Every finding on record at Center at Park West LLC, The

Based on observation, record review and staff interview, the facility failed to store, prepare, distribute and serve food in a sanitary manner in the kitchen.Specifically, the facility failed to:-Ensure food items in the main kitchen refrigerator were labeled and dated;-Maintain the ice scoop holder and the microwave in a sanitary condition; and, -Ensure raw meat was stored in a manner that prevented cross contamination of ready-to-eat foods.Findings include:I. Failure to properly label and date food itemsA. Professional reference The Colorado Retail Food Establishment Regulations, (3/16/24), retrieved on 6/30/26, read in pertinent part, Working containers holding food or food ingredients that are removed from their original packages for use in the food establishment shall be identified with the common name of the food. (3-302.12) Refrigerated, ready-to-eat, time/temperature control for safety food prepared and held in a food establishment for more than 24 hours shall be clearly marked to indicate the date or day by which the food shall be consumed on the premises, sold, or discarded. (3-501.17)B. Facility policy and procedure The Food Storage policy, revised 2/8/21, was provided by the nursing home administrator (NHA) on 6/25/26 at 3:29 p.m. The policy revealed in pertinent part, Each item is to be accurately dated upon receipt. When items are opened or in use,'use-by-dates are to be labeled upon them followed by storing the item in the proper area such as the refrigerator, freezer, or dry storage area located in the kitchen. All items requiring refrigeration should be stored at a temperature of 36-41 degrees Fahrenheit or below and are to be dated properly.C. ObservationsThe initial tour of the kitchen was completed on 6/22/26 at 9:05 a.m., and revealed the following:At 9:17 a.m., seven fruit cups and three strawberry cream pies were in the kitchen refrigerator without labels identifying the food item, preparation date, or discard date.During a follow-up tour of the kitchen on 6/23/26 at 4:00 p.m., the following was observed:Three fruit cups were observed in the kitchen refrigerator without labels identifying the food items, preparation date, or discard date.D. Staff interviewsThe dietary manager (DM) was interviewed on 6/23/26 at 4:01 p.m. The DM said the fruit cups were prepared the previous day and should have been labeled by the staff member who prepared them. The DM said the fruit cups were good for three days.Cook #1 was interviewed on 6/25/26 at 10:42 a.m. [NAME] #1 said the staff member who prepared the food was responsible for ensuring it was covered, labeled, and dated before placing it in the refrigerator. [NAME] #1 said the dietary aide (DA) typically prepared salads, sandwiches, and fruit cups. [NAME] #1 said food items that were missing preparation dates or labels should be discarded because staff would not know when the items were prepared, especially if staff had not worked for several days.Dietary aide #1 was interviewed on 6/25/26 at 11:01 a.m. Dietary aide #1 said the dietary aides were responsible for preparing fruit cups and that fruit cups were good for three days. Dietary aide #1 said prepared food items were supposed to be labeled and dated so staff would know when they were prepared and to ensure expired food was not served. Dietary aide #1 said if food items were missing preparation dates or labels, staff would have to look at meal tickets to determine when the items were prepared. Dietary aide #1 said they were not supposed to serve expired food.The DM was interviewed again on 6/25/26 at 11:55 a.m. The DM said prepared food items should be identified and dated before being placed in the refrigerator to ensure expired food was not served. The DM said all kitchen staff were responsible for ensuring prepared food items were labeled and dated before being stored in the refrigerator and whoever put the food away was responsible for labeling and dating it. The DM said unlabeled food should be discarded and staff should be educated.II. Failure to maintain the ice scoop holder and the microwave in a sanitary conditionA. Professional referenceThe Colorado Retail Food Establishment Regulations (3/16/24), retrieved on 06/30/26, read in pertinent part, Equipment food-contact surfaces and utensils shall be clean to sight and touch. (4-601.11). Nonfood-contact surfaces of equipment shall be kept free of an accumulation of dust, dirt, food residue, and other debris. (4-601.11) The premises shall be free of items that are unnecessary to the operation or maintenance of the establishment. (6-501.114)B. Facility policy and procedure The Food Storage policy, revised 2/8/21, was provided by the NHA on 6/25/26 at 3:29 p.m. The policy revealed in pertinent part, Ice will be produced, stored, and dispensed in a manner to avoid contamination. Ice scoops will be stored outside of the ice dispenser in a closed, clean container or in the ice machine in the scoop storage container provided by the manufacturer. Ice scoops will be cleaned and sanitized daily. Employees will follow proper cleaning and sanitizing instructions for all kitchen equipment. Equipment and work areas should be cleaned and sanitized after use. C. ObservationsThe initial tour of the kitchen was completed on 6/22/26 at 9:05 a.m., and revealed the following:At 9:21 a.m., the ice