Every finding on record at Cedars Healthcare Center

Based on observations and interviews, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in the main kitchen and dishroom. Specifically, the facility failed to ensure:-Staff used proper hand hygiene during meal service;-Food was held at the correct temperature;-Kitchen was maintained, in good repair to be able to have a cleanable surface.Findings include: I. Failed to ensure dietary staff performed appropriate hand hygiene during meal serviceA. Professional referenceThe Colorado Department of Public Health and Environment Colorado Retail Food Establishment Rules and Regulations, revised 3/16/24, was retrieved on 6/17/26. It revealed in pertinent part, 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 and after touching bare human body parts other than clean hands and clean, exposed portions of arms; after using the toilet room; after coughing, sneezing, using a handkerchief or disposable tissue; using tobacco products, eating, or drinking; after handling soiled equipment or utensils; 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. (2-301.15)B. Facility policy and procedureThe Handwashing/Hand Hygiene policy and procedure, revised December 2025, was provided by the nursing home administrator (NHA) on 6/11/26 at 3:38 p.m. It read in pertinent part, Hand hygiene is indicated before touching a resident, before preparing or handling food, medications, or parenteral solutions, before clean or aseptic procedures, before moving from on a soiled body site to a clean body site on the same resident, after exposure to blood, body fluids, excretions, or contaminated surfaces, after touching a resident, after touching the resident's environment or belongings, after glove removal, and whenever hands are visibly soiled. Wash hands with soap and water when hands are visibly soiled with blood or body fluids, before eating and after using the restroom, after contact with a resident with infectious diarrhea The use of gloves does not substitute for hand hygiene. Always perform hand hygiene after gloves are removed.C. ObservationsDuring a continuous observation on 6/9/26, beginning at 4:59 p.m. and ending at 5:55 p.m. the following was observed during meal service in the main kitchen:At 5:03 p.m. cook #2 took off his gloves and did not wash his hands before putting on a new pair of gloves. At 5:03 p.m. cook #2 made a bacon, lettuce and tomato (BLT) sandwich wearing gloves, he then dropped french fries into the fryer and took off his gloves he did not wash his hands before putting new gloves on. At 5:16 p.m. cook #2 made a grilled cheese sandwich wearing gloves, he then took his gloves off and put new gloves on without washing his hands in between. At 5:23 p.m. cook #2 changed the song on his cell phone that was sitting on the counter playing music, with his gloved right pinky. He did not change his gloves after touching his phone.At 5:30 p.m. cook #1 wrote down the food temperatures in the temperature binder. He did not wash his hands afterwards. He then went to the food service line and began meal service. At 5:30 p.m. cook #2 opened a drawer with his right gloved hand, he closed the drawer with the same hand then put a piece of sliced cheese on to a burger with the same hand. At 5:32 p.m. cook #2 changed his gloves and did not wash his hands in between. D. Staff interviews The dietary manager (DM) was interviewed on 6/11/26 at 11:28 a.m. He said he expected his staff to wash their hands any time they changed tasks and when they changed their gloves. II. Failure to hold food at the correct temperatureA. Professional reference The Colorado Department of Public Health and Environment Colorado Retail Food Establishment Rules and Regulations, revised 3/16/24, was retrieved on 6/17/26. It revealed in pertinent part, Time/Temperature control for safety food, hot and cold holding at 135 degrees F (farenehit) or higher and 41 degrees F and lower. (Chapter 3)B. Facility policy and procedureThe Food Receiving and Storage policy and procedure, revised November 2022, was provided by the NHA on 6/11/26 at 3:38 p.m. It read in pertinent part, The Danger Zone means temperatures above 41 degrees Fahrenheit and below 135 degrees Fahrenheit that allow the rapid growth of pathogenic microorganisms that can cause foodborne illness. Potentially hazardous food and time/temperature control for safety foods are stored at or below 41 degrees Fahrenheit, unless otherwise specified by law.C. ObservationsDuring a continuous observation on 6/9/26, beginning at 4:59 p.m. and ending at 5:55 p.m. the following was observed during meal service in the main kitchen: At 5:03 p.m. cook #2 made a BLT sandwich. CK #2 left containers of sliced lettuce, sliced tomato, and sliced onion by the meal service table. On another prep table close to the grill there was sliced cheese, shredded lettuce, shredded cheese, hard boiled eggs, and turkey sandwich meat. -The items were not on ice, and continued to be used during meal service.At 5:52 p.m. cook #2 took the temperature of the food items: -The sliced lettuce was 60 degrees F.-The sliced tomatoes were 60 degrees F.-The sliced onion was 59 degrees F.-The shredded cheese was 53 degrees F.-The hard boiled eggs were 63.1 degrees F.-The turkey lunch meat was 56.1 degrees F.-The shredded lettuce was 48.9 degrees F.D. Staff interviewsThe DM and the registered dietitian (RD) were interviewed together on 6/11/26 at 11:28 a.m. The RD said that they threw all the food away that had been left out during the meal service on 6/9/26. The DM said they normally stored those items on ice during meal service. He said that cook #2 must had forgotten that evening. He said that there was a risk of people getting sick if the food was not held at the correct temperature. III. Failed to ensure the main kitchen was maintained, in good repair to be able to have a cleanable surface. A. Professional referenceThe Colorado Department of Public Health and Environment Colorado Retail Food Establishment Rules and Regulations, revised 3/16/24, was retrieved on 6/17/26. It revealed in pertinent part, Intake and exhaust air ducts shall be cleaned and filters changed so they are not a source of contamination by dust, dirt, and other materials Floors, floor coverings, walls, wall coverings, and ceilings shall be designed, constructed, and installed so they are smooth and easily cleanable. Equipment, food-contact surfaces and utensils shall be clean to sight and touch. (Chapter 4,5 and 6)B. Facility policy and procedureThe Kitchen Sanitization policy and procedure, revised November 2022, was provided by the NHA on 6/11/26 at 3:38 p.m. It read in pertinent part, All utensils, counters, shelves and equipment are kept clean, maintained in good repair and are free from breaks, corrosions, open seam, cracks, and chipped areas that may affect their use or proper cleaning. Seals, hinges, and fasteners are kept in good repair. All equipment, food contact surfaces and utensils are cleaned and sanitized using heat or chemical sanitizing solutions. C. Observations During the initial tour of the kitchen on 6/8/26 at 8:15 a.m. the following was observed: -The floor under the steam tables had several holes that were approximately one foot by three inches and gouges in the floor. -The floor in the dishroom had several holes, chips and large gouges to count, missing from the floor. There was also a large crack that ran from under the dishwasher to the other side of the dishroom.-The window above a food preparation table had a window-mounted air conditioner. The portion over the air conditioner had a piece of fiberglass, being held in place with red duct tape. However, the red tape was coming loose and air was coming in from a hole due to the fiberglass not being flush with the window. There was a piece of cardboard on the other side of the window. Dust and debris were covering the inside of the window, which was directly above the food preparation table.-In the dry storage, there were two large plastic containers on wheels that held flour. The outside of the containers were visibly dirty, with stains and residue from the flour on the outside. The scoops used to scoop the contents out were hanging on the outside of the plastic container by a hook. The scoops were open to air and had residue from the flour on the scoops. During a follow-up visit to the kitchen on 6/9/26 at 4:59 p.m., the window had the same piece of cardboard and the tape was peeling and air was coming in directly from the window, and the dust and cobwebs were there. The preparation table directly underneath the window was being used and had food items sitting on the table. During another follow-up visit to the kitchen on 6/11/26 at 11:28 a.m., the window had the same piece of cardboard, the tape holding the fiberglass was peeling, there was air coming in from the outside and dust and debris covered the inside of the window. In the dry storage area the two plastic containers on wheels with flour were visibly dirty and there was residue on the scoops. D. Staff interviewsThe DM and the RD were interviewed together on 6/11/26 at 11:28 a.m. The DM said that maintenance and the administration were aware of the floor. He said they were coming up with a plan to fix the floor. He said he was not sure of the timeline. He said the air conditioner was recently moved to that window. He said that the taped fiberglass had blown in during a recent storm and that there was a lot of dust and cotton from the cottonwood trees outside. He said the cardboard was in the window to block the sun when the cooks were using the preparation table. He said he would clean the dust and debris from the window. He said that he cleaned the outside of the bins of flour once a month. He said that he had pouches ordered for the scoops but the hooks for them were backordered.

Based on observations, record review and interviews, the facility failed to provide care to each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life for 12 (#2, #8, #13, #35, #37, #50, #69, #74, #92, #33 #44, #43, #93, #103 and #57) out of 55 sample residents.Specifically, the facility failed to respond to call lights in a timely manner for Resident #2, Resident #8, Resident #13, Resident #35, Resident#37, Resident #50, Resident #69, Resident #74, Resident #92, Resident #33, Resident #44, Resident #43, Resident #93, Resident #103 and Resident #57. Findings include:I. Facility policy and procedureThe Call System, Residents Call policy, revised September 2022, was provided by the assistant director of nursing (ADON) on 6/11/26 at 4:22 p.m. It read in pertinent part, Residents are provided with a means to call staff for assistance throughout a communication system that directly calls a staff member or a centralized work station. Calls for assistance are answered as soon as possible, but no later than 5 minutes. Urgent requests for assistance are addressed immediately. Call light response times are reviewed as part of the QAPI (quality assurance process improvement) program.II. Resident interviewsResident #69 was interviewed on 6/8/26 at 9:47 a.m. Resident #69 said it was hard to get a CNA to answer the call light at night. He said there was only one CNA for 30 residents on site during the night shift. He said he filed a complaint before regarding the call light response time. He said he had to wait 40 to 45 minutes to get assistance last week. He said the staff told him they were busy with other residents and that there was only one CNA on site. He said he was sure about his waiting time, because he checked the timing on his tablet.Resident #8 was interviewed on 6/8/26 at 10:15 a.m. Resident #8 said the call light response time could take up to an hour. He said by the time the call light was answered he often forgot what was the reason for calling for assistance.Resident #2 was interviewed on 6/8/26 at 10:50 a.m. Resident #2 said it was hard to find a nurse when needed. Resident #2 said the call light response time could take up to 30 minutes. Resident #92 was interviewed on 6/8/26 at 11:20 a.m. Resident #92 said call light response time can be very long; it could take up to 30 minutes or even more. She said the slow call light response time bothered her. Resident #50 was interviewed on 6/8/26 at 2:21 p.m. Resident #50 said the staff did not answer her call light timely. Resident #35 was interviewed on 6/8/26 at 2:43 p.m. Resident #35 said she had to wait for the certified nurse aides (CNA) to respond to her call and it often took 30 minutes to get assistance. Resident #37 was interviewed on 6/8/26 at 3:00 p.m. Resident #37 said the call light response time was slow. She said it could take between one to two hours for the call light to be answered. Resident #74 was interviewed on 6/8/26 approximately at 3:20 p.m. She said her family had to ask several times for the CNAs to assist her even though she used her call light. She said the residents are not checked in on often enough and they do not pay attention to make sure her call light is within her reach. Resident #13 was interviewed on 6/8/26 at 4:33 p.m. Resident #13 said it took 30 minutes for staff to respond to her call lights. Resident #33 was interviewed on 6/10/26 at 11:59 a.m. Resident #33 said on Saturday night he had to wait an hour and 15 minutes and he was not happy about it. Resident #33 said it should not take longer than 15 minutes to answer a call light. Resident #33 said the CNAs did not answer lights for residents who were outside of their assigned group of residents. Resident #44 was interviewed on 6/10/26 at 12:00 p.m. Resident #44 said generally, the night shift staff response time was terrible. Resident #93 said staff take hours to answer the call light. Resident #93 said sometimes she was waiting and had to go to the bathroom so bad she was in pain. Resident #93 said certain CNAs are worse than others. Resident #43 was interviewed at 12:00 p.m. Resident #43 said the day shift staff on her side of the building were more untimely than the night shift staff. Resident #43 said she had to ask for help again an hour and a half later.III. Record reviewsAn audit of call light response times from 3/29/26 to 4/29/26 was provided by the nursing home administrator (NHA) on 6/10/26 for Resident #57. Review of the call light response during this period revealed the following call light response times: The call light was activated and not answered for 15 to 20 minutes, 20 timesThe call light was activated and not answered for 20 to 30 minutes, 25 timesThe call light was activated and not answered for 30 to 40 minutes, 18 timesThe call light was activated and not answered for 40 to 50 minutes, four times. An audit of call light response times from 5/18/26 to 6/7/26 was provided by the NHA on 6/10/26 for Resident #13. Review of the call light response during this period revealed the following call light response times: The call light was activated and not answered for 15 to 20 minutes, 25 timesThe call light was activated and not answered for 20 to 30 minutes, 35 timesThe call light was activated and not answered for 30 to 40 minutes, 14 timesThe call light was activated and not answered for 40 to 50 minutes, four times. An audit of call light response times from 5/18/26 to 6/8/26 was provided by the NHA on 6/10/26 for Resident #103. Review of the call light response during this period revealed the following call light response times: The call light was activated and not answered for 15 to 20 minutes, seven timesThe call light was activated and not answered for 20 to 30 minutes, six times.The call light was activated and not answered for 30 to 40 minutes, three times.The call light was activated and not answered for 40 to 50 minutes, two times. The call light was activated and answered for 50 to 60 minutes, one time.An audit of call light response times from 5/18/26 to 6/8/26 was provided by the NHA on 6/10/26 for Resident #74. Review of the call light response during this period revealed the following call light response times: The call light was activated and not answered for 15 to 20 minutes, 20 times.The call light was activated and not answered for 20 to 30 minutes, 32 times.The call light was activated and not answered for 30 to 40 minutes, 10 times.The call light was activated and not answered for 40 to 50 minutes, one time. An audit of call light response times from 5/18/26 to 6/8/26 was provided by the NHA on 6/10/26 for Resident #70. Review of the call light response during this period revealed the following call light response times: The call light was activated and not answered for 15 to 20 minutes, 20 times.The call light was activated and not answered for 20 to 30 minutes, 35 times.The call light was activated and not answered for 30 to 40 minutes, 20 times.The call light was activated and not answered for 40 to 50 minutes, five times.The call light was activated and not answered for 50 to 60 minutes, six times. An audit of call light response times from 5/18/26 to 6/8/26 was provided by the NHA on 6/10/26 for Resident #93. Review of the call light response during this period revealed the following call light response times: The call light was activated and not answered for 15 to 20 minutes, seven times.The call light was activated and not answered for 20 to 30 minutes, 24 times.The call light was activated and not answered for 30 to 40 minutes, six times.The call light was activated and not answered for 40 to 50 minutes, nine times.The call light was activated and not answered for 50 to 60 minutes, four times. An audit of call light response times from 5/18/26 to 6/8/26 was provided by the NHA on 6/10/26 for Resident #2. Review of the call light response during this period revealed the following call light response times: The call light was activated and not answered for 15 to 20 minutes, five times.The call light was activated and not answered for 20 to 30 minutes, five times.The call light was activated and not answered for 30 to 40 minutes, two times.The call light was activated and not answered for 40 to 50 minutes, one time.The call light was activated and not answered for 50 to 60 minutes, two times. An audit of call light response times from 5/18/26 to 6/8/26 was provided by the NHA on 6/10/26 for Resident #69. Review of the call light response during this period revealed the following call light response times: The call light was activated and not answered for 15 to 20 minutes, three times.The call light was activated and not answered for 20 to 30 minutes, six times.The call light was activated and not answered for 30 to 40 minutes, three times.The call light was activated and not answered for 50 to 60 minutes, one time. An audit of call light response times from 5/18/26 to 6/8/26 was provided by the nHA on 6/10/26 for Resident #33 . Review of the call light response during this period revealed the following call light response times: The call light was activated and not answered for 15 to 20 minutes, two times.The call light was activated and not answered for 20 to 30 minutes, two times.The call light was activated and not answered for 30 to 40 minutes, one time.IV. Staff interviewCertified nurse aid (CNA) #1 was interviewed on 6/10/26 at 2:33 p.m. CNA #1 said Resident #70 complained the most about the slow call light response time. She said she had never filed grievance in Resident #70`s behalf nor she felt she needed to offer Resident #70 to file a grievance.Licensed practical nurse (LPN) #7 was interviewed on 6/11/26 approximately 4:00 p.m. LPN #7 said an acceptable response time was around ten minutes. She said staff response time was usually faster than ten minutes. She said staff triaged phone calls and an emergency call light activation took priority. The NHA interviewed on 6/11/26 approximately at 5:00 p.m. The NHA said he was newly employed at the facility within the last 30 days. He said that the long call light response times were brought to his attention. He said he was aware of the problem and was working on a resolution. He said he needed to discuss the problem with QAPI first and then make plans for remediation.

Based on interviews, and record review the facility failed to ensure prompt efforts by the facility to resolve grievances the resident may have for one (#33) of two out of 55 sample residents Specifically, the facility failed to make prompt efforts to resolve Resident #33's grievances.Findings include:I. Facility policy and procedureThe Grievances/Complaints, Recording and Investigating policy, revised April 2017, was provided by the nursing home administrator (NHA) on 6/11/26 at 4:11 p.m. It read in pertinent part, All grievances and complaints filed with the facility will be investigated and corrective actions will be taken to resolve the grievances. Upon receiving a grievance and complaint report, the grievance officer will begin an investigation into the allegations. The department director will be notified of the nature of the complaint and that an investigation is underway. The grievance officer will record and maintain all grievances and complaints on the Resident Grievance Complaint Log. The Resident Grievance/Complaint Investigation Report Form will be filed with the administrator within five working days of the incident. The resident, or person acting on behalf of the resident, will be informed of the findings of the investigation, as well as any corrective actions recommended, within (a blank that was not filled in by the facility) working days of the filing of the grievance or complaint.-The policy failed to have a specific time frame on when the grievance needed to be completed.II. Resident #33A. Resident status Resident #33, age greater than65, was admitted on [DATE]. According to the June 2026 computerized physician orders (CPO), diagnoses included major depressive disorder and type 2 diabetes.The 5/21/26 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score of 15 out of 15. B. Resident #33 interviewResident #33 was interviewed on 6/10/26 at 11:49 a.m. Resident #33 said that several months ago, there were several grievances that were filled out and he did not feel they were addressed.C. Record reviewA grievance form for Resident #33 was provided by the NHA on 6/9/26 at 3:52 p.m. The grievance form was completed by the assistant director of nursing (ADON) on 5/11/26. The grievance form indicated Resident #33 felt a nurse was not administering all of his medications and did not talk to him. The grievance form documented that the resolution was The grievance form resolution identified that the named nurse was contacted by the director of nursing (DON) on 5/12/26 and that Resident #33 was encouraged to notify management immediately if a similar situation were to occur. The grievance form read the resolution must be reviewed with the grievant and had a line for the grievant to sign upon agreeing with the resolution.-There was no signature from Resident #33, indicating the resolution was not reviewed with or approved by Resident #33.D. Staff interviewsRegional clinical resource #2 was interviewed on 6/11/26 at 2:28 p.m. Regional clinical resource #2 said when a grievance was written, it went to the department it pertained to. Regional clinical resource #2 said the NHA was also alerted and would disperse to the appropriate departments. Regional clinical resource #2 said the facility changed the entire grievance policy, process, and grievance form itself recently. Regional clinical resource #2 said the facility discussed the new changes in a QAPI meeting in may 2026. Regional clinical resource #2 said there were a lot of components to the grievance process change and they started a log on 6/3/26. Regional cynical resource #2 said for a grievance form to be considered resolved, the grievant should have signed it.-However, Resident #33 did not have a signature of resolution on the grievance form.The director of nursing (DON) was interviewed on 6/11/26 at 3:15 p.m. The DON said the grievance process included meeting with the resident to find out what the concern was, and filling out the grievance form accordingly. E. Facility follow-up On 6/11/26 the NHA provided an updated copy of the 5/12/26 grievance form that indicated the resident signed the form on 6/11/26 (during the survey) and one month after the grievance was filed. retrieved a signature on the grievance form from Resident #33. However, this was after the state had brought it to their attention.The facility provided an impropmtu quality assurance and performance improvement (QAPI) meeting/four point plan of correction agenda and summary form on 6/14/26 at 5:26 p.m. The form revealed staff held a QAPI meeting on 6/3/26 and discussed opportunities for improvement on the grievance process. -However, the facility did not follow-up on Resident 33's grievance for a month.

Based on record review and interviews, the facility failed to report alleged violations of physical abuse to the State Survey and Certification Agency in accordance with state law for three (#56, #79 and #74) of six residents reviewed for abuse out of 55 sample residents. Specifically, the facility failed to:-Ensure an incident of alleged verbal abuse for Resident #56 was reported to the State Survey Agency;-Ensure an incident of alleged sexual abuse for Resident #79 was reported to the State Survey Agency; and,-Ensure an incident of alleged injury of unknown origin for Resident #74 was reported in a timely manner to the State Survey Agency. Findings include: I. Facility policy and procedure The Abuse Prevention policy and procedure, undated, was provided by the nursing home administrator (NHA) on 6/8/26 at 12:58 p.m. It read in pertinent part, All employees who have reasonable cause to believe a resident has suffered abuse are responsible for reporting that information to the executive director or upon his/her absence, to a supervisor. If to a supervisor, he/she shall pass along the information to the executive director immediately. II. Resident #56 A. Resident status Resident #56, age less than 65, was admitted on [DATE]. According to the June 2026 computerized physician orders (CPO), diagnoses included right-sided hemiplegia and hemiparesis following cerebral infarction, history of traumatic brain injury, and anxiety disorder. The 3/12/26 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score of 15 out of 15. She was independent with most of her activities of daily living (ADL). B. Resident interview Resident #56 was interviewed on 6/8/26 at 3:17 p.m. Resident #56 said approximately eight to nine months ago, licensed practical nurse (LPN) #8 would not give her her scheduled pain medications. She said he got right in her face and yelled at her. She said he scared her when he got in her face. She said she had requested that he no longer be her nurse after the incident, but he continued to be her nurse for approximately six months afterwards. She said it caused her a lot of depression and anxiety because he continued to be her nurse. She said it made her feel like the facility cared more about his well-being than her well-being, because they did not do anything. She said because the facility did not do anything, it made her feel like LPN #8 felt it was okay to treat her that way. She said she felt that when LPN #8 got in her face and yelled at her, it was abusive behavior. She said she continued to avoid LPN #8 whenever she saw him in the facility. C. Record review A grievance form was filled out on 7/9/25 at 6:30 a.m. by the staff development coordinator. The grievance documented Resident #56 was crying due to attempting to explain her Oxycontin was not being administered as ordered. The grievance documented LPN #8 insisted the resident's Oxycontin was PRN (as needed), however Resident #56's medication was in fact scheduled. The form documented LPN #8 was in Resident #56's face when the staff development coordinator arrived. The grievance outcome/resolution documented that LPN #8 was asked to step back, reconsider his approach with Resident #56 and to lower his voice and walk away if the situation escalated. The outcome/resolution documented LPN #8 would apologize to Resident #56. At the bottom of the grievance, in a different handwriting, it was documented that Resident #56 requested that LPN #8 no longer be her assigned nurse due to him approaching her in the same manner previously. There were no other signatures on the grievance form other than the staff development coordinator's. There was no indication on the grievance form that a resolution had been made. -The facility failed to report the allegations of verbal abuse to the State Agency. Cross-reference F600 for failure to protect residents from abuse. D. Staff interviews The staff development coordinator was interviewed on 6/10/26 at 4:49 p.m. The staff development coordinator said Resident #56 felt that she was not getting her pain medication timely and consistently from LPN #8. She said Resident #56 also felt like LPN #8 was not addressing her pain fairly and appropriately. She said when she arrived at the nurses' station that morning (7/9/25), she saw that LPN #8 was about a foot away from from Resident #56's face and was hollering at her. The staff development coordinator said LPN #8 was not being respectful. She said he made Resident #56 cry and made her fearful. She said she felt she had to intervene because both LPN #8 and Resident #56 raised their voices and were disturbing the other residents. She said she did not consider the incident to be abuse, because LPN #8 did not hit Resident #56. She said she also allowed LPN #8 a 60-day to 90-day trial to see if he could improve his medication pass with Resident #56. She said that she was monitoring his medication pass by looking at the narcotics sheet. She said there was no documentation of the education or discussion with LPN #8. She said she did speak with Resident #56 about the 60-day to 90-day trial and that the resident was okay with the plan. The director of nursing (DON) and regional clinical resource #1 were interviewed together on 6/11/26 at 9:19 a.m. The DON said she was aware of the situation between LPN #8 and Resident #56. She said she had spoken to LPN #8 and he had told her that he was concerned that Resident #56 was under the influence. The DON said he raised his voice because he wanted to make sure that Resident #56 was understanding him. She said that when she spoke to LPN #8, she directed him to have another nurse give Resident #56 her medications. She said he was no longer to administer Resident #56's medications. She said that she expected to have the nurse that gave the medications to the resident to also pull the medications, that way there would be no questions as to who gave the medications. She said that she had not seen the grievance form regarding Resident #56's concern prior to 6/11/26 and if she had seen it before, she would have opened an investigation of verbal abuse and reported the alleged abuse. III. Resident #79 A. Resident status Resident #79, age less than 65, was admitted on [DATE]. According to the June 2026 CPO, diagnoses included traumatic brain injury (TBI), adjustment disorder with mixed mood and depressed mood, chronic obstructive pulmonary disorder (COPD - lung disease), and emotional lability. The 5/7/26 MDS assessment revealed Resident #79 had severe cognitive impairment with a BIMS score of four out of 15. Resident #79 was dependent on staff for most of his ADLs. B. Facility investigation The facility's investigation was provided by the NHA on 6/9/26 and revealed the following: On 5/14/26 certified nurse aide (CNA) #10 reported to the DON that he saw Resident #79 performing oral sex on his guardian in Resident #79's bathroom on 5/1/26. The investigation documented CNA #10 was afraid to report it because Resident #79's guardian had seen that it was him who saw them. He said the guardian knew what vehicle he drove and was afraid of retaliation from the guardian. The investigation documented CNA #10 thought it was okay because the guardian and Resident #79 were dating. The investigation documented CNA #10 saw a change in Resident #79's behavior after the incident. CNA #10 said the resident would push his guardian away or pull away from his guardian and had increased agitation when his guardian was around. The investigation documented that the social services director (SSD) and social services assistant #2 met with Resident #79 on 5/14/26. They asked him if his guardian ever touched him, and Resident #79 said Yes. They asked Resident #79 to demonstrate using his hand to show them where his guardian would touch him. Resident #79 used his right hand and placed it outside of his pants on his penis and groin area and stated like this. They asked Resident #79 if it was okay for his guardian to touch his penis and Resident #79 stated No. They asked Resident #79 if his guardian had ever placed his mouth on his penis and Resident #79 stated No. They asked Resident #79 if his guardian ever asked him to place his mouth on his guardian's penis and Resident #79 stated No. The investigation documented a capacity for sexual consent assessment was done on 5/14/26. The assessment documented that Resident #79 had a BIMS score of four which meant he had severe cognitive impairment and a TBI. The assessment documented that Resident #79 did not want his penis touched by his guardian. The assessment documented that Resident #79 could say no, but struggled with reasoning. It documented that Resident #79 confused his wants and needs based on the expectations of others. The assessment documented that if Resident #79 did not want to be touched, he would make statements that justified why he allowed it. The investigation documented a meeting with the SSD, the DON, the assistant director of nursing (ADON) and Resident #79's guardian on 5/15/26. The investigation documented they met with Resident #79's guardian to discuss the newly implemented supervised visitation policy during the duration of the investigation. They explained to the guardian that an allegation of sexual abuse was made. They said until the investigation was completed and he was deemed safe to be alone with Resident #79, he was only allowed to meet with Resident #79 in the dining room or on the front patio, both being supervised areas. The investigation documented Resident #79's guardian got visibly upset and yelled that he cared for Resident #79 and he would never do such a thing and that they did not want him there for Resident #79 like the other places! The investigation documented that Resident #79's guardian was getting more aggressive and was warned that if he continued to behave in an aggressive manner, they would have to ask him to leave. It documented that Resident #79's guardian then abruptly got up and began to walk towards Resident #79's room. The SSD, the DON and the ADON followed him for supervision and safety. The guardian then started to yell at Resident #79 and said I can't see you anymore because of them, you know why, someone said I had you in the bathroom and you were sucking my dick! Management intervened right away, telling the guardian that it was inappropriate and asked him to leave. He then forcefully removed his hat from Resident #79's head and told him, You won't see me ever again. He then left the building accompanied by the ADON. The DON and the SSD stayed with Resident #79 and assessed his psychological and social well-being. The investigation summary documented that a staff member witnessed Resident #79 and his guardian in the bathroom. The guardian was having oral sex performed on him by Resident #79. Resident #79 was deemed unable to give sexual consent per assessment. Resident #79 continued to make his needs known. He was able to move on his own throughout the facility and able to make decisions within his day-to-day life. Due to his TBI, his mentation fluctuated and at times resembled that of a young child. Resident #79 called everyone mom and dad. The court was notified and guardianship was immediately suspended. Resident #79 still wanted contact with his guardian and it was explained to both Resident #79 and his guardian that visits were to be supervised. The investigation documented that the courts appointed a temporary guardian. The investigation documented that all staff were made aware that if Resident #79's guardian came to visit, the visit was to be supervised. All staff were retrained on reportable occurrences and the SSD would continue to monitor Resident #79's psychological and social well-being. -However, the incident was not reported to the State Agency until 5/14/26, 13 days after CNA #10 witnessed the incident. C. Staff interviews CNA #10 was interviewed on 6/10/26 at 10:08 a.m. CNA #10 said that on 5/1/26 he was looking for Resident #79 for his restorative program. He said it was close to lunch time and the only reason he looked in the bathroom was because he knew Resident #79 was beginning to be able to take himself to the toilet. He said he knocked and opened the door and he saw the guardian on the toilet with his pants all the way down and Resident #79 was in his wheelchair performing oral sex on his guardian. He said he quickly closed the door and apologized. He said Resident #79 seemed willing to do it. He said he had heard that Resident #79 and his guardian were a couple from management. He said he told the abuse coordinator, who was the DON. He said he only told her because Resident #79 began to behave differently. He said he saw Resident #79 getting aggressive and pushing his guardian away the rest of that day (5/1/26). He said he did go on vacation that week and when he got back the following week was when he told the DON. He said Resident #79's birthday was during the week that he got back from vacation and he had wished Resident #79 a happy birthday and his guardian did not know it was Resident #79's birthday. He said the fact that his guardian did not know Resident #79's birthday, mixed with the fact that Resident #79 was pushing his guardian away, prompted him to tell the DON about the incident. He said he did get immediate education on reporting abuse the day that he told the DON. The DON and regional clinical resource #1 were interviewed together on 6/11/26 at 9:19 a.m. The DON said that she had been the abuse coordinator for the facility for two years. She said she would soon be sharing the role with the NHA. She said she was aware that Resident #79 and his guardian had a romantic relationship prior to the resident living at the facility. She said she did immediate training with CNA #10 about abuse and reporting. She said that the facility recently had training with all staff on abuse. She said she was planning to touch on abuse in their monthly meetings with staff. IV. Resident #74 A. Resident status Resident #74, age [AGE], was admitted on [DATE]. According to the June 2026 CPO, diagnoses included hemiplegia (a form of paralysis that causes the complete or partial loss of voluntary muscle movement on one side of the body), vascular dementia, aphasia (a neurological language disorder that impairs a person's ability to communicate, speak, read, or write), and hypertension (high blood pressure). The 4/8/26 MDS assessment revealed Resident #74 had severe cognitive impairments with a BIMS score of three out of 15. Resident #74 was dependent upon staff for upper and lower body dressing, personal hygiene, rolling left and right in bed and transferring. The assessment revealed Resident #74 did not have verbal or physical behaviors directed toward others. B. Resident interview Resident #74 was interviewed on 6/10/26 at 4:50 p.m. Resident #74 said Resident #123 had given her a bruise. C. Record review Review of the facility's investigation report timeline revealed CNA #2 worked on 3/7/26 at about 4:00 p.m. and noticed a bruise on Resident #74's face and reported it to the nurse. According to the investigation, CNA #2 was the first staff member to report the bruise. Review of the State Agency reporting portal revealed the facility reported the incident on 3/9/26. The report documented the incident occurred on 3/8/26. -However, the facility's investigation revealed the bruise was noted by CNA #2 on 3/7/26 at approximately 4:00 p.m. -The facility failed to report the injury of unknown origin to the State Agency until 3/9/26, over 24 hours after the bruise was noticed. D. Staff interviews CNA #2 was interviewed on 6/11/26 at 12:56 p.m. CNA #2 said she asked Resident #74 how she got the bruise (on 3/7/26). CNA #2 said the resident did not say anything, and just looked at CNA #2. CNA #2 said she did not want to press Resident #74 further regarding how she got the bruise. CNA #2 said she reported the bruise to the nurse right after talking to Resident #74. The DON was interviewed on 6/11/26 at 7:48 p.m. The DON said Resident #74's facial bruise was of unknown origin at the time CNA #2 reported it to the nurse. The DON said after she spoke to the regional consultant, she was under the impression that it could be reported within 24 hours as there was no immediate harm or death. The DON said the facility initiated the investigation, but did not report to the State Agency until the next day. The DON said she made these decisions based on the direction of her previous consultant.

