulcer to her lower calf. A Pain Evaluation, dated 5/24/18, documented Resident #1 had pain at times due to chronic [MEDICAL CONDITION], occasional headaches, and her posterior right calf. The evaluation documented an acceptable pain level for Resident #1 was 6 out of 10 and her pain occurred mostly in the morning. A History and Physical Note, dated 5/25/18, documented Resident #1 had chronic back pain, a stage 4 pressure ulcer to her right calf which caused her pain, and [MEDICAL CONDITION]. Resident #1's Transfer orders to the facility, dated 5/23/18, documented the following regarding pain: * Resident #1 was to receive 650 mg Tylenol (pain relief) every 4 hours as needed for mild pain, (pain score 1-3) not to exceed 3 grams in 24 hours, ordered 4/27/18. * Resident #1 was to receive [MEDICATION NAME] cream 4% as needed for wound debridement, ordered 4/29/18. Resident #1's admission (MONTH) (YEAR) Physician orders documented the following regarding pain: * Resident #1 was to receive 650 mg Tylenol every 4 hours as needed for mild pain, ordered 5/24/18. * Resident #1 was to receive [MEDICATION NAME] cream 4% applied to her heel wound as needed for pain with wound debridement, ordered 5/24/18. * Staff were to monitor and document Resident #1's pain ratings at the start of each shift using verbal and non-verbal scale of 0-10, ordered 5/24/18. Resident #1's pressure ulcer was located on her right calf and not on her heel. Resident #1's physician's order was not transcribed for the correct wound location of the right calf. Resident #1's physician orders did not include other pain medications to include scheduled pain medications or medications to be administered if she experienced greater than mild pain The (MONTH) and (MONTH) (YEAR) MARs documented Resident #1's pain was consistently greater than 3 and ranged between 4 and 8 on a 0-10 pain scale. Resident #1 was administered a dose of PRN Tylenol on 5/25/18 at 1:52 AM and 2:04 PM, 5/26/18 at 12:15 AM, and 6/3/18 at 4:30 PM. A Progress Note, dated 6/3/18 at 9:54 PM, documented Resident #1 stated the 650 mg of Tylenol for pain was not effective and her pain level was as high as a 7 out of 10 at times. The note included a request for an order for [REDACTED].>On 6/5/18 at 9:43 AM, Resident #1 was observed speaking with a Physicians Assistant (PA) and complained about her leg hurting. Two CNAs were present in the room with the PA. A Progress Note, dated 6/3/18 at 1:44 PM, documented a PA visited Resident #1 and she received new orders for [MEDICATION NAME] 50 mg every 6 hours for pain. A 6/5/18 Physician order documented Resident #1 was to receive 50 mg of [MEDICATION NAME] every 6 hours as needed for pain. On 6/5/18 at 3:49 PM, Resident #1 stated she her leg was hurting around her knee and down to her ankle. Resident #1 stated staff had not offered her pain medications that day or the previous day, and she would like some. She stated the medication provided prior to that had been ineffective. Resident #1 stated her pain had not been managed well. Resident #1 stated she had told a staff member that morning about the pain in her leg and they had not provided her with pain medications as of the time of the interview. Resident #1 stated her pain had not been managed well. On 6/5/18 at 3:52 PM, the Activities Director visited Resident #1 and did not ask Resident #1 if anything she could do for her. On 6/5/18 at 3:53 PM, a laundry staff member entered Resident #1's room and did not ask Resident #1 if there was anything she could do for her. On 6/5/18 at 3:56 PM, RN #1 was notified of Resident #1's pain in her leg and her request for pain medications. RN #1 stated she would have to call the pharmacy to verify when the pain medications would be delivered. On 6/6/18 at 9:10 AM, the Clinical Resource Nurse stated the [MEDICATION NAME] cream was supposed to be applied to Resident #1's right calf wound. She stated Resident #1 did not currently have pressure ulcers on her heels. The Clinical Resource Nurse stated the order should have been clarified. The nurse did not know why Resident #1's pain medication was ordered two days after it was requested. The Clinical Resource Nurse stated the facility should have called the physician on 6/3/18 to obtain an order for [REDACTED].>b. Resident #1 was to receive 650 mg Tylenol every 4 hours as needed for mild pain, ordered 5/24/18. A 6/5/18 Physician orders documented Resident #1 was to receive 50 mg of [MEDICATION NAME] every 6 hours as needed for pain. The (MONTH) and (MONTH) (YEAR) MARs documented the time of the administration of Resident #1's PRN pain medications. Resident #1's MAR indicated [REDACTED]. Resident #1's MAR indicated [REDACTED]. A Progress Note, dated 6/5/18 at 10:44 PM, documented the effectiveness of the medication, 6 hours after the medication was administered. On 6/6/18 at 9:10 AM, the Clinical Resource Nurse stated staff should be monitoring for efficacy of pain medications within 1-2 hours after giving the medications. The Clinical Resource Nurse stated 6 hours was too long to wait. 2. Resident #2 was admitted to the facility on [DATE] with multiple diagnoses, including [MEDICAL CONDITION] and a hip replacement. An admission Physician's Orders, dated 5/24/18, documented Resident #2 received [MEDICATION NAME] 7.5 mg twice a day for arthritis; [MEDICATION NAME] 225 mg every 12 hours for [MEDICAL CONDITION]; [MEDICATION NAME] ER (extended release) 20 mg one tablet three times a day for 7 days for pain; and [MEDICATION NAME]/APAP ([MEDICATION NAME]) 10/325 mg two tablets every 4 hours as needed for pain. Resident #2's narcotic record documented [MEDICATION NAME] 75 mg 3 tabs to equal 225 mg twice a day. The narcotic record, dated 5/24/18, documented 18 doses were received by the pharmacy. The narcotic record documented Resident #2 received [MEDICATION NAME] as follows on: * 5/25/18 at 9:15 AM one tablet with 17 remaining, * 5/25/18 at 8:40 PM one tablet with 16 remaining, * 5/26/18 at 8:45 PM one tablet with 15 remaining, * 5/27/18 at 8:10 AM one tablet with 12 remaining, * 5/27/18 at 8:25 PM one tablet with 11 remaining. Resident #2 was administered 1 tablet, not 3 tablets at each administration, as ordered by the physician. Resident #2 did not receive a morning administration of [MEDICATION NAME] on 5/26/18, as ordered. A (MONTH) (YEAR) MAR, dated 5/29/18 at 12:41 AM, documented Resident #2 received non-pharmacological interventions: repositioning, dim light/quiet environment, and hot/cold applications that were ineffective. On 6/5/18 at 9:20 AM, Resident #2 stated the facility was not managing his pain with medications or ice. Resident #2 stated he rarely received his scheduled pain medications on time and only received ice once for his right hip. On 6/6/18 at 9:15 AM, the DNS and the Clinical Resource Nurse stated the Pharmacist reviewed Resident #2's medications and brought it to the facility's attention that the nurses were administering one tablet of the [MEDICATION NAME] 75 mg, not three tablets to equal 225 mg per the physician's orders. The Clinical Resource Nurse stated there were several medication errors, inaccurate calculations, and initiated an investigation. The DNS and the Clinical Resource Nurse stated Resident #2's pain was not controlled when he did not receive the correct dose of [MEDICATION NAME]. The DNS stated the CNA's applied ice to Resident #2's hip daily, but was unable to provide documentation.