scoop holder contained an accumulation of white residue in the interior bottom surface of the ice scoop holder.During a follow-up tour of the kitchen on 6/24/26 at 10:45 a.m., the same white residue was observed in the interior bottom surface of the ice scoop holder.At 11:36 a.m. the interior of the microwave in the kitchen contained dried food splatter and yellow grease accumulation D. Staff interviewsCook #1 was interviewed on 6/25/26 at 10:42 a.m. [NAME] #1 said the microwave and the ice scoop holder were cleaned by the dietary aides or by any staff member who uses them. [NAME] #1 observed the interior of the microwave during the survey and said that it did not look clean. [NAME] #1 said she would clean the microwave.Dietary aide #1 was interviewed on 6/25/26 at 11:01 a.m. Dietary aide #1 said whoever used the microwave or the ice scoop holder was responsible for cleaning it if they made a mess. Dietary aide #1 said the microwave and the ice scoop holder should be cleaned after use because food residue and debris left on the equipment could contaminate other food or utensils and create an unsanitary condition.The DM was interviewed on 06/25/2026 at 11:55 a.m. The DM said the microwave should be cleaned frequently, especially when spills occur. The DM said the dietary aides or any staff member who used the microwave or observed spills were responsible for cleaning it. The DM said the ice machine had been working intermittently and maintenance was on site to repair it. The DM said it was everyone's responsibility to clean the ice scoop holder when residue is observed and, ultimately, it is the DS's responsibility to ensure it is cleaned to help prevent cross-contamination.III. Failure to store raw meat in a manner that prevented cross contaminationA. Professional referenceThe Colorado Retail Food Establishment Regulations (3/16/24), retrieved on 06/30/26, read in pertinent part, Food shall be protected from cross contamination by separating raw animal foods during storage, preparation, holding, and display from: raw ready-to-eat food including other raw animal food such as fish for sushi or molluscan shellfish, or other raw ready-to-eat food such as fruits and vegetables; cooked ready-to-eat food; and fruits and vegetables before they are washed. (3-302.11).B. Facility policy and procedure The Food Storage Policy, revised 2/8/21, was provided by the NHA on 6/25/26 at 3:29 p.m. The policy revealed in pertinent part, When storing raw meat, it must be properly sealed and separated from all other foods during storage. It should always be below ready-to-eat foods. Raw meat should be stored in order of top to bottom on shelves: fish, beef, ground beef, and poultry.C. ObservationsThe initial tour of the kitchen was completed on 6/22/26 at 9:05 a.m., and revealed the following:At 9:06 a.m. a utility cart in the cook line area contained three packages of raw beef stored on the top shelf. Directly beneath the raw beef, on the lower shelf of the same cart, was a covered pan containing a prepared salad mixture.D. Staff interviewsCook #1 was interviewed on 6/25/26 at 10:42 a.m. [NAME] #1 said raw meat and ready-to-eat foods should be stored separately to prevent cross-contamination. [NAME] #1 said raw chicken is stored on the bottom shelf of the speed rack in the walk-in cooler, raw pork and beef are stored above the chicken, and precooked foods are stored above the raw meats. [NAME] #1 said ready-to-eat foods and salads are stored on a separate speed rack. [NAME] #1 said if ready-to-eat foods were stored directly below packages of raw beef, the ready-to-eat foods should be discarded because raw meat juices could drip onto the food and cause cross-contamination, making the food unsafe to serve.Dietary aide #1 was interviewed on 6/25/26 at 11:01 a.m. Dietary aide #1 said the cooks were responsible for properly storing raw meats and ready-to-eat foods. Dietary aide #1 said storing ready-to-eat food beneath raw meat creates a risk of cross-contamination. Dietary aide #1 said if she observed ready-to-eat food stored below raw meat, she would discard the ready-to-eat food because it could have been contaminated by raw meat juices and would no longer be safe to serve.The DM was interviewed on 6/25/26 at 11:55 a.m. The DM said raw meat should be stored below ready-to-eat foods to prevent cross-contamination because storing ready-to-eat food beneath raw meat creates a risk of contamination from raw meat juices. The DM said the prepared salad mixture stored on the utility cart outside the refrigerator beneath the packages of raw beef on 6/22/26 was from the previous day and had been used for chicken wraps. The DM said she had noticed the salad in the refrigerator that morning and intended to discard it because it could not be used again.