Based on observations and interviews, the facility failed to ensure all drugs and biologicals were properly stored, secured, and labeled in accordance with accepted professional standards in two of two medication carts and two of two medication rooms.Specifically, the facility failed to ensure:-Residents' medications were labeled and dated appropriately with the resident's name and the date the medication was opened; and, -Loose medications were not in the medication carts.Findings include:I. Facility policy and procedureThe Medication Labeling and Storage policy, revised February 2023, was provided by the nursing home administrator (NHA) on [DATE] at 2:05 p.m. It read in pertinent part, The nursing staff is responsible for maintaining medication storage and preparation areas in a clean, safe and sanitary manner. If the facility has discontinued, outdated or deteriorated medications or biologicals, the dispensing pharmacy is contacted for instructions regarding returning to or destroying these items. Multi-dose vials that have been opened or accessed (needle punctured) are dated and discarded within 28 days unless the manufacturer specifies a shorter or longer date for the open vial.II. ObservationsOn [DATE] at 9:48 a.m. the medication cart on the Broadway unit was observed with registered nurse (RN) #2. The following items were observed:There was one fluticasone propionate 50 microgram (mcg) per actuation (mcg/act) nasal spray bottle stored in an appropriately labeled medication box.-However, the medication bottle inside the box was not labelled with the resident's name or the date the medication was opened for Resident #90.There was one oxycodone (pain medication) 100 milligram (mg) per 5 milliliter (ml) oral suspension bottle stored in an appropriately labeled medication box.-However, the individual medication bottle inside the box was not labelled with the resident's name or the date the medication was opened for Resident #28.There was one small, white round pill found on the bottom of the narcotic drawer (see staff interview below). The pill had a capital M printed on one side and a number two printed on the other side.There was a medication cup with one yellow tablet in the narcotic drawer. There was no name or date on the medication cup (see staff interview below).On [DATE] at 10:01 a.m. the medication room on the Broadway unit was observed with RN #2. The following item was found:An uncovered medication cup labeled Tylenol 500 mg, which contained 27 tablets. There was no expiration date or open date on the cup.On [DATE] at 10:14 a.m. the Main unit medication room was observed with licensed practical nurse (LPN) #5. The following items were found:One Ozempic 2mg/3ml injector pen stored in an appropriately labeled medication box.-However, the individual injector pen inside the box was not labelled with the resident's name or the date the medication was opened for Resident #33.One accessed multi-dose Tuberculin (Tb) purified protein derivative (PPD) 5 Tb units (TU)/0.1ml vial stored in an appropriately labeled medication box.-However, the multi-dose vial inside the box was not labeled with the date the medication was opened.On [DATE] 11:26 a.m. the Swing unit medication cart was observed with LPN #4. The following item was found:One mometasone furoate-formoterol fumarate dihydrate (Dulera) 100-5 mcg/act aerosol inhaler stored in an appropriately labeled medication box.-However, the individual inhaler device inside the box was not labelled with the resident's name or the date the medication was opened for Resident #7.III. Staff interviewsRN #2 was interviewed on [DATE] at 9:48 a.m. RN #2 said Resident #90's nasal spray medication had been discontinued, and she said she was not sure how long a discontinued medication should have remained in the medication cart for. RN #2 said it was important to ensure the medication bottle was labeled inside its medication box in order to prevent medication errors if the box became lost or damaged. RN #2 removed Resident #90's discontinued medication from the medication cart and placed it in the medication room.RN #2 identified the loose small, white pill in the bottom of the narcotic drawer as Resident #107's Dilaudid medication. She said the resident received three pills per dose, and one of the pills must not have been administered to the resident at some point. RN #2 said the unlabeled medication cup had been prepared for Resident #105. She said the yellow tablet was a Clonazepam 0.5 mg tablet. RN #2 said Resident #105 had been recently removed from nothing by mouth (NPO) status, and she was about to administer the medication. She said it was best practice to label the medication cup with the resident's name if she was not immediately administering the medication.RN #2 was interviewed again on [DATE] at 10:01 a.m. RN #2 said she knew it was wrong to have a medication cup with tablets in the medication storage area. She said she thought a nurse noticed there were only 500 mg Tylenol capsules on the unit, so they brought 500 mg Tylenol tablets to the medication room for the residents who could not take capsules. RN #2 said the tablets should have been covered because it was an infection control issue. RN #2 used a marker to label the identified items in her medication cart and medication room with the residents' names and the dates the medications were opened.LPN #5 was interviewed on [DATE] at 10:14 a.m. LPN #5 said it was important to make sure the individual injector pen was labeled with the resident's name to prevent medication errors if its box became damaged or lost.LPN #5 said the multi-use TB vial was opened, and she did not know what date it was opened. She said it was important to ensure the vial was labeled because multi-use vials were only good for 30 days after it was opened. LPN #5 said a TB vial should not be administered after its best-by date. LPN #5 used a marker to label the identified items in her medication cart and medication room with the residents' names and the dates the medications were opened.LPN #4 was interviewed on [DATE] at 11:26 a.m. LPN #4 said it was important to make sure the inhaler device was labeled inside the box to prevent medication mix ups if the box was lost. LPN #4 used a marker to label the identified items in her medication cart and medication room with the residents' names and the dates the medications were opened.The director of nursing (DON) and regional clinical resource (RCR) #1 were interviewed together on [DATE] at 3:35 p.m. The DON said the individual medication bottles should have been labeled inside their respective medication boxes so the medications did not get mixed up, and so the nursing staff could practice the rights of medication administration. RCR #1 said it prevented staff from documenting that a medication was unavailable because they could not find it. The DON said she would not have expected to find a medication cup with Tylenol tablets in the medication room. She said the facility had plenty of bottles that could have been dated with the open date and to ensure it really was Tylenol being administered from that medication cup.The DON said she would not have expected to see a loose Dilaudid pill or a pre-dispensed clonazepam tablet in an unlabelled medication cup. She said loose pills in the medication cart could be difficult to identify and she would expect her nursing staff to dispose of the medication when it was discovered. The DON said if the nurse could identify who the pill belonged to she would expect them to notify the physician and let them know there was a potential for missing a pill in a dose.The DON said a multi-use vial of TB was typically good for 28 days after opening, but she would have had to review the manufacturer's recommendations for the best-by date. She said if an expired vial had an unknown efficiency and could have created false positive results.

Based on observation and interviews, the facility failed to maintain an infection control program designed to provide a safe, sanitary and comfortable environment to help prevent the development and transmission of disease and infections. Specifically the facility failed to:-Ensure proper infection control practices, including enhanced barrier precautions, were followed during wound care;-Ensure proper hand hygiene during medication administration; and,-Ensure dwell times were followed during the disinfection process of the vital sign tower and resident glucometer. Findings include: I. Wound care failures A. Professional reference According to the Centers for Disease Control and Prevention's (CDC) Implementation of Personal Protective Equipment (PPE) Use in Nursing Homes to Prevent Spread of Multidrug-resistant Organisms (MDROs), (4/2/24), retrieved on 6/16/26, from https://www.cdc.gov/long-term-care-facilities/hcp/prevent-mdro/PPE.html, Multidrug-resistant organism (MDRO) transmission is common in skilled nursing facilities, contributing to substantial resident morbidity and mortality and increased healthcare costs. Enhanced Barrier Precautions (EBP) are an infection control intervention designed to reduce transmission of resistant organisms that employs targeted gown and glove use during high-contact resident care activities. EBP may be indicated for residents with any of the following: Wounds or indwelling medical devices, regardless of MDRO colonization status, and infection or colonization with an MDRO. B. Facility policy and procedure The Enhanced Barrier Precautions policy, revised August 2022, was provided by the nursing home administrator (NHA) on 4/9/26 at 4:42 p.m. It read in pertinent part, Enhanced barrier precautions (EBP) are used as an infection prevention and control intervention to reduce the spread of multidrug-resistant organisms (MDRO) to residents. EBP employs targeted gown and glove use during high-contact resident care activities when contact precautions do not otherwise apply. Examples of high-contact resident care activities requiring the use of gown and gloves for EBP include: dressing; bathing/showering; transferring; providing hygiene; changing linens; changing briefs or assisting with toileting; device care or use (central line, urinary catheter, feeding tube, tracheostomy/ventilator); and wound care (any skin opening requiring a dressing). B. Facility policy and procedure The Wound Care policy, revised April 2026, was provided by the nursing home administrator (NHA) on 6/11/26 at 4:22 p.m. It read in pertinent part, The purpose of this procedure is to provide guidelines for the care of wounds to provide healing. Equipment and supplies: Dressing material, as indicated such as gauze, tape, and scissors; clean drape; cleaning solution, personal protective equipment such as gowns, gloves, mask as needed. Steps in the procedure: perform hand hygiene; establish a clean field on resident's overbed table, place all items to be used during the procedure on the clean field; place disposable cloth next to the resident to protect the bed linen ant other body sites, put on exam gloves; pull one glove over the dressing and discard into appropriate receptacle, remove the second glove; and perform hand hygiene. To clean the wound: Apply clean gloves; place a piece of gauze over the wound, leaving the margins of intact skin exposed; clean the area around the wound usually covered by the dressing, tape, or gauze with antiseptic or soap and water; remove dry gauze from the wound; clean and apply treatments as ordered; apply appropriate dressing, mark tape with initials, date and time and apply to dressing. C. Observations On 6/9/26 at 10:05 a.m. registered nurse (RN) #3 was providing wound care to Resident #4. RN #3 had already begun the dressing change when the observation began. RN #3 was wearing a mask and gloves for the dressing change. The treatment cart was in the resident's room with supplies scattered directly on top of the cart. -RN #3 failed to follow EBP during wound care and failed to have dressing supplies on a clean surface. RN #3 was applied a border dressing to the resident's leg wound. RN #3 then covered the resident with her blankets when finished. -There was no barrier pad under the resident leg to provide a clean working surface. RN #3 cleared the treatment cart of all supplies placing them into a red trash can in the resident's room. RN #3 locked his cart and completed hand hygiene with soap and water. RN #3 left the resident room with the treatment cart. At 10:12 a.m. RN #3 took the cart down the hall to Resident #60's room. RN #3 spoke to the resident and advised he was there to complete her wound care. He began to set up supplies for the residents' gluteal fold and sacrum wound. RN #3 took out one border dressing and one border foam dressing, opened the packaged, dated and initialed them and placed them directly on top of the treatment cart. -RN #3 failed to disinfect the treatment cart or create a clean barrier prior to placing supplies on top of the treatment cart. RN #3 sanitized his hands with alcohol based hand rub (ABHR), then applied gloves. He went to the resident's bed and touched the bed control to lay the head of the bed down and raise it to a good working height. RN #3 returned to his treatment cart and opened the top drawer, he opened multiple drawers with gloves on. RN #3 pulled a stack of gauze from the drawer and while he held them, sprayed them with wound cleanser, he then placed them directly onto the bedside table. -RN #3 failed to sanitize the bed side table or apply a barrier pad prior to placing gauze on the bedside table. RN #3 pulled the sheets back from the resident and noticed the resident had a bowl movement and needed to be cleaned up prior to him completing the dressing. RN #3 said he needed to get a certified nurse aide (CNA) to clean the resident up. He locked the cart and pressed the call light. Walking out of Resident #60's room he ran into an unidentified CNA and asked her to clean the resident up. RN #3 said he would return to Resident #60's room once the resident was ready. At 10:20 a.m. RN #3 took the treatment cart to Resident #28's room. -RN #3 failed to disinfect the treatment cart between resident rooms. RN #3 performed hand hygiene with ABHR and applied gloves. RN #3 opened the treatment cart touching the keys from his pocket. He pulled out gauze from a bulk pack in a lower drawer, applied wound cleanser to the gauze and placed it directly onto the resident's bed sheet. -RN #3 failed to place the gauze on a clean working surface. RN #3 removed the old dressing from the resident. He wiped the wound with the gauze that was on the resident's bed. RN #3 completed picture images of the wound. RN #3 returned to the treatment cart, opened the drawers and collected supplies. RN #3 took out a package of collagen (specialized wound treatment) and a border foam dressing. He removed his gloves, applied new ones without performing hand hygiene, took a marker out of pocket to sign and date the new dressing. -RN #3 failed to perform hand hygiene between gloves changes. RN #3 returned to the resident bed placing supplies on to his bed. He opened packages that were on the resident's bed, tore a piece of the collagen off with his hands and applied it to the wound bed, and covered the wound with the bordered foam dressing. -RN #3 failed to place supplies on a clean working surface. RN #3 said the dressing was complete at 10:27 a.m. RN #3 left Resident #28's room with the treatment cart and returned to Resident #60's room. He entered Resident #60's room with the entire treatment cart. -RN #3 failed to disinfect the treatment cart between rooms. RN #3 washed his hands with soap and water. He raised Resident #60's bed. RN #3 used a X to prepare to take pictures of the residents' wounds. He applied gloves and used his keys to open the treatment cart. RN #3 collected the stickers needed for measurement taken from the top drawer of the treatment cart. He also collected bulk gauze from the drawer and sprayed it with a wound cleanser in his hand. He then went to the resident's bed and positioned the resident in order to take a picture of the right gluteal fold wound. The electronic device used for picture measurements touched the resident bed during the picture process. RN #3 took the gauze and placed it on the resident's bed. -RN #3 failed to have a clean working area for supplies. RN #3 removed his gloves, performed hand hygiene with ABHR and applied new gloves. RN #3 opened several drawers on the treatment cart and collected more gauze, which he sprayed with wound cleanser, then placed the gauze directly onto the top of the treatment cart. RN #3 then pulled out a package of collagen and two border foam dressing. RN #3 opened the dressing and pulled out a maker to initial and date them. He took all of the items to the resident's bed and placed them directly onto the resident bed. -RN #3 failed to place dressing supplies on a clean working surface. RN #3 started with the right gluteal fold wound, cleansed with gauze, he tore open the collagen package and ripped a piece off and applied it to the wound bed. RN #3 then covered the wound with a border foam dressing. RN #3 removed his gloves and applied new ones. -RN #3 failed to perform hand hygiene between glove changes. RN #3 moved to resident's sacral wound. RN #3 took gauze from the supply on the bed, dabbed the wound three times with the same piece of gauze then folded the piece of gauze over and dabbed three more times. -RN #3 failed to clean the wound in a hygienic manner. He packed the wound with collagen and covered it with border foam dressing. RN #3 cleared all trash from the area. Removed his gloves and performed hand hygiene with ABHR. He left Resident #60's room with the treatment cart. RN #3 took the cart into another resident room after completing Resident #60's treatment. D. Staff interviews RN #3 was interviewed on 3/11/26 at 10:41 a.m. RN #3 said he had been in the position of wound care nurse for about a month and the facility had assisted him in taking a nine hour training for wound care. RN #3 said he was instructed by the staff development coordinator to apply a mask, gown and gloves only if a resident had a history of having a multi drug resistant organism (MDRO). RN #3 said if the resident did not have a history of MDRO, he just needed to wear gloves for dressing changes. RN #3 said hand sanitization should be done with ABHR or soap and water after every glove change and between residents. He said this was to prevent contamination or infection. RN #3 said he was not aware he failed to perform hand hygiene between all glove changes during wound care observation. RN #3 said his supervisor told him to take the treatment cart with him to every room to ensure he had all the supplies needed for a treatment with him but the supervisor did not tell him to take the cart into the room. RN #3 said he took the cart into the resident's room in order to cut down on walking back and forth to the cart if he missed a supply or needed more supplies while in the resident's room. RN #3 said he wiped down the treatment cart with a disinfectant wipe at the beginning of his shift and at the end of his shift. RN #3 said he did not do it in between resident rooms but would start in the future as it could lead to infection since it was going into multiple resident rooms throughout his shift. RN #3 said he should disinfect the resident's bed side table prior to placing supplies on them or he could use the top of the treatment cart to place supplies. He said supplies should not be placed on the resident's bed or a surface that had not been disinfected. He said the area should be disinfected to prevent the spread of bacteria/infections. RN #3 said supplies that touched a surface that had not been disinfected should be replaced with new supplies. The director of nursing (DON), who was also the infection preventionist, was interviewed on 6/11/26 at 1:15 p.m. The DON said the wound care nurse should wear gloves and a gown during wound care. The DON said other PPE such as a mask and goggles would depend on the type of wound. The DON said gloves should be changed in between wound care. She said the PPE and the glove changes were in place to prevent the spread of infection. The DON said the wound care nurse should clean and sanitize the work area, usually the resident's bedside table, and place a barrier on the work station. The DON said the nurse then should take the needed supplies into the room and place the supplies on the barrier. She said it was not protocol to place supplies on the resident's bed especially if there was no barrier. The DON said the cart should be left at the doorway and if the cart was taken to the room the whole cart would need to be sanitized every time it left a room and before entering the next room. II. Failed to ensure hand hygiene was performed appropriately between residents A. Facility policy and procedure The Handwashing/Hand Hygiene policy, revised December 2025, was provided by the NHA on 6/11/26 at 2:05 p.m. It read in pertinent part, Hand hygiene is the primary means for preventing healthcare-associated infections (HAI) and the transmission of multidrug-resistant organisms (MDRO). This facility requires strict adherence to evidence-based hand hygiene practices for all personnel. Hand hygiene is indicated: before touching a resident; before preparing or handling food, medications or parenteral solutions; before clean or aseptic procedures (for example, before wound care or inserting an intravenous catheter); before moving from work on a soiled body site to a clean body site on the same resident; after exposure to blood, body fluids, excretions or contaminated surfaces; after touching a resident; after touching the resident's environment or belongings; after glove removal; and, whenever hands are visibly soiled. Applying alcohol-based hand rubs: apply a generous amount of product to the palm of one hand and rub your hands together. Follow manufacturers' directions for volume of product to use; and, rub hands together for at least 20 seconds, covering all surfaces of the hands and fingers until the hands are dry. B. Observation During a continuous observation of medication administration on 6/9/26, starting at 4:08 p.m. and ending at 4:23 p.m., the following was observed: At 4:13 p.m. licensed practical nurse (LPN) #2 administered medications to Resident #107. At 4:15 p.m. LPN #2 knocked on Resident #122's door and prepared to measure the resident's blood glucose (sugar) level. -However, LPN #2 did not perform hand hygiene after exiting Resident #107's room and before she entered Resident #122's room. C. Staff interviews LPN #2 was interviewed on 6/9/26 at 4:15 p.m. LPN #2 said she thought she had performed hand hygiene after she exited Resident #107's room. She said it was important to perform hand hygiene between residents to prevent the cross contamination of pathogens between residents. The DON was interviewed on 6/11/26 at 3:35 p.m. The DON said indications for hand hygiene during the medication administration process included before entering the resident's room, after exiting the resident's room and between cares. She said it was important to perform hand hygiene between residents to prevent the spread of infection. III. Failed to ensure staff disinfected the vital signs equipment and glucometers appropriately between residents A. Professional reference Assadian O, Harbarth S, Vos M, et al. Practical Recommendations for Routine Cleaning and Disinfection Procedures in Healthcare Institutions: A Narrative Review. The Journal of Hospital Infection, (July 2021) 113:104-114, was retrieved on 6/16/26 from https://www.journalofhospitalinfection.com/article/S0195-6701(21)00105-5/fulltext. It revealed in pertinent part, High-touch surfaces, on the other hand, are usually close to the patient, are frequently touched by the patient or nursing staff, come into contact with the skin and, due to increased contact, pose a particularly high risk of transmitting pathogens (virus or microorganism that can cause disease) Healthcare-associated infections (HAIs) are the most common adverse outcomes due to delivery of medical care. HAIs increase morbidity and mortality, prolonged hospital stay, and are associated with additional healthcare costs. Contaminated surfaces, particularly those that are touched frequently, act as reservoirs for pathogens and contribute towards pathogen transmission. Therefore, healthcare hygiene requires a comprehensive approach. This approach includes hand hygiene in conjunction with environmental cleaning and disinfection of surfaces and clinical equipment. According to Super Sani-Cloth Germicidal Disposal Wipe, PDI, (2018), retrieved on 6/16/26 from https://pdihc.com/wp-content/uploads/2018/08/Super-Sani-Cloth-Tech-Data-Bulletin_0619-UPDATE_07168610.pdf, Super Sani-Cloth germicidal disposable wipe is a premoistened, nonwoven durable wipe containing a quaternary ammonium chloride/alcohol based solution. Recommended for use in hospitals and other critical care areas where the control of the hazards of cross-contamination between treated surfaces is required. Some organisms are removed from the surface by thoroughly wiping the surface with the wipe. Most remaining organisms are killed within two minutes by exposure to the liquid in the wipe. B. Observations On 6/9/26 at 4:15 p.m. LPN #2 was measuring Resident #122's blood glucose level during medication administration. LPN #2 gathered blood sugar test supplies from the medication cart, knocked on Resident #122's door and identified the resident. LPN #2 donned (put on) gloves and measured the resident's blood sugar. After measuring Resident #122's blood sugar, LPN #2 threw away the trash, doffed (removed) her gloves and performed hand hygiene with hand sanitizer upon exiting the room. Once she returned to the medication cart, LPN #2 unlocked the cart, removed the Super Sani-Cloth wipes and wiped the resident's personal glucometer for less than ten seconds. -LPN #2 did not allow the surfaces of Resident #122's glucometer to remain wet with the Super Sani-Cloth wipe for the recommended two minute dwell time (see professional reference above) before she returned the glucometer to the medication cart. On 6/10/26 at 8:43 a.m. RN #1 donned gloves and used the Super Sani-Cloth wipes to disinfect the blood pressure cuff and pulse oximeter (a non-invasive medical device that clips onto a fingertip to measure the oxygen saturation in your blood) device. RN #1 finished wiping the surfaces of the blood pressure cuff and pulse oximeter device at 8:43 a.m. -RN #1 did not allow the surfaces of the vital signs equipment to remain wet with the Super Sani-Cloth wipe for the recommended two minute dwell time (see professional reference above). C. Staff interviews LPN #2 was interviewed on 6/9/26 at 4:23 p.m. LPN #2 said she did not know what the chemical dwell time was. She opened the bottom drawer of the medication cart, looked at the container and said it was two minutes. She said it was important to follow chemical dwell times to properly disinfect and clean germs from the device. RN #1 was interviewed on 6/10/26 at 9:10 a.m. RN #1 said he did not know what the chemical dwell time was. RN #1 walked to the nurse's station, looked at the container and said the chemical dwell time was two minutes. He said it was important to disinfect the equipment properly to kill pathogens and prevent cross contamination between residents. The DON was interviewed on 6/11/26 at 3:35 p.m. The DON said after measuring a resident's blood glucose, the nursing staff should disinfect the glucometer using the Super Sani-Cloth wipes. She said the wipes had a two minute chemical dwell time, which meant all surfaces of the glucometer and the vital signs equipment should have remained wet for two minutes. The DON said it was important to follow the chemical dwell time to prevent the spread of infection between residents.

Based on record review, observations and interviews, the facility failed to ensure prompt action was taken upon the filing of a grievance of a group.Specifically, the facility failed to ensure resident complaints expressed during the resident council meetings were documented on a grievance and resolved to the residents satisfaction.Findings include:I. Facility policy and procedure The Grievances/Complaints, Recording and Investigating policy, revised April 2017, was provided by the nursing home administrator (NHA) on 6/11/26 at 4:11 p.m. It read in pertinent part, All grievances and complaints filed with the facility will be investigated and corrective actions will be taken to resolve the grievances. Upon receiving a grievance and complaint report, the grievance officer will begin an investigation into the allegations. The department director will be notified of the nature of the complaint and that an investigation is underway. The grievance officer will record and maintain all grievances and complaints on the Resident Grievance Complaint Log. The Resident Grievance/Complaint Investigation Report Form will be filed with the administrator within five working days of the incident. The resident, or person acting on behalf of the resident, will be informed of the findings of the investigation, as well as any corrective actions recommended, within (a blank that was not filled in by the facility)working days of the filing of the grievance or complaint.-The policy failed to have a specific time frame on when the grievance needed to be completed.II. Resident group interview Five residents (#19, #33, #44, #93 and #108) who were identified by the facility and assessment as interviewable, were interviewed together as a group on 6/10/26 at 11:49 a.m. The residents in the group confirmed there were grievances brought up in the resident council meeting. They said they were not informed of how it was resolved. The residents said they did not get a response from the grievance official. The group said there had been several grievances that had been filled out and did not get addressed. The group said when they had problems, they had to keep complaining until someone did something. III. Resident council minutesThe April 2026 resident council minutes documented a concern was brought up that there were not enough washcloths. The minutes documented a resident was missing a robe, and another resident had a concern and wanted to talk to someone in person after the meeting. The 5/26/26 resident council minutes documented a concern related to privacy curtains, and complaint about transition service. The 5/26/26 resident council minutes documented, Minutes from previous meeting read and approved. Although no information was documented on the resolution from the April 2026 resident council grievances. A request was made for the grievances related to the April 2026 and May 2026 resident council concerns. They were not provided during the survey. D. Staff interviewsThe activity director (AD) was interviewed on 6/11/26 at 4:50 p.m. The AD said he was present during the resident council meetings and that he took notes for the council. He said the resident council met monthly. He said he invited the residents and put the announcement on the calendar. The AD said the department heads attended the meeting. He said he had not written any grievances from the complaints received in the April 2026 and May 2026 council meetings. The AD said he did not follow up with the resident who wished to talk privately, he thought nursing followed up with him. The social work consultant was interviewed on 6/11/26 at 5:45 p.m. The social work consultant said there were no grievances found from the April 2026 and May 2026 resident council meetings. E. Facility follow-up On 6/11/26 at 7:06 p.m. the social work consultant said she would review the grievance policy and updated it as needed.

Based on record review and interviews, the facility failed to ensure one (#56) of six residents were free from abuse out of 55 sample residents. Specifically, the facility failed to:-Protect Resident #56 from verbal abuse by licensed practical nurse (LPN) #8; and,-Removed LPN #8 from Resident #56's care following the incident of verbal abuse.Findings include:I. Facility policy and procedureThe Resident Abuse Prevention policy and procedure, undated, was provided by the nursing home administrator (NHA) on 6/8/26 at 12:58 p.m. It read in pertinent part, Each resident must have the right to be free from physical, mental or sexual abuse, neglect, corporal punishment, involuntary seclusion, and any physical restraints. All employees who have reasonable cause to believe a resident has suffered abuse are responsible for reporting that information to the executive director or upon his/her absence, to a supervisor. If to a supervisor, he/she shall pass along the information to the executive director immediately. II. Incident of verbal abuse by LPN #8 towards Resident #56 on 7/9/25A. Grievance form A grievance form was filled out on 7/9/25 at 6:30 a.m. by the staff development coordinator. The grievance documented Resident #56 was crying due to attempting to explain her Oxycontin was not being administered as ordered. The grievance documented LPN #8 insisted the resident's Oxycontin was PRN, however Resident #56's medication was in fact scheduled. The form documented LPN #8 was in Resident #56's face when the staff development coordinator arrived. The grievance outcome/resolution documented that LPN #8 was asked to step back, reconsider his approach with Resident #56 and to lower his voice and walk away if the situation escalated. The outcome/resolution documented LPN #8 would apologize to Resident #56. At the bottom of the grievance in a different handwriting, documented that Resident #56 requested that LPN #8 no longer be her assigned nurse due to him approaching her in the same manner previously. There were no other signatures on the grievance other than the staff development coordinator's. There was no indication on the grievance that a resolution had been made. -However, LPN #8 continued to be Resident #56's assigned nurse for the next nine months (see record review below). Cross-reference F585: failure to resolve grievances. B. Resident #561. Resident statusResident #56, age less than 65, was admitted on [DATE]. According to the June 2026 computerized physician orders (CPO), diagnoses included right-sided hemiplegia and hemiparesis following cerebral infarction, history of traumatic brain injury, and anxiety disorder. The 3/12/26 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score of 15 out of 15. She was independent with most of her activities of daily living (ADL). 2. Resident interviewResident #56 was interviewed on 6/8/26 at 3:17 p.m. She said approximately eight to nine months ago LPN #8 would not give her her scheduled pain medications. She said he got right in her face and yelled at her. She said he scared her when he got in her face. She said she had requested that he no longer be her nurse after the incident, but he continued to be her nurse for approximately six months afterwards. She said it caused her a lot of depression and anxiety, because he continued to be her nurse. She said it made her feel like the facility cared more about his well-being than her well-being, because they did not do anything. She said because the facility did not do anything it made her feel like LPN #8 felt it was ok to treat her that way. She said she felt that when LPN #8 got in her face and yelled at her, it was abusive behavior. She said she continued to avoid LPN #8 whenever she sees him in the facility. C. Record reviewThe trauma-informed care plan, revised 5/5/26, revealed Resident #56 had been the victim of domestic abuse both physical and emotional with previous partners. Pertinent interventions included offering mental health services as needed and monitoring for signs and symptoms of depression. -Review of Resident #56's electronic medical record (EMR) did not reveal the facility provided the resident with psychological-social follow-up or monitor the resident for ongoing psychological-social changes, such as crying, after the incident of verbal abuse on 7/9/25. Review of the medication administration record (MAR) from 7/12/25 to 4/18/26 revealed LPN #8 administered medications to Resident #56 on 118 days following the verbal abuse incident on 7/9/25. Resident #56's patient health questionnaire-9 (PHQ-9) (a standardized questionnaire to screen, diagnose, and measure depression) score rose from zero in September 2025 to five in November 2025, indicating an increase in depression. D. Staff interviewsThe staff development coordinator was interviewed on 6/10/26 at 4:49 p.m. She said Resident #56 felt that she was not getting her pain medication timely and consistently from LPN #8. She said Resident #56 also felt like LPN #8 was not addressing her pain fairly and appropriately. She said when she arrived at the nurse's station that morning (7/9/25) she saw that LPN #8 was about a foot away from from Resident #56's face and was hollering at her. The staff development coordinator said LPN #8 was not being respectful. She said he made Resident #56 cry and made her fearful. She said she felt she had to intervene because both LPN #8 and Resident #56 raised their voices and were disturbing the other residents. She said she did not consider the incident to be abuse, because LPN #8 did not hit Resident #56. She said she also allowed LPN #8 a 60 to 90 day trial to see if he could improve his medication pass with Resident #56. She said that she was monitoring his medication pass by looking at the narcotics sheet. She said there was no documentation of the education or discussion with LPN #8. She said she did speak with Resident #56 about the 60 to 90 day trial and that the resident was ok with the plan. -However, there was no documentation of the conversation with Resident #56 and Resident #56 requested to not have LPN #8 work with her any longer (see record review and resident interview above). The scheduler was interviewed on 6/10/26 at 5:09 p.m. She said she had only been in the schedular role since May 2026. She said she worked as a certified nurse aide at the facility before she took the scheduler role. She said she had heard that Resident #56 had requested that LPN #8 no longer work on her hall. She said she was still being trained so she did not have much to do with the situation. She said she tried to accommodate the needs of the residents as best she can. The social services director (SDD) and social services assistant #2 were interviewed together on 6/10/26 at 6:50 p.m. The SDD said she was not aware of the situation between LPN #8 and Resident #56. Social services assistant #2 said she had heard about the situation and was told that the nurse (LPN #8) was going to moved from her hall. Social services assistant #2 said there was no follow-up with the resident after the incident on 7/9/25. Social services assistant #2 said she thought everything was taken care of following the incident.The director of nursing (DON) and the regional clinical resource #1 were interviewed together on 6/11/26 at 9:19 a.m. The DON said she was aware of situation between LPN #8 and Resident #56. She said she had spoken to LPN #8 and he had told her that he was concerned that Resident #56 was under the influence. The DON said he raised his voice because he wanted to make sure that Resident #56 was understanding him. She said that when she spoke to LPN #8, she directed him to have another nurse give Resident #56 her medications. She said he was no longer to administer Resident #56's medications. She said that she expected to have the nurse that gave the medications to the resident to also pull the medications, that way there would be no questions as to who gave the medications. She said that she had not seen the grievance prior to 6/11/26 and if she had seen it before she would have opened an investigation of verbal abuse. Cross-reference F609: failure to report alleged abuse.

Based on record review, interviews, and observations, the facility failed to ensure two (#13 and #79) of two residents out of 55 sample residents received treatment and care in accordance with professional standards of practice. Specifically, the facility failed to:-Administer the correct dose of medication and accurately chart administration times for Resident #13; and, -Ensure Resident #79's medications were available for administration.Findings include: I. Professional reference According to [NAME], P.A., [NAME], A.G., et.al., Fundamentals of Nursing, 10 ed. (2021), E. [NAME], St. Louis Missouri, pp. 607-609. To prevent medication errors, follow the seven rights of medication administration consistently every time you administer medications. Many medication errors can be linked in some way to an inconsistency in adhering to these seven rights: The right medication The right dose The right patient The right route The right time The right documentation The right indication Right medication: When preparing medication from bottles or containers, compare the label of the medication container with the MAR (medication administration record). Right documentation: Nurses and other health care providers use documentation to communicate with one another. Many medication errors result from inaccurate documentation. Therefore, always document medication accurately at the time of administration and identify any inaccurate documentation before you give medications. II. Facility policy and procedure The Administering Medications Policy was provided by the nursing home administrator (NHA) on 6/11/26 at 4:22 p.m. The policy read in pertinent part, Medications are administered in accordance with prescriber orders, including any required time frame. Medication administration times are determined by resident need and benefit, not staff convenience. The individual administering the medication checks the label three times to verify the right resident, right medication, right dosage, right time and right method (route), of administration before giving the medication. When opening a multi-dose container, the date opened is recorded on the container. III. Resident #13 A. Resident status Resident #13, age less than 65, was admitted to the facility 8/20/24. According to the June 2026 computerized physician orders (CPO), diagnoses included hyperkeratosis of the feet (a thickening of the skin's outer layer caused by an overproduction of keratin, a tough, protective protein), chronic pain and contractures related to rheumatoid arthritis. The 5/21/26 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score of 13 out of 15. Resident #13 was dependent on staff for dressing, hygiene, rolling in bed, and transferring. The assessment identified that Resident #13 had a limited range of motion and impairments in all extremities. The assessment identified that Resident #13 had pain almost constantly and had scheduled and PRN (as needed) pain medications. B. Resident interview and observations Resident #13 was interviewed on 6/8/26 at 4:34 p.m. Resident #13 said the staff were not always putting cream on her feet as ordered. Resident #13 said when the staff did put the cream on her feet, it helped her dry feet feel better. During the interview, Resident #13's had thick yellow and white crusts covering the soles of both feet. Resident #13 said it had been months since the staff put the cream on her feet. D. Record review Resident #13's skin integrity care plan, initiated 8/22/24 and revised on 3/30/26, revealed Resident #13 had potential for impairment to skin integrity related to mobility limitations, contractures, weakness, discomfort, and incontinence of bowel and bladder. Pertinent interventions included to keep skin clean and dry and to use lotion on dry skin as needed. Review of Resident #13's June 2026 CPO revealed the following physician's orders: Urea External Cream 40% (Urea). Apply to soles of bilateral feet topically two times a day for hyperkeratosis. The order started on 11/11/25. Resident #13's medication administration record (MAR) revealed that RN #3 charted that Resident #13's Urea 40% foot cream was administered on 6/9/26 at 4:06 p.m. -However, observations revealed RN #3 did not administer the Urea 40% foot cream to Resident #13 (see observations above). D. Observation and staff interview On 6/9/26 at 4:10 p.m. registered nurse (RN) #3 was administered Resident #13's medications. RN #3 did not administer Resident #13's Urea 40% foot cream. RN #3 was interviewed on 6/9/26 at 4:35 p.m. during medication administration. RN #3 said they were going to administer the Urea cream, but had not yet. RN #3 said Resident #13 should have Urea cream available. RN #3 looked in his medication cart and could not find the cream. RN #3 searched for the cream in a separate cart. RN #3 found the Urea cream in the second cart. RN #3 said Resident #13's order was for 40% Urea cream. The container held 20% Urea cream. RN #3 said Resident #13's order was to apply the cream twice daily. The Urea cream container had Resident #13's name written on it in black marker. The container was PurOrganica 20% Urea cream, which held 4 ounces (oz) total. The container had a date written in black marker which read 9/27/25. RN #3 said the date was the date the medication was first opened. RN #3 said the Urea cream was supposed to be applied to Resident #13's feet. RN #3 said the container was 20% Urea cream but the order was for 40% Urea cream. RN #3 said he would tell the nurses to pay closer attention to the physician's orders. RN #3 said he would call the pharmacy and request for them to deliver the correct dose of medication. RN #3 called the pharmacy at 4:49 p.m. RN #3 said the pharmacy said the insurance did not approve the 40% cream. RN #3 said he would let the director of nursing (DON) know, so that she could overnight the correct cream from online. RN #3 changed his charting on the MAR from given to not given. RN #3 said he changed his charting and wrote a note that explained why he did not give the medication. E. Additional interviews Pharmacist #2 was interviewed on 6/11/26 at 1:06 p.m. Pharmacist #2 said the purpose of the Urea 40% cream was to help with severe dry skin. Pharmacist #2 said the cream was used to shed the top layer of skin and get rid of calluses which promotes normal healing of the skin and help keep the layers of skin softer. Pharmacist #2 said the 20% urea cream would not be as effective as the ordered 40% cream, because it was half the strength of what Resident #13 should have been getting. Pharmacist #2 said if Resident #13 was receiving 20% and not 40% urea cream, it would not be as effective, the treatment duration could last longer. Pharmacist #2 said the facility must have been obtaining the cream from an outside source because the pharmacy never dispensed the medication for Resident #13. Pharmacist #2 said the facility had never requested a dose of the medication from the pharmacy. The director of nursing (DON) was interviewed on 6/11/26 at 6:48 p.m. The DON said the five rights of medication administration were the right resident, right drug, right route, right dose and right time. The DON said she had overnight ordered the correct dose of 40% Urea cream from online and had given the cream to the nurse to administer by the next morning at 9:00 a.m. The DON said she had been ordering the cream online. The DON said that staff were supposed to let her know when there were only a few applications of cream left so she could re-order the creams. The DON said she ordered two extra creams this time, so when she gave a nurse the last bottle she would know it was time to re-order. IV. Resident #79 A. Resident status Resident #79, age less than 65, was admitted on [DATE]. According to the June 2026 CPO, diagnoses included diffuse traumatic brain injury, chronic obstructive pulmonary disease (COPD - a progressive, incurable lung disease that restricts airflow and makes breathing difficult) and chronic respiratory failure with hypoxia (lack of oxygen in the blood). The 5/7/26 MDS assessment revealed the resident was severely cognitively impaired with a BIMS score of four out of 15. He was dependent on staff for toileting, showering and lower body dressing. He required partial/moderate assistance with repositioning and personal hygiene. B. Record review Review of Resident #79's CPO revealed the following physician's order: Sodium chloride (saline) nasal solution 0.65 percent (%). Two sprays in both nostrils two times a day for nasal congestion, ordered 10/31/25. C. Observation and staff interview On 6/11/26 at 8:46 a.m. licensed practical nurse (LPN) #4 was administering medications to Resident #79. LPN #4 labeled a medication cup with the resident's name and began dispensing medications. She said Resident #79's nasal spray was not in the medication cart, and she would have to go downstairs to get a replacement bottle for administration. At 8:53 a.m. LPN #4 administered the medications. -However, LPN #4 did not pause the administration process to try to obtain a replacement bottle, send a message or ask for help to ensure the medication was available to administer. D. Staff interviews LPN #4 was interviewed on 6/11/26 at 12:44 p.m. LPN #4 said she did not administer Resident #79's nasal spray medication and the resident missed the dose. She said she went downstairs after she finished administering the resident her medications, but she did not see a replacement bottle down there. LPN #4 said if she did not administer the medication on time and tried to give it later, then it would be too close to the next dose and could potentially have a negative impact on the resident. The DON was interviewed on 6/11/26 at 3:35 p.m. The DON said she would have expected the nurse to pause and obtain the medication to administer immediately. She said the facility had nasal spray medication bottles in stock. The DON said she would educate the nurse to replace an over-the-counter medication when the last of it was used so it would be replaced for the next shift. She said the nursing staff were expected to notify the physician about missed or late administrations of medications due to unavailability.

Based on observations, record review and interviews, the facility failed to ensure one (#8) of four residents received treatment and care in accordance with professional standards of practice out of 55 sample residents. Specifically, the facility failed to obtain physician's orders for Resident #8's wound in a timely manner.Findings include:I. Resident #8A. Resident statusResident #8, age [AGE], was admitted on [DATE]. According to the June 2026 computerized physician's orders (CPO), diagnoses included type 2 diabetes mellitus with diabetic neuropathy and hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side. The 5/7/26 minimum data set (MDS) assessment revealed the resident had mild cognitive impairment with a brief interview for mental status (BIMS) score of 12 out of 15. The resident was dependent on staff for upper and lower body dressing, bed mobility and transfers. B. Resident interview and observationOn 6/9/26 at 9:45 a.m. Resident #8 was lying in bed with a dressing on his right lower forearm, dated 6/8/26. On his left forearm there was elastic wrap (type of wound dressing) around his arm that was not dated. Resident #8 said he was not exactly sure how the right forearm wound happened, but believed he bumped it on the side table. He said a nurse saw it yesterday (6/8/26) and put the dressing on it. Resident #8 said he remembered the nurse putting the elastic bandage on his left forearm, but was unsure the reason it was there.On 6/10/26 at 2:00 p.m. Resident #8 lying in bed with the same dressing on his right lower forearm, dated 6/8/26. The elastic wrap remained on his left arm, undated.Resident #8 said his right arm had not been addressed since the dressing was placed on 6/8/26 and the left arm dressing had not been done in a few days. C. Record reviewA progress note, dated 6/4/26 at 5:56 p.m., revealed wound rounds were completed that day. Resident #8 was seen by the wound care team and the note revealed the following orders were recommended: provide treatment to the left abrasion with abdominal pad (medical dressing), Kerlix (wound dressing), and elastic wrap daily and as needed (PRN).-However, review of the June 2026 CPO did not reveal the order from the wound rounds completed on 6/4/26 were entered into the resident's electronic medical record (EMR). A progress note with an effective date of 6/8/26 at 6:11 p.m. was created on 6/10/26 at 2:14 p.m., (during the survey) revealed Resident #8 had a skin tear to the right forearm. The wound was cleansed with wound cleanser and medihoney (sterilized honey used in wound care) was applied.-However, review of the EMR on 6/8/26 revealed there was no physician's order for wound cleanser or medihoney for the right forearm.A progress note, dated 6/10/26 at 12:55 p.m., revealed the interdisciplinary team (IDT) discussed the new skin tear to the right distal forearm. Resident #8 was evaluated by the wound care team and placed on wound care rounds.A progress note, dated 6/10/26 at 2:53 p.m., revealed the new order for the left arm included abdominal pad, Kerlix and elastic bandage. -However, the orders were recommended by the wound care physician on 6/4/26, six days prior.A progress note, dated 6/10/26 at 3:19 p.m., revealed the wound to the left arm was treated per the current wound care physician's orders. A progress note dated 6/10/26 at 3:28 p.m. revealed the skin tear to Resident #8's right arm was cleaned with wound cleanser, medihoney and a bandage was applied. The treatment administration record (TAR) was updated to reflect the treatment orders.-However, the facility failed to timely enter and obtain the physician's orders for the treatment of the wound care for three days after the skin tear occurred. A progress note, dated 6/10/26 at 4:57 p.m., revealed the skin issue on Resident #8's right lateral wrist had not been evaluated. There was partial flap loss. The wound was acquired in-house on 6/8/26. The skin tear on the left elbow with partial flap loss. The wound was acquired in-house on 6/4/26.Review of the June 2026 CPO revealed the following physician's orders:Left arm abrasion was to be clean with wound cleanser, pat dry and apply skin prep every day for left upper extremity edema, dated 5/23/26, discontinued date 6/10/26.Clean the left arm abrasion with wound cleanser, pat dry, apply abdominal pad, Kerlix, and and an elastic bandage every day, dated 6/11/26-The facility failed to update the physician's orders in the resident's EMR for seven days after the wound care physician recommended a change.Cleanse skin tear to right arm with wound cleanser, apply medihoney and cover with a bandage every day, dated 6/11/26.-The facility failed to obtain wound care orders for the right arm wound for four days after the skin tear was identified.-Review of Resident #8's comprehensive care plan did not reveal interventions related to the resident's skin issues. D. Staff interviewsLicensed practical nurse (LPN) #2 was interviewed on 6/10/26 at 1:30 p.m. She said she saw the skin tear on Resident #8's right arm on 6/8/26 and put a dressing on the wound at that time. She said when a skin tear was identified, the nurse should complete a change of condition notification, notify the physician for further orders, and notify the wound team for an assessment of the skin tear. LPN #2 said there was a change of condition in Resident's #8 record and thought it was for the skin tear she discovered on 6/8/26, however the change of condition was for another issue. LPN #2 said the left arm was wrapped in the elastic wrap because he had edema in the left arm and fluid was seeping out. She said there was not a wound and the wrap did not need to be changed daily. -However, Resident #8 had a wound on his arm and the orders were changed to reflect the new wound care orders (see record review above).Registered nurse (RN) #3 was interviewed at 2:15 p.m. He said he was not aware of the elastic wrap on Resident #8's arm or the skin tear on Resident #8's right arm. RN #3 said he had observed Resident #8's arms prior to the interview. He said the bandage underneath the elastic bandage was not dated or initialed. RN #3 and LPN #2 were interviewed together at 2:30 p.m. RN #3 said according to the Resident #8's physician's order Resident #8 should not have an elastic wrap and the wound should not be covered. He said he read through the orders and said the treatment on Resident #8's arm was not correct. LPN #2 said she saw an email from the wound care physician with new recommendations for the left arm after on 6/4/26. She said the order was not entered into the EMR.-However, LPN #2 said earlier the left arm did not have a wound and the elastic wrap was placed for Resident #8's edema. See interview above.RN #3 said when there was a new skin issue the identifying nurse should contact the physician for orders, complete a change of condition assessment and notify the wound care team in order. RN #3 said the wound care team assessed new skin issues immediately and relied on the physician's orders to proceed with treatment. RN #3 said the wound care team then recommended if a resident would need to be followed by the wound care physician. RN #3 said the wound care physician rounded on Thursdays with RN # 1 (another wound care nurse). RN #3 said the wound care physician made recommendations and sent the recommendations to the facility. RN #3 said RN #1 entered the wound care physician's orders into the resident's CPO for the nurses to follow. RN #3 said the physician's orders for Resident #8's left arm were missed on 6/4/26 and not entered 6/10/26. The director of nursing (DON) was interviewed on 6/10/26 at 5:40 p.m. The DON said if a new skin tear was identified she expected the nurse to make a note in the risk management that would alert staff members to a change in a resident's condition. The DON said the physician and responsible party should be notified. The DON said the physician would give orders for the nurses to follow until the wound care team can assess. The DON said the bandages should be dated and initialed by the staff providing the care.

Based on observations, record review, and interviews, the facility failed to ensure proper treatment and assistive devices to maintain hearing abilities for one (#7) of two residents reviewed for ancillary services of 55 sample residents. Specifically, the facility failed to ensure Resident #7 received follow-up from the audiologist.Findings include:I. Resident #7A. Resident statusResident #7, age less than 65, was admitted [DATE]. According to the June 2026 computerized physician orders (CPO), diagnoses included major depressive disorder, hemiplegia (weakness) and hemiparesis (paralysis) following cerebral infarction (stroke), type 2 diabetes mellitus, epilepsy, generalized anxiety disorder and chronic pain syndrome.The 4/8/26 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score of 15 out of 15. She was dependent on staff for toileting, showering, dressing and transferring between surfaces. The 4/8/26 MDS assessment also revealed the resident used hearing aids.B. Resident interview and observationsResident #7 was interviewed on 6/8/26 at 2:29 p.m. Resident #7 said her hearing aids stopped working about two to four weeks ago, but the audiologist had not been there to see her.Resident #7 was interviewed again on 6/9/26 at 10:59 a.m. Resident #7 said she was able to put her hearing aids in her ears independently and the battery functions properly, but they did not connect or work the way they should.On 6/10/26 at 10:30 a.m. Resident #7 said her hearing aids were still not functioning properly.C. Record reviewReview of Resident #7's June 2026 CPO revealed the following physician's order:May have Dental, Podiatry, Ophthalmology, Audiology Consults, ordered 12/17/24.Review of Resident #7's progress notes revealed the following documentation:On 2/16/26 at 6:57 p.m. a healthcare practitioner's note documented Resident #7 stated she just received hearing aids on 2/11/26 and she was not happy with them. The note documented the resident had bilateral hearing loss.On 6/10/26 at 4:01 p.m. (during the survey) social services assistant #1 documented this writer sent an email to the audiologist in regard to the resident's hearing aids not working properly. The social services team and the NHA were notified.On 6/11/26 at 6:18 p.m. (during the survey) a social services note documented the audiologist would see the resident on 6/15/26. The resident has been notified. The resident would have a hearing aid check for repair.The 4/10/26 audiology note documented the resident was fit to 80 percent (%) of prescriptive gain based on their hearing loss; the resident was instructed on the proper insertion and removal of hearing aids; a charging case was placed in the resident's room; and, connected aids through the myPhonak app and in bluetooth for media streaming. The resident was able to stream a phone call and media through both hearing aids. Follow up in one month for necessary adjustments. -However, Resident #7 did not receive follow up for approximately two months after the concern was identified. -Review of Resident #7's comprehensive care plan, initiated 10/10/19, did not reveal a person centered care plan for the resident's bilateral hearing loss or hearing aids.III. Staff interviewsCertified nurse aide (CNA) #1, CNA #3 and CNA #5 were interviewed together on 6/10/26 at 12:10 p.m. All three CNA staff members said if there was a change in ancillary devices, such as new hearing aids, they would become aware because the nurse would let them know and it was documented in the care plan. The CNAs said they reported any problems with hearing aids to the nurse and an appointment was made for them to be seen. All three CNA staff members said they were unaware that Resident #7 used hearing aids.Registered nurse (RN) #1 was interviewed on 6/10/26 at 2:48 p.m. RN #1 said a change in ancillary services, such as new hearing aids, would be reported to social services and documented in the progress notes. He said the audiologist came to the facility once per month - someone in social services was responsible for setting up the residents' appointments. RN #1 said he thought Resident #7 used to use hearing aids, but he did not want to give misinformation.The social services director (SSD) was interviewed on 6/10/26 at 3:05 p.m. The SSD said Resident #7 had always used hearing aids, and she was able to put them in her ears and remove them independently. She said Resident #7 let her know her hearing aids were not working very well, and she said she would get with social services assistant #1 on this. The SSD said audiology was currently going to the facility monthly but was not coming in June 2026. She said the potential negative impact of the resident's hearing aids functioning improperly was the inability to understand, communicate and feeling uncomfortable.Social services assistant #1 was interviewed on 6/10/26 at 3:31 p.m. Social services assistant #1 said she knew that Resident #7's hearing aids were not functioning properly, and she became aware when the resident notified her last month. She said the audiologist was at the facility in May but Resident #7 was not on the list to be seen. Social services assistant #1 said she was responsible for scheduling and coordinating ancillary services and audiology should have had her on the list to be seen in May 2026. She said the audiologist was scheduled to return to the facility in July, but she would see if any audiologists could come to see Resident #7 this month.The SSD was interviewed again on 6/11/26 at 11:39 a.m. The SSD said the audiologist was coming to the facility tomorrow for Resident #7's hearing aids.The director of nursing (DON) was interviewed on 6/11/26 at 3:35 p.m. The DON said the SSD and social services assistant #1 communicated with the ancillary staff to schedule appointments. She said she never knew Resident #7 to complain about her hearing. The DON said properly functioning hearing aids were important not only for the understanding, but so the resident can be involved in conversation, hear correctly and have the confidence that she understood what was being communicated.

Based on observations, record review and interviews, the facility failed to ensure an environment free from risk of accidents and hazards for two (#55 and #93) of seven residents reviewed for accident hazards out of 55 sample residents.Specifically, the facility failed to:-Ensure Resident #55 was not vaping in the dining room near other residents wearing oxygen; and, -Implement a smoking care plan to ensure safe smoking habits for Resident #93. Finding include: I. Facility policy and procedure The Smoking policy, revised October 2023, was provided by the nursing home administrator (NHA) on 6/11/26 at 3:38 p.m. It read in pertinent part: Smoking is only permitted in designated resident smoking areas, which are located outside of the building. Smoking is not allowed inside the facility under any circumstances. Electronic cigarettes and smokeless tobacco are permitted in designated areas only. The staff consults with the attending physician and director of nursing services to determine if safety restrictions need to be placed on a resident's smoking privileges based on the Safe Smoking Evaluation. A resident's ability to smoke safely is re-evaluated quarterly, upon significant change (physical or cognitive) and as determined by the staff. Any smoking-related privilege, restrictions, and concerns are noted on the care plan, and all personnel caring for the resident shall be alerted to these issues. II. Resident #55 A. Resident status Resident #55, age less than 65, was admitted on [DATE]. According to the June 2026 computerized physician orders (CPO), diagnoses included Wernicke's encephalopathy (acute life-threatening neurological disorder caused by severe deficiency of thiamine), major depressive disorder, emphysema, and nicotine dependence. The 3/26/26 minimum data set (MDS) assessment revealed Resident #55 had moderate cognitive impairment with a brief interview for mental status (BIMS) score of nine out of 15. The assessment revealed Resident #55 was independent with most of his activities of daily living (ADL). The assessment indicated he used tobacco. B. Observations On 6/9/26 at 12:40 p.m. Resident #55 was sitting at a table in the dining room. He was sitting at a table with three unidentified residents. The resident on his right was using oxygen via nasal cannula. Resident #55 took a puff off of his e-cigarette. On 6/9/26 at 12:46 p.m. Resident #55 remained at the table with the three other unidentified residents and took another puff off of his C. Record review The smoking care plan, initiated 3/31/25, documented Resident #55 was a safe smoker and was educated on the facility's smoking policy. The care plan documented Resident #55 was able to light his own cigarette, discard ashes appropriately and was able to keep lighter and smoking materials at his bedside. The care plan documented he was able to smoke unsupervised -The care plan did not address the resident's e-cigarette use until 6/9/26 (during the survey). On 6/9/26 (during the survey) Resident #55's care plan was updated to include that he was seen using e-cigarettes in the dining room. The care plan documented education was provided to the resident about the dangers and consequences involved with vaping inside the building. Resident #55 was put on a behavioral achievement plan directed towards routine safety and compliance with the smoking policy. He was put on supervised smoking and would be re-evaluated for unsupervised smoking at the end of two weeks. Review of Resident #55's electronic medical record (EMR) revealed a Smokers Code of Conduct signed by the resident on 5/14/26. Review of Resident #55's EMR revealed a Smokers Code of Conduct signed by the resident on 6/9/26 (during the survey process). D. Staff interviews The NHA was interviewed on 6/9/26 at 12:50 p.m. He said Resident #55 admitted to vaping at the dining room table. He said when he first started in May 2026, he had the social services department review all the residents that smoked and go over the code of conduct with all of them. He said Resident #55 was recently educated on the smoking code of conduct (see above record review). The dietary manager (DM) was interviewed on 6/9/26 at 12:59 p.m. He said he had never seen residents smoking in the dining room before. He said if he was to see it, he would report it immediately to the director of nursing (DON) or the NHA. He said smoking inside was an issue, because there could be people who were allergic to smoke or people could have a hard time breathing. He said it was also a concern because some residents were on oxygen. Dietary aide #1 was interviewed on 6/9/26 at 1:01 p.m. She said she had not seen residents smoking in the dining room before. She said if she were to see it she would report it to her supervisor. She said smoking in the dining room could cause issues for other residents who should be around smoke and for people on oxygen. The assistant director of nursing (ADON) was interviewed on 6/9/26 at 1:33 p.m. He said cigarette smoking inside was not allowed. He said that e-cigarettes and regular cigarettes were treated the same way. He said if a resident was caught smoking inside they were immediately educated, and they would be put on supervised smoking. He said people who were on oxygen should not be smoking with their oxygen on or be around people who are smoking. He said oxygen was an accelerant. He said he had not seen any residents smoking inside, but he had caught residents right after they were smoking inside. He said he had never heard of Resident #55 smoking inside. He said that if a certified nurse aide (CNA) or nurse caught a resident smoking inside they would report it to him, the DON, or the NHA. The DON was interviewed on 6/9/26 at 2:36 p.m. She said Resident #55 had never smoked inside before. She said he had always smoked cigarettes and he had always been really good about going outside and smoking. She said this was the first time she had heard of him having an e-cigarette. III. Resident #93 A. Resident status Resident #93, age less than 65, was admitted on [DATE]. According to the June 2026 CPO, medical diagnoses included hemiplegia (paralysis) and hemiparesis (weakness) following cerebral infarction (stroke) affecting the left non-dominant side, dysphagia (difficulty swallowing) and vascular dementia (a decline in thinking and memory skills caused by restricted or blocked blood flow to the brain). The 5/14/26 MDS assessment revealed the resident was moderately cognitively intact with a BIMS score of 12 out of 15. She required substantial/maximal assistance with activities of daily living (ADL) including showering, dressing, toileting and transferring between surfaces. B. Resident interview Resident #93 was interviewed on 6/8/26 at 9:35 a.m. Resident #93 said she smoked sometimes, but she knew she should not do that. C. Record review Review of the facility's smoking list, dated 5/28/26, revealed Resident #93 had been identified as a smoker. Review of Resident #93's progress notes revealed the following documentation: On 8/5/25 at 3:34 p.m. a health care practitioner's note documented Resident #93 reported smoking maijuana recently. On 8/22/25 at 4:27 p.m. a nursing progress note documented Resident #93 smoked marijuana periodically. On 12/17/25 at 3:32 p.m. a health care practitioner's note documented Resident #93 stated today she planned to start smoking marijuana again. On 3/17/26 at 10:24 a.m. a physician's progress note documented Resident #93 was reported smoking marijuana last week. The note documented the resident had a history of marijuana use including smoking and taking edibles. The note documented Resident #93 reported using while in the facility. -Review of Resident #93's electronic medical record (EMR) did not reveal a smoking evaluation was completed at the time of the survey. Review of Resident #93's smoking care plan, initiated 6/10/26, revealed the resident continued to enjoy smoking. Resident #93 smoked/vaped intermittently, was a safe smoker with staff setup, and had been educated regarding the facility's smoking policy. Pertinent interventions included instructing the resident about smoking risks and hazards, and about smoking cessation aids that were available; instructing the resident about the facility's policy on smoking: locations, times and safety concerns; Resident #93 could smoke/vape unsupervised after staff setup; Resident #93 was able to: discard ashes appropriately and discard cigarette butts; Resident #93's smoking supplies were stored in the nurse's medication cart as she desired to have them. Resident #93 required staff setup for lighter use related to decreased dexterity (the ability to perform physical actions with the hands) with her diagnosis of hemiplegia; notifying the charge nurse immediately if it was suspected the resident had violated the facility's smoking policy; and, observing clothing and skin for signs of cigarette burns. -However, the smoking care plan was not initiated and the resident was not identified as a supervised or unsupervised smoker until the survey. D. Staff interviews CNA #3 was interviewed on 6/10/26 at 2:00 p.m. CNA #3 said she knew if a resident could smoke supervised or unsupervised, because it would be documented on the 24-hour report. She said the 24-hour report was updated daily with any changes. CNA #3 said the residents' smoking status should be documented on the care plan, but she said she knew it was always on the 24-hour report. She said Resident #93 was an independent smoker, but she was not sure if that was documented on Resident #93's care plan. Registered nurse (RN) #1 was interviewed on 6/10/26 at 2:48 p.m. RN #1 said most of the residents at the facility were supervised smokers, but it depended on the resident. He said there was a list at every nurse's station that documented which resident was a supervised or independent smoker, and social services probably documented that information in the residents' care plan. RN #1 said social services evaluated who was safe to smoke independently and who was not. He said Resident #93 did not really smoke. RN #1 said he did not know if she was an independent smoker and he did not know where the list that documented who his supervised smoking residents was. He said he did not know if Resident #93 had a smoking care plan in place. The social services director (SSD) and social services assistant #2 were interviewed together on 6/10/26 at 3:05 p.m. Social services assistant #2 said the social services team was responsible for conducting smoking evaluations if the resident indicated that they smoked on admission to the facility. She said if a resident changed their mind and started smoking after admission, the nursing staff needed to alert social services that a smoking evaluation needed to be completed, or sometimes the nursing staff completed the assessment themselves. Social services assistant #2 said the smoking evaluation should be completed before the smoking care plan was initiated, and the nursing staff documented the smoking care plans. She said Resident #93 was an independent smoker, but she did not smoke all the time. Social services assistant #2 said she would have to check Resident #93's care plan to see if the smoking care plan or smoking evaluation was documented. The SSD and social services assistant #2 said it was important to ensure there was a smoking evaluation and smoking care plan in place to ensure resident safety, and in order for the staff to know if the resident was safe to smoke. The DON and regional clinical resource #1 were interviewed together on 6/11/26 at 3:35 p.m. The DON said the SSD performed smoking evaluations on admission, and it was documented in the EMR and in the quarterly MDS evaluations. The DON said she was responsible for completing the smoking evaluations as part of the quarterly evaluations. She said the resident's smoking status should be documented in the care plan. The DON said Resident #93 needed help lighting a cigarette but was able to smoke independently when she did rarely smoke. She said she would have to look in Resident #93's care plan to see if a smoking care plan was documented. The DON said the resident should have a smoking care plan even if the resident smoked intermittently. Regional clinical resource #1 said the smoking care plan was updated on 6/10/26, during the survey.

Based on observations, record review and interviews, the facility failed to ensure two (#53, and #70) of four residents who required respiratory care received care consistent with professional standards of practice out of 55 total sample residents. Specifically, the facility failed to:-Ensure Resident #53 and Resident #70's oxygen flow rate was set per physician`s order; and,-Ensure Resident #70's oxygen concentrator was functioning. Findings include:I. Resident #53 A. Resident statusResident #53, age greater than 65, was admitted on [DATE]. According to the June 2026 computerized physician orders (CPO), diagnoses included chronic respiratory failure with hypoxia, chronic obstructive pulmonary disease (COPD), and dependence on supplemental oxygen (02).The 5/20/26 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score of 13 out of 15. The resident was independent with all her activities of daily living (ADL). The MDS assessment indicated Resident #53 was receiving oxygen therapy.B. ObservationsResident #53 was interviewed on 6/8/26 at 1:20 p.m. Resident #53 was lying on her bed and she was wearing a nasal cannula. There was an oxygen concentrator next to her bed. She was receiving 2.5 liters per minute (LPM) via a nasal cannula.Resident #53 said she received 3 LPM oxygen therapy via a nasal cannula. She said she only had to use oxygen when she was in bed and the oxygen therapy was not continuous. She said she had a hard time breathing when she was laying down. She said her oxygen flow on the oxygen concentrator was set to 2.5 LPM. She said her oxygen concentrator should be set to 3 LPM. At 4:39 p.m. Resident #53 was sleeping in her bed. She was wearing the oxygen and it was set to 2.5 LPM.-However, Resident #53`s physician's order indicated the oxygen flow rate was supposed to be 3 LPM (see record review below).C. Record reviewReview of the June 2026 CPO revealed the following physician's orders:-Oxygen therapy at 3 LPM per nasal cannula when in bed, ordered on 4/1/26.-However, observations revealed Resident #53's oxygen was not administered per physician orders (see observations above). The oxygen care plan, revised 5/25/26, revealed the resident had oxygen therapy. The care plan revealed she had the potential for altered respiratory pattern due to inability to maintain an effective airway clearance, related to diagnoses of COPD, emphysema, chronic hypoxic respiratory failure. Pertinent interventions included administering oxygen as ordered. Review of the June 2026 medication administration record (MAR) revealed nursing staff were documenting and signing off that Resident #53 was receiving oxygen at 3 LPM. -However, observations revealed Resident #53's oxygen concentrator was set to 2.5 LPM (see observations above). E. Staff interviewsCertified nurse aide (CNA) #7 was interviewed on 6/8/26 at 1:28 p.m. CNA #7 said Resident #53 received 3 LPM oxygen through a nasal cannula. He said Resident #53 only used oxygen when she was lying in her bed. Licensed practical nurse (LPN) #6 was interviewed on 6/10/26 at 10:10 a.m. She said Resident #53 was receiving 3 LPM oxygen via nasal cannula when she was lying down. She said the concentrator were programmed and they would go back to their programmed setting if it was turned off then back on. She said nurses should check the concentrator setting daily to ensure the ordered O2 therapy was followed. She said Resident #53`s oxygen flow should be set to 3 LPM.The director of nursing (DON) was interviewed on 6/11/26 at 11:34 a.m. The DON said Resident #53 would reset her oxygen concentrator especially after her smoke break. She said Resident #53`s tendency to adjust her own O2 concentrator flow was not mentioned in the care plan, but the facility would correct that. II. Resident #70A. Resident statusResident #70, age less than 65, was admitted on [DATE] and readmitted on [DATE]. According to the June 2026 CPO, diagnoses included chronic respiratory failure, chronic diastolic heart failure, unspecified asthma, obstructive sleep apnea, and dependence on supplemental oxygen The 5/21/26 MDS assessment revealed the resident was cognitively intact for a BIMS score of 15 out of 15. The resident needed assistance with toileting, dressing, bathing, transfers, and mobility. The MDS assessment indicated Resident #70 was receiving oxygen therapy.B. ObservationsOn 6/8/26 at 11:58 a.m. Resident #70`s the oxygen flow meter on the concentrator was moving between 6.5 to 8 LPM.At 2:57 p.m. Resident #70`s the oxygen flow meter on the concentrator was fluctuating between 6 to 8 LPM.On 6/9/26 8:30 a.m Resident #70`s the oxygen flow meter on the concentrator was fluctuating between 6 to 7.5 LPM.At 10:17 a.m. Resident #70`s the oxygen flow meter on the concentrator was fluctuating between 6 to 7.5 LPM.At 3:28 p.m. Resident #70`s the oxygen flow meter was fluctuating between 6 to 7.5 LPM.On 6/10/26 at 3:47 p.m. Resident #70`s the oxygen flow meter was fluctuating between 6 to 7.5 LPM.On 6/11/26 at 10:21 a.m. Resident #70`s the oxygen flow meter was fluctuating between 6.5 to 7.5 LPM.C. Record reviewA review of Resident #70's June 2026 CPO revealed the following physician's orders:-Humidified oxygen at 6 LPM continuously per nasal cannula. Ordered on 1/3/26. Review of the oxygen care plan, revised 9/12/26, revealed the resident had the potential for an ineffective respiratory pattern due to need of oxygen therapy, secondary to diagnosis of chronic hypoxic respiratory failure, asthma, seasonal allergies, and obesity hypoventilation syndrome. Pertinent interventions were following the oxygen orders and observing oxygen precautions. Review of the June 2026 medication administration record (MAR) revealed nursing staff were documenting and signing off that Resident #70 was receiving oxygen at 6 LPM. -However, observations revealed Resident #'s 70 oxygen concentration was not administered on a steady 6 LPM flow (see observations above). D. Resident interviewResident #70 was interviewed on 6/9/26 at 3:26 p.m. She said staff have never mentioned that her respirator was broken and that the flow meter ball was fluctuating. She said staff did not checking the flow setting on the concentrator since it was in the bathroom and they always forgot. She said that the oxygen supply company maintained the concentrator once a week. E. Staff interviewsCNA#3 was interviewed on 6/10/26 at 9:11 a.m. CNA #3 said she attempted to read the flow setting. She said she could not tell the flow rate as the flow meter was going up and down. She said the flow meter showed 6.5 LPM. She said the flow meter showed 7.6 LPM a second later. LPN #6 was interviewed on 6/10/26 at 10:10 a.m. She said Resident #70 was receiving 6 LPM. She said it was the nurses responsibility to check the oxygen concentrator to ensure the concentrator was set correctly. LPN #3 was interviewed on 6/10/26 at 11:00 a.m. LPN #3 said staff did not check the oxygen concentrator machine setting daily. The oxygen concentrator when the resident reported they were not getting enough O2. He said every machine should be set to the correct setting and there was no need to adjust the flow daily. The oxygen supply company representative was interviewed on 6/10/26 at 10:50 a.m. He said his title was respiratory practitioner. He said the facility was serviced once a week. He said they replaced oxygen tubing weekly and wiped down the machine. He said he was unsure when the last service day was. He said there was no outstanding order for a faulty oxygen concentrator machine. He said the flow meter should be steady otherwise it would not give the correct oxygen service to the resident. He said a faulty machine should be removed from the floor. The DON was interviewed on 6/10/26 at 10:58 a.m. She said the most recent visit form the oxygen company was on 6/7/26. The DON was interviewed on 6/11/26 at 11:34 a.m. She said if staff noticed malfunctioning equipment the nurse should replace the machine and notify the assistant director of nurses (ADON) or DON. She said an oxygen concentrator should produce steady oxygen flow and should not fluctuate.