Based on observations, record review and interviews, the facility failed to ensure respiratory care was provided in accordance with professional standards for four (#84, #81, #88 and #49) of eight residents out of 37 sample residents.Specifically, the facility failed to:-Ensure a physician's order was obtained for the use, setting, and required cleaning of Resident #84 and Resident #81's CPAP (continuous positive airway pressure) machines;-Ensure Resident #88's oxygen was administered according to the physician's orders; and,-Ensure Resident #49's nebulizer (medical device that converts liquid medication into a fine mist) equipment was cleaned and maintained appropriately. Findings include: I. Failed to ensure a physician's order was obtained for the use, setting, and required cleaning of Resident #84 and Resident #81's CPAP machines A. Facility policy and procedure The Bi-level Positive Airway Pressure (BiPAP)/Continuous Positive Airway Pressure (CPAP) policy, revised 2/8/21, was provided by the nursing home administrator (NHA) on 6/24/26 at 4:51 p.m. It revealed in pertinent part, The resident will receive necessary respiratory care and services in accordance with professional standards of practice, resident's care plan, and the resident's choice. Residents will have orders that include settings for CPAP/BiPAP. CPAP/BiPAP will be cleaned per manufacturer's guidelines. B. Resident #84 1. Resident status Resident #84, age less than 65, was admitted on [DATE]. According to the June 2026 computerized physician orders (CPO), diagnoses included asthma, chronic obstructive pulmonary disease (COPD) and acute and chronic respiratory failure. The 6/25/26 minimum data set (MDS) assessment revealed the resident had moderate cognitive impairment with a brief interview for mental status (BIMS) score of 12 out of 15. The MDS assessment revealed that the resident required a CPAP machine and continuous oxygen. 2. Observations On 6/22/26 at 2.16 p.m. Resident #84 was sitting on her bed with her oxygen on via nasal cannula. There was a CPAP machine on a sofa with the mask and tubing connected to the CPAP. There was no storage bag. On 6/23/26 at 9:15 a.m. Resident #84 was lying in bed with her CPAP mask over her nose. Resident #84's CPAP machine was in the same spot on the sofa. The humidifier chamber was connected to the resident's CPAP machine; there was an unmeasurable amount of water in the chamber, and condensation was visible on the walls of the chamber. On 6/24/26 at 4:33 p.m. Resident #84 was asleep in bed. She was not wearing her CPAP mask. She was wearing a nasal cannula and receiving oxygen via the oxygen wall unit. The humidifier chamber of the CPAP machine had a minimal amount of water in it. Condensation was visible on the walls of the humidifier chamber. 3. Resident interview Resident #84 was interviewed on 6/24/26 at 2:35 p.m. Resident #84 said she wore her CPAP every night. Resident #84 said the facility staff had not cleaned her CPAP machine since her admission to the facility (on 6/19/26). Resident #84 said her CPAP machine and mask had been left on the sofa without protective covers. 4. Record review A review of Resident #84's respiratory care plan, initiated 6/19/26, revealed the resident had respiratory risks related to deficiencies/abnormalities in pulmonary function, including COPD, asthma, chronic respiratory failure, and sleep apnea. Interventions included administering and providing respiratory therapy and respiratory treatment interventions per the physician's order and the use of a CPAP per physician's orders. -The care plan failed to include documentation for settings, cleaning instructions and cleaning frequency for the CPAP machine. -Review of Resident #84's June 2026 CPO did not reveal physician's orders for the CPAP settings or maintenance of the CPAP machine. Review of Resident #84's June 2026 medication administration record/treatment administration records (MAR/TAR) did not reveal documentation that cleaning was being completed for the resident's CPAP machine. C. Resident #81 1. Resident status Resident #81, age greater than 65, was admitted on [DATE]. According to the June 2026 CPO, diagnoses included sepsis due to methicillin susceptible staphylococcus aureus (a severe life threatening medical emergency that occurs when a localized infection caused by a specific strain of bacteria enters the bloodstream and triggers a violent, body wide immune response, type 2 diabetes mellitus, metabolic encephalopathy (a temporary or permanent brain dysfunction caused by a chemical imbalance in the body) and muscle weakness. The 4/22/26 MDS assessment revealed the resident had moderate cognitive impairment with a BIMS score of 12 out of 15. The MDS assessment indicated the resident utilized a BiPAP. 2. Observations On 6/22/26 at 1:14 p.m. Resident #81 was sitting in his room in his wheelchair with his oxygen on via nasal cannula. There was a CPAP machine on a sofa with the mask and tubing connected to the CPAP. There was no protective bag covering the mask. The face of the mask was directly resting on the sofa. The humidifier chamber contained an unmeasurable amount of water, and condensation was visible on the sides and top of the chamber. On 6/23/26 at 11:55 a.m. Resident #81 was sitting in his wheelchair in his room. The CPAP machine was still on the sofa by his bed, with the mask and tubing connected to it. There was no protective bag covering the mask. The humidifier chamber contained an unmeasurable amount of water, and condensation was visible on the sides and top of the chamber. 3. Resident interview Resident #81 was interviewed on 6/23/26 at approximately 12:10 p.m. Resident #81 said he had been using his CPAP machine since he was admitted to the facility (on 4/15/26). Resident #81 said the CPAP machine had not been cleaned since his admission to the facility. Resident #81 said the CPAP machine had been stored on the bedside sofa with the mask and tubing. Resident #81 said he had not seen the mask and tubing stored in a protective cover. 