Based on observations, record review and interviews, the facility failed to manage pain in a manner consistent with professional standards of practice, resident-centered care plans and resident's goals preferences for one (#2) of two residents reviewed for pain out of 55 sample residentsSpecifically, the facility failed to:-Complete a thorough assessment of the residents pain, including the site and pain goals; and,-Include person-centered non pharmacological pain interventions on the resident's care plan.Findings include: I. Facility policy and procedure:The Pain-clinical protocol policy, revised in April 2025, was received from the nursing home administrator (NHA) on 6/11/26 at 4:22 p.m. It read in pertinent part, The provider and staff will identify individuals who have pain or who are at risk for having pain. This includes reviewing known diagnoses and conditions that commonly cause pain. It also includes a review for any treatments the residents currently are receiving for pain, including complementary and non-pharmacologic treatments. The staff will reassess the individual`s pain and related consequences at regular intervals, at least each shift for acute pain or significant changes in level of chronic pain, and at least weekly in stable chronic pain. The staff will evaluate and report on the resident's use of standing and PRN (as needed) analgesics. If there are more than occasional analgesic requests, the provider will consider changing to regular administration of at least one analgesic with another medication for PRN use, increasing the standing dose of an existing analgesic, and/or adding nonpharmacological measures.II. Resident #2A. Resident status Resident #2, age less than 65, was admitted on [DATE] and readmitted on [DATE]. According to the June 2026 computerized physician orders (CPO), diagnoses included hemiplegia and hemiparesis following other nontraumatic intracranial hemorrhage affecting left non-dominant side, malignant neoplasm of upper-outer quadrant of the right female breast (a cancerous tumor), malignant neoplasm of nipple and areola right female breast (a cancerous tumor), malignant neoplasm of unspecified site of the left female breast (a cancerous tumor), secondary malignant neoplasm of brain (a cancerous tumor).The 4/8/26 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score of 15 out of 15. The MDS documented the resident required extensive assistance with bathing, dressing, toileting, hygiene, and transferring. She needed set-up assistance with eating and moderate assistance with oral hygiene. The MDS documented the resident was receiving pain medications regimen and received scheduled and as needed (PRN) pain medication.B. Resident observation On 6/8/26 at 10:56 a.m. Resident #2 was lying in her bed. She was drifting in and out of sleep. Resident #2`s had her right hand over her breast and the fingers were curled. She appeared to be in pain and said she did not want to speak because she was in pain. C. Resident and representative interviewResident #2`s significant other was interviewed on 6/8/26 at 10:56 a.m. He said he visited Resident #2 daily. He said Resident #2 experienced pain daily. He said Resident #2 frequently complained of pain. He said her pain was located in her right breast, knees, and throughout her body. He said Resident #2 received acetaminophen twice daily and oxycodone on an as needed basis. He said her pain medications were often administered late. He said on several occasions Resident #2 waited 40 minutes after requesting oxycodone. He said acetaminophen provided some relief for a while when administered on time. Resident #2 was interviewed on 6/9/26 at 3:10 p.m. Resident #2 said she experienced daily pain since admission because of her cancer. She reported staff assessed her pain level daily. She said her pain level was mostly above six out of ten. She said her acceptable pain level was six but that was not acceptable anymore. She said she reported her pain level was greater than 6 out of 10 on most days to the staff. She said the oxycodone had not been scheduled. She said she was not aware that she could have requested it to be scheduled. She said the facility did not offer any adjustments to her pain medication regiment prior to that day recently. Resident #2 was interviewed again on 6/11/26 at 9:47 a.m. Resident #2 said the oxycodone had been scheduled two days ago. She said the facility should have scheduled it much earlier. She said her pain has not been managed and that her pain had always been too high since the admission. She said the as needed Oxycodone was not effective earlier to manage her pain. She said she reported pain to the certified nurse aides (CNA) and all the nurses all the time. Resident #2 was interviewed on 6/11/26 at 5:14 p.m. Resident #2 said she spent most of her time in bed or attending medical appointments. She said she did not recall discussing a pain management plan with facility staff. She said the facility did not explain why the oxycodone was not routinely scheduled. She said the facility did not inform her that she was awaiting approval from the primary care physician for scheduled oxycodone prior 6/8/26. She said she was willing to tolerate some pain but the pain had been excessive since the admission. C. Record reviewThe 3/24/26 readmission data collection tool revealed the resident had chronic pain and was currently verbalizing pain. The resident had intermittent pain.The assessment documented pharmacological and non pharmacological interventions were used. The assessment documented the resident's pain interfered with her activities of daily living. -The assessment failed to specify other locations of pain other than back pain. The assessment failed to document person-centered what non-pharmalogical pain interventions. The assessment did not include when the pain started and how long the pain lasted. The pain assessment failed to show the resident's pain goal. The 4/7/26 pain evaluation documented the resident had frequent pain in the past five days. The pain occasionally had affected her sleep and frequently affected her day to day activities because of the pain. The assessment failed to include the resident's pain goal.The pain care plan, initiated on 1/20/26, revealed Resident #2 expressed pain. She was at risk for alteration in comfort related to pain secondary to diagnosis of breast cancer, and left hemiparesis status post cerebrovascular accident. The care plan interventions included monitoring/recording reporting her pain, evaluating the effectiveness of her pain medication, completing an evaluation of the effectiveness of her pain regimen to include assessing the need and response to PRN pain medication, reporting to the medical provider if pain medications were not meeting needs, notifying the physician promptly for re-evaluation of my pain regimen if it has been determined that my analgesic is ineffective or pain rating has increased or stayed the same and provide non-pharmacological interventions should be used. -However, the care plan failed to include non-pharmacutical approaches. D. Staff interviewsLicenced practical nurse (LPN) #3 was interviewed on 6/9/26 at 2:14 p.m. LPN #3 said Resident #2 received Tylenol 325 mg twice daily and oxycodone on an as needed basis. He said opioids were typically ordered on as-needed basis at the beginning to evaluate effectiveness and monitor for potential medication-seeking behaviors. He said Resident #2 consistently reported pain levels above her acceptable pain level. He said Resident #2 should be on scheduled oxycodone. He said due to Resident #2`s cancer diagnosis, she was expected to be in more pain than the average resident. He said Resident #2 had been requesting oxycodone regularly every six hours. LPN #6 was interviewed on 6/10/26 at 2:50 p.m. LPN #6 said she assessed for pain levels before administering PRN pain medication. She said Resident #2 was too shy to ask for oxycodone on her own. She said staff always had to ask her if she wanted to take her pain medication. She said if she saw that a resident`s pain level was above their acceptable level of pain prior to taking pain meds, she would inform the physician. CNA #1 was interviewed on 6/11/26 at 11:01 a.m. CNA #1 said Resident #2 complained about her pain in her right breast daily. She said Resident #2 often requested her to notify the nurse that she needed pain medication. She said non-pharmateutical interventions were to wash Resident #2`s face with a washcloth; to place the washcloth on her tumor or to offer a drink. She said Resident #2 only asked for Oxycodone once or twice during her shift. She said Resident#2`s body language did not show pain but Resident #2 was not too shy to let her know if she was in pain and needed medication. LPN #7 was interviewed on 6/11/26 at 10:27 a.m. LPN #7 said Resident #2 was receiving cancer treatment and experienced a lot of pain. She said Resident #2 did not complain much about her pain. She said Resident #2 asked for her as needed oxycodone when her pain was too high. She said it was a good indicator to have an as needed pain medication scheduled if a resident asked for pain medication day after day. She said Resident #2 was not shy to ask for her oxycodone when her pain was unbearable. She said Resident #2`s pain assessment level had been consistent for a long period of time. She said that was probably the reason the oxycodone was scheduled recently. The director of nursing (DON) was interviewed on 6/11/26 at 11:40 a.m. The DON said Resident #2 was alert and oriented and capable of requesting her medication when needed. She said the nursing staff assessed the resident`s pain level daily. She said residents could choose whether to take PRN medication. The DON said the process for transitioning a medication from as needed to scheduled use varied based on the resident`s circumstances. She said the physician determined when a PRN medication should be transitioned to a scheduled medication. She said the physician would discuss the change with the resident before making that decision. The DON said Resident #2 recently began cancer treatment and may have been in the evaluation waiting period for oxycodone.

Based on observations, record review and interviews, the facility failed to ensure one (#7) of two residents reviewed for ancillary services out of 55 sample residents received dental services timely. Specifically, the facility failed to ensure Resident #7 was provided with assistance to obtain replacement dentures.Findings include:I. Facility policy and procedureThe Availability of Dental Services policy, revised August 2007, was provided by the nursing home administrator (NHA) on 6/11/26 at 4:22 p.m. It read in pertinent part, Oral healthcare and dental services will be provided to each resident. Dental services are available to all residents requiring routine and emergency dental care. Social services will be responsible for making necessary dental appointments. All requests for routine and emergency dental services should be directed to social services to assure that appointments can be made in a timely manner. Residents with lost or damaged dentures will be promptly referred to a dentist.II. Resident #7A. Resident statusResident #7, age less than 65, was admitted [DATE]. According to the June 2026 computerized physician orders (CPO), diagnoses included major depressive disorder, hemiplegia (weakness) and hemiparesis (paralysis) following cerebral infarction (stroke), type 2 diabetes mellitus, epilepsy, generalized anxiety disorder and chronic pain syndrome.The 4/8/26 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score of 15 out of 15. She was dependent on staff for toileting, showering, dressing and transferring between surfaces. She required substantial/maximal assistance with personal and oral hygiene, including inserting and removing dentures into and from the mouth, and managing denture soaking and rinsing of the equipment.B. Resident interviews and observationsResident #7 was interviewed on 6/8/26 at 2:29 p.m. Resident #7 said she was told by the dentist she was eligible for a free, one time replacement of her dentures. She said she had not been seen for a while and she did not know the status of the replacement dentures. Resident #7 said she wanted to wear dentures, and they would be especially helpful when she ate tough meat served by the facility.On 6/9/26 at 10:59 a.m. Resident #7 was not wearing dentures. On 6/10/26 at 10:30 a.m. Resident #7 was not wearing dentures.Resident #7 was interviewed again on 6/10/26 at 4:23 p.m. Resident #7 said she received a letter from Medicaid, dated 2/3/26, which approved the replacement of a complete set of dentures. She said this afternoon was the first she had heard about the replacement dentures going through an appeal process.C. Record reviewReview of Resident #7's June 2026 CPO revealed the following physician's order:May have Dental, Podiatry, Ophthalmology, Audiology Consults, ordered 12/17/24.Review of the 6/30/25 dental visit notes revealed Resident #7 lost her upper and lower dentures that were made on 12/1/21.Review of the 1/28/26 dental visit notes revealed Resident #7 was seen on 1/28/26. Resident #7 lost her upper and lower dentures that were made on 12/1/21. Periapical xrays (an xray that captures the entire length of one or two teeth, from the chewing surface to the root tip and the surrounding jawbone) taken for Once in a Lifetime program replacement.Review of Resident #7's progress notes revealed the following documentation:On 2/5/26 at 4:54 p.m. a social services note documented the resident saw the dentist on 1/28/26. The dentist was trying to get another set of dentures made for the resident.On 4/15/26 at 10:40 a.m. a communication with the resident note documented the registered dietitian (RD) review for weight management - spoke with the resident about her goals. The resident mentioned she was supposed to get dentures.-However, the RD did not notify social services that Resident #7 was wondering about the status of her replacement dentures.On 6/10/26 at 5:15 p.m. (during the survey) a social services note documented the resident shared that she had not had a follow up regarding dentures that the facility's dentist was making under the Once in a Lifetime program. This writer asked for more information for follow up. The resident stated, It was not something I really wanted and there was not much I needed dentures for, but once the dentist was in the building and told me about the program and how he could make better dentures now than he did back then, I got excited. I have a letter that I was approved. The resident shared when the dentist came to see her at that time to see how her dentures were fitting and found they were lost - that was when he informed the resident of the Once in a Lifetime Program (according to records, xrays were taken on 1/28/26 to send for once in a life replacement).On 6/10/26 at 6:20 p.m. (during the survey) a social services note documented this writer went to follow up on the progress with the facility's dentist. The dentist had stated that he went through a couple of appeals and dentures were not made because Medicaid would not pay for them. This writer thought he was speaking of Resident #7, but the dentist corrected himself and stated that he had appealed for other residents but did not proceed with Resident #7 because he had a history of not getting paid by Medicaid after approval and dentures were made. This writer told the dentist that our facility will pay for dentures when a resident's insurance did not cover it. The dentist further stated he did not think it would be an issue as the resident was able to eat fine and did not express a need or want for dentures since losing the last set he made. This writer requested documentation of resident's dental visits and for an invoice to expedite payment to have these dentures made as the resident was showing interest in having them now. The dentist will send it this evening. The dentist said he can rush them and they can be done in about four weeks. This writer will continue to follow.On 6/11/26 at 12:05 p.m. the social services director (SSD) provided an email from the accounts payable manager which said she spoke to the facility's dentist to confirm the facility would send payment for Resident #7's replacement dentures. The email revealed the dentist said he would get started on the replacement dentures.-However, follow up about Resident #7's replacement dentures was not provided for six months.III. Staff interviewsCertified nurse aide (CNA) #1, CNA #3 and CNA #5 were interviewed together on 6/10/26 at 12:10 p.m. CNA #1 said when a new resident was admitted to the facility, the CNAs documented the residents' belongings including glasses, dentures, hearing aids and clothes on an inventory list. CNA #1, CNA #3 and CNA #5 said when dentures were misplaced or lost they reported it to the nurse and looked everywhere for them. All three CNA staff members said Resident #7 did not use dentures, and the potential negative impact of a resident being without their dentures was that they could not eat well.Registered nurse (RN) #1 was interviewed on 6/10/26 at 2:48 p.m. RN #1 said when a new resident was admitted to the facility, the nursing staff documented items that were brought with the resident on an intake form. He said when dentures were misplaced or lost, the staff reported it to social services for them to follow-up. RN #1 said he did not know for sure, but he did not think Resident #7 had dentures or should have had dentures. He said a resident would struggle to eat and possibly lose weight if they were without their dentures. The RD was interviewed on 6/10/26 at 2:55 p.m. The RD said when she performed interviews with the residents she would ask them if they used dentures, and if they did only sometimes she would document that information in a progress note. The RD said Resident #7 did not have dentures on 4/15/26 but the resident tolerated a regular texture diet. She said she reported Resident #7's concern about her replacement dentures. She said she usually messaged the dentist and social services. The RD said a resident would possibly lose weight and have decreased oral intake if they were without their dentures.-However, the RD did not provide documentation of the notification of Resident #7's replacement dentures until after survey exit (see facility follow-up below).The SSD was interviewed on 6/10/26 at 3:05 p.m. The SSD said if a resident used dentures, it should be documented in the residents' care plan. She said if dentures were misplaced or lost, it would get reported to social services and they would help the resident look for the dentures and set up an appointment with the dentist. The SSD said if Medicaid would not pay for the replacement, the facility would pay for it. She said Resident #7 used to have dentures and was on a program for a replacement. The SSD said she spoke to the dentist recently, and he was going through a third appeal process. She said she just spoke to Resident #7 and she was aware of the status of her replacement dentures as of today. The SSD said she reminded the dentist that if Medicaid would not pay for the replacement the facility was obligated to replace them.Social services assistant #1 was interviewed on 6/10/26 at 3:31 p.m. Social services assistant #1 said she managed the ancillary services. She said the dentist was just at the facility and she spoke with him - he said he was on the third appeal for the replacement dentures. SSA #1 said it was possible that Resident #7 only knew about the approval and not the appeals.The SSD was interviewed again on 6/10/26 at 6:40 p.m. The SSD said she clarified with the facility's dentist, and Resident #7 was not going through an appeal process. He said he was confused with other residents. She said Resident #7's dentures were denied by Medicaid even though they were originally approved. The SSD said she told the dentist that the facility can pay for dentures if Medicaid refused to pay, and there was no reason a resident should go without their dentures. She said the new dentures have been expedited and should arrive within four weeks. The SSD said there was a missed opportunity for staff to follow up on the status of Resident #7's replacement dentures, and the RD should have notified her about the dentures.The SSD was interviewed a third time on 6/11/26 at 11:39 a.m. The SSD said the dentist was coming to the facility on 6/15/26 to get impressions for a new set of dentures. She said the xrays for the new dentures were already taken.The director of nursing (DON) and regional clinical resource #1 were interviewed together on 6/11/26 at 3:35 p.m. The DON said if a new resident was admitted with dentures it would be documented on the admission evaluation form completed by nursing staff. She said the RD would verify if the resident used dentures on their initial assessment and it would be documented in a RD note so ancillary services were aware. The DON said staff would be aware of the resident's denture use because it was documented on the 24-hour report, which was updated every morning to reflect changes in the facility. She said if dentures were misplaced or lost, staff notified social services to get the resident on the ancillary services list and notified the dietitian to monitor for adverse reactions.The DON said Resident #7 did not currently have dentures. She said there should have been communication from the dietitian to the interdisciplinary team to notify social services to obtain replacement dentures.Regional clinical resource #1 said Resident #7 could have experienced psychosocial impact by not feeling heard about her desire for replacement dentures.IV. Faility follow-upRegional clinical resource #1 provided documentation of the RD requesting from the facility's dentist an estimate for new dentures for Resident #7 on 1/30/25 at 7:10 a.m. The SSD was carbon copied (cc'd) on the email.On 1/30/25 at 10:13 a.m. the facility's dentist responded via email and said it looked like Resident #7 had her dentures made in 2021, so unfortunately Medicaid would not cover them again until 2028. The total for a new set of dentures was going to be $2,903.00. The SSD was cc'd on the email.-However, the resident still had not received replacement dentures in June 2026.

Based on record review, observations and interviews, the facility failed to ensure one (#7) of six residents reviewed for quality of care out of seven sample residents, received treatment and care in accordance with professional standards of practice.IMMEDIATE JEOPARDYResident #7 was admitted on [DATE] with diagnoses of Parkinson's disease (a progressive disease that causes symptoms such as tremors, stiffness and slow movement), epilepsy without status epilepticus (seizure lasting longer than five minutes, or two or more seizures without the resident gaining consciousness in between them), chronic respiratory failure, dependence on supplemental oxygen and cognitive communication deficit.On 6/26/25, Resident #7 experienced seizure activity that lasted longer than 30 minutes. During the seizure activity, the resident was observed to be having seizures by several staff members. The nurse practitioner (NP) was notified three times, by three different staff members, during the resident's seizure activity, however the NP did not ask staff to obtain vital signs or conduct any assessment of the resident. The NP did not give staff a physician's order to send Resident #7 to the emergency department (ED) until the resident had been experiencing seizure activity for over 30 minutes.When emergency medical services (EMS) arrived at the facility, Resident #7's airway was compromised, and he required an artificial airway placement (a medical device inserted into the trachea (windpipe) to maintain or restore a patient's airway, especially when they cannot breathe effectively on their own). Resident #7 was admitted to the intensive care unit (ICU) and placed on a ventilator.On 6/26/25, Resident #7 experienced a situation of serious harm. The facility's failure to implement a plan to ensure staff were trained on how to monitor residents for seizure activity, how to identify seizure activity and respond timely and appropriately when a resident was experiencing seizures to ensure the incident did not reoccur created the potential for serious harm to Resident #7 and other residents with a seizure disorder if the situation was not immediately corrected. ADDITIONAL FAILURES FOR RESIDENT #7Further review of Resident #7's electronic medical record (EMR) revealed Resident #7 readmitted to the facility following his hospitalization for seizure activity on 7/7/25. On 7/9/25 a physician's order was given for midazolam (an anticonvulsant medication for breakthrough seizure activity), however, the facility failed to ensure the medication was obtained from the pharmacy until 7/15/25, six days after the medication was obtained.Additionally, the facility failed to ensure nursing staff were trained on how to appropriately administer the midazolam medication to Resident #7 in the event the resident experienced another seizure episode.Specifically, the facility failed to:-Provide timely assessment and intervention during a change of condition for Resident #7; and,-Obtain Resident #7's breakthrough seizure medication in a timely manner after a new physician's order was given on 7/9/25 and ensure staff were trained on how to administer the medication to the resident.Findings include:IMMEDIATE JEOPARDYI. Findings of Immediate Jeopardy On 6/26/25, at 1:33 p.m. a care conference was held with the resident's representative. The resident's representative reported to the clinical team that she was concerned whether or not the resident's seizure medications were effective for Resident #7, as he had had several seizures in the last hour. After the care conference conference, around 1:49 p.m., registered nurse (RN) #3 called the NP and received a verbal physician's orders for lab work for Resident #7. -However, RN #3 did not check on the resident and did not assess him for seizure activity. At 2:00 p.m. RN #2 was notified by a dietary staff member of Resident #7's emergency. RN #2 went to Resident #7's room and observed Resident #7 having seizure activity. -However, RN #2 did not complete or document the resident's vital signs or overall condition. RN #2 contacted the same NP a second time, at approximately 2:20 p.m. and reported the seizure activity for Resident #7. The NP said she needed to review the resident's chart and would call back. -However, the NP did not call back within the next 10 minutes. At 2:30 p.m. the NP was called a third time by licensed practical nurse (LPN) #4 to notify the NP about Resident #7's seizure activity that had been occurring for more than 30 minutes. The NP gave a physician's order to send the resident to the hospital via EMS. Resident #7 was admitted to the ICU and placed on a ventilator. The director of nursing (DON) was interviewed on 7/10/25 at 3:20 p.m. The DON said Resident #7 had a history of behaviors. The DON said the resident would stare at the wall and not respond to staff if the staff were not providing his care as he preferred. The DON said Resident #7 had Parkinson's tremors, and when he was first discovered on 6/26/25, he had tremors. The DON said when the staff realized the tremors were worse, they called EMS.Staff interviews on 7/14/25 (during the survey) revealed that staff was not able to recognize the difference between the resident's Parkinson's tremors and seizure activity. The staff said they had not received any recent training on seizure management (see interviews below).During the survey, the facility was unable to find documentation to indicate the licensed nursing staff completed assessments or vitals signs during the time period on 6/26/25 when Resident #7 was experiencing seizure activity (see record review and interviews below).The DON was interviewed on 7/14/25 at 9:50 a.m. The DON said the facility's IDT had not reviewed Resident #7's seizure incident. She said she reviewed the incident and determined facility staff responded appropriately to Resident #7 on 6/26/25. The DON said she was unable to locate documented nursing assessments or vital signs related to the incident. The DON said the staff completed an Hospital Transfer form, which acted as the assessment.The facility failed to provide the licensed nursing staff education regarding seizure activity monitoring and procedures to follow in the event that a resident was experiencing a seizure. On 7/15/25 at 12:40 p.m. the nursing home administrator (NHA) and the DON were notified that the facility's failure to timely assess and intervene appropriately when Resident #7 had a change of condition related to seizure activity and the facility's failure to educate the licensed nursing staff regarding seizure activity monitoring and procedures after the incident on 6/26/25 created the potential for serious harm if the situation was not immediately corrected. B. Facility plan to remove the immediate jeopardyOn 7/16/25 at 3:10 p.m. the NHA provided a plan to remove the immediate jeopardy situation. The removal plan read: Plan of Correction: Beginning 7/11/25 and completed on 7/15/25, the nursing staff were provided seizure-specific education, including types of seizures, management of seizures, and response to seizures.Monitoring for seizure activity would occur every two hours for all residents with a seizure diagnosis, starting 7/15/25.Resident #7's midazolam rescue inhaler was received on 7/15/25 and placed in the Main Hall medication cart. The charge nurse on duty, RN #2, for Resident #7 was educated on the proper use of medication on 7/16/25.On 7/15/25 the facility identified additional residents with a seizure condition based on medical diagnosis and history and physical.Starting 7/15/25 the identified residents with a seizure diagnosis would have physician's orders in place to monitor seizure activity and the number of seizures every shift, with a note to contact the physician if seizure activity was observed.Beginning 7/16/25 all residents with a seizure diagnosis would be reviewed every morning by the interdisciplinary team (IDT). The residents' medication administration records (MAR) and plan of care would be reviewed daily with the IDT to ensure that new findings (such as seizure activity) were communicated to the physician. The IDT would ensure there was physician feedback documented in the resident's medical records.On 7/15/25 the care plans for all residents with a seizure diagnosis had been updated to reflect seizures and monitoring.On 7/15/25 Resident #7's Kardex (staff directive tool utilized to provide personalized resident care) was reviewed to ensure documentation was listed as indicated to reflect seizures and monitoring.On 7/15/25 physician's orders for parameters were placed in all residents' charts with a seizure diagnosis that read For seizure lasting greater than five minutes, despite interventions or if airway compromised, call 911 and send to ED (emergency department).On 7/15/25 a physician's order was added to Resident #7's CPO for differentiation of tremors versus seizures. This would be assessed by pulse oximetry (a non-invasive method used to measure the oxygen saturation level in the blood) per the physician. Oxygen saturations (level of oxygen in the blood) would be monitored every shift.C. Measures implemented to prevent recurrenceOn 7/16/25 the medical director (MD) initiated seizure-specific training to the nursing staff.On 7/11/25 the staff development coordinator (SDC) began educating the nursing staff on types of seizures and seizure management, as specified by the physician's orders, the residents' Kardex and the care plans. Each nurse would receive the training before the beginning of their next shift.On 7/11/25 all nursing staff would be educated by the SDC on appropriate documentation of emergency situations, changes in condition and physician notification. Each nurse would receive the training before the beginning of their next shift.D. Removal of immediate jeopardyOn 5/16/25 at 5:50 p.m. the NHA was notified that the immediate jeopardy situation was removed, based on the facility's plan and evidence of its implementation. However, deficient practice remained at a G level, actual harm that is not immediate jeopardy, isolated.II. Professional referencePotter, P. A., & [NAME], A. G. (2023). Fundamentals of Nursing E-Book (11th ed., pp. 824-834). Elsevier Health Sciences was reviewed and included instructions for nurses for managing seizure activity as follows: Call 911 if a person has repeated seizures, if a seizure lasts five minutes or longer, or if seizures occur closer together than usual for that person. When a seizure begins, note the time, track the duration of the seizure, and notify the provider immediately. Time the seizure from the beginning to the end of the active seizure. Turn the person onto their side if they are not awake or aware, with the mouth pointing toward the ground. Prolonged or repeated seizures indicate status epilepticus, a medical emergency that requires intensive monitoring and treatment. It is important that you observe the patient carefully before, during, and after the seizure so that you can document the episode accurately. Seizure precautions encompass nursing interventions to protect a patient from traumatic injury, to position for adequate ventilation and drainage of oral secretions, and to provide privacy.III. Facility policy and procedureThe Change in a Resident's Condition or Status policy and procedure, dated February 2021, was received from the DON on 7/14/25 at 12:01 a.m. It read in pertinent part, Our facility promptly notifies the resident, the attending physician, and the resident's representative of the resident's medical condition and status. The nurse will notify the resident's attending physician when there has been a significant change in the resident's physical condition. A significant change is a major decline in the resident's status that will not normally resolve itself without intervention by staff and is ultimately based on the judgment of the clinical staff. Except in medical emergencies, notifications will be made within 24 hours of a change occurring in the resident's status. The nurse will record in the resident's medical record information relative to changes in the resident's status.IV. Resident #7A. Resident statusResident #7, age greater than 65, was admitted on [DATE], discharged to the hospital on 6/26/25 and readmitted on [DATE]. According to the July 2025 computerized physician's order (CPO), diagnoses included Parkinson's disease, epilepsy without status epilepticus, chronic respiratory failure, dependence on supplemental oxygen, and cognitive communication deficit. The 6/19/25 minimum data set (MDS) assessment revealed the resident was moderately cognitively impaired with a brief interview for mental status (BIMS) score of 11 out of 15. Resident #7 was dependent on staff assistance for all activities of daily living (ADL). The MDS assessment identified Resident #7 had a seizure disorder or epilepsy and was prescribed midazolam. B. Resident #7's representative interviewResident #7's representative was interviewed on 7/14/25 at 3:41 p.m. The representative said that on 6/26/25 at approximately 12:30 p.m., she arrived at the facility to visit Resident #7. The representative said that between 12:30 p.m. and 1:30 p.m., she observed Resident #7 experience three seizures. She said each seizure lasted a few minutes, in which Resident #7 had tremors, his body was stiff and he was unable to respond. She said each seizure lasted longer than the previous seizure and the third seizure was not normal for Resident #7 because it lasted longer and he did not recover as quickly from the seizure. The representative said she was scheduled to attend a care conference for Resident #7 on 6/26/25 at 1:30 p.m. The representative said when she arrived for the care conference, she reported to the staff that she was concerned that the resident's recent medication changes were causing seizures and that she wanted the medication stopped. The representative said the care conference ended promptly due to Resident #7 having seizure activity. The representative said when she returned from the care conference to Resident #7's room, he was not responsive and was experiencing a seizure. The representative said nurses went to the resident's room to check on Resident #7. She said she did not recall what actions the nurses took, but said she heard a discussion and was aware the provider was contacted. The representative said the nurse never left Resident #7's room and did not administer any medications to stop the seizure activity. The representative said she heard the nurses discussing facility protocol and procedure, and the agency nurse (LPN #4) asked the facility staff what the facility protocol and procedure were for emergencies. The representative said before EMS arrived, she heard Resident #7 having gurgling sounds when he was breathing. C. Record review1. Care planThe neurological status care plan, initiated on 6/24/18, revealed the resident had an altered neurological condition related to a seizure disorder and Parkinson's disease with a history of antipsychotic medication use. Pertinent interventions included assessing Resident #7 for effects of psychotropic medications, involuntary dystonia (muscle spasms), akinesia (restlessness), akinesia (difficulty with voluntary movements), rigidity, and tremors (initiated 6/27/18), placing the resident on his side, maintaining an open airway and removing obstacles to ensuring a safe environment if seizure activity occurred (initiated 6/27/18), notifying the physician if the resident had a seizure (initiated 6/27/18), following seizure precautions, including not leaving the resident alone, protecting the resident from injury removing or loosening tight clothing (initiated 6/27/18), providing medications for breakthrough seizures as ordered and monitoring for side effects and effectiveness (initiated 7/14/25), monitoring for seizure activity every shift (initiated 7/14/25), monitoring for tremors, rigidity, changes in level of consciousness and slurred speech every shift (initiated 7/14/25), notifying the physician in the event of seizure activity (initiated 7/14/25) and providing visual checks every two hours and as needed for signs and/or symptoms of seizures (initiated 7/14/25).2. EMS documentationThe 6/26/25 EMS documentation was provided on 7/18/25 at 10:05 a.m. from the EMS company. The EMS documentation, dated 6/26/25 at 2:41 p.m., revealed Resident #7 was unresponsive. The resident's blood pressure was 140/80 millimeters of mercury (mmHg), his heart rate was 160 beats per minute (BPM -normal adult range is 60 to100 BPM), and had premature ventricular contractions (abnormal heart rhythm). The resident's respirations were 20 breaths per minute and his breathing was labored. His blood sugar was 170 milligrams per deciliter (mg/dl) and his body temperature was 102 degrees Fahrenheit (F). The EMS staff administered an injection of Versed (a medication to slow down brain activity), placed the resident on high-flow oxygen with a non-rebreather mask and suctioned Resident #7's airway. The EMS staff noted Resident #7 did not have an intact airway and the resident was not taking adequate breaths. The EMS staff removed the non-breather oxygen mask and inserted an artificial airway. The EMS staff provided respiration assistance to the resident using a bag, valve and mask technique with suction. 3. NP documentationThe Summary of Episode note, dated 6/27/25 at 7:39 p.m., written by the NP, was received from the DON on 7/15/25 at 3:34 p.m. The episode summary documented Resident #7's respiratory rate was 18 breaths per minute, his blood pressure was 118/78 mmHg, his body temperature was 98.2 F, his rate rate was 77 BPM, his oxygen saturation level was 82% (percent) and his blood sugar level was 122 mg/dl.-However, the vital signs documented in the episode summary note were the vital signs that had been documented in Resident #7's EMR on 6/25/25 at 8:31 p.m. (the night before the resident's seizure episode), with the exception of the resident's blood sugar level which was documented on 6/14/25, 12 days prior to the seizure episode. -The NP's episode summary note did not include documentation of the verbal telephone orders for lab work that were provided to RN #3 at 1:49 p.m. or the telephone calls RN #2 and LPN #4 made to the NP. -There were no additional provider progress notes documented in the EMR until 7/7/25, when Resident #7 returned from the hospital.4. Change in condition assessmentThe 6/26/25 2:45 p.m. Hospital Transfer form documented at 2:45 p.m. was provided by the DON on 7/15/25 at 3:34 p.m. The Hospital Transfer form documented Resident #7's respiratory rate was 18 breaths per minute, his blood pressure was 118/78 mmHg, his body temperature was 98.2 F, his rate rate was 77 BPM, his oxygen saturation level was 82% (percent) and his blood sugar level was 122 mg/dl.-However, the vital signs documented in the Hospital Transfer form were the vital signs that had been documented in Resident #7's EMR on 6/25/25 at 8:31 p.m. (the night before the resident's seizure episode), with the exception of the resident's blood sugar level which was documented on 6/14/25, 12 days prior to the seizure episode.-Review of Resident #7's EMR revealed there were no additional vital signs obtained or documented in the resident's EMR after the resident's representative reported seizure activity and the facility staff observed the resident with seizure activity on 6/26/25. -The Hospital Transfer form documented that Resident #7 had a risk for seizures but did not include information about the 6/26/25 seizure activity on the form.5. Progress notes-There was no documentation to indicate RN #3 notified the NP about the seizure activity before the care conference.The 6/26/25 at 2:32 p.m. nursing progress note, documented by RN #2, revealed RN #2 was called to Resident #7's room at 2:00 p.m. where he observed Resident #7 with seizure activity. Resident #7 was unconscious and had involuntary movement which lasted longer than 30 minutes. -However, there was no documentation in Resident #7's EMR to indicate that RN #2 assessed Resident #7, recorded what time the NP was contacted, the NP's response, or what time emergency services were contacted.The 6/26/25 at 3:07 p.m. nursing progress note, documented by LPN #4, revealed LPN #4 revealed that the NP was called a third time, and informed that Resident #7 had continued seizure activity for 30 minutes. The note revealed that a physician's order was obtained from the NP to transfer Resident #7 to the ED. -However, there was no documentation in Resident #7's EMR to indicate that LPN #4 assessed Resident #7, what time the NP was contacted, the NP's response, or what time emergency medical services were contacted. -Review of Resident #7's EMR revealed there was no documentation to indicate an assessment was conducted by a licensed nurse during Resident #7's seizure activity on 6/26/25.D. Staff interviewsRN #2 was interviewed on 7/10/25 at 3:00 p.m. RN #2 said nurses could provide several interventions to manage residents' seizure activity. RN #2 said if a resident had seizure activity, they should be placed on their side and the provider should be notified. He said if the resident had medications for breakthrough seizures ordered the medications should be administered when the resident was experiencing a seizure.The DON was interviewed on 7/10/25 at 3:20 p.m. The DON said Resident #7 had a history of behaviors. The DON said the resident would stare at the wall and not respond to staff if the staff were not providing his care as he preferred. The DON said Resident #7 had Parkinson's tremors, and when he was first discovered on 6/26/25, he had tremors. The DON said when the staff realized the tremors were worse, they called EMS.The DON was interviewed again on 7/14/25 at 9:50 a.m. The DON said the facility's IDT had not reviewed Resident #7's seizure incident. The DON said she was unable to locate documented nursing assessments or vital signs related to the incident. The DON said the staff completed a Hospital Transfer form, which acted as the assessment.Certified nurse aide (CNA) #1 was interviewed on 7/14/25 at 1:00 p.m. CNA #1 said she did not remember receiving any training regarding seizure monitoring or seizure protocol. She said if she noticed a resident having abnormal movement, she would notify the nurse on duty. She said Resident #7 had mild tremors to his right arm because he had Parkinson's disease. She said Resident #7 was always able to answer questions and respond appropriately. CNA #2 was interviewed on 7/14/25 at 1:20 p.m. CNA #2 said she did not know who she needed to monitor residents for seizure activity because that was the nurse's job. She said her nurse manager never told her that she needed to monitor residents for seizure activities and she was not trained to do so. LPN #1 was interviewed on 7/14/25 at 2:00 p.m. LPN #1 said it was her first day working at the facility. LPN #1 said she did not receive any facility-specific training before the start of her shift. She said if she noticed a resident having continuous seizures for more than one minute, she would reach out to the physician for emergency medication orders. She said if a seizure was noted to last more than five minutes, she would immediately call 911 for medical transfer to the hospital. She said additionally, she would complete a progress note to document the event details because the facility did not have a seizure-specific documentation assessment.RN #1 was interviewed on 7/14/25 at 2:10 p.m. RN #1 said if a resident was having a seizure, he would protect the resident from injury by making sure their limbs did not hit any bed rails and he would turn the resident's head to the side so they did not aspirate. RN #1 said that if a resident had a seizure for more than three minutes, he would call 911. RN #1 said he did not know if that was the facility's protocol, but that was what he would do, based on his years of experience as a bedside nurse. RN #1 said typically, the DON would do the education for the staff regarding what to monitor for resident seizure activity. RN #1 said he thought he received education on seizures, but he was not sure.LPN #3 was interviewed on 7/14/25 at 2:17 p.m. via telephone. LPN #3 said she looked at the residents' care plans for interventions on how to monitor a resident with a history of seizures. She said she would also check the physician's orders for rescue medication to stop the seizure if it exceeded five minutes in duration. She said immediate action would include assessing the resident's vital signs, documenting the type and duration of the seizure and notifying the physician immediately. She said it was important to follow these steps because if a seizure lasted more than five minutes, it could cause brain damage or death. She said she started working at the facility four months ago. LPN #3 said she did not remember receiving any type of training on seizure protocol.The NP was interviewed on 7/15/25 at 10:00 a.m. The NP said she remembered the events of that day (6/26/25). The NP said she received a total of three calls from the staff regarding Resident #7. The NP said the first call was regarding a medication change and she ordered STAT labs. She said about 20 minutes later, she received a second call from a nurse saying that Resident #7 was having active prolonged seizures. The NP said during the second call, she told the nurse on the phone that she would review Resident #7's EMR and give him a call back. The NP said she did not ask for vital signs or a resident assessment and the staff did not provide her with information obtained from a resident assessment. She said she received the third call a few minutes later, from a different nurse, indicating that Resident #7 needed to go to the hospital. The NP said she did not ask for Resident #7's assessment or vital signs during the third phone call. She said she gave a verbal physician's order to the third nurse to send the resident to the hospital. The medical director (MD) was interviewed on 7/15/25 at 10:30 a.m. The MD said he often had issues with the nurses at the facility not completing assessments on residents in emergency situations. The MD said he was not notified the day that Resident #7 had a seizure (6/25/25). The MD said if he was notified of the seizure activity, he would have asked the nurses to do a complete assessment in order to help him correctly treat the acute issue. The MD said based on the severity and the resident's medical history, a prolonged continuous seizure lasting in excess of 30 minutes could cause harm to a resident.E. Facility follow-upOn 7/14/25 at 8:15 a.m. (during the survey) the DON provided a written statement from RN #2. The statement, dated 7/13/25, read in pertinent part, This writer (RN #2) and LPN #4 assessed Resident #7 for Parkinson's disease signs and symptoms due to the resident always having involuntary upper arm movement, while monitoring oxygen saturation and vital signs. -However, review of Resident #7's EMR did not reveal additional documentation of the resident's vital signs after the vital signs that were taken on 6/25/25 at 8:31 p.m. (see record review above).RN #3 sent an email communication to the DON on 7/15/25 at 2:07 p.m. (during the survey). The email was provided by the DON on 7/15/25 at 3:34 p.m The email documented that RN #3 had attended the care conference for Resident #7 on 6/26/25 at 1:33 p.m. via telephone. RN #3 said she notified the NP that Resident #7's representative was concerned about the resident's medications after the resident had a couple of episodes of staring into space for a few seconds on 6/26/25, before the care conference. RN #3 said she informed the representative that she would notify the physician of the concerns and that the facility would see if there was a different medication for Resident #7. RN #3 documented in the email that she notified the NP on 6/26/25 at 1:49 p.m. of the staring episodes. RN #3 said the NP ordered STAT (immediate, without delay) labs for the resident. RN #3 documented in the email that she informed RN #2 about the lab work.-However, review of Resident #7's EMR did not reveal any documentation regarding RN #3's conversation with the resident's representative or her phone call with the NP, where physician's orders were obtained for lab work. V. ADDITIONAL FAILURES FOR RESIDENT #7A. Facility policy and procedureThe Administering Medications policy, dated April 2019, was provided by the DON on 7/15/25 at 10:06 a.m. The policy read in pertinent part, Medications are administered in a safe and timely manner, and as prescribed. Only persons licensed or permitted may prepare, administer, and document the administration of medications. The director of nursing services (DON) supervises and directs all personnel who administer medications and/or have related functions. Medications are administered by prescriber orders, including any required time frame. Medication administration times are determined by resident need and benefit, not staff convenience. Factors that are considered include: - Enhancing the optimal therapeutic effect of the medication; -Preventing potential medication or food interactions; and-Honoring resident choices and preferences, consistent with their care plan. The individual administering the medication checks the label three (3) times to verify the right resident, right medication, right dosage, right time, and right method (route) of administration before giving the medication. If a drug is withheld, refused, or given at a time other than the scheduled time, the individual administering the medication shall initial and circle the medication administration record (MAR) space provided for that drug and dose. The individual administering the medication signs the resident's MAR on the appropriate line after giving each medication and before administering the next ones. As required or indicated for a medication, the individual administering the medication records in the resident's medical record:-The date and time the medication was administered;-The dosage;-The route of administration;-The injection site (if applicable);-Any complaints or symptoms for which the drug was administered;-Any results achieved and when those results were observed; and,-The signature and title of the person administering the drug.B. Resident #71. Record reviewA review of Resident #7's July 2025 CPO revealed the following physician's order:Midazolam nasal solution solution 5 mg/0.1ml. Administer one spray in the left nostril every 24 hours as needed for breakthrough seizure activity. Administer one spray to the left nostril for one dose, repeat dose in the other nostril for one dose in ten minutes, if needed, ordered 7/9/25 at 2:11 p.m. -However, the midazolam medication was not delivered until 7/15/25 at approximately 8:00 p.m. (see DON interview below).C. Staff interviews RN #2 was interviewed on 7/10/25 at 3:00 p.m. RN #2 said if a resident had medications for breakthrough seizures ordered the medications should be administered when the resident was experiencing a seizure. RN #2 said emergency medications were available in the emergency medication kit which was stored in the medication room, however, he said he was unaware if there were emergency medications for seizures available in the facility.The DON was interviewed on 7/14/25 at 4:52 p.m. The DON said she was unaware that the midazolam medication was not available for Resident #7. The DON said the nurses should have monitored the status of the resident's midazolam until it was delivered from the pharmacy. The DON was interviewed again on 7/16/25 at 3:00 p.m. The DON said Resident #7's Midazolam medication ordered for seizures on 7/9/25 was delivered on 7/15/25 at approximately 8:00 p.m.The DON said it was the responsibility of the licensed nurses to follow up with the pharmacy when they realized a medication was not delivered promptly. The DON said this was concerning because Resident #7 could have had another seizure and there was no medication available.

Based on record review and interviews, the facility failed to maintain medical records in accordance with accepted professional standards and practices for two (#1 and #2) of six residents out of seven sample residents.Specifically, the facility failed to accurately document the administration of scheduled medications for Resident #1 and Resident #2. Findings include:I. Facility policy and procedureThe Administering Medications policy, dated April 2019, was provided by the director of nursing (DON) on 7/15/25 at 10:06 a.m. The policy read in pertinent part, Medications are administered in a safe and timely manner, and as prescribed. Only persons licensed or permitted may prepare, administer, and document the administration of medications. The director of nursing services (DON) supervises and directs all personnel who administer medications and/or have related functions. Medications are administered by prescriber orders, including any required time frame. Medication administration times are determined by resident need and benefit, not staff convenience. Factors that are considered include: - Enhancing the optimal therapeutic effect of the medication; -Preventing potential medication or food interactions; and-Honoring resident choices and preferences, consistent with their care plan. The individual administering the medication checks the label three (3) times to verify the right resident, right medication, right dosage, right time, and right method (route) of administration before giving the medication. If a drug is withheld, refused, or given at a time other than the scheduled time, the individual administering the medication shall initial and circle the medication administration record (MAR) space provided for that drug and dose. The individual administering the medication signs the resident's MAR on the appropriate line after giving each medication and before administering the next ones. As required or indicated for a medication, the individual administering the medication records in the resident's medical record:-The date and time the medication was administered;-The dosage;-The route of administration;-The injection site (if applicable);-Any complaints or symptoms for which the drug was administered;-Any results achieved and when those results were observed; and,-The signature and title of the person administering the drug.The Leave of Absence (LOA) policy, revised 8/1/24, was provided by the DON on 7/15/25 at 10:06 a.m. The policy read in pertinent part, This policy applies to all healthcare providers involved in the preparation of a resident for a leave of absence medications.A physician should provide an order indicating the resident may take a leave of absence, along with a list of medications to be taken during the leave. The facility nurse and prescriber should review the list of current medications, the total number of doses required for each medication, and the length of time the resident will need the medication. The facility should have the resident sign for the receipt of medications for the leave of absence. The facility should chart the following on the MAR:-Quantity of each medication released to the resident or responsible party,-Date medication is released to the resident or responsible party,-Time medication is released to the resident or responsible party, and,-Name of the person receiving the medication. The facility should record the release of controlled substances that require tracking on a separate inventory sheet for the leave of absence. When the resident returns to the facility, the nurse should count all doses of controlled substances and document the doses used while on leave of absence.II. Resident #1A. Resident statusResident #1, age greater than 65, was admitted on [DATE]. According to the July 2025 computerized physician orders (CPO), diagnoses included panic disorder, anxiety, schizoaffective disorder (mental illness), iron deficiency anemia, protein-calorie malnutrition, dementia, fibromyalgia (pain disorder) and chronic pain. The 4/16/25 minimum data set (MDS) assessment revealed Resident #1 was cognitively intact with a brief interview for mental status (BIMS) score of 15 out of 15. Resident #1 was independent with all activities of daily living (ADL). B. Resident #1's family member interviewA family member for Resident #1 was interviewed via telephone on 7/10/25 at 11:14 a.m. The family member reported she picked Resident #1 up for a pass on 5/19/25 to 5/22/25. She said the facility provided her with medications for one day, but did not provide a list of the medications because she was not Resident #1's designated representative. The family members reported that the medications received on 5/19/25 were incorrect medications. The family member said she returned to the facility on 5/20/25 and then received additional medications for 5/20/25. The family member said the medications received for 5/20/25 were correct but were different from the medications received for 5/19/25.C. Record reviewReview of Resident #1's MARS and treatment administration records (TARS), from 2/1/25 to 7/15/25, revealed there were multiple days when the resident's medications did not include staff documentation to indicate the medications were administered to the resident. Additionally, there were multiple days when the entry for medications read 09, which indicated a progress note was required to explain if a medication was not provided or treatment refused (see interviews below).Review of #1's MARs and TARS revealed the following:Med Pass, 240 milliliters (ml), two times a day for nutritional support, ordered 2/1/25.-There was no documentation to indicate the Med Pass was administered on 2/6/25, 2/18/25, 4/11/25, 4/13/25, 5/19/25, 6/2/25, 6/8/25, 6/10/25, 6/12/25. -The administration entry for the Med Pass was coded as 09 with no corresponding progress note on 3/2/25, 3/4/25, 3/9/25, 3/11/25, 3/16/25, 3/18/25, 3/23/25, 3/25/25, 3/30/25, 5/1/25, 5/4/25, 5/6/25, 5/11/25, 5/13/25, 5/25/25, 5/27/25, 5/30/25, 6/1/25, 6/3/25, 6/8/25, 6/10/25, 6/15/25, 6/17/25, 6/22/25 and 6/29/25.Tylenol 500 milligrams (mg) give three times a day for pain, ordered 1/30/25. -There was no documentation to indicate the Tylenol medication was administered on 3/29/25 for the bedtime dose.Glucosamine 500 mg three times a day for supplement, ordered 1/30/25.-The administration entry for the glucosamine medication was coded as 09 with no corresponding progress note on 5/20/25 morning, and 5/22/25 for the morning and afternoon dose.-There was no documentation to indicate the glucosamine medication was administered on 2/6/25 afternoon, 2/18/25 afternoon, 5/19/25 bedtime, 6/2/25 afternoon , 6/8/25 afternoon, 6/10/25 afternoon and 6/12/25 afternoon.Gabapentin 100 mg three times a day for right arm nerve pain, ordered 3/5/25. -There was no documentation to indicate the gabapentin medication was administered on 5/19/25 evening, 6/2/25, 6/8/25, 6/10/25, 6/12/25. -On 5/20/25 and 5/21/25, the gabapentin medication was documented as administered, however Resident #1 was out of the facility on a pass with family from 5/19/25 to 5/22/25 (see interview above).Oxycodone 10 mg one tablet every six hours for chronic pain, ordered 2/3/25. There was no documentation to indicate the oxycodone medication was administered on 5/4/25 at 5:00 a.m. and 5/19/25 at 5:00 p.m.-On 5/21/25 at 11:00 a.m. and 5:00 p.m., the oxycodone 10 mg medication was documented as administered, however, Resident #1 was out of the facility on a pass with family from 5/19/25 to 5/22/25 (see interview above).Benztropine one mg daily for tremors, ordered 1/31/25.-There was no documentation to indicate the benztropine medication was administered on 6/2/25, 6/8/25, 6/10/25 and 6/12/25.Paliperidone 234 mg/1.5 ml, inject one time a day on the 17th of each month for schizoaffective disorder, ordered 2/17/25. -There was no documentation to indicate the paliperidone medication was administered on 4/17/25.Track hours of sleep every shift for insomnia, ordered 1/30/25. -The administration entry for the hours of sleep tracking was coded as 09 with no corresponding progress note on the day shift on 6/3/25 and 6/30/25. -The administration entry for the hours of sleep tracking was coded as 09 with no corresponding progress note on the evening shift on 6/6/25, 6/7/25, 6/13/25, 6/14/25, 6/15/25, 6/20/25, 6/27/25 and 6/28/25.Monitor oxygen nasal cannula placement and oxygen saturation every shift for COPD, ordered 1/30/25. -The administration entry for the oxygen nasal cannula placement and oxygen saturation was coded as 09 with no corresponding progress note on the day shift on 6/3/25 and 6/30/25.-The administration entry for the oxygen nasal cannula placement and oxygen saturation was coded as 09 with no corresponding progress note on the evening shift on 6/6/25, 6/7/25, 6/13/25, 6/14/25, 6/15/25, 6/20/25, 6/27/25, 6/28/25 and 6/30/25.Monitor behavior for antipsychotic medication use every shift for delusions, ordered 2/27/25. -The administration entry for the behavior monitoring for antipsychotic medication use for delusions was coded as 09 with no corresponding progress note on the day shift on 6/3/25, 6/6/25, 6/7/25, 6/14/25, 6/14/25, 6/15/25, 6/20/25, 6/21/25, 6/27/25, 6/28/25 and 6/30/25.-The administration entry for the behavior monitoring for antipsychotic medication use for delusions was coded as 09 with no corresponding progress note on the evening shift on 6/27/25, 6/28/25 and 6/30/25.Monitor behavior for antipsychotic medication use every shift for depression, ordered 2/27/25. -The administration entry for the behavior monitoring for antipsychotic medication use for depression was coded as 09 with no corresponding progress note on the day shift on 6/3/25, 6/6/25, 6/7/25, 6/14/25, 6/14/25, 6/15/25, 6/20/25, 6/21/25, 6/27/25, 6/28/25 and 6/30/25.-The administration entry for the behavior monitoring for antipsychotic medication use for depression was coded as 09 with no corresponding progress note on the evening shift on 6/27/25, 6/28/25 and 6/30/25. Monitor behavior for rapid heart rate, racing thoughts, and anxiety for anxiety every shift, ordered 2/27/25. -The administration entry for the behavior monitoring for rapid heart rate, racing thoughts, and anxiety for anxiety was coded as 09 with no corresponding progress note on the day shift on 6/3/25, 6/6/25, 6/7/25, 6/14/25, 6/14/25, 6/15/25, 6/20/25, 6/21/25, 6/27/25, 6/28/25 and 6/30/25.-The administration entry for the behavior monitoring for rapid heart rate, racing thoughts, and anxiety for anxiety was coded as 09 with no corresponding progress note on the evening shift on 6/27/25, 6/28/25 and 6/30/25.Monitor behavior for depression, sadness, and suicide ideation for antidepressant use every shift, ordered 2/27/25.-The administration entry for the behavior monitoring for depression, sadness, and suicide ideation for antidepressant use was coded as 09 with no corresponding progress note on the day shift on 6/3/25, 6/6/25, 6/7/25, 6/14/25, 6/14/25, 6/15/25, 6/20/25, 6/21/25, 6/27/25, 6/28/25 and 6/30/25.-The administration entry for the behavior monitoring for depression, sadness, and suicide ideation for antidepressant use was coded as 09 with no corresponding progress note on the evening shift on 6/27/25, 6/28/25 and 6/30/25.III. Resident #2A. Resident statusResident #2, age greater than 65, was admitted on [DATE]. According to the July 2025 CPO, diagnoses included depressive disorder, diabetes, epilepsy, asthma and stroke, anxiety, muscle weakness, obesity and iron deficiency anemia.The 4/9/25 MDS assessment revealed Resident #2 was cognitively intact with a BIMS score of 15 out of 15. Resident #2 was independent with ADLs.B. Record reviewReview of Resident #2's MARS and TARS, from 2/1/25 to 7/15/25, revealed there were multiple days when the resident's medications did not include staff documentation to indicate the medications were administered to the resident. Additionally, there were multiple days when the entry for medications read 09, which indicated a progress note was required to explain if a medication was not provided or treatment refused.Review of Resident #2's MARs and TARS revealed the following:Levothyroxine 75 micrograms (mcg) one tablet daily for thyroid hormone, ordered 12/18/24.-There was no documentation to indicate the levothyroxine medication was administered on 2/6/25 and 5/6/25. Ozempic 2 mg, inject every Monday for diabetes, ordered 1/6/25.-There was no documentation to indicate the Ozempic medication was administered on 3/24/25, 4/14/25, 5/5/25, 5/12/25, 5/26/25 and 6/2/25; -The administration entry for the Ozempic medication was coded as 09 with no corresponding progress note on 2/24/25, 3/3/25, 3/10/25, 3/17/25, 3/24/25 and 4/28/25. Snack for diabetes management, give a snack two times daily, ordered 1/30/25-There was no documentation to indicate the snack was given on 4/18/25, 4/23/25, 5/4/25, 5/5/25, 5/7/25, 5/11/25, 5/14/25, 5/21/25, 5/25/25 and 5/28/25.Blood sugar monitoring, check twice daily and notify the provider if over 400 milligrams/deciliter (mg/dl), ordered 12/17/24.-There was no documentation to indicate the blood sugar monitoring was completed in the morning on 2/6/25, 6/1/25 and 6/6/25.-There was no documentation to indicate the blood sugar monitoring was completed in the afternoon on 3/14/25, 3/17/25, 5/4/25 and 5/5/25.On 6/24/25, the blood sugar was 443 mg/dl. -There was no documentation that the provider was notified of the high reading.On 6/25/25, the blood sugar was 426 mg/dl. -There was no documentation that the provider was notified of the high reading.Oxycodone give 5 mg every eight hours for pain, ordered 12/17/24. -There was no documentation to indicate the oxycodone 5 mg medication was administered on 2/2/25 at 6:00 a.m., 2/6/25 at 6:00 a.m., 2/8/25 at 6:00 a.m., 2/14/25 at 6:00 a.m., 2/16/25 at 6:00 a.m., 2:00 p.m. and 9:00 p.m., 2/23/25 at 6:00 a.m., 3/7/25 at 6:00 a.m., and 3/8/25 at 6:00 a.m. Oxycodone 5 mg pain medication give every four hours, ordered 3/14/25 to start at 6:00 p.m. -The administration entry for the oxycodone 5 mg medication was coded as 09 with no corresponding progress note on 3/18/25 at 2:00 p.m.Oxycodone 5 mg for pain management, give 5 mg every eight hours, ordered 3/18/25 to start at 2:00 p.m. -There was no documentation to indicate the oxycodone 5 mg medication was administered on 3/18/25 at 2:00 p.m. and 3/22/25 at 6:00 a.m., 3/30/25 at 2:00 p.m., 4/11/25 at 6:00 a.m. and 4/14/25 at 2:00 p.m. -The administration entry for the oxycodone 5 mg medication was coded as 09 with no corresponding progress note on 3/29/25 at 6:00 a.m. and 3/30/25 at 6:00 a.m.Oxycodone 5 mg for pain management, give three times a day, ordered 4/14/25. -There was no documentation to indicate the oxycodone 5 mg medication was administered on 6/8/25, 6/10/25 and 6/12/25 for the afternoon doses. Eliquis 5 mg, one tablet twice daily for blood thinner, ordered on 12/18/24. -There was no documentation to indicate the Eliquis medication was administered on 3/26/25 in the morning, 3/26/25 in the afternoon, and 5/4/25 in the afternoon.Anticoagulant monitoring, monitor every shift, notify provider if adverse outcome is present, ordered 12/17/24. -The administration entry for the anticoagulant monitoring was coded as 09 with no corresponding progress note on 3/3/25, 3/10/25, 3/11/25, 3/13/25, 3/20/25, 3/25/25, 3/31/25, 4/1/25, 4/3/25, 4/8/25, 4/14/25, 4/15/25, 4/17/25, 4/21/25, 4/22/25, 4/24/25, 4/28/25, 4/29/25, 5/1/25, 5/6/25, 5/8/25, 5/12/25, 5/13/25, 5/15/25, 5/19/25, 5/20/25, 5/22/25, 5/26/25, 5/27/25, 5/29/25, 6/2/25, 6/3/25, 6/14/25, 6/20/25 and 6/30/25.Lantus 100 units/ml inject 53 units every morning, ordered 12/17/24. -There was no documentation to indicate the Eliquis medication was administered on 3/26/25 and 5/23/25. Mupirocin ointment, 2% (percent) for infection. Apply to left toe daily, ordered 3/14/25. -There was no documentation to indicate the Mupirocin ointment was administered on 3/14/25, 3/16/25, 6/14/25 and 6/16/25.Lyrica 150 mg twice daily for pain management, ordered on 12/17/24.-There was no documentation to indicate the Lyrica medication was administered in the morning on 3/16/25.-The administration entry for the Lyrica medication was coded as 09 with no corresponding progress note on 3/15/25 in the morning. Dulera inhaler 100-5 micrograms (mcg) give two puffs twice daily for asthma, ordered 3/10/25. -There was no documentation to indicate the Dulera inhaler was administered in the evening on 5/4/25.Cetaphil cream for dry skin. Apply two times daily, ordered 12/18/24.-There was no documentation to indicate the Cetaphil cream was administered in the evening on 5/4/25 in the evening.Eucerin cream for skin treatment. Apply to face twice daily, ordered 5/12/25.-There was no documentation to indicate the Eucerin cream was administered on 5/21/25. -The administration entry for the Eucerin cream was coded as 09 with no corresponding progress note on 5/8/25, 5/10/25 and 5/20/25. Keppra 250 mg give one tablet twice daily for seizure prevention. -There was no documentation to indicate the Keppra medication was administered in the morning and the afternoon on 5/4/25.Miconazole 2% apply to skin twice daily for skin infection, ordered 12/19/24.-The administration entry for the miconazole was coded as 09 with no corresponding progress note on 6/8/25, 6/10/25, 6/14/25, 6/15/25, 6/17/25, 6/20/25, 6/22/25 and 6/29/25.Macrobid 100 mg twice daily for infection, ordered 6/18/25 to start at 4:00 p.m. -The administration entry for the Macrobid medication was coded as 09 with no corresponding progress note on 6/18/25 at 4:00 p.m. IV. Staff interviewsLicensed practical nurse (LPN) #2 was interviewed on 7/10/25 at 12:15 p.m. LPN #2 said the MAR was used to document medications and treatments ordered by the physician. LPN #2 said that when the MAR reflected a blank for a scheduled medication or treatment, that indicated the medication or treatment was not completed. LPN #2 said the MAR had specific codes to use for the nurses to indicate if residents refused or if they were out of the facility. LPN #2 said the use of the code 09 meant a progress note was required to explain if a medication was not provided or was refused or for other concerns. LPN #2 said the nurse documentation entered from a 09 code was saved to the corresponding resident's progress notes. The director of nursing (DON) was interviewed on 7/10/25 at 1:31 p.m. The DON said that she received a grievance from a family member of Resident #1 regarding the medications provided when the resident was on pass from 5/19/25 to 5/22/25. The DON said she recognized the documentation was not sufficient and educated staff on the policy regarding how to document when residents went on a pass and what medications were provided. The DON was interviewed again on 7/14/25 at approximately 8:30 a.m. The DON said that when there was a blank entry on the MAR, that would indicate the medication or treatment was not completed as ordered by the physician. The DON said that if applicable, the nurse would use the 09 code and enter a corresponding progress note with the reason the medication or treatment was not administered. The DON said that she had not identified trends for the medication administrations not being documented. The DON said she reviewed the MARs every day for completeness. She said if a MAR included blank entries or if she had other concerns, she printed the MAR and took the MAR to the nurse involved. The DON said she expected that all physician's orders would be completed promptly. The DON said she began reviewing the MARs for completeness in March 2025 and had not identified concerns.The DON was interviewed a third time on 7/14/25 at 5:06 p.m. The DON said she had no performance improvement projects for quality improvement regarding medication administration documentation. She said the staff development coordinator (SDC) was responsible for completing residents' MAR audits and she had not been notified of any concerns. The DON said that she expected medications and treatments to be signed off by the nurse when they were administered. The DON was interviewed a fourth time on 7/16/25 at 5:07 p.m. The DON said she completed daily audits of resident's MARs so she could address any concerns the same day. The DON said, in the nursing world, if it is not documented then it did not happen. The DON said if blood glucose checks were not documented, then she would follow up with the resident and the nurse. The DON said the nurses should document medication administrations or their medication refusals in the resident's MARs at the time of the medication administration or the refusal.

Based on record review and interviews, the facility failed to ensure one (#1) of three residents out of five sample residents received treatment and care for optimal skin condition of a contracted hand, in accordance with professional standards of practice. Specifically, the facility did not provide adequate skin care to prevent skin breakdown in Resident #1's contracted hands and between the resident's fingers and the thumb. Findings include: I. Professional reference According to the [NAME] Health NHS Foundation Trust Hand Contractures, February 2022, retrieved on 8/28/24, from https://www.oxfordhealth.nhs.uk/wp-content/uploads/sites/24/2023/06/1.6.3-Hand-Contractures-Advice-Sheet-for-Care-Homes.pdf, It is vital to adequately manage this condition in order to prevent pressure sores and skin breakdown in the palm and fingers. Once a hand contracture is present it can become very painful. Movements can be uncomfortable, but it is essential to maintain adequate hand hygiene; Hand hygiene is essential management of hand contractures. This should be achieved by regular washing and drying of the hand at least two to three times a day. It is especially important to ensure the skin is properly dry. If the skin is wet/sweaty this increases the changes to the normal skin barrier and can lead to breakdown, sores and infections. Allowing a little time to dry the hand will prevent skin from breaking down and prevent odor, which can become offensive. Also, ensure nails are regularly cut to prevent digging into the hand. II. Facility policy and procedure On 8/20/24 a request was made to the director of nursing (DON) for the facility's policy on contracture management and skin integrity management. -The facility did not provide any policies by the end of the survey on 8/20/24. III. Resident #1 A. Resident status Resident #1, age less than 65, was admitted to the facility on [DATE]. According to the computerized physician's orders (CPO), diagnoses included quadriplegia (paralysis of all four limbs), traumatic brain injury and muscle contractures to several body parts. The 7/30/24 minimum data set (MDS) assessment documented the resident had moderately impaired cognition with a brief interview for mental status (BIMS) score of eight out of 15. The resident had contractures to several body parts. The resident was dependent upon staff for mobility and was unable to perform some positioning due to a medical condition. The resident was at risk of developing pressure injuries. B. Observations Resident #1 was observed in bed on 8/19/24 at 11:22 a.m. and 8/20/24 at 3:12 p.m. Resident #1 had contractures in both his right and left hands where his fingers were resting on the palms of his hands. The resident was wearing a splint on his right hand and his left hand had a bandage on the thumb and a small single gauze pad, folded in half, between each of his fingers. There was no type of absorbent material in the palm of either hand to absorb moisture buildup and protect the palms from skin breakdown. C. Resident and family interview A resident family representative was interviewed on 8/19/24 at 10:00 a.m. The representative said Resident #1 had developed sores on his hands from his contracted fingers and the nursing staff were not providing consistent preventative care. The representative said that family members were supplementing hand hygiene when nursing staff did not provide the necessary care to maintain the resident's skin integrity. The resident's representative said the resident's hands frequently had a foul odor, there was redness between his fingers and his palms and his fingers were often overly moist from sweat buildup and lack of proper hygiene. Resident #1 and his family representative were interviewed on 8/19/24 at 11:32 a.m. The family representative said they had to continually remind the nursing staff to place protective materials in the resident's hand to prevent skin injury from pressure and moisture build-up. Resident #1 was interviewed on 8/20/24 at 2:15 p.m. Resident #1 said he did not want to wear his splints but he was agreeable to the gauze being placed between his fingers and said the nurses did not place any gauze or other absorbing materials between his contracted fingers or where they rested on his hand and palms. D. Record review An admission progress note dated 4/22/24 documented Resident #1's hospital diagnoses including severe spasticity, left facial asymmetry, bilateral upper extremities with flexion contractures, his hands were clenched and his left lower extremity was unable to release. A skin wound note dated 7/13/24 documented Resident #1 had a new skin issue on the left thumb which looked to be from moisture due to the contracture of the hands of the resident. A physician's note dated 7/24/24 documented Resident #1 was seen for new open wounds in his palms and between his fingers due to hand contractures. There was no sign of infection or yeast overgrowth, but the resident only allowed a limited examination due to the pain of spreading his fingers apart for the examination. A physician note dated 7/25/24 documented Resident #1 had contractures to the right and left upper extremity. The resident's left thumb had an open wound , (related to contracture pressure) and had received a status of not healed. Healing was expected to be delayed due to identified factors of impaired mobility, the inevitable effect of aging, and malnutrition. The contracture management care plan, initiated 7/25/24 revealed Resident #1 had potential for impairment to skin integrity and had contractures present on admission. The resident had a left thumb with an open wound related to contractures. The goal of the care plan was for the resident to maintain or develop clean and intact skin. Care plan interventions included providing therapy for splinting and contracture management, educating the resident/family/caregivers on causative factors and measures to prevent skin injury, following facility protocols for treatment of injury, identifying and documenting potential causative factors and eliminating and resolving them where possible, monitoring and documenting the location, size and treatment of skin injury and reporting abnormalities to the physician. Further review of the progress notes revealed the resident was resistant to wearing his hand splints consistently as recommended he was agreeable to wearing the gauze pads between his fingers and his wound dressings. The resident's guardian was also contributing to the removal of the splints when the resident complained about not wanting to wear the splints. IV. Staff interviews The licensed practical nurse (LPN) #1 was interviewed on 8/20/24 at 1:14 p.m. LPN #1 said the resident frequently refused his splints and or his family would remove them when they came in for visits. LPN #1 said the resident was at risk for skin breakdown due to his contracture and the nursing staff assisted him with hand hygiene as much as he would tolerate. The resident had developed a pressure wound on his hand due to his contractures and he was tolerant of wound care and the addition of gauze pads being placed between the fingers. LPN #1 said the resident did not have an order for a washcloth or other absorbent material to be placed between his contracted fingers and his palm and they did not apply any gauze pads on the palms of his hands. The DON was interviewed on 8/20/24 at 4:15 p.m. The DON said the facility was working with Resident #1 and his family to help them understand the importance of using splints to manage his hand contracture and not removing the bandage in between bandage changes. The DON said the family wanted to see the wound and would often remove the bandage to look at the wound when it was not time for a bandage change and this was impairing wound healing. Additionally, the family was not consistent in encouraging the resident to wear his splints consistently as recommended. The DON said she was not sure if the nursing staff had tried to apply a washcloth or some other type of thin absorbent material to the resident's palm to protect skin integrity but she would talk to the interdisciplinary treatment team to find out what had been tried. The DON said they were in the process of setting up a meeting with the resident's family to discuss Resident #1's care and care needs as well as his contractures and treatment of his wound and maintenance of the skin on his hands in particular.