4. Record review A review of Resident #81's June 2026 CPO revealed the following physician's orders: Initiate CPAP at bedtime. Enter settings 4.0 cm (centimeters). No oxygen required for this order, ordered 4/16/26. CPAP cleaning instructions: Hand-wash mask/headgear (may be washed without being disassembled) using warm water and mild soap. Rinse well with quality drinking water. Allow to air dry out of direct sunlight, ordered 6/23/26. -However, Resident #81's CPAP use had been initiated on 4/16/26, but the CPAP cleaning order was not initiated until 6/23/26 (during the survey). A review of Resident #81's respiratory care plan, initiated 4/15/26, revealed that the resident had respiratory risks related to deficiencies/abnormalities in pulmonary function. Interventions included administering and providing respiratory therapy and respiratory treatment interventions per the physician's order and the use of a CPAP per physician's orders. -However, the care plan failed to establish or include any specific protocols, frequencies, or staff responsibilities regarding the cleaning, sanitization, and maintenance of the CPAP equipment. D. Staff interviews Licensed practical nurse (LPN) #2 was interviewed on 6/24/26 at 3:34 p.m. LPN #2 said he did not usually work on the unit and was not sure what Resident #84 and Resident #81's CPAP orders were. LPN #2 looked at Resident #84's June 2026 CPO and said there was no physician's order for the resident's CPAP use, settings, cleaning, and maintenance of the device. LPN #2 said Resident #81 had a physician's order for CPAP use; however, she did not see a physician's order for device cleaning or maintenance. LPN #2 said there should be a physician's order for the settings and cleaning of the CPAP machine to prevent possible respiratory infections. LPN #3 was interviewed on 6/24/26 at 3:45 p.m. LPN #3 said she was the unit manager. LPN #3 said all CPAP machines required a physician's order for the use, settings, and maintenance of each device. LPN #3 said during the admission process, the admitting nurse should ensure that the admitting physician's orders included the use of any medical devices the residents were admitted with. LPN #3 said it was important to ensure physician's orders were in place for each medical device to ensure proper use and maintenance of the equipment. The nurse practitioner (NP) was interviewed on 6/24/26 at 4:22 p.m. The NP said all CPAP machines should have an active physician's order, including an order for cleaning and maintenance of the device. The director of nursing (DON) and the regional director of clinical services were interviewed together on 6/24/26 at 5:09 p.m. The DON said the facility had independently identified an opportunity for improvement during a mock survey conducted on 6/11/26. He said following that review, the issue regarding physician's orders and respiratory equipment cleaning concern was immediately entered into the quality assurance performance improvement (QAPI) program, and a formal Plan of Correction was initiated on 6/11/26. The DON said all nursing staff were trained to ensure respiratory compliance. The DON said he did not know why the staff failed to ensure compliance with the physician's orders for Resident #81. The DON said he would immediately provide re-education to the nursing staff. The DON said he could not explain the reason the plan of correction for their mock survey did not prevent Resident #84's CPAP failures. II. Failed to ensure Resident #88's oxygen was administered according to the physician's orders A. Facility policy and procedure The Oxygen Administration policy, revised 8/3/23, was provided by the NHA on 6/24/26 at 4:51 p.m. It revealed in pertinent part, For a resident receiving oxygen therapy, the resident's record must reflect ongoing evaluation of the resident's respiratory status, response to oxygen therapy and include, at a minimum, the attending practitioner's orders. The ResMed CPAP Cleaning Manufacturer Guidelines, undated, was provided by the NHA on 6/24/26 at 4:51 p.m. It revealed in pertinent part, Hand wash mask/headgear (may be washed without being disassembled) using warm water and mild soap. Rinse well with drinking-quality water. Allow to air dry out of direct sunlight. Flex fit CPAP cleaning instructions: Hand-wash the headgear in pure soap dissolved in lukewarm water. Do not soak for longer than ten minutes, then rinse in fresh water and allow to dry out of direct sunlight. It is not necessary to remove the clip from the headgear when washing. Only have to clean every seven days. Respironics CPAP cleaning instructions: Hand-wash the mask in warm water with mild liquid soap, ensuring all visible dirt is removed. Rinse thoroughly with warm water to remove soap. Allow the mask to air dry out of direct sunlight. Astral- Hand wash mask/headgear (may be washed without being disassembled) using warm water and mild soap. Rinse well with drinking-quality water. Allow to air dry out of direct sunlight. B. Resident #88 1. Resident status Resident #88, age greater than 65, was admitted on [DATE]. According to the June 2026 CPO, diagnoses included COPD and dependence on supplementary oxygen. The 6/25/26 MDS assessment revealed the resident had moderate cognitive impairment with a BIMS score of 12 out of 15. The MDS assessment indicated Resident #88 received oxygen therapy. 2. Observations On 6/22/26 at 2:23 p.m. Resident #88 was lying on his bed in his room. He was wearing a nasal cannula connected to an oxygen wall outlet, set to 2.5 liters per minute (LPM) of oxygen. On 6/23/26 at 9:05 a.m. Resident #88 was lying in bed with his oxygen wall outlet set to 2.5 LPM. On 6/24/26 at 10:07 a.m. Resident #88 moved to a different room. Resident #88 was observed in bed in the new room with his nasal cannula on and the oxygen flow rate on the oxygen wall outlet was set at 2.5 LPM. -However, the resident's physician's order for oxygen specified an oxygen flow rate of 1 LPM (see record review below). 3. Resident interview Resident #88 was interviewed on 6/24/26 at 11:14 a.m. Resident #88 said he did not know what liter flow he was receiving for his oxygen use. Resident #88 said he was unable to reach the wall outlet to tamper with his oxygen. Resident #88 said the facility staff managed the liter flow of her oxygen. 4. Record review Review of Resident #88's June 2026 CPO revealed the following physician's orders: Oxygen to be on at 1 LPM (continuously), delivered through a nasal cannula. May titrate if oxygen drops below 88% (oxygen saturation level), increasing by 0.5LPM every five minutes until oxygen is 88% to 94%. Re-evaluate in 24 hours and titrate back down by 0.5 LPM every five minutes until oxygen is between 88% and 90%. If the resident has COPD and oxygen dropped below 85%, may titrate by 0.5 LPM every five minutes until oxygen is 85% to92%. Re-evaluate in 24 hours and bring back down by 0.5 LPM until oxygen is 85% to 90% every shift and as needed. -However, observations revealed the resident's oxygen flow rate was set to 2.5 LPM (see observations above). The oxygen therapy care plan, initiated 6/19/26, documented that Resident #88 had respiratory risk related to respiratory deficiencies and abnormalities in pulmonary function. Interventions included administering oxygen as ordered, monitoring breath sounds as needed, and monitoring for shortness of breath. -The care plan did not include the physician's orders for oxygen flow rate and oxygen titration. Review of Resident #88's vital signs documentation from 6/19/26 to 6/24/26 revealed the following: -On 6/19/26 at 6:00 p.m. Resident #88's oxygen saturation level was 98% on 1 LPM; -On 6/19/26 at 7:10 p.m. Resident #88's oxygen saturation level was 95% on room air; -On 6/20/26 at 7:01 a.m. Resident #88's oxygen saturation level was 96% on room air; -On 6/20/26 at 4:20 p.m. Resident #88's oxygen saturation level was 96% on room air; -On 6/20/26 at 8:23 p.m. Resident #88's oxygen saturation level was 96% on room air; -On 6/21/26 at 8:00 a.m. Resident #88's oxygen saturation level was 92% but the LPM was not documented;. -On 6/21/26 at 9:11 p.m. Resident #88's oxygen saturation level was 98% but the LPM was not documented; -On 6/22/26 at 6:44 a.m. Resident #88's oxygen saturation level was 92% but the LPM was not documented; -On 6/22/26 at 8:24 p.m. Resident #88's oxygen saturation level was99% but the LPM was not documented; -On 6/23/26 at 7:02 a.m. Resident #88's oxygen saturation level was 96% but the LPM was not documented; -On 6/23/26 at 7:33 p.m. Resident #88's oxygen saturation level was 92% but the LPM was not documented; -On 6/24/26 at 8:00 a.m. Resident #88's oxygen saturation level was 100% but the LPM was not documented. -However, there was no documentation indicating the resident needed more oxygen, based on the documented oxygen saturations (see observations above). C. Staff interviews Registered nurse (RN) #1 was interviewed on 6/24/26 at 3:41 p.m. RN #1 observed Resident #88's oxygen wall outlet flow rate setting and acknowledged the resident's oxygen flow rate was set at 2.5 LPM. RN #1 said she was not aware of any medical necessity that would require increased oxygenation or any new oxygen orders in Resident #88's electronic medical record (EMR). After RN #1 reviewed the physician's order for Resident #88's oxygen, she confirmed the oxygen flow rate was supposed to be set at 1 LPM. RN #1 said she would normally check a resident's oxygen flow rate setting and their oxygen saturation level during her shift, and if there was a discrepancy noted, she would investigate the reason the oxygen flow rate was different from what the physician's order indicated and adjust it if needed. She said nurses should not document the incorrect oxygen flow rate on the EMR. The NP was interviewed on 6/24/26 at 4:22 p.m. The NP said prescribed oxygen was a medication, not a comfort measure. The NP said changing the oxygen flow rate for a resident outside of a physician's order could have adverse consequences for a resident with COPD. The NP said it was critical that the clinical staff thoroughly documented any medical necessity that required additional or less oxygen and immediately notified the provider. The NP said the residents' care plans should be updated to include interventions for staff to follow. The director of nursing (DON) and the regional director of clinical services were interviewed together on 6/24/26 at 5:09 p.m. The DON said the nursing staff were expected to document any changes in oxygen flow rate and the rationale for the change in the residents' EMR. The regional director of clinical services said oxygen was part of the residents' medications and that all physician's oxygen