Based on observations and interviews, the facility failed to maintain an infection control program designed to provide a safe, sanitary and comfortable environment to help prevent the development and transmission of diseases and infection on two of three units. Specifically, the facility failed to: -Ensure housekeeping staff were following the proper cleaning techniques for cleaning resident rooms and disinfecting high frequency touch areas (call lights, door handles and handrails); -Ensure housekeeping staff were trained appropriately on housekeeping procedures; and, -Ensure surface disinfectant times were adhered to. Findings include: I. Professional reference Assadian O, Harbarth S, Vos M, et al. Practical recommendations for routine cleaning and disinfection procedures in healthcare institutions: a narrative review. The Journal of Hospital Infection. 2021 Jul;113:104-114, retrieved on 3/22/24, revealed in pertinent part: High-touch surfaces, on the other hand, are usually close to the patient, are frequently touched by the patient or nursing staff, come into contact with the skin and, due to increased contact, pose a particularly high risk of transmitting pathogens (virus or microorganism that can cause disease) Healthcare-associated infections (HAIs) are the most common adverse outcomes due to delivery of medical care. HAIs increase morbidity and mortality, prolonged hospital stay, and are associated with additional healthcare costs. Contaminated surfaces, particularly those that are touched frequently, act as reservoirs for pathogens and contribute towards pathogen transmission. Therefore, healthcare hygiene requires a comprehensive approach. This approach includes hand hygiene in conjunction with environmental cleaning and disinfection of surfaces and clinical equipment. The Centers for Disease Control (CDC) Environment Cleaning Procedures, retrieved on 3/22/24 from, https://www.cdc.gov/hai/prevent/resource-limited/cleaning-procedures.html#, read in pertinent part, High-Touch Surfaces: The identification of high-touch surfaces and items in each patient care area is a necessary prerequisite to the development of cleaning procedures, as these will often differ by room, ward and facility. Common high-touch surfaces include: -bedrails -IV (intravenous) poles -sink handles -bedside tables -counters -edges of privacy curtains -patient monitoring equipment (keyboards, control panels) -call bells -door knobs Proceed from cleaner to dirtier areas to avoid spreading dirt and microorganisms. Examples include: -During terminal cleaning, clean low-touch surfaces before high-touch surfaces. -Clean patient areas (patient zones) before patient toilets. -Within a specified patient room, terminal cleaning should start with shared equipment and common surfaces, then proceed to surfaces and items touched during patient care that are outside of the patient zone, and finally to surfaces and items directly touched by the patient inside the patient zone. In other words, high-touch surfaces outside the patient zone should be cleaned before the high-touch surfaces inside the patient zone. -Clean general patient areas not under transmission-based precautions before those areas under transmission-based precautions. II. Facility policy and procedure The Housekeeping Services policy and procedure, undated, was provided by the nursing home administrator (NHA) on 3/19/24 at 11:30 a.m. It read in pertinent part, General [NAME] is start from top to bottom, cleanest to dirtiest. Start the room clean by hand hygiene and put on appropriate personal protective equipment. Knock on the door, state your name, and let the resident know you are housekeeping and here to clean the room, Place 'wet floor'/caution' sign at entrance to resident room. Spray toilet inside and outside, bathroom doorknob, sink, faucet, counter area and assist rails in bathroom with alkaline bathroom cleaner allow to set for dwell time, do not wipe yet. Spray assist rails if present with multi-surface disinfectant cleaner, allow to set for dwell time. Using a duster dust all horizontal surfaces working from high to low for TVs, over bed lights, vanity light, lamps, blinds, pictures (if present), top of door frames. III. Manufacturer's Instructions The disinfectant used in the facility was Ecolab Rapid Multi Surface disinfectant cleaner. The label on the disinfectant cleaner read in pertinent part, A one-step hospital use germicidal cleaner and deodorant designed for general cleaning, disinfecting, and controlling mold and mildew odors on hard, non-porous surfaces: 1. Pre-clean visibly soiled surfaces. 2. Apply solution with a sponge, brush, cloth, mop, low pressure mechanical spray device, or coarse trigger sprayer to hard, non-porous surfaces. 3.Spray 6-8 (six to eight) inches from the surface, making sure to wet surfaces thoroughly. All surfaces must remain visibly wet for 3-5 (three to five) minutes. IV. Observations During a continuous observation on 3/19/24, beginning at 10:30 a.m. and ending at 11:09 a.m., housekeeper (HSKP) #1 was observed cleaning room [ROOM NUMBER] on the Main unit and room [ROOM NUMBER] and room [ROOM NUMBER] on the University unit. HSKP #1 followed the same cleaning process in all three rooms. The following observations were made in each room: -HSKP #1 used a bathroom cleaner solution, which was not a disinfectant, and wiped all horizontal surfaces in each room (night stand, drawers and tray table). -HSKP #1 wiped the surfaces in each room with a water soaked soap cloth for four seconds per surface. -No high frequency touch areas (call lights, door knobs, light switches, closet handles, bathroom grab bars and bed remote) were disinfected by HSKP #1 in any of the three rooms. -The bathroom safety rail, which was shared between two residents, was not disinfected in all three rooms. During a continuous observation on 3/19/24, beginning at 11:30 a.m. and ending at 11:45 a.m., HSKP #2 was observed cleaning room [ROOM NUMBER] on the University unit. The following observations were made: -HSKP #2 diluted the surface disinfectant cleaner with water, however, the product label did not indicate the solution should be diluted with water. -HSKP #2 sprayed four sprays of the diluted Ecolab disinfectant cleaner onto a cloth and wiped downall of the horizontal surfaces in the room (night stand, drawers and tray table). The surfaces in the room remained visibly wet for less than 30 seconds. -No high frequency touch areas (call lights, door knobs, light switches, closet handles, bathroom grab bars and bed remote) were disinfected by HSKP #2. V. Staff interviews HSKP #1 was interviewed on 3/19/24 at 11:10 a.m. HSKP #1 said she did not disinfect the room with the approved disinfecting/cleaning product for the facility. She said she did not know how long the disinfectant was required to remain on surfaces. She said she did not clean all high frequency touch areas in the resident's room. HSKP #1 said she only received training when she was hired in a language she did not understand well. HSKP #1 said she was never evaluated by her supervisor. HSKP #2 was interviewed on 3/19/234 at 11:45 a.m. HSKP #2 said she did not know how long the disinfectant was required to remain on surfaces. She said she did not know what high frequency touch areas were. She said she was never supervised, evaluated and/or provided feedback regarding her room cleaning processes. The housekeeping director (HKD) was interviewed on 3/19/24 at 12:15 p.m. The DOH said there were areas of opportunity related to housekeeping and routine room cleaning procedures. The DOH said housekeeping staff did not clean the residents' rooms according to the facility's procedure. The DOH said the approved facility disinfectant should be used when cleaning resident rooms and all high frequency touch areas should be disinfected. The DOH was uncertain of the correct dwell time for the disinfectant product. The DOH said he needed to provide training to all housekeeping staff and needed to revise the current training and onboarding program to cover surface disinfectant times, room cleaning procedures and high frequency touch areas. The director of nursing (DON) was interviewed on 3/19/23 at 1:03 p.m. The DON said the surface disinfectant time of five minutes should be adhered to in order to ensure surfaces were properly disinfected and all pathogens were destroyed. The DON said high frequency touch areas should be disinfected and only approved facility disinfectant products should be used.

Based on observations, record review and interviews, the facility failed to ensure residents were free from physical restraints for two (#180 and #40) of six residents out of 34 sample residents. Specifically the facility failed to: -Ensure Resident #180 was evaluated on admission for use of a restraint; -Ensure a consent was signed for use of a restraint for Resident #180 and #40; -Ensure there was a physician's order for restraints for resident #180 and #4; and, -Ensure there was a quarterly wander risk evaluation completed for Resident #40. Findings include: I. Facility policy and procedure The Use of Restraint policy, revised April 2017, was received from the nursing home administrator (NHA) on 3/18/24 at 8:04 a.m. It revealed in pertinent part, Restraints shall only be used for the safety and well being of the residents. Prior to placing a resident in a restraint, there shall be a pre-restraining assessment and review to determine the need for restraint. Restraints shall only be used upon the written order of a physician and after obtaining consent from the resident and/or representative. Residents and/or sponsors shall be informed about the potential risks and benefits. Restrained individuals shall be reviewed regularly (at least quarterly) to determine whether they are candidates for restraint reduction, less restrictive methods of restraints, or total restraint elimination. II. Resident #180 A. Resident status Resident #180, age younger than 65, was admitted on [DATE]. According to the March 2024 computerized physician orders (CPO), diagnoses included cerebral palsy (affects a person's ability to move and their posture). The 3/7/24 minimum data set (MDS) assessment was not completed at the time of survey. The baseline care plan documented the resident had an activity of daily living (ADL) self care deficit and was dependent on staff for mobility. B. Observations On 3/13/24 at 12:47 p.m., Resident #180 was sitting in his wheelchair with a seat belt secured over his lap. On 3/18/24 at 9:11 a.m., Resident #180 was sitting in his wheelchair with a seat belt secured over his lap. A wound vacuum (vac, specialized machine for wound drainage and healing) was strapped in with the seatbelt against Resident #180 thigh. On 3/18/24 at 2:40 p.m., Resident #180 was in his room with visitors and licensed practical nurse (LPN) #3. He was sitting in his wheelchair with the wound vac next to his thigh. The seat belt was secured over the wound vac and the resident's lap. C. Record review -The March 2024 CPO failed to document a physician's order for seat belt use for Resident #180. -The 2/29/24 nursing admission assessment for Resident #180 failed to document the use of a seat belt while in a wheelchair. -The 2/29/24 baseline care place failed to document the use of a seat belt while the resident was in his wheelchair. -There was no facility safety risk evaluation completed for Resident #180 to use a seat belt while in the wheelchair. D. Staff interviews LPN #3 was interviewed on 3/18/24 at 2:42 p.m. LPN #3 said there was no order for Resident #180 to use a seatbelt restraint in the wheelchair. LPN #3 was unable to locate an assessment for use of restraints, such as a seat belt in Resident #180's electronic medical record (EMR). LPN #3 said the wound vac should not be strapped into the seatbelt as it affected the seat belt from being secured and could lead to potential skin concerns or, if the seat belt was not positioned properly, the resident could slip out and the seat belt could cause more harm than good. The director of rehabilitation (DOR) was interviewed on 3/18/24 at 3:09 p.m. THe DOR said the facility did not currently have any residents who needed a seatbelt on their wheelchair. The DOR said Resident #180 was a new admission who she evaluated on 3/6/24 but she was unaware the resident had a seatbelt. The DOR said Resident #180 would not be able to independently release the seatbelt due to his mobility issues. The director of nursing (DON) was interviewed on 3/18/24 at 3:18 p.m. The DON said the therapy department needed to complete a safety evaluation for seatbelt use and then the nursing department would obtain consent for the restraint to be used. The DON said it was important for the therapy department to evaluate the resident for safety to identify risks of entrapment and if the resident could easily release the seatbelt if he needed to get out of the wheelchair. The DON said the wound vac should not be secured with the wheelchair seatbelt. III. Resident #40 A. Resident status Resident #40, age greater than 65, admitted on [DATE]. According to the March 2024 CPO, diagnoses include Alzheimer's disease (memory impairment), dementia (memory impairment) and chronic kidney disease (decreased kidney function). The 1/4/24 MDS assessment revealed the resident had moderately impaired short term and long term memory impairment. The assessment did not document the use of a wander/elopement device. B. Record review Review of Resident #40's care plan initiated on 5/26/19, documented the resident was an elopement/wander risk related to history of wandering behaviors and would not be able to find her way back. The care plan further revealed on n 1/6/21 the wander guard was discontinued secondary to Resident #40 not exhibiting wandering behaviors. The care plan indicated the wanderguard was replaced on 5/22/23 as Resident #40 preferred to keep the wander guard on and became upset when it was removed. -However, the resident did not attempt to exit the facility without staff assistance. The care plan interventions placed by the facility included a wandering/elopement risk evaluation to be completed on admission,quarterly and as needed. The 1/3/22 wander risk evaluation documented Resident #40 was a low risk for elopement/wandering. -There were no further wander risk evaluations documented in Resident #40's EMR after 1/3/22. -The 7/6/23, 10/5/23 and 1/4/24 MDS assessments all documented Resident #40 did not have a wander/elopement alarm. Restorative certified nurse aide (CNA) documentation identified Resident #40's wander guard was checked for proper function 13 times in March 2024 and 12 times in February 2024. A consent for the wander guard was signed on 5/10/19 by Resident #40. -There was no new consent signed for the 5/22/23 reapplication of the wander guard. The March 2024 CPO documented an order, initiated on 3/13/24 (during the survey), to place a wander guard to person for safety per resident's request/comfort. Check functioning every shift. C. Staff interview The DON was interviewed on 3/18/24 at 3:30 p.m. The DON said she did not know why there was not an order to check wander guard placement for Resident #40 until 3/13/24 (during the survey). The DON said the last order to check placement for the wander guard was discontinued on 1/7/21 but she was unable to determine why it was discontinued. The DON said the facility should have obtained a new consent when the wander guard was reapplied to Resident #40. The DON said a restorative CNA was responsible to check the function of the wander guards and it should be completed at least weekly. The DON said residents should be re-evaluated for wandering on admission and quarterly. IV. Facility follow-up The facility provided documentation for Resident #180 on 3/19/24, after the survey was completed, which included the following:. -Safety device authorization and consent signed on 3/18/24 (during the survey) for a seat belt to the resident's motorized wheelchair.

Based on record review and interviews, the facility failed to ensure one (#1) of three residents out of eight sample residents received treatment and care in accordance with professional standards of practice. The facility failed to identify and respond to Resident #1's non-pressure related skin condition resulting in the development of osteomyelitis (bone infection), hospitalization and amputation of his left great toe. Resident #1, diagnosed with heart disease with heart failure and type 2 diabetes mellitus, was admitted to the facility 12/14/21. The facility failed to follow standards of practice in identifying, documenting, reporting to physicians and providing treatment per physician orders. The facility responded by educating nursing staff on the appropriate protocol for wound identification, management, condition changes and notification to appropriate parties. The education proved to be ineffective when the nurses were interviewed and revealed they were not able to identify when a skin condition should be reported to the doctor and documented. The plan was not comprehensive enough and had not included those who were diabetic and dependent with mobility. In addition, the licensed practical nurse (LPN) #4 who had completed the skin assessment on Resident #1 on 10/3/23 had documented there were no wounds. Hospital records revealed it resulted in the distal aspect of Resident #1's left great toe to be necrotic (death of cells or tissue) with an open wound down to bone. The x-ray series of the left foot showed the osteomyelitis of the left great toe with destruction of the distal aspect of the phalanx (bones in toe). Resident #1 required evaluation and treatment at the emergency department (ED), eight days of hospitalization from [DATE] to 10/13/23 with amputation of the great left toe. The facility's failure to implement an immediate and comprehensive review of the facility's system and response to Resident #1's non-pressure related skin condition, placed residents at risk for serious harm if not immediately corrected. Findings include: I. Immediate Jeopardy A. Findings of immediate jeopardy Review of the investigation of the resident's skin breakdown on 10/6/23 for Resident #1, observations conducted from 10/12/23 through 10/17/23 and staff interviews revealed the facility failed to take immediate and comprehensive steps following discovery of Resident #1's left great toe necrosis and opened wound down to bone on 10/6/23. There was no evidence the facility thoroughly investigated the incident to uncover and address root cause analysis and uncover why the nurses completed inaccurate assessments. B. Facility notice of immediate jeopardy On 10/12/23 at 4:15 p.m. the nursing home administrator (NHA) was notified that the facility's failure to identify and respond to preventable skin conditions created an immediate jeopardy situation. C. Facility plan to remove immediate jeopardy On 10/16/23 at 5:59 p.m. the facility submitted a final plan for the immediate jeopardy. The plan read: On 10/12/23 facility will immediately assess all residents who are bed fast, diabetic, dependent with toileting, dependent with transfers and dependent for bathing and are at risk for developing wounds and implement interventions to prevent the development of wounds. Their care plans will be reviewed and updated to ensure interventions are in place Beginning 10/12/23 and completed 10/15/23 the facility assessed all residents currently residing at community for developing wounds and implemented interventions to prevent the development of wounds. Residents identified in this full house skin sweep as having skin breakdown their care plans were reviewed and updated to ensure interventions are in place by 10/15/23. Beginning 10/12/23 100% of Nursing staff ( RN's [Registered nurses], LPN's [licensed practical nurses] and C.N.A's [certified nurse aides]) will be educated before they work their next shift until completed to ensure they can identify and respond appropriately to skin condition concerns (including infections, pain, etc) with any other residents. IDENTIFICATION Residents will receive the care and services necessary to prevent the development of additional wounds and /or worsening wounds. The facility will ensure the tracking of all wounds is accurate, consistent, and complete. In addition, the facility will ensure residents with risk for skin breakdown are identified utilizing the admission data collection tool, the RAI (resident assessment instrument) care planning process, and the Braden scale, and review of comorbidities and will provide treatment interventions associated with those risks and monitoring of wounds to prevent wounds from declining. On 10/12/23 the facility immediately evaluated all residents' skin who are at risk for developing wounds and implemented interventions to prevent the development of wounds. Residents identified in this full house skin sweep as having skin breakdown their care plans were reviewed and updated to ensure interventions are in place by 10/15/23. SYSTEMIC CHANGES Beginning 10/12/23 100% of Nursing staff ( RNs , LPNs, C.N.As) prior to working their next shift will be educated until completed to ensure they can identify and respond appropriately to skin condition concerns (including infections (including osteomyelitis and sepsis), pain, etc) with any other residents. Residents will be reviewed for their risk of skin breakdown on admission utilizing the Braden and the admission skin assessment, weekly times four weeks after admission, quarterly, annually, and with significant changes in status, which includes development of wounds. Licensed nurses communicate any newly identified wounds to the IDT (interdisciplinary team) via the 24 hour communication report. Residents with wounds will be reviewed and progress will be evaluated weekly with corresponding documentation. All of the residents residing at the facility will have a total skin evaluation completed weekly by a licensed nurse, which is documented in the treatment administration record on (medical record system). Immediate action to include treatment orders and notification of MD (medical doctor)/family will be provided for any issues noted. The care plans will be reviewed/revised/updated as indicated at that time. Beginning 10/12/23 completed 10/15/23, 100% of all licensed nursing staff and C.N.A's will be inserviced on the system above as well as identification, treatment, and prevention of wounds according to policy and procedure and required actions when a wound is identified. Those who didn't attend education will be provided 1:1 (one-to-one) education prior to their next working shift. Any agency staff will be educated prior to working their scheduled shift. MONITORING The Nurse Managers will review the resident's treatment records for completion of the weekly skin assessments as well as ordered treatment documentation three times a week for one month, and then weekly for one month, then monthly and prn (as needed) until a pattern of compliance has been met. (Medical record system) telephone orders will be reviewed in the morning meeting (stand-up) to review new orders and follow up as needed. Quality of care rounds will be completed by the DON/MDS/designee weekly for three months and then prn to ensure care planned interventions for residents with wounds are in place. Issues identified will be corrected at that time with on-the-spot reeducation. The completed quality of care rounds will be reviewed by the QAPI (quality assurance and performance improvement) team recommendations will be addressed as needed to ensure continued compliance. Results of treatment sheet reviews will be reviewed by the QAPI committee. Recommendations will be addressed as needed to ensure continued compliance. Identified issues will be reported to the monthly QAPI committee to ensure the plan has been implemented, achieved, sustained and evaluated for its effectiveness. D. Removal of immediate jeopardy Based on the facility's plan above, the immediate jeopardy was removed on 10/16/23 at 5:59 p.m. However, deficient practice remained at a G scope and severity. II. The facility failed to identify and respond to Residents #1's non-pressure related skin condition A. Professional reference [NAME], J. L. L., [NAME], Y. G. et al. (2019). Optimal management of diabetic foot osteomyelitis. Diabetes Metabolic Syndrome and Obesity. National Library of Medicine. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6593692/ retrieved on 10/13/23. Diabetic foot osteomyelitis (DFO) is the most frequent infection associated with diabetic foot ulcer, occurs in >20% of moderate infections and 50-60% of severe infections and is associated with high rates of amputation. DFO represents a challenge in both diagnosis and therapy, and many consequences of its condition are related to late diagnosis, delayed referral, or ill indicated treatment. B. Facility policy and procedure The Pressure Ulcers/Skin Breakdown Clinical Protocol policy and procedure, revised April 2018, was provided by the DON on 10/12/23 at 3:19 p.m. It read in pertinent part, Assessment and recognition: The nursing staff and practitioner will assess and document an individual's significant risk factors for developing pressure ulcers; for example, immobility, recent weight loss, and a history of pressure ulcer(s). In addition, the nurse shall describe and document/report the following: full assessment of pressure sore including location, stage, length, width, and depth, presence of exudates or necrotic tissue; pain assessment; resident's mobility status; current treatments, including support surfaces; and all active diagnoses. The Acute Condition Changes Clinical Protocol policy and procedure, revised March 2018, was provided by the DON on 10/12/23 at 3:19 p.m. It read in pertinent part, Assessment and recognition: Direct care staff, including nursing assistants will be trained in recognizing subtle but significant changes in the resident (for example, a decrease in food intake, increased agitation, changes in skin color or condition) and how to communicate these changes to the nurse. C. Resident #1-risk of skin breakdown 1. Resident status Resident #1, age 93, was admitted on [DATE]. According to the October 2023 computerized physician orders (CPO), the diagnoses included heart disease with heart failure and type 2 diabetes mellitus. The 9/21/23 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score of 14 out of 15. He was totally dependent with the assistance of two people for transfers, the extensive assistance of one person for bed mobility, dressing, toileting, personal hygiene and supervision with set up assistance with eating. He did not have any pressure wounds, venous or arterial wounds or diabetic foot wounds. He was at risk for pressure ulcer/injury. His Braden scale for predicting pressure sore risk assessment was conducted 8/1/23 and revealed a score of 14 indicating a moderate risk. 2. Review of 10/6/23 incident On 10/12/23 at 11:56 a.m. the DON provided the investigation of the resident's skin breakdown on 10/6/23. The report revealed the following in pertinent part: Wound chart audit: Resident #1 current wound left great toe. Medication/orders: left great toe status post twice a day 3/30/22 to 4/13/22; collagen 3/23/22 to 3/30/22; Right great toe: xeroform dressing 3/12/22 to 3/16/22; 3/10/22 to 3/12/22. Wound history: On 10/6/23 showered by CNA after dinner, noted left great toe open. 4/13/22 left great toe vascular resolved. 3/23/22 left great toe stable. 3/16/22 left toe improved. 3/9/22 right toe 'error' is left toe. 3/2/22 antibiotics initiated left toe infection, mild infection. Braden: 8/1/23 score 14. Pain 6 (scale 1-10). Labs: 10/2/23 white blood counts within normal limits. Skin evaluation dates: 10/3/23 LPN #4 no new wounds; 9/26/23 LPN #4 no new wounds; 9/19/23 LPN #4 no new wounds; 9/12/23 LPN #4 no new wounds; 9/5/23 LPN #1 no new wounds; 9/3/23 LPN #5 no new wounds; 8/28/23 LPN #5 no new wounds; 8/22/23 LPN #4 one new wound but no note; 8/20/23 LPN #1 no new wounds; 8/13/23 LPN #5 no new wounds; 8/8/23 LPN #4 no new wounds; 8/1/23 LPN #4 no new wounds; 7/25/23 LPN #3 no new wounds. Nurses notes: 7/7/23 podiatrist no areas of concern; 4/7/23 podiatrist no areas of concern. Add foot cradle to bed, chart review, staff interviews. Interviews conducted by DON: 10/6/23 CNA #1: Last night after giving him a shower. There was already a bandaid on it. It's been awhile since I've worked with him. LPN #4: Noticed for a couple months. Was on the list for wound cleanser and bandaid. No order in chart. 'I think there was, seriously you have to check. It has been intact, didn't question wound rounds or need to report.' One-to-one education. LPN #3: Last I saw it, it was just a scab. LPN #4 was doing treatment on days. Last saw it as scab four days ago. Education on scab versus eschar. Podiatrist debrided eschar, resulting in exposed wound. Skin evaluations, started 10/6/23 for residents with a Braden score of 12 and less and if history of skin impairment. -However, Resident #1 had a score of 14 (see Braden scale above) which identified him at moderate risk but he would not have been included in the skin evaluations based on this criteria. 3. Record review-steps taken after the resident's skin breakdown identified on 10/6/23. The 10/3/23 total body skin assessment, conducted weekly, was reviewed. It revealed the skin assessment was conducted by LPN #4. It documented Resident #1 had no new wounds. 10/6/23 at 4:05 a.m. Health status note: Resident's shower provided by female CNA after dinner, noted his left great toe open area, toe red and warm to touch. Cleansed area with wound cleanser, pat dried and covered with bandaid temporarily. To notify the wound nurse when she comes early this morning. Podiatrist visit 10/6/23 revealed, Left great toe distally has a wound that is palpable to bone. The bone feels as if it has deteriorated and is infected. The distal phalanx appears to be destroyed distally. X-rays three views, augmentin 875 mg bid until patient can get into the hospital. Patient should be transferred to (hospital name) today for evaluation and treatment of the left toe pending approval from vascular. 10/6/23 at 12:08 p.m. Social services note: Resident was seen by the podiatrist today. Podiatrist recommended resident be sent out to the hospital for treatment of osteomyelitis of the L (left) big toe on the L foot. Podiatrist did explain to resident that he will likely need the toe amputated. Podiatrist spoke with the resident's nurse. Nurse is calling resident's doctor and POA (power of attorney). 10/6/23 at 1:37 p.m. Infection note type and location of infection: Left great toe. Osteomyelitis. Current Signs and Symptoms: Inflammation of bone caused by infection. Adverse Reactions: none. Treatment/Response: Vital signs within normal limits: 101/69 (blood pressure),70 (heart rate), 16 (respiration), 91% Room Air (oxygen saturation), 97.5 (temperature). Alert and Oriented x3 (person, place, and time) baseline. Podiatrist visited with resident and ordered that he be sent to the ER (emergency room ) for vascular consult, and treatment. Resident is Full Code and agreed to go to the ER for treatment. Hospital notes Resident #1 was admitted to hospital on 10/6/23 at 2:15 p.m. Emergency department encounter noted in pertinent part, The distal aspect of his left great toe is necrotic with open wound down to bone. X-ray series of the left foot shows the osteomyelitis of the left great toe with destruction of the distal aspect of the phalanx. Patient summary in pertinent part, Nursing home resident sent to hospital by nursing home podiatrist for admission on 10/6/23 for suspect osteomyelitis of left great toe with open painful wound, elevated CRP (for tracking infections). Interval history: Left great toe remains sore. Says he has been receiving care for this at the skilled nursing facility (SNF) where he stays. -However, the facility had no physician orders for wound care to the left toe, the nursing staff had not documented there was a wound, the nurses were applying wound cleanser and a bandaid. Hospital assessment and plan: Diabetic foot infection left great toe, likely osteomyelitis. Ceftrianone and vancomycin (antibiotics) initiated in the ED 10/6/23 and have been continued. Open wound with [NAME] drainage, toe appears necrotic. Reason for continued hospitalization : IV(intravenous) antibiotics and surgical intervention for left great toe. Surgery 10/8/23, pre and postoperative diagnosis: Left great toe infection. Principal procedure: Left great toe amputation with primary closure. Resident #1 was discharged back to the facility on [DATE] at 4:24 p.m. Operative procedure performed: Amputation left great toe. III. Staff interviews LPN #1 was interviewed on 10/12/23 at 11:25 a.m. She said she was the wound care nurse that rounded with the wound physician once a week. She said skin assessments were scheduled and done during shower day by the CNAs and nurses. She said if a skin issue was identified they would notify her by text message right away and she would follow up with the resident and include those residents in the wound care physician rounds. She said she had not been notified by the staff that Resident #1 had a scab. She said skin issues and skin assessments were documented on the skin assessment form in the resident's medical record and there was a check off box on the treatment assessment record (TAR) that a skin assessment was completed. The wound care physician would come in once a week for residents that were identified with skin issues or wounds. She said she was not able to follow up with Resident #1's scab since the nursing staff had not notified her. The DON was interviewed on 10/12/23 at 11:30 a.m. She said that Resident #1 was not on wound care physician rounds. She said LPN #3 notified her on 10/6/23 that Resident #1 had a wound on the left great toe. She said she notified the podiatrist on 10/6/23 and he came in, assessed the wound and recommended Resident #1 be transported to the hospital for evaluation and treatment for osteomyelitis of his left great toe wound. She said there was no documentation on the skin assessment forms of new wounds and no prior notification by nurses of an existing wound. She had been told by nurses during interviews they had known about the scab on Resident #1's left great toe. She said they conducted an investigation and had interviewed nurses and began auditing every resident with a Braden score of 12 or less. They were in the process of educating staff on how to identify wounds and what to do after a wound had been identified. She said the cause of the wound was due to the resident's immobility and diabetes diagnosis. The medical director (MD) was interviewed on 10/12/23 at 1:36 p.m. He said he was a wound care certified physician. He said he became aware on 10/6/23 that Resident #1 had developed a wound on his foot and ended up in the hospital that required an amputation. He said Resident #1 was in bed all the time and never got out of bed. He said Resident #1 was difficult to reposition. He said Resident #1 was a high risk of developing wounds on his feet and losing more toes. He said Resident #1 had issues with arterial insufficiency. He said a protective boot would have helped prevent the formation of the wound. He said for someone who had diabetes or was compromised, a wound would take at least a week to develop. LPN #3 was interviewed on 10/12/23 at 2:10 p.m. She said skin assessments were done from head to toe scheduled weekly during the resident's showers. She said when nursing staff identified any new wound issues they were reported to the wound nurse and the DON. She said any new or existing skin wound or issue should be documented under the skin assessment in the resident's medical record. She said a new scabbed area was reported depending on whether it looked like it was healing, if it appeared to be healing then it was not a problem and reporting was not needed. She said if a scabbed area looked like it was getting worse then it would be reported. She said Resident #1 had a scabbed area on his left great toe for approximately three weeks and had looked like it was dried blood and appeared to be healing. She said she was called on 10/5/23 after Resident #1's shower and the scab had come off the left great toe and it was bleeding and the toe was red. She placed a bandaid on it at that time and notified the wound nurse and the DON on 10/6/23 in the morning. LPN #4 was interviewed on 10/12/23 at 2:44 p.m. She said skin assessments were done during shower time once a week. She said that if a new skin issue was identified a skin risk assessment was done and the doctor, the DON and the wound nurse was called in order for there to be follow-up with the wound doctor. She said skin conditions should be reported and assessed were moisture associated skin damage, new open areas, abrasions and scabbed areas that were new. She said she was aware of the wound on Resident #1's left great toe and said an evening nurse had noticed it approximately two weeks ago. She said it had not been documented in the medical record and it had not been reported to the physician, wound nurse or DON. She said staff had thought he had just hit his foot on the footboard of his bed. IV. Facility follow-up Documentation was received from the DON on 10/12/23 at 3:19 p.m. The action plan for wounds read in pertinent part, Compliance plan Pressure injuries. Through the facility's own quality monitoring and QAPI plan the facility has self identified some deficient practices pertaining to the pressure injury system, those include but are not limited to: Action plan: All residents Braden reviewed for risk. Any resident that has a Braden of 12 or less a complete skin assessment to be completed. Any areas of concern that are noted during assessment will be documented, physician will be notified, and treatment will be implemented. Residents found with wounds that indicate an assessment need from the wound MD will be added to the rounding list. All CNAs and nurses will be educated on the appropriate protocol for wound identification, management, and condition changes. Education will also include notification to appropriate parties. Correction: Residents will receive the care and services necessary to prevent the development of additional pressure injuries and/ or worsening pressure injuries. The Facility will ensure the tracking of pressure injuries is accurate, consistent, and complete. In addition, the facility will ensure residents with risk for skin breakdown are identified and will provide treatment interventions associated with those risks and monitoring of pressure injuries to prevent pressure injuries from declining. Identification: On or before 10/9/23 DON/designee will review records of those residents residing at the facility, specifically the most recent Braden risk score, to identify those residents at low, medium, and high risk for development of pressure injuries. The care plans will be reviewed/revised/updated as indicated to ensure interventions are in place to address identified risks at that time and identify any resident whose care plan may not appropriately address resident's risk. The DON/designee will meet along with IDT to evaluate all residents currently with pressure injuries to review current care plan interventions (including mattress and cushion) to evaluate effectiveness. Care plan will be revised if indicated. Systemic changes: Residents will be reviewed for their risk of skin breakdown on admission, weekly times four weeks after admission, quarterly, annually, and with significant changes in status, which includes development of new pressure injuries. Licensed nurses communicate any newly identified pressure injuries to the IDT via the 24 hour communication report. Residents with pressure injury will be reviewed daily and pressure injury progress will be evaluated weekly with corresponding documentation. All of the residents residing at the facility will have a total skin evaluation completed weekly by a licensed nurse, which is documented in the treatment administration record. Immediate action to include treatment orders and notification of MD/family will be provided for any issues noted. The care plans will be reviewed/revised/updated as indicated at that time. Prior to 10/23/23 all licensed nursing staff will be inserviced on the system above as well as prevention of pressure injury according to policy and procedure and required actions when a pressure injury is identified. An attendance sheet will be kept and reconciled with an active roster of licensed nursing staff and those unable to attend will be provided with 1:1 reeducation. Prior to 10/23/23 all CNA's will be inserviced on prevention of pressure injuries. An attendance sheet will be kept and reconciled with an active roster of CNA's and those unable to attend will be provided with 1:1 reeducation. Monitoring: The nurse managers will review the resident's treatment records for competition of the weekly skin assessments as well as ordered treatment documentation three times a week for one month, and then weekly for one month, then monthly and prn until a pattern of compliance has been met. Telephone orders will be reviewed in the morning meeting (stand-up) to review new orders and follow up as needed. DON and/or designee will facilitate. Quality of care rounds will be completed by the DON/MDS/designee weekly for three months and then prn to ensure care planned interventions for residents with pressure injuries are in place. Issues identified will be corrected at that time with on the spot reeducation. The completed quality of care rounds will be reviewed by the QAPI team Recommendations will be addressed as needed to ensure continued compliance. Results of treatment sheet reviews will be reviewed by the QAPI committee. Recommendations will be addressed as needed to ensure continued compliance. Identified issues will be reported to the monthly QAPI committee to ensure the plan has been implemented, achieved, sustained and evaluated for its effectiveness. Compliance 10/31/23. -However the plan had not included a complete skin assessment for those who were diabetic and for those who were dependent with functional mobility. It had included a plan to screen residents with a Braden score of 12 or less however Resident #1 had a score of 14 and would have been missed using this criteria. The nurse staff education did not include a written test to assess knowledge base.

Based on observations, interviews, and record review, the facility failed to ensure respect and dignity during resident to resident interactions in three (#50, #36, and #2) of three out of 32 sample residents. The facility failed to ensure Resident #50 had a dignified living experience. The facility failed to address complaints made by Resident #50 regarding negative comments and name calling being said to her by Resident #20 since October 2020. Resident #20 made comments regarding Resident #50's weight, which weretwo-ton, fat, and lazy. When Resident #50 was called these names, it made her feel self-conscious about her weight, humiliated, was embarrassing in front of her friends, and made her feel less of herself. The facility failed to ensure Resident #36 was not subjected to racially insensitive comments made by another resident, which in turn was hurtful and made him feel angry, hurt, discriminated against, and awful bad. In addition, the facility ensure staff were knocking on doors before entering. Findings include: I. Resident status A. Resident #50 status Resident #50, age 41, was admitted on [DATE]. According to the August 2021 computerized physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] The 4/14/21 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) assessment score of 15 out of 15. The resident required extensive assistance for activities of daily living. The resident had no behaviors. B. Resident #20 status Resident #20, age 87, was admitted on [DATE]. According to the August 2021 CPO, diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] The 6/1/21 MDS assessment revealed the resident had a moderate cognitive impairment with a BIMS assessment score of 11 out of 15. The resident required extensive assistance for activities of daily living. It indicated the resident had no behaviors. II. Resident #50 interviews and observation Resident #50 was interviewed on 8/11/21 at 2:20 p.m. She said Resident #20 calls her two-ton. She said Resident #50 will also call her fat and lazy. She said when this happened it humiliated her as she was self-conscious about her weight. She said staff was aware of this situation but nothing had been done. She said this had been happening since October 2020. During an interview with Resident #20 on 8/12/21 at 9:46 a.m., the resident referred to Resident #50 as two- ton. She said the resident had certified nurse aides in her room for an excess amount of time because she was talking to them and that took time away from the rest of the residents. The resident was interviewed again on 8/13/21 at 5:41 p.m. She said she had an interaction with Resident #20 earlier in the day in the smoking area. She said Resident #20 yelled two-ton repeatedly while Resident #50 was being pushed inside by the life enrichment assistant (LEA) #2. She said LEA #2 told her to ignore Resident #20 and not give Resident #20 a reaction. She said she did not file a grievance but told the social worker (SW) who said he would come by later in the day to talk. She said the interaction was embarrassing as it happened in front of her friends and that it made her feel less of herself. The resident was interviewed on 8/17/21 at 2:21 p.m. She said the SW never came by following the incident with Resident #20 on 8/13/21. III. Record review -Review of Resident #50's and Resident #20's medical record failed to show any evidence that the negative comments were addressed. IV. Staff interviews The LEA #2 was interviewed on 8/17/21 at 9:37 a.m. He said that on 8/13/21, he was pushing Resident #50 in the smoking area when Resident #20 began to yell two-ton repeatedly. He said he told Resident #50 to ignore Resident #20's comments and name calling and not to give her attention. He said Resident #20 makes negative comments to a few of the residents at the facility. Certified nurse aide (CNA) #3 who worked with the resident on a regular basis was interviewed on 8/17/21 at 2:10 p.m. She said Resident #20 called Resident #50 negative names almost daily. She said the nursing home administrator, director of nursing, and social worker knew about this but that nothing had been done. The SW was interviewed on 8/17/21 at 3:30 p.m. He said he had spoken to Resident #20 about her behaviors but that he could not tell her what she can or cannot say to other residents. He said Resident #50 had agreed to move to a new room in order to decrease interactions with Resident #20. He said he was made aware of these negative interactions between the residents a week prior. He said that Resident #50 reported to him that the name calling made her uncomfortable and self conscious as she was already self conscious about her weight and these interactions did not make her feel good. The DON was interviewed on 8/17/21 at 3:35 p.m. She said Resident #20 had been calling Resident #50 negative names for a few months. She said she heard the name calling on one occasion. She said she immediately talked to Resident #20 about it but it continued. V. Resident #36 A. Resident status Resident #36, age 91, was admitted on [DATE]. According to the August 2021 CPO diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The 6/15/21 minimum data set (MDS) assessment showed the resident was cognitively intact with a brief interview for mental status (BIMS) of 15 out of 15. The resident was independent in all self care areas. The resident had no behavior issues. B. Resident interview Resident #36 was interviewed on 8/11/21 at 10:33 a.m. The resident said he could not relax living here at the facility. He said he had lived at the facility for the past five years and has had six different roommates. He said Resident #1 used to be his roommate, however, he moved approximately six months ago. Resident #1 was moved because he was making racial comments and name calling to him. The name calling was in regards to using the N word (considered a racial slur) to an African American male resident. He said when he was moved, he was moved directly across the hall from his room, and now he continued to use the N word toward himself and his current roommate. Resident #36 went on to say that the comments made him angry, and it was hurtful and made him feel awful bad and he did not understand why the facility had not done anything about this problem. He said the staff were aware and he did not like being treated this way, he feels he was discriminated against. C. Resident #1 Resident #1, age 93, was admitted on [DATE]. According to the August 2021 computerized physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The 5/5/21 minimum data set (MDS) assessment revealed the resident had severe cognitive impairment with a brief mental status (BIMS) score of two out of 15. The resident required limited assistance of one person for bed mobility, transfers, bathing, hygiene, dressing and toilet use. He required supervision for mobility and eating. The resident was coded for having adequate vision without glasses. The resident was coded for not exhibiting verbal behaviors directed towards others. D. Observation On 8/11/21 at 9:00 a.m.,the resident was observed to be sitting in his doorway. Resident #1's room is directly across from Resident #36's room. On 8/11/21 at 9:33 a.m., the resident was observed to be walking with restorative certified nurse aide (RCNA) #2 down the hall. Resident #1 said to the RCNA #2 that he just saw that N word down the hall by his room. RCNA #2 did not address what Resident #1 said and continued to encourage him to focus on his walking. E. Record review Resident #36's electronic medical record failed to show any evidence that the facility reacted and handled this situation accordingly. F. Interview The RCNA #2 was interviewed on 8/17/21 at 11:28 a.m. The RCNA #2 said she had heard Resident #1 say the ' N word on 8/11/21 while he was walking in the morning. She said she would try to encourage him to talk about something else, but did not address what he was saying. She said Resident #1 said that word often and had heard him say it more than once. She said Resident #1 has talked about his wife having an affair with an African American man and that was why she believed he said that word when he saw the two African American residents who live across the hall from him. She said Resident #1 was roommates with an African American resident and the facility moved him across the hall when they identified he was calling his roommate the N word. She said she thought moving Resident #1 to a different hall would make a difference because he would not see the African American resident every day and having him live across the hall from him gives him more opportunity to say that word. Certified nurse aide (CNA) #3 was interviewed on 8/17/21 at a.m. The CNA confirmed Resident #1 called both Resident #36 and another resident the derogatory name (N word). The CNA said she had reported it to the administration, however, nothing had come of it. She said that she knew it bothered the gentlemen it was said to. CNA #3 said the resident had an experience in his past life with his wife having an extra marital affair with an African American man. She said that did not justify the reason to call the residents the derogatory name. The social worker (SW) was interviewed on 8/17/21 at 3:33 p.m. The SW said he was aware that Resident #1 used the N word toward Resident #36. The SW said that he has heard Resident #1 use the N word toward Resident #36. He said he had explained why it was inappropriate to use the word, however, he hoped it stuck. He said each time it was used a grievance form should be filled out. However, the SW said there have been no grievances filled out. VI. Knock on door A. Resident status Resident #2, age 62, was admitted [DATE]. According to the August 2021 CPO diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The 5/5/21 minimum data set (MDS) assessment showed the resident was cognitively intact with a BIMS score of 15 out of 15. The resident required supervision with personal hygiene. B. Resident interview Resident #2 was interviewed on 8/12/21 at 9:52 a.m. The resident said that he did not like when staff entered his room without knocking. He said they just rush in without knocking. He said he had complained but had not had any resolution. C. Observations The resident's door had a sign on it to knock before entering. On 8/11/21 at 11:00 a.m.,the certified nurse aide (CNA) #5 taking orders for the meal was observed to go in and out of resident doors without knocking. On 8/12/21 at approximately 2:00 p.m., licensed practical nurse (LPN) #2 was observed to enter a room without knocking. On 8/16/21 at approximately 10:00 a.m., an unidentified housekeeper walked into Resident #2's room without knocking. D. Record review The grievance form was completed on 6/1/21 which documented LPN #5 entered the residents room without knocking. The grievance documented they (staff) walk right in, regardless if the door is open or shut. E. Interview The DON was interviewed on 8/18/21 at 11:55 a.m. The DON said she received the grievance and educated the LPN to be supportive to the resident and to knock before entering the room. She said she would provide education.

Based on observations, record review and interviews, the facility failed to ensure infection control practices were established and maintained to provide a safe, sanitary and comfortable environment to help prevent the possible development and transmission of Coronavirus (COVID-19) and other communicable diseases and infections. Specifically, the facility failed to ensure staff applied appropriate personal protective equipment (PPE) when entering the room of a resident who tested COVID-19 positive, as well as when entering the room of a recently admitted resident in quarantine. In addition, the facility failed to implement symptom-based strategy and exclude an employee from work following her report of signs and symptoms of COVID-19. These failures created the likelihood of serious harm, the spread of highly infectious COVID-19 to facility residents on two or four facility units, if not immediately corrected. Findings include: I. Status of COVID-19 in the facility The first known positive COVID-19 case at the facility was Resident #1 on 6/30/2020, according to the director of nursing (DON) in an interview on 7/8/2020 at 12:35 p.m. She said Resident #1 left the facility to go shopping, so he was tested for COVID-19 on 6/24/2020. His results came back positive on 6/30/2020. She said after Resident #1 was confirmed positive for [MEDICAL CONDITION], the facility isolated the resident, notified the local health department, and implemented testing for all the residents in the facility 7/1/2020-7/2/2020. She said the facility also re-educated staff on proper isolation precautions including PPE use; however, not all staff received the education. She said there were no other residents with symptoms of COVID-19 or with positive results, although some residents' results were still pending. II. Immediate Jeopardy A. Findings of immediate Jeopardy 1. Failure of staff to don appropriate PPE prior to entering a COVID-19 positive resident's room and the room of a recently admitted resident who was on 14-day quarantine. a. On 7/8/2020 at 1:58 p.m., agency registered nurse (RN) #1 donned a gown and gloves outside the room of Resident #1, who had tested positive for COVID-19 on 6/30/2020. She wore a surgical mask, gown and gloves; she did not don an N95 respirator or other respirator-type mask and she did not don any eye protection. She knocked and entered the resident's room. At 2:02 p.m., RN #1 exited the room wearing only a surgical mask and she immediately went down the hallway and entered room [ROOM NUMBER] to answer the call light. b. On 7/8/2020 at 12:58 p.m., the call light was on outside of Resident #4's room. There was an isolation cart outside the room. The resident's door was open and Resident #4, who was admitted to the facility 6/26/2020 and resided in bed A, was in his wheelchair with his back to the door. At 1:02 p.m., agency certified nurse aide (CNA) #1 entered the room wearing a surgical mask; she did not don any PPE. When the resident asked for ice water, the CNA reached across the resident for his water pitcher and exited the room. She walked down the hallway toward the dining area of the Freedom unit, returning to Resident #4's room with a pitcher of ice water. 2. Failure to implement symptom-based strategy and exclude an employee from work following her report of signs and symptoms of COVID-19. On 6/28/2020 at 6:36 a.m., agency CNA #4 reported to the facility that she had a fever the day before (6/27/2020). She also reported she had a new cough, shortness of breath (SOB) and had been around her cousin who was in close contact with an individual who tested positive for COVID-19. Review of the facility schedules and interviews with staff revealed CNA #4 worked at the facility on 6/30/2020 and 7/1/2020, during the period, per the CDC, she was to be monitored for symptoms. The above failures in infection control practices created an immediate jeopardy situation with the likelihood of serious harm to residents, staff, and others if not corrected immediately. On 7/9/2020 at 6:15 p.m. the nursing home administrator (NHA) and DON were notified the above failures created a situation of immediate jeopardy in infection prevention and control (F880). B. Plan to remove the immediate jeopardy On 7/10/2020 at 9:36 a.m., the NHA provided a plan to remove the immediate jeopardy. The plan read: Proposed removal Plan -Facility staff failed to wear PPE in a room with a resident who is COVID positive. Residents that are COVID positive, potentially could be affected by this statement of alleged deficient practice, therefore, this plan of correction is written to address all such residents. One resident (Resident #1), was identified during the survey. On 7/9/2020 at 9:30 p.m., NHA, DON, staff development coordinator (SDC) and/or qualified designees initiated re-education to the licensed staff, CNAs, dietary, housekeeping, laundry, maintenance and administrative staff on the expectation and importance to wear PPE in a room with a resident who is COVID positive. Staff members who are on vacation or currently off shall be provided re-education upon return to work. Re-education will also include documentation return demonstration of proper PPE donning and utilization. The facility will track training to ensure that all facility and agency staff receive training at the beginning of their shift. Training will continue every shift until all staff have received the mandated training. The NHA is responsible to ensure compliance is achieved and maintained. -The facility failed to ensure proper screening was completed for an employee who stated signs/symptoms of COVID No specific recipients were identified in this alleged statement of deficient practice. Therefore, this plan is written to address all residents residing in the facility. Employees shall continue to be screened prior to starting of their work assignments. Employees who have been identified with signs/symptoms of COVID shall not be allowed to pass the screening desk, sent home and the findings shall be noted on the screening tool. Immediately, the screener shall notify the NHA, DON, SDC, and/or qualified staff member shall follow-up directly with the team member for additional inquiry and follow-up of their condition, need for further action and/or removal from the shift assignment. All staff assigned to complete employee, resident and visitor screening will have mandatory re-education, provided by the NHA, DON, SDC and/or qualified designee, regarding the pre-shift screening process. Re-education will include directives to immediately notify the NHA and DON, or qualified designee, of any identified signs/symptoms during a screen. Re-education was initiated on 7/9/2020 at 9:30 p.m., and will continue every shift until all staff have received the mandated training. The NHA, DON, SDC initiated re-education of licensed staff and managers regarding what to do in the event an employee demonstrates signs/symptoms during a shift, including immediate notification to the NHA, DON, and/or infection control preventionist (ICP), so appropriate follow-up action can be completed with the identified individual in a timely fashion. This shall include but not limited to, refusal for admittance back into the facility until notification of clearance has been provided by the NHA, DON, Medical Director and/or qualified designee. Re-education was initiated on 7/9/2020 at 9:30 p.m. and will continue every shift until all staff have received the mandated training. Daily, during stand-up, the screening tool shall be reviewed by the NHA and discussed with the DON, SDC, ICP and/or other department heads. This will include validating employees that have been identified with signs/symptoms of COVID have been redirected out of the facility; and, notification has been provided to the employee and/or department head for removal off the schedule until appropriate action and follow-up has been taken. Non-compliance with the screening process and guidelines will be immediately addressed, including disciplinary action up to suspension and/or termination as appropriate. The NHA is responsible to ensure compliance is achieved and maintained. -The facility staff failed to wear PPE in a resident's room that was a new admission and on isolation precautions for 14 days. Residents that are on isolation precautions, potentially could be affected by this statement of alleged deficient practice, therefore, this plan of correction is written to address all such residents. One resident (Resident #4), was identified during survey. On 7/9/2020 at 9:30 p.m., the NHA, DON, SDC, and qualified designees, initiated re-education to licensed staff, CNAs, dietary, housekeeping, laundry, maintenance and administrative staff on the expectation and importance to wear PPE in a room with a resident who is on isolation precautions for 14 days. Staff members who are on vacation or currently off shall be provided re-education upon return to work. Re-education will also include documented return demonstration of proper donning of PPE prior to entering a resident's room who is on isolation precautions. Re-education will continue every shift until all staff have received the mandated training. The DON is responsible to ensure compliance is achieved and maintained. C. Removal of immediate jeopardy On 7/10/2020 at 1:15 p.m., the NHA and DON were notified the immediate jeopardy was lifted, based on observations and interviews that showed implementation of the facility's plan above; however, deficient practice remained at an E level scope and severity (a pattern with the potential for more than minimal harm). III. Failure of staff to don appropriate PPE prior to entering a COVID-19 positive resident room and the room of recently admitted resident on 14-day quarantine. A. Professional reference and facility policy 1. Professional reference The Centers for Disease Control and Prevention, Preparing for COVID-19 in Nursing Homes, retrieved from: https://www.cdc.gov/coronavirus/2019-ncov/hcp/long-term-care.html (updated 6/25/2020) read, in pertinent part: Residents with known or suspected COVID-19 should be cared for using all recommended PPE, which includes use of N95 or higher level respirator (or facemask if a respirator is not available), eye protection (i.e., goggles or a disposable face shield that covers the front sides of the face), gloves, and gown. Create a Plan for Managing New Admissions and Readmissions Whose COVID-19 Status is Unknown. Depending on the prevalence of COVID-19 in the community, this might include placing the resident in a single-person room or in a separate observation area so the resident can be monitored for evidence of COVID-19. HCP (health care providers) should wear an N95 or higher-level respirator (or facemask if a respirator is not available), eye protection (i.e., goggles or a disposable face shield that covers the front and sides of the face), gloves, and gown when caring for these residents. Residents can be transferred out of the observation area to the main facility if they remain afebrile and without symptoms for 14 days after their admission . 2. Facility policy The Coronavirus (COVID-19) Droplet precautions policy and procedure, dated 3/16/2020, provided by the NHA on 7/9/2020 at 1:15 p.m., read, in pertinent part: This procedure provides guidelines for droplet precautions for residents with known or suspected novel Coronavirus (COVID-19) generated during coughing, sneezing, talking, and/or while performing procedures. A. Persons Under Investigation for COVID-19: 1. Place a mask on resident. 2. Place resident in a private room and close the door . 8. Wear a mask. 9. Wear clean gown when entering the room . 14. Use disposable dinner ware . dispose of in the Resident's room. B. Persons Testing Positive for COVID-19: 1. Follow the procedure outlined above in section A. 2. Follow guidance of local Department of Public Health for consideration of transport to an acute care facility and recommended next steps. B. Resident #1 - failure of staff to don appropriate PPE prior to entering a COVID-19 positive resident room 1. Resident status Resident #1, age 46, was admitted on [DATE]. According to the July 2020 computerized physician orders [REDACTED]. The 4/28/2020 minimum data set (MDS) assessment revealed the resident was cognitively impaired with brief interview for mental status (BIMS) score of 11 out of 15. He did not exhibit any behaviors. He required supervision with bed mobility and toileting, and limited one-person assistance with transfers, dressing and locomotion on the unit. He was always continent of bowel and bladder. Record review revealed Resident #1 was detected with COVID-19, per a COVID-19/Coronavirus lab test dated 6/29/2020. 2. Observation and interview 7/8/2020 On 7/8/2020 at 1:58 p.m., registered nurse (RN) #1 donned a gown and gloves outside of Resident #1's room. The RN wore a surgical mask, gown and gloves; however, she did not don a N95 respirator or other respirator-type mask and she did not don eye protection. She knocked and entered Resident #1's room. At 2:02 p.m., RN #1 exited the room wearing only a surgical mask and she immediately went down the hallway and entered room [ROOM NUMBER] to answer the call light. Registered nurse (RN) #1, interviewed on 7/8/2020 at 2:08 p.m., said she worked for an agency and had worked at the facility for seven weeks PRN (as needed) but full time hours. She said Resident #1 was on droplet precautions but recently had tested negative for COVID-19. She was not sure of the facility's infection control protocol, but said the resident was not off isolation and, therefore, assumed all PPE was needed to enter the resident's room. She said this meant the appropriate PPE for Resident #1 was a gown, gloves, eyewear (per the RN, the facility did not have any face shields), and N95 mask. Nonetheless, RN #1 confirmed that prior to entering Resident #1's room (see above), she did not don eyewear (goggles) or apply a N95 mask. -She said she did not use her N95 mask because it was locked in the nursing cart, although she said she had used it earlier when she gave Resident #1 his lunchtime medication. She then walked to the main nursing station down another hallway where the N95 mask was visible in her backpack. -She said she did not put on any goggles when entering Resident #1's room because goggles were missing from the isolation cart. She said the last time she saw the goggles on the isolation cart was when she went into the room at 12:30 p.m. (At 2:18 p.m., RN #1 placed goggles on the isolation cart outside Resident #1's door along with additional PPE). In a subsequent interview on 7/14/2020 at 12:20 p.m., RN #1 said she returned to work at the facility on 7/9/2020 7/10/2020, and at that time she received education on donning and doffing PPE and on droplet precautions. She said on 7/8/2020, her N95 mask was in her backpack because she had just gone on break. She said she was unsure if she had received any training on reuse of N95 masks and assumed she could reuse them. She said when she returned to work at the facility she received training to throw her N95 mask away after use. C. Resident #4 - failure of staff to don appropriate PPE prior to entering the room of a recently admitted resident on 14-day quarantine. 1. Resident status Resident #4, age 80, was admitted to the facility on [DATE]. According to the July 2020 CPO, his [DIAGNOSES REDACTED]. Due to his recent admission, a MDS assessment had not been completed. The admission assessment, dated 6/26/2020, documented the resident was alert and oriented to person, place, time and situation. He required two-person assistance with transfers. 2. Observations and interview On 7/8/2020 (12 days after Resident #4's admission) at 12:58 p.m., the call light was on outside of Resident #4's room. There was an isolation cart outside the room. The resident's door was open and Resident #4, who resided in bed A, was sitting up in his wheelchair with his back to the door. There was a sit-to-stand lift (mechanical lift) observed in the room blocking the door to the bathroom. There was no one in bed B. At 1:02 p.m., CNA #1 entered the room wearing only a surgical mask. Prior to entering the room, she did not don a gown, gloves or eyewear. When the resident asked for ice water, the CNA reached across the resident for his water pitcher and exited the room. She walked down the hallway toward the dining area of the Freedom unit, returning to Resident #4's room with a pitcher of ice water. CNA #1, interviewed on 7/8/2020 at 1:03 p.m., said she was an agency CNA and had worked the day shift at the facility for three months. She said the only PPE needed when caring for Resident #4 was her mask and gloves. CNA #2 was interviewed on 7/8/2020 at 1:08 p.m. She said she was familiar with Resident #4. She confirmed there were two residents residing in Resident #4's room and said the isolation cart outside the room was for the resident in bed B who was on [MEDICAL TREATMENT]; staff were to use a mask, gown and gloves at all times. She knew the resident in bed A had been in the hospital, but she was not sure if he was still on isolation. D. Additional interviews and documentation regarding PPE use 1. The DON and the staff development coordinator/infection control preventionist SDC/ICP were interviewed on 7/8/2020 at 4:05 p.m. a. The DON said RN #1 should have used all full PPE when entering Resident #1's room on 7/8/2020, as the resident was on droplet precautions. The DON said the facility had conducted updated COVID-19 education for staff on 7/1/2020 following the discovery of Resident #1's positive test for COVID-19 on 6/30/2020. She said RN #1 had not received this education as she had not been working on the unit that day. b. Review of documentation on the 7/1/2020 education revealed 16 staff had received the education. Out of the 16, only seven direct care staff participated (four nurses, two CNAs, and one occupational therapist). Neither RN #1 nor CNA #1 participated in the training. There was no evidence of additional training for staff who had not participated in the 7/1/2020, or for agency staff who worked intermittently since 7/1/2020. c. The SDC/ICP said she tried to follow-up with agency staff by catching them during their shifts, to ensure they received updates and education on COVID-19. She said she observed staff and used return demonstration, along with spot checks for proper infection control practices, as needed. IV. Failure to ensure staff did not work during the recommended 72-hour symptom-based strategy monitoring period, after exhibiting symptoms of COVID-19. A. Professional reference and facility policy 1. Professional reference The Centers for Disease Control and Prevention, Return to Work Criteria for HCP with suspected or Confirmed COVID-19, retrieved from: https://www.cdc.gov/coronavirus/2019-ncov/hcp/return-to-work.html (updated 5/5/2020), read, in pertinent part, Symptom-based strategy. Exclude from work until: At least 3 days (72 hours) have passed since recovery defined as resolution of fever without the use of fever-reducing medications and improvement in respiratory symptoms (e.g., cough, shortness of breath); and, at least 10 days have passed since symptoms first appeared. 2. Facility policy The facility's Coronavirus (COVID-19) policy and procedure (dated 3/16/2020) read in pertinent part, Coronavirus (COVID-19) may be characterized by mild to severe respiratory infection. Symptoms may appear 2-14 days after exposure and may include: 1. Fever 2. Cough 3. Shortness of breath 4. Sore throat 5. Gastrointestinal illness (e.g. nausea, vomiting, and diarrhea). -It may be reasonable to suspect a COVID-19 if any of the following criteria are met: Residents or team members exhibit signs of a fever, respiratory illness, sore throat, shortness of breath, gastrointestinal symptoms and have had exposure to at-risk individuals diagnosed with [REDACTED]. -Team Member Screening, all team members are screened for fever and/or respiratory symptoms prior to the beginning of each shift. Complete the Team Member portion of the Team Member, Resident, and Visitor Screening Tool and Log. If a team member answers yes to any of the screening questions, s/he is instructed to return home . -Team Members, In the event that a team member has had known exposure (close contact) to an individual with COVID-19, the team member is instructed to self-isolate for a period of 14 days from the date of known exposure. Refer to the Coronavirus (COVID-19) Team Member Guidelines and the Coronavirus (COVID-19) Team Member Decision Tree for further guidance. Team members are instructed that they may resume work in accordance with the recommendations outlined within Return to Work Guidelines. B. Record review Review of facility screenings revealed on 6/28/2020 at 6:36 a.m., agency CNA #4 reported to the facility that she had a fever the day before (6/27/2020). She also reported she had a new cough, shortness of breath (SOB) and reported she had been around her cousin who was in close contact with an individual who tested positive for COVID-19. Review of the facility schedule and interview with staff revealed CNA #4 did not work at the facility 6/28 and 6/29/2020; however, she worked on 6/30/2020 and 7/1/2020, during the CDC 72-hour symptom-based strategy monitoring period. C. Interviews on facility screening and CNA #4 The NHA, DON, SDC/ICP and human resources/payroll representative (HRP) were interviewed on 7/9/2020 at 5:05 p.m. 1. The HRP said she was responsible for reviewing the employee/visitor screening logs. She said she was supposed to review them daily to ensure no staff were working with signs and symptoms of COVID-19. She said at times, she is not able to review the logs because she is too busy. She said she did not follow-up with the logs the week of 6/28/2020. 2. The DON said on 6/28/2020, there were several staff call outs and the supervisor working that day had pulled staff from other areas. She said if staff had signs or symptoms of COVID-19, they were sent home. Then, staff was keep the facility updated on their symptoms or inform the facility if they were assessed by a physician. She said she was not working the week CNA #4 reported signs and symptoms of COVID-19; that week, the MDS coordinator (MDSC) was responsible to follow-up with staff members who had symptoms of COVID-19. She said she had spoken with the MDSC during survey on 7/9/2020, and the MDSC told her that she was not notified CNA #4 had symptoms of COVID-19, so there was no follow-up. The DON said the management team should have followed up to ensure no staff member was working with signs and symptoms of COVID-19. The DON said when she spoke to CNA #4 during survey on 7/8/2020, the CNA told her she had asthma, chronic cough and was always SOB. She said the CNA stated had visited with her cousin and could not say if he was positive for COVID-19. The DON said she had contacted the weekend supervisor (WS) during survey on 7/9/2020, who told her several staff had called out on 6/28/2020, so she (WS) helped on the floor and pulled the restorative CNA to help work the floor. She said she did not remember which staff member was sent home on 6/28/2020, she only remembered there was a CNA sent home because the CNA had signs and symptoms of COVID-19. She had acknowledged to the DON that she had not notified the DON or any other manager of a CNA having COVID-19 signs and symptoms and this was why no one followed up to ensure the CNA did not return to work. 3. Medical records staff (MR) was interviewed on 7/9/2020 at 5:20 p.m. She said she covered at the receptionist area on 6/28/2020. She confirmed the facility screening form on 6/28/2020 that included a report of fever and possible COVID-19 exposure belonged to CNA #4. She said she was told by the WS to not let CNA #4 in the facility and to send her home. 4. The scheduler at the outside staffing agency where CNA #4 was employed was interviewed on 7/15/2020 at 10:35 a.m. She said she scheduled all agency staff to work at multiple facilities. She said CNA #4 reported to her she traveled out of town and visited with family that tested positive for COVID-19. She said she had to take her off the schedule for the week of 7/12/2020 and she required her to be tested for COVID-19. She said the CNA's test results were pending. She confirmed CNA #4 did not work at the facility 6/28/2020 and she called in on 6/29/2020. She verified, however, that CNA #4 did work at the facility on 6/30/2020 and on 7/1/2020. 5. CNA #4 was interviewed on 7/16/2020 at 11:38 a.m. She said on 6/28/2020, she was screened by the facility for COVID-19. She said that morning her temperature was 100.1 degrees and she reported she had a fever the previous day (over 100 degrees), a new cough, but her SOB was not new because she always had SOB. She said she reported she had visited with her cousin who had been exposed to someone who was positive COVID-19 in the last few days. She said she was sent home for her symptoms and she did not work the following day, but worked Tuesday and Wednesday (6/30/2020 and 7/1/2020). She said no one at the facility told her to self-quarantine; she said she was not provided any education to not return to work for 72 hours or until she did not have any symptoms of COVID-19 and was not told to test herself for COVID-19 until later instructed by the agency to get tested . 6. The medical director was interviewed on 7/10/2020 at 10:30 a.m. He said he rounded at the facility frequently at least twice a week to provide guidance to the facility staff. He said he attended quality assurance performance improvement (QAPI) meetings monthly. The most recent meeting was 6/17/2020. He said he was aware of staff were not following PPE infection control process, not following the CDC guidelines and said he gave guidance on proper use of PPE, and shared the latest recommendations regarding COVID-19. He said agency staff needed to follow the facility protocols, and he expected the facility to provide training with latest recommendation on appropriate procedures. He said the facility tested all their residents this last week for COVID-19 and all were negative so far. He said he was aware of the immediate jeopardy situation. He said shortly after the June QAPI meeting, they discussed Resident # 1 noncompliance with facility directive not to leave the facility. He said the DON told him Resident #1 left the facility to go shopping, so he told the facility to isolate the resident immediately. He said the DON was out of town but he spoke with managerial staff at the facility and told them to isolate the resident. He said a couple of months ago the facility tested all their staff for COVID-19 and all were negative, but they had not completed any staff testing since then. He said moving forward, the facility planned to complete weekly testing for COVID-19 for eight weeks. V. Facility follow-up after survey exit The facility provided documentation of staff education via email on 7/15/2020 at 1:05 p.m. The documentation revealed, initially, 44 staff were educated on droplet precautions, proper use of PPE with return demonstration, and employee and visitor screening from 7/9/2020 to 7/10/2020. There were also 20 agency staff who had signed they received education on droplet precautions and PPE with return demonstration from 7/9/2020 to 7/13/2020.