orders needed to be followed. The regional director of clinical services said that failure to follow the physician's order for oxygenation could result in health complications, such as respiratory failure, depending on each resident's condition. III. Failed to ensure Resident #49's nebulizer (medical device that converts liquid medication into a fine mist) equipment was cleaned and maintained appropriately A. Facility policy and procedure The Nebulizer policy, revised 3/28/24, was provided by the NHA on 6/24/26 at 4:51 p.m. It revealed in pertinent part, For a resident receiving a nebulizer treatment, the nurse is to ensure that the resident completed the nebulizer treatment. Nurses are to follow physician's orders of administering the nebulizer treatment. Once the resident completes the treatment, nurses are to rinse the mouth piece or face mask when completed. B. Resident #49 1. Resident status Resident #49, age [AGE], was admitted on [DATE]. According to the June 2026 CPO, diagnoses included personal history of pulmonary embolism (blood clot in lung), type 2 diabetes (abnormal glucose control, and heart failure. The 6/16/26 MDS assessment revealed the resident was cognitively intact with a BIMS score of 15 out of 15. He required supervision or touching assistance with eating, oral hygiene, personal hygiene, and needed substantial assistance with toileting. The MDS assessment did not document the resident used continuous oxygen therapy. 2. Resident interview and observations Resident #49 was interviewed on 6/23/26 at 9:20 a.m. Resident #49 said the staff did not clean his nebulizer mask before applying it that day. A nebulizer machine and mask were observed on the couch in the resident's room. The mask remained attached to the tubing. The nebulizer mask had a visible dark brown foreign substance and residue buildup inside it. Resident #49 was interviewed again on 6/24/26 at 1:56 p.m. Resident #49 said he had been given a nebulizer treatment about an hour earlier. Resident #49 said he did not know if staff had cleaned the mask after it was used. The nebulizer mask was observed attached to the tubing and resting on the resident's nightstand. There was moisture and condensation present inside the mask. The brown unidentified foreign substance was still present inside the mask. 3. Record review A review of Resident #49's June 2026 CPO revealed the following physician's order: Albuterol Sulfate nebulization solution 2.5 milligrams (mg)/3 milliliters (ml) 0.083%, one vial, inhale orally via nebulizer every four hours as needed for shortness of breath, ordered on 6/21/26. -However, there were no physician's orders for cleaning, sanitizing or storing the nebulizer equipment. Resident #49's care plan, initiated 6/12/26, revealed the resident was at respiratory risk related to respiratory conditions and/or deficiencies/abnormalities in pulmonary function. Pertinent interventions included administering medications per physician's orders, monitoring breath sounds as needed, monitoring the resident's nail beds and skin color for changes as needed, monitoring pulse oximetry (measurement of blood oxygen saturation) every shift; if less than 88%, start oxygen at 1 to 5 liters per minute (LPM) continuously, delivered through nasal cannula, and titrate to greater than or equal to 88%. -The care plan failed to include interventions related to cleaning, sanitizing, drying, or storing the resident's nebulizer equipment. C. Staff interviews Certified nurse aide (CNA) #1 was interviewed on 6/24/26 at 3:25 p.m. CNA #1 said Resident #49 received nebulizer treatments on an as-needed basis, up to four times daily. CNA #1 said the CNAs were responsible for sterilizing the nebulizer equipment after each use by wiping the nebulizer mask with a purple-top disinfectant wipe. CNA #1 said she had not been trained on how often the nebulizer mask should be cleaned. CNA #1 said after cleaning the nebulizer mask, it was stored on the resident's bedside table. CNA #1 said she had not previously seen residue buildup inside the nebulizer mask, but if she observed residue, she would replace the mask. CNA #1 said the nebulizer mask should be cleaned after each use because it was important for infection control. CNA #1 observed the residue buildup inside Resident #49's nebulizer mask. She said it was unacceptable and proceeded to remove the nebulizer mask from the tubing and discard it. RN #1 was interviewed on 6/24/26 at 3:55 p.m. RN #1 said after each nebulizer treatment, the nebulizer mask should be washed in the sink, rinsed with water, and hung to air dry. RN #1 said the nebulizer mask should be washed after each use for infection control purposes. RN #1 said using a purple-top disinfectant wipe was not the proper method to clean the nebulizer equipment. RN #1 said nurses were responsible for ensuring the cleanliness of the residents' nebulizer equipment. RN #1 said if a CNA observed residue inside the nebulizer mask, the CNA should notify the nurse. RN #1 said Resident #49's last nebulizer treatment had been administered at 2:42 p.m. that day (6/24/26). RN #1 said there should be a physician's order and care plan for cleaning the nebulizer equipment to ensure it was properly disinfected and to prevent the spread of germs. The regional director of clinical services and the DON were interviewed together on 6/24/26 at 4:12 p.m. The DON said the