Based on observations, interviews and record review, the facility failed to ensure the resident environment remained free from accident hazards as possible, affecting one (#10) out of 15 sample residents. The facility failed to ensure residents did not smoke with oxygen. On 6/7/19 at 10:47 a.m. Resident #10, who was severely cognitively impaired, was observed smoking a cigarette in the courtyard smoking area accompanied by a staff member. Further observations revealed a portable oxygen tank with oxygen flowing at three liters per minute hanging on the back of the resident's wheelchair with the oxygen tubing and nasal cannula resting on her shoulder. At 10:48 a.m. the surveyor turned the resident's oxygen off when the staff member reported she did not know how to do so. Resident #10 smoking with oxygen in use created an immediate jeopardy situation given the likelihood of serious harm if immediate action was not taken. Findings include: I. Immediate Jeopardy A. Findings of Immediate Jeopardy On 6/7/19 at 10:47 a.m. Resident #10, who was severely cognitively impaired, was observed smoking a cigarette in the courtyard smoking area accompanied by a staff member, a social service assistant (SSA). Further observations revealed a portable oxygen tank with oxygen flowing at three liters per minute hanging on the back of the resident's wheelchair with the oxygen tubing and nasal cannula resting on her shoulder. At 10:48 a.m., the surveyor turned the oxygen off when the social services assistant (SSA) reported she did not know how to do so. B. Facility notice of Immediate Jeopardy On 6/7/19 at 1:40 p.m. facility staff, including the nursing home administrator (NHA), the director of nursing (DON), and the assistant director of nursing (ADON) were informed of the findings of Immediate Jeopardy under F689, Accidents. C. Facility plan to remove Immediate Jeopardy On 6/7/19 at 10:50 a.m., the NHA provided the following plan to remove the Immediate Jeopardy. The plan read: At the time of Immediate Jeopardy identification, the cannula was removed from affected resident. The oxygen flow was turned off on portable and removed from resident. Resident was assessed by a Licensed Registered Nurse and found to be safe. Oxygen cannula was placed back on resident by qualified staff once back in the facility. Resident physician placed order on 6/7/19 to safely remove oxygen when resident desires to go outside and safely smoke. Resident Care Plan was updated on 6/7/19. Identification: It is determined by the interdisciplinary team (IDT) that all residents residing at the facility who smoke are at potential risk for the alleged deficiency. Systemic changes: On 6/7/19 the Social Services Assistant was educated on Safe Smoking Policy and Procedure. Beginning 6/7/19 qualified staff is safely removing and reapplying oxygen for residents who want to smoke. Education: Beginning 6/7/19 and continuing until completed, the facility staff in all departments: nursing, housekeeping, maintenance, social services, administration, dietary, activities and agency will be reeducated by DON/designee on the facility Smoking Policy, supervised smoking times and safe removal and storage of portable oxygen prior to exiting facility and proceeding to smoking area in East Courtyard. Staff in all listed departments working on 6/7/19 were educated on 6/7/19. All other staff in all departments will be educated on facility Smoking Policy prior to their next shift in the facility. All new hires and agency staff will be educated by DON/designee upon hire on smoking policy, supervised smoking times and safe removal and storage of portable oxygen prior to exiting facility and proceeding to smoking area in the East Courtyard. Comprehension of this information will be validated by successfully completing a quiz. On 6/7/19, signs were posted by both exits into the East Courtyard and in the smoking area that read, Attention: Oxygen tanks or [MEDICATION NAME] are not allowed in the smoking area. Thank You! Administrator. Beginning 6/7/19 and continuing until completed, resident care plans for residents who smoke will be audited for accuracy and appropriate interventions. On 6/7/19, all residents who smoke were re-educated on our Safe Smoking Policy and signed Policy Acknowledgment. Beginning 6/7/19, all new residents who smoke will be given physician orders [REDACTED]. Monitoring: The DON/designee will complete resident smoking area rounds at every supervised smoking session - at 930h, 1330h, 1630h, 1930h, and 2130h for 2 weeks, then weekly for 2 months and then as needed to ensure safe resident smoking compliance. If there is non-compliance at any point, the Don/designee will again resume rounds at every smoking session - at 930h, 1330h, 1630h, 1930h, and 2130h for 2 weeks, then weekly for 2 months and then as needed to ensure safe resident smoking compliance. The DON/designee will monitor staff and agency education on Smoking Policy weekly for 2 months and then as needed to ensure accuracy and completion of staff and agency education. The NHA/designee will ensure that the Facility's Safe Smoking Policy will be reviewed monthly for 3 months and then as needed at the facility QAPI meeting to ensure compliance. Date of Compliance: 6/7/19 D. Removal of Immediate Jeopardy The facility's plan to remove Immediate Jeopardy was accepted and Immediate Jeopardy was lifted on 6/7/19 at 5:54 p.m. Record review revealed the facility had educated and trained all staff currently working in the building regarding the resident smoking policy and oxygen as well as posted the signage set out in the facility plan. II. Failure to ensure the resident environment remained as free of accident hazards as possible. A. Reference - hazard of smoking with oxygen According to the National Fire Protection Association (2016) Medical Oxygen Safety. Retrieved from: https://www.nfpa.org/~/media/files/public-education/resources/safety-tip-sheets/oxygensafety.pdf?la=en, Portable medical oxygen in the home has grown over the past decade. Medical oxygen adds a higher percentage of oxygen to the air a patient uses to breathe. Fire needs oxygen to burn. If a fire should start in an oxygen-[MEDICATION NAME] area, the material burning will burn more quickly. According to the American [MEDICATION NAME] Society website (2016). Patient Education: Oxygen therapy. Retrieved from: http://www.[MEDICATION NAME].org/patients/patient-resources/resources/oxygen-therapy.pdf, You should never smoke while using oxygen. Your nose, hair, and clothing can catch fire very quickly and cause life-threatening burns. Keep oxygen at least 6 feet (2 meters) away from any open flame . B. Smoking policy The facility Smoking policy, effective 11/28/17, was provided by the DON on 6/7/19 at 12:27 p.m. It read in pertinent part: Extreme caution is used when a resident who uses oxygen smokes. Residents with continuous oxygen or PRN oxygen orders are required to have physician orders. The tank cannot be with the resident while smoking or in the smoking area. C. Resident #10 1. Resident status Resident #10, [AGE] years of age, was admitted to the facility on [DATE]. According to the 6/2019 computerized physician orders [REDACTED]. According to the 3/14/19 minimum data set (MDS), the resident was significantly cognitively impaired scoring a 5 out of 15 on the brief interview for mental status (BIMS) exam. The resident exhibited minimal verbal and resistive behaviors. The resident required limited to extensive assistance of one to two staff members with activities of daily living and required a staff member to propel her wheelchair. Record review revealed the resident had orders effective 8/24/18 for oxygen via nasal cannula titrated to keep O2 saturation above 88%. The resident's safe smoking evaluation dated 5/20/19 read the resident required supervision for smoking, the resident's smoking materials were to be stored by staff, and a safe smoking care plan was required. A smoking care plan, initiated 9/13/18 and revised on 6/7/19, read in pertinent part that the resident desired to smoke at the facility and required supervision. Interventions included assisting the resident to the appropriate smoking area and providing supervision and assistance with smoking; resident smoking materials were to be kept with staff; instruct and remind resident as needed about the facility policy on smoking, locations, times, and safety concerns. 2. Failure to ensure the resident environment remained as free of accident hazards as possible - failure to ensure residents did not smoke with oxygen in use. On 6/7/19 at 10:47 a.m. Resident #10 was observed smoking a cigarette in the courtyard smoking area accompanied by a staff member, a social service assistant (SSA). Further observations revealed a portable oxygen tank with oxygen flowing at three liters per minute hanging on the back of the resident's wheelchair with the oxygen tubing and nasal cannula resting on her shoulder. At 10:48 a.m. the surveyor turned the dial on the oxygen tank to the off position and interviewed the SSA. The SSA stated the resident told her the oxygen tank was turned off. She stated she did not know how to check the tank to ensure it was turned off or know how to turn it off. She said she had worked at the facility about three months and never taken a resident out to smoke before today. She said she had not received training on the facility smoking policy, and was not aware the portable oxygen tank needed to be turned off, removed from the wheelchair and left inside the building when the resident went outside to the courtyard to smoke. On 6/7/19 at 11:03 a.m. the SSA was interviewed a second time and stated she took the resident out to smoke at the request of a certified nurse aide (CNA) because the resident was upset and yelling on the unit about not being able to finish her cigarette during the supervised smoking time at 9:30 a.m. She stated the CNA, who worked for an agency and who was unfamiliar to her, was busy with other residents on the unit at the time. She stated, again, that she had never taken a resident out to smoke before and was not aware oxygen tanks could not be out in the smoking area. She stated she knew oxygen was combustible but thought it was only unsafe in enclosed spaces, not outside. On 6/7/19 at 11:55 a.m. licensed practical nurse (LPN #2) stated residents are taken out to smoke by CNAs or nurses if the CNAs are too busy. He said supervised smoking times were at 9:30 a.m., 1:30 p.m., 4:30 p.m. and a couple more times in the evening. He stated the facility only had a few supervised smokers and said residents that smoke are evaluated on admission and quarterly to determine if they need supervision or not. On 6/7/19 at 11:59 a.m. CNA #3, too, stated the supervised smokers are taken out to smoke at assigned times by either a CNA or a nurse. She stated that she did not know of any other staff members taking residents out to smoke. She said oxygen is removed from residents who smoke and use oxygen prior to the residents going out to the smoking area. On 6/7/19 at 12:05 p.m. CNA #8, who worked for an agency, stated each supervised smoking time is assigned to a CNA by rotating the CNA assigned by unit. She stated she did not know of any other staff besides nurses or CNAs taking residents out to smoke. She stated she had received education and training on the smoking policy and procedure prior to starting her first shift at the facility. On 6/7/19 at 1:24 p.m. CNA #5, who worked for an agency and who was caring for Resident #10 that morning, stated the SSA offered to take Resident #10 out to smoke earlier that day. -She stated that she did not remind the SSA to remove the resident's oxygen tank because she did not know she needed to and did not know the SSA did not know the facility's smoking policy and procedure. -She stated she had only worked three or four shifts in the facility and she had never taken supervised smokers out to smoke before. However, she stated she knew that residents who used oxygen and smoked needed their oxygen tank removed and left in the building before going to the smoking area. She stated that she received education from the facility regarding the smoking policy and procedures prior to her first shift in the facility. On 6/7/19 at 1:30 p.m. the DON and NHA stated only nurses and CNAs were supposed to take residents out to smoke and oxygen tanks should be removed and left in the building prior to entering the smoking area. The DON and NHA stated that all staff should be trained on the smoking policy and smoking safety even if they are not likely to take residents out to smoke. However, they acknowledged they did not know if this was currently the case. Review of the doors exiting to the courtyard revealed no signs alerting staff and visitors to remove oxygen tanks prior to entering the smoking area.

Based on observations, record review and interviews, the facility failed to ensure the resident environment remained as free of accident hazards as possible and one (#4) of three out of eight sample residents for falls received adequate supervision and assistance devices to prevent accidents. Specifically: Resident #4 entered the facility on 11/2/16 with no recent falls but at risk for falls given a history of right sided weakness and severe cognitive impairment. Record review and interview revealed the facility failed to refine the resident's plan of care as expected per policy based on the resident's assessed functional abilities, cognitive limitations and behaviors. The resident experienced five falls from 11/14/16 to 3/10/17 and her fall on 11/25/16 resulted in a wrist fracture. Record review and interviews revealed the facility failed, following each fall, to implement individualized, resident-centered fall interventions to prevent additional falls and injury. Ineffective interventions were not discontinued, planned interventions were not timely implemented and new interventions that were recommended were not communicated to facility staff and incorporated into the resident's plan of care. Observations further revealed the presence of a bed cane on resident #4's bed that had not been identified per facility policy and assessed for safety. The findings included: I. Facility policy and procedure A. The 10/11 Fall Management & Investigation Program policy was provided by the regional director of health services (RDHS) on 4/6/17 at 3:38 p.m. The document revealed the following pertinent information: -All residents are considered to be at risk for falls on admission until all review processes are completed and reviewed . -A fall care plan and all interventions are to be resident specific . -Resident falls .are to be analyzed for patterns, trends, causal factors, and used as a basis for implementation of process improvement systems . -Resident safety devices were Any device used in the care of the resident to enhance their safety and ability (walker, can, quad cane) . -The Data Collection Tool must be completed within 8 (eight) hours of admission/readmission, annually, or with significant change in status . -When a level of risk has been determined (completed MDS, PT (physical therapy) screening, etc.) the information will be used to refine the resident plan of care . -An Incident/Accident Report must be completed when a resident falls within 24 hours of accident . -Fall interventions will be reviewed for continued effectiveness . -Interventions will be revised as indicated by the incident and current resident needs .Revised interventions will be routinely reviewed and updated to ensure effectiveness . B. The 10/11 Bed-Safety Guidelines policy revealed the following pertinent information: -Minimize the potential risk of resident entrapment associated with the appropriate use of Bed-Safety Rails and/or other types of safety positioning devices that attach to resident beds . -Bed-Safety Rails: Adjustable metal or rigid plastic bars that attach to the bed . -Assistive Devices: Any device whose primary purpose is to maximize the independence and the maintenance of health of an individual . -The devices will only be used according to the resident's reviewed needs and only with a physician's written order . -The Data Review Tool, MDS assessment (bed mobility score), and Physical Restraint/Bed Safety Risk Review is be completed for each resident on admission, re-admission, annually and when a change in status . -PT (physical therapy) or OT (occupational therapy) will perform a Rehab Screening by a designated qualified healthcare professional on admission, re-admission, or when a change in status . -The resident, their family or, legal representative will participate in the reduction plan development and revision whenever possible . II. Resident #4 Resident #4, age 94, was admitted on [DATE]. According to the face sheet, [DIAGNOSES REDACTED]. According to the resident assessment, dated 2/8/17, the resident was severely cognitively impaired. She required limited assistance of one staff member with bed mobility, transfers, dressing, and toilet use. She had functional limitation in range of motion (ROM) on one side of both the upper and lower extremities. She used a walker and wheelchair with mobility, and had falls since admission into the facility. She had one without injury, one with injury, and one fall with major injury. A. Prior to fall #1 Record review and interview revealed the facility failed to refine the resident's plan of care as expected per policy (see above) based on the resident's assessed functional abilities, cognitive limitations and behaviors. 1. Record review The admission MDS assessment, dated 11/9/16, revealed the resident was severely cognitively impaired, required extensive assistance with bed mobility, transfers, dressing and toilet use, and use a walker a wheelchair for ambulation. She required supervision in her room, but did not have a recent history of falls. The 4/17 Physician Orders revealed the following pertinent information: - Order date: 11/2/16, floor mat next to the bed at all times while in bed. Check the placement at every shift (three shifts); - Order date: 11/2/16, pressure alarm to bed and wheelchair at all times. Check placement and function at every shift; - Order date: 11/2/16, Prozac (antidepressant) 10 mg orally every day for depression; - Order date: 11/2/16, Lasix (diuretic) 10 mg orally every day for hypertension; - Order date: 11/2/16, Miralax (laxative)17 gm mixed with six ounces of fluid of choice orally every day; and - Order date: 11/2/16, Lipitor (statin) 40 mg orally every day at bedtime for [DIAGNOSES REDACTED]. The 11/3/16 Data Collection Tool revealed the resident was severely impaired with decision making and had a history of [REDACTED]. The resident was anxious, wandered, and fearful. She required physical assistance with bed mobility, transfers, and toilet use. She was unable to answer the sleep/rest questions. The 11/3/16-3/13/17 Quick Note was provided to the facility by the outside therapy provider on 4/6/17 at 3:35 p.m. during survey. A Quick Note, per the Director of Nurses (DON) on 4/6/17 at 3:40 p.m., was documentation from the outside provider that was not readily accessible in the facility's clinical record and thus not readily available to facility staff. The notes revealed the following pertinent information: - On 11/3/16 the resident was seen by PT for a medical respite assessment. The assessment determined the resident had decreased functional mobility, decreased right-sided attention, decreased balance, decreased coordination, decreased safety awareness, and decreased independence with functional mobility and gait following CVA. She had no pain and required minimum assistance with mobility. -On 11/11/16 the resident was seen by PT. PT recommended she receive constant education on safety with transfers, rollator locks (rollator - a walker with wheels), and the front wheeled walker. B. Staff interviews Licensed practical nurse (LPN) #1 was interviewed on 4/6/17 at 8:42 a.m. She said fall assessments were completed after a fall occurred. Fall interventions were in place upon admission, but she was not sure how the interventions were identified. The care plans were reviewed periodically by the nurses. She said physician orders [REDACTED]. The facility physical therapist (FPT) was interviewed on 4/6/17 at 8:51 a.m. She said after a resident experiences a fall, the resident's safety, including environmental factors are reviewed and new interventions are put into place based on the incident that had occurred. Fall interventions included auto lock brakes, bed positioning, non-skid strips on the floor, clutter free and general environment, fall mats, and assistive devices such as bed canes. Post fall, the care plan was updated with new fall interventions, and reviewed each time the resident fell for effectiveness of the interventions. physician's orders [REDACTED]. The DON was interviewed on 4/6/17 at 10:23 a.m. She said the admission assessment determined if the resident was at risk for falls, and a care plan was developed based on the assessment. The care plans were reviewed and interventions modified after a fall occurred. All residents were determined to be high risk for falls upon admission into the facility, and all fall interventions were put into place. As the resident experienced falls, the care plans and interventions were modified to fit the needs of the residents. The staff development coordinator (SDC) was interviewed on 4/6/17 at 11:55 a.m. She said she completed the admission care plan for resident #4. The resident had CVA and weakness which placed her at moderate risk for falls, but she was not determined to be a high risk due to not falling in the past 30 days. -She said all interventions were put immediately into place because the resident was forgetful, unable to use the call light, and had impulsive behaviors. The alarms allowed staff the opportunity to know the resident required assistance, but some residents were unable to identify the sounds and were unaffected. Other initial interventions included fall mat, low bed, and gripper socks/shoes. -She said a fall mat and low bed were inappropriate interventions for resident #4 because she had dementia and was able to self-ambulate; a fall mat was a tripping hazard and a low bed made it difficult for the resident to get up and down. The regional director of health services (RDHS) was interviewed on 4/6/17 at 4:06 p.m. She said the resident assessment was used to determine and assess resident safety. The outcome was documented on the care plans, and reviewed quarterly, annually, or upon a change of condition. C. Failure to develop and implement and individualized, resident-centered plan of care and interventions to prevent falls Review of the resident's admission care plan by the SDC, dated 11/3/16, identified the resident was at moderate risk for falls according to the fall risk review tool. She had a left CVA and right-sided weakness. Interventions included: -PT (physical therapy)/OT (occupational therapy)/restorative nursing referral; -Call light usable and within reach; -Bed in lowest position; -Keep room free from clutter; -Ensure proper footwear; -Equipment need: wheelchair; -Floor mat by my bed; -Alarm while in my chair/bed; and -All staff were informed of my fall risk. The resident's care plan was not refined to reflect the resident's known behaviors (see SDC interview above - forgetful, unable to use the call light, and impulsive) or her need for constant education on safety with transfers and use of her walker, as documented in the 11/11/16 Quick Note. There was no evidence of a Physical Restraint/Bed Safety Risk Review (see facility policy above) further identifying the resident's fall risk and safety devices. B. Fall #1 Record review revealed the facility failed to implement individualized, resident-centered fall interventions planned and/or recommended to prevent additional falls and injury. 1. Record review The 11/14/16 Quality Improvement Post Fall Investigation revealed the resident had a fall without injury at 9:00 p.m. Her physical status was unsteady gait, balance problems, weak, sight impairment, and she was continent. Prior to the incident, she was attempting and going to the bathroom. The devices/equipment used were bed and chair alarms, low bed, floor mat, wheelchair, and walker/cane. She required the assistance of one staff member and was wearing socks. Her current medications included: antidepressant, laxatives, hypertensive, and diuretic. The environmental factor identified was poor lighting. The 11/14/16 SBAR (situation, background, assessment, recommendation) Communication Form and Progress Note revealed the resident was .forgetful, got up to go to the BR (bathroom), only had socks on, lost her balance and fell . The nurse found the resident sitting on her bottom and near the bathroom after the pressure alarm sounded. The 11/16/16 Post Fall Investigation revealed gripper socks and relocation closer to the nursing station as interventions. The evaluation, analysis, and interventions required additional input due to impulsive and noncompliant. Review of Quick Notes after the resident's 11/14/16 fall revealed: - On 11/21/16 the resident was noted by PT to be unsafe by attempting to ambulate with no assistive device and removing oxygen. Her gait was unsteady and she was holding onto walls. She required constant supervision when ambulating and reminders to use her wheeled walker. - On 11/21/16 the resident was seen by occupational therapy (OT) for ADL (assistance with daily living) retraining, functional mobility, fine motor skills and safety techniques. The resident expressed fear of being alone at night. She was told staff will be checking in on her at night and the social worker was notified. She required standby assistance with all transfers and mobility due to unsafe techniques, decreased problem solving and motor planning. - On 11/22/16 the resident was seen by PT. Her primary concern was wanting her eyes checked and revealed she required different glasses. She had safety gait issues, loss of balance, poor safety judgment, poor obstacle judgment, and poor sequencing using device with turns. She was educated on wheelchair brakes. She had one fall in the past three months (11/14/16) and risk factors associated with the fall included: balance, diagnosed cognitive impairment and/or dementia, fall in the past three months, vision, and poor safety insight. The assessment summary revealed she had a change of condition assessment and a restorative nursing program was recommended. - On 11/23/16 the resident was seen by OT. The OT assessment revealed she was incontinent of bladder and required depends/adult briefs. She had trouble seeing things at a distance. Education on fall prevention was provided. 2. Staff interviews The DON was interviewed on 4/6/17 at 3:45 p.m. She said resident #4's interventions after her fall 11/14/16 were bed and chair alarms, bed in the low position, walker/cane, and gripper socks. 3. Failure to implement individualized, resident-centered fall interventions planned and/or recommended to prevent additional falls and injury. According to the 11/3/16 admission care plan, staff was instructed to ensure the resident used proper footwear which staff interviews revealed meant gripper socks and shoes. Nonetheless, see below; an order for [REDACTED]. The 11/14/16 post fall investigation did not examine or determine a possible root cause of the fall; the fall investigation failed to evaluate the resident's medication use and toileting assistance or follow up on the environmental factor of poor lighting in the bedroom. A toileting schedule/program was not implemented until 3/16/17, well after the resident had sustained additional falls. The 11/24/16 Interdisciplinary Progress Notes revealed the resident was moved to a new room on 11/23/16, a recommendation made on 11/14/16. A pressure alarm had been placed on the bed and chair. The note further read, the resident .does not ring or wait for help . She ambulates to the bathroom with the assistance of one staff member to void. However, the note did not indicate how frequently the resident should be checked given her behaviors of not ringing or waiting for help. Moreover, the Interdisciplinary Progress Notes and fall interventions did not reference the resident's fear of being alone at night. Although the care plan (last updated with new interventions on 11/16/16) identified the resident had vision loss, the care plan did not address the issue of poor lighting or the resident's reported trouble seeing things at a distance as identified in the 11/23/16 Quick Note. C. Fall #2 Record review revealed resident #4 fell on [DATE], sustaining a wrist fracture. Facility expectations, per policies and staff interviews, to prevent such a fall, were not met and planned and recommended interventions were not timely implemented. 1. Record review The 11/25/16 Interdisciplinary Progress Notes revealed a certified nurse aide (CNA) observed the resident sitting on the floor at 3:00 a.m. at the side of the bed. She was leaning at the edge of the bed and trying to get up. The resident said she slid on the floor coming from the toilet. She had a complaint of left wrist pain. She was unable to remember to use the call light. The bed was low and the alarm was sounding. The 11/25/16 Resident Transfer revealed the resident had a left distal radial fracture. She was attempting to get to the bathroom at approximately 3:00 a.m. She was found on the floor in her room. She had a complaint of left wrist pain. The 11/25/16 diagnostic company's notes revealed the resident had a distal radial fracture which appeared comminuted (break or splinter of the bone into more than two fragments) and intra-articular. The notes documented it appeared acute, but was obscured. The 11/25/16 Quality Improvement Post Fall Investigation, which would have revealed physical status of the resident, behaviors prior to fall, activity (at time of/just prior to incident), devices/equipment, ambulatory status/footwear, current medications, environment factors, sequelae, and fall pattern, could not be located by the facility staff. The 11/25/16 SBAR Communication Form and Progress Note revealed the resident had a history of [REDACTED]. The document did not reveal details related to the fall or injury. Review of Quick Notes following the resident's 11/25/16 fall with fracture revealed: - On 11/28/16 PT saw the resident and documented she had poor safety insight and did not demonstrate carryover between PT sessions. She had a fall over the weekend, which resulted in a distal left radius fracture. A trial with a wheeled walker was performed and the resident was found hugging the wall on her way to the restroom. - On 11/29/16 OT saw the resident and advised the facility to have two staff members assist the resident with toilet transfers. The resident was educated on asking for assistance with standing and using the restroom. On 12/1/16, an initial Physical Restraint/Bed Safety Risk Review was completed and revealed the resident was a fall risk; she had a fall within the past 30 days, resulting in a radial fracture. The risk review identified the resident was impaired with decision making skills, had signs of delirium, required assistance with transfers, had an unsteady gait, was independent with mobility, and propelled in her wheelchair. It also identified she had a new room, was compulsive on standing, and did not use the call light. She had a bed and wheelchair alarm and the bed safety devices used were low bed and fall mat. The 12/2/16 Post Fall Investigation revealed, No interventions already in place and the Resident had decrease safety awareness and will attempt self-transfer. The fall interventions were deemed appropriate, revealing they were in place to ensure resident safety in least restrictive environment, The 12/16 Resident Bowel and Bladder revealed the resident had seven occurrences of incontinent bladder. The 12/13/16 Restorative Screening and Data Collection revealed the resident had a cast, weakness, and painful joints. She required minimal to moderate assistance to ambulate, and needs were positioning, joint mobility, and ambulation. The 12/19/16 Interdisciplinary Progress Notes revealed to continue with fall interventions and encourage resident to call for assistance and use call light. 2. Staff interviews The DON was interviewed on 4/6/17 at 3:22 p.m. She said a resident would be deemed a high fall risk upon admission based on a history of falls, mobility and transfer deficits, and not being oriented to a new location. Fall interventions were required to be reviewed and modified after each fall. -She reported resident #4 required the assistance of one staff member with bed mobility, transfers, and toilet use, but was continent and ambulatory. She had dementia, was forgetful, impulsive, and poor safety awareness. She said after resident #4's falls, the interdisciplinary team met and reviewed the incident in order to identify any hazards and/or contributing factors to the fall. As the team reviewed the interventions, old interventions were reviewed and ruled out. She revealed resident interventions were individualized and what may work for one resident was not appropriate for another resident. -She said resident #4 did not have the appropriate footwear on when she fell [DATE] and 11/25/16, and an order was written for gripper socks. She also said the resident's bed was in the low position and the fall mat was in place, interventions that were not appropriate for resident #4. She was a high fall risk and attempted to self-ambulate. The DON was interviewed on 4/6/17 at 3:45 p.m. She said resident #4's did not have any new interventions in place after her fall 11/25/16, because the old interventions were still active. The resident was impulsive and required redirection. She said a toileting program was implemented. 3. Failure to timely implement individualized, resident-centered fall interventions planned and/or recommended to prevent additional falls. Review of the 4/17 Physician Orders revealed gripper socks referenced by the DON above, were ordered 11/28/16 for fall prevention. See above; the 11/14/16 SBAR Communication Form and Progress Note revealed the resident had only socks on when she fell . Therefore, the order for gripper socks was written 14 days after the resident's 11/14/16 fall and three days after the 11/25/16 fall with fracture. Review of the 4/17 Physician Orders revealed a toileting program, reference by the DON above, was ordered on [DATE], even though toileting issues had been a factor in the resident's two falls. Review of the resident's care plan revealed no interventions for poor lighting identified after the first fall, no instructions to staff regarding the level of supervision the resident required to prevent non-assisted transfers, and no instructions to staff on two person transfers with toileting. Finally, although facility notes and assessments as well as staff interview revealed the resident lacked safety awareness and the ability to use the call light effectively, the care planned intervention to ensure the resident's call light was usable and within reach remained on the care plan. Review of the Interdisciplinary Progress Notes, and the resident's 11/9/16 and 2/8/17 MDS assessment, likewise, did not reveal the resident required two staff members with toilet transfers. (See: 11/29/16 OT Quick Note above.) D. Fall #3 Record review revealed the resident fell again, hitting her head on 12/21/16. The facility lacked evidence this fall was analyzed and existing fall prevention interventions were reviewed. 1. Record review The 12/21/16 Interdisciplinary Progress Notes revealed the resident was found on the floor in the room in front of the sink. She had a large bump on the back of the head. On 12/22/16, a note revealed she was attempting to walk. She had a pressure alarm to bed and chair, fall mat, and bed in the low position. A Quality Improvement Post Fall Investigation, a SBAR Communication Form and Progress Note, and a Post Fall Investigation were not provided for review by the facility. The 4/17 Physician Orders revealed an order dated 12/23/16 for auto lock brakes to wheelchair for fall prevention. According to the 11/11/16 Quick Note, an intervention for auto locks brakes to the wheelchair was already in place. 2. Staff interviews The director of medical records (DMR) was interviewed on 4/5/17 at 3:00 p.m. She said all documents related to the fall investigations and care plans had been provided. The DON was interviewed on 4/6/17 at 3:20 p.m. She said resident #4 had experienced four falls inside of the facility. D. Fall #4 Record review revealed the facility failed to comprehensively review the resident's fall interventions in order to discontinue ineffective interventions and develop new interventions based on the resident's known risks. 1. Record review Record review revealed the resident was experiencing bladder incontinence. -The 1/17 Resident Bowel and Bladder revealed the resident had eight occurrences of incontinent bladder. -The 2/17 Resident Bowel and Bladder revealed the resident had six occurrences of incontinent bladder. - The 3/17 Resident Bowel and Bladder revealed the resident had 15 occurrences of incontinent bladder. Further record review revealed another fall related to toileting. A 3/6/17 Quality Improvement Post Fall Investigation revealed the resident had a fall without injury at 10:45 a.m.; prior to the incident, she was getting up/off the toilet. Her physical status was unsteady gait and balance problems. The devices/equipment used was bed and chair alarms. She required the assistance of one staff member, and no current medications or environmental factors were documented. The 3/6/17 SBAR Communication Form and Progress Note was unable to be located by the facility staff. The 3/8/17 Post Fall Investigation revealed Continue current fall interventions. The interventions included: bed and wheelchair alarm, auto lock brakes, encourage to ask for assistance with needed, and call light within reach. 2. Staff interviews The DON was interviewed on 4/6/17 at 10:23 a.m. She said the SBAR Communication Form and Progress Note forms were not required to be completed when the nurses documented the content of the form in the progress notes. The forms were completed after falls with or without injury, and transfers to the hospital. 3. Failure to review and revise interventions to prevent further resident falls. The facility investigation did not reveal all the interventions revealed on the resident's plan of care. The list of medications and environmental factors were not documented. See above, the post fall investigation read to continue current fall interventions that included encourage to ask for assistance with needed, and call light within reach; these interventions were known to be ineffective. Moreover, there was no reference to the resident's need for supervision and how frequently she should be observed to prevent additional falls and injury. E. Fall #5 Record review revealed another resident fall related to toileting and an order for [REDACTED]. 1. Record review The 3/10/17 Quality Improvement Post Fall Investigation revealed the resident had a fall without injury at 4:30 a.m.; prior to the incident she was getting out of bed and going to the bathroom. Her physical status was unsteady gait and continent. The devices/equipment used was bed and chair alarms, low bed, and wheelchair. She required the assistance of one staff member, and no current medications or environmental factors documented The list of medications and environmental factors were not documented. The 3/10/17 Acute Care Plan: Falls revealed the interventions included: monitor for causative agents, use alarm/safety equipment as ordered, continue alarm to bed and wheelchair, auto lock brakes to wheelchair, low bed, fall mat, establish a toileting program, and encourage to call/ask for assistance. The 3/10/17 SBAR Communication Form and Progress Note revealed the resident was found lying on the floor and on her left side with her head towards the front of the bed. The form/note did not reveal medication alerts, vital signs, mental status change, functional status changes, respiratory, GI/abdomen, GU/urine changes, recent lab results, advance care planning information, and RN assessment on potential problem. 2. Staff interviews The DON was interviewed on 4/6/17 at 3:45 p.m. She said resident #4's fall mat had been removed from the resident's bedroom, unknown date and replaced with the black, gripper strips on the floor. She said moving forward, interventions for resident #4 may include a light in the bathroom, moving the bed, and OT evaluations. 3. Failure to timely implement a toileting program. Although toileting had been a factor in previous falls and the resident was documented as experiencing increased incidents of incontinence, plans to specifically address toileting were not developed until after the resident's fifth fall. Specifically: -The 3/13/17 Post Fall Investigation revealed the interventions were check placement of bed and wheelchair alarm, toilet upon awaking, before and after meals and at night, and encourage the resident to ask for assistance. -The 4/17 Physician Orders revealed an order dated 3/16/17 for a toileting schedule - upon rising, before and after meals, and at night. There was still no instruction to staff, however, on the resident's need for increased monitoring and supervision. F. Current status Observations revealed the resident had a bed cane attached to her bed that was not identified anywhere in her record. Interviews revealed its use was not assessed or monitored for safety. 1. Observations and Interview Resident #4 was interviewed and observed on 4/5/17 at 1:09 p.m. She said she had memory concerns and believed she had a fall recently. She lifted her left hand which had a black brace and said she hurt herself from the fall. Her bed had a bed cane on the upper right side (against the wall). She was sitting in her wheelchair. Resident #4 was observed on 4/5/17 at 3:56 p.m. She was lying in bed. Her bed had a bed cane on the upper right side (against the wall). 2. Record review Review of Quick Notes the 12/1/16 Physical Restraint/Bed Safety Risk Review, which identified types of restraints and bed safety devices, the 12/13/16 Restorative Screening and Data Collection, the 11/3/16 Data Collection Tool, Physician Orders, Interdisciplinary Progress Notes, and the resident's care plans did not reveal the resident had a bed cane. The undated document, titled Resident with Bed Canes was provided on 4/6/17 at 4:35 p.m. The document revealed 21 residents used bed canes. 3. Staff interviews CNA #4 was interviewed on 4/5/17 at 3:22 p.m. She said bed canes were provided to residents who required assistance with bed mobility, transfers, and cares. Restorative RCNA (RCNA)) #2 was interviewed on 4/5/17 at 3:24 p.m. She said the RCNAs instructed residents on how to use bed canes for bed mobility and said bed canes required an assessment for safety and use. The OT was interviewed on 4/6/17 at 8:39 a.m. She said therapy did not assess for the use of bed canes. Therapy was responsible for assisting the resident and/or caregivers on instructions how to use the bed cane in order to prevent accidents or harm. The PT was interviewed on 4/6/17 at 8:51 a.m. She said justifications for use a bed cane included mobility, functional limitations, spine precautions, sitting and standing balance, transfer balance, and increasing independence. -The PT said safety concerns identified with the use of bed canes included skin tears, bruising, and limitations with ROM. The bed cane was not identified as a potential entrapment concer