nebulizer mask should be washed after each use and allowed to air dry. The DON said it was the nurse's responsibility to disinfect the nebulizer mask because the nurse administered the treatment. The DON said staff received training regarding nebulizer equipment maintenance and infection prevention during the annual skills fair. The regional director of clinical services said cleaning the nebulizer equipment was part of standard nursing practice and assumed knowledge, similar to other routine nursing responsibilities. The regional director of clinical services said cleaning instructions did not need to be included in the care plan because cleaning the nebulizer equipment was the standard of care. The regional director of clinical services said the nebulizer mask should be cleaned after each use for infection control purposes. CNA #1 was interviewed again on 6/24/26 at 4:20 p.m. CNA #1 said when she had previously referred to cleaning the nebulizer mask with a purple-top disinfectant wipe, she was referring to cleaning the exterior of the mask.

Based on observations and interviews, the facility failed to maintain an infection control program designed to provide a safe and sanitary environment to prevent the development and transmission of diseases and infection on two of two units.Specifically, the facility failed to:-Ensure isolation signage was correct for Resident #76's room; -Ensure staff wore the appropriate personal protective equipment (PPE) when entering Resident #1's room;-Ensure staff properly cleaned shared vital signs equipment between residents;-Ensure Resident #36's reusable therapeutic cold pack was not stored in a public refrigerator with food;-Ensure a medication vial was cleaned or discarded after it had rolled across the floor; and,-Ensure hand hygiene was performed after a wrapper was picked up from the kitchen floor.Findings include:I. Facility policy and procedureThe Infection Control policy, revised 1/29/25, was provided by the nursing home administrator (NHA) on 6/22/26 at 2:17 p.m. It read in pertinent part, All staff shall assume that all residents are potentially infected or colonized with an organism that could be transmitted during the course of providing patient care services. Hand hygiene shall be performed in accordance with our facility's established hand hygiene procedures. All staff shall use PPE according to established facility policy governing the use of PPE. Licensed staff shall adhere to safe injection and medication administration practices. Environmental cleaning and disinfection shall be performed according to facility policy. A resident with an infection or communicable disease shall be placed on transmission based precautions as recommended by current CDC (Centers for Disease Control and Prevention) guidelines. All reusable items and equipment requiring special cleaning, disinfection or sterilization shall be cleaned in accordance with our current procedures governing the cleaning and sterilization of soiled or contaminated equipment. Isolation signs are used to alert staff, family members, and visitors of transmission based precautions.II. Transmission based precaution signage and PPE failuresA. Professional referenceAccording to the CDC's Implementation of Personal Protective Equipment (PPE) Use in Nursing Homes to Prevent Spread of Multidrug-resistant Organisms (MDROs), (4/2/24), retrieved on 6/30/26, 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. Examples of high-contact resident care activities requiring gown and glove use for Enhanced Barrier Precautions 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; wound care: any skin opening requiring a dressing.According to the CDC's Precautions to Prevent Transmission of Infectious Agents, (11/22/23), retrieved on 6/30/26 from https://www.cdc.gov/infection-control/hcp/isolation-precautions/precautions.html, Contact precautions are intended to prevent transmission of infectious agents, including epidemiologically important microorganisms, which are spread by direct or indirect contact with the patient or the patient's environment. Healthcare personnel caring for patients on contact precautions wear a gown and gloves for all interactions that may involve contact with the patient or potentially contaminated areas in the patient's environment. Donning PPE (personal protective equipment) upon room entry and discarding before exiting the patient room is done to contain pathogens, especially those that have been implicated in transmission through environmental contamination.B. Observations and staff interviewsOn 6/22/26 at 12:30 p.m. certified nurse aide (CNA) #4 entered Resident #76's room. CNA #4 was not wearing a gown or gloves when she entered the room. CNA #4 delivered a meal tray to Resident #76. Resident #76's room had a contact precautions sign posted on the door to alert all staff to wear gowns and gloves when entering the room.On 6/22/26 at 4:55 p.m. Resident #76's precautions sign had been changed from contact precautions to enhanced barrier precautions (EBP).On 6/25/26 at 9:00 a.m. CNA #2 entered Resident #1's room. CNA #2 was not wearing a gown when he entered the room. CNA #2 walked to the resident's bedside table with a meal tray. He set the meal tray down and his clothing touched the bedside table. Resident #1's room had a contact precautions sign posted on the door to alert all staff to use gowns and gloves when entering the room. LPN #4 was preparing to administer medications to residents and was outside of Resident #1's room. LPN #4 said Resident #1 was on contact precautions and this required all staff to wear gowns and gloves when entering his room. LPN #4 then told CNA #2 that he should wear a gown whenever he entered Resident #1's room.III. Failed to clean vital signs equipment between residentsA. Professional referenceThe CDC's Recommendations for Disinfection and Sterilization in Healthcare Facilities, (2024), was retrieved on 6/30/26 from https://www.cdc.gov/infection-control/hcp/disinfection-sterilization/summary-recommendations.html#:~:text=Ensure%20that%2C%20at%20a%20minimum,once%20daily%20or%20once%20weekly. It read in pertinent part, Clean medical devices as soon as practical after use. Perform either manual cleaning or mechanical cleaning. Perform low-level disinfection for noncritical patient-care surfaces and equipment (blood pressure cuffs) that touch intact skin.B. ObservationsOn 6/24/26 at 9:00 a.m. registered nurse (RN) #3 retrieved manual blood pressure equipment from the nurses' station. RN #3 wrapped a blood pressure cuff around his own arm to check for size. RN #3 then took the blood pressure equipment to Resident #76's room, wrapped the blood pressure cuff around Resident #76's arm and checked the resident's blood pressure. RN #3 then took the blood pressure monitoring equipment to Resident #77's room, wrapped the blood pressure cuff around Resident #77's arm and checked the resident's blood pressure. -However, RN #3 did not clean the blood pressure monitoring equipment after wrapping the cuff around his own arm or after checking Resident #76's blood pressure and Resident #77's blood pressure.IV. Failed to ensure Resident #36's reusable therapeutic cold pack was not stored in a public refrigerator with foodA. Resident interview and observations Resident #36 was interviewed on 6/22/26 at 2:30 p.m. Resident #36 said she placed two reusable therapeutic cold packs on her back each day. Resident #36 said she placed the reusable cold packs in a freezer every morning that was accessible to all residents. Resident #36 said that staff did not assist her with storage of the reusable cold packs. Resident #36 was interviewed again on 6/23/26 at 5:55 p.m. Resident #36 said she had placed her reusable cold packs in the freezer that morning (6/23/26). On 6/23/26 at 6:00 p.m. the refrigerator freezer for storage of residents' food was observed. Two reusable cold packs, approximately eight by 10 inches each, were in the freezer, unlabeled and without Resident #36's name, open to air and not in a sealed package. The reusable cold packs were near a box of popsicles. On 6/24/26 at 4:45 p.m. the reusable cold packs were observed in the same refrigerator freezer, unlabeled and open to air, next to the popsicles. B. Staff interviewRN #6 was interviewed on 6/24/26 at 5:10 p.m. RN #6 said the refrigerator freezer in the common area on the unit was for residents' food, not residents' reusable cold packs. RN #6 said Resident #36's reusable cold packs should be cleaned and sanitized by staff, labeled with the resident's name and sealed in a plastic storage bag. RN #6 said the reusable cold packs were supposed to be stored in a storage freezer on the unit that was specifically for residents' ice packs.V. Failed to ensure a medication vial was cleaned or discarded after it was on the floorA. ObservationOn 6/24/26 at 9:35 a.m. RN #1 retrieved a box which contained a vial of tuberculin purified protein derivative (PPD) from the medication refrigerator. RN #1 removed the vial from the box and then dropped the vial on the floor. The vial rolled across the floor. RN #1 picked up the vial and set it on the counter. RN #1 then changed her gloves and performed hand hygiene. She wiped the top of the tuberculin PPDvial with an alcohol wipe and then drew up the medication in a syringe for administration. RN #1 then placed the vial back in the box and returned it to the medication storage refrigerator.-However, RN #1 did not clean the outside of the or inspect the vial for potential damage after the vial rolled across the floor of the room, prior to drawing up a dose from the vial.VI. Failed to ensure hand hygiene was performed after a wrapper was picked up from the kitchen floor A. ObservationOn 6/24/26 at 11:01 a.m. the dietary manager (DM) wiped the probe thermometer with an alcohol pad after taking food temperatures. The alcohol pad wrapper fell onto the floor. The DM picked up the wrapper from the floor, discarded the wrapper and then continued taking food temperatures of the rice, spinach, and gravy without performing hand hygiene. VII. Staff interviewsThe infection preventionist (IP) was interviewed on 6/24/26 at 9:53 a.m. The IP said Resident #76's room should have consistently had an EBP sign on the door, not a contact precautions sign. The IP said staff might have run out of EBP signs, so they might have put a contact precautions sign on the door as a place holder. The IP said one of the nurses on the unit saw the incorrect signage and corrected it to the appropriate precautions. The IP said she would expect CNA #2 to wear a gown and gloves if he entered Resident #1's room for any reason. The IP said if a gown was not worn in a contact precautions room, an infection could spread to others.The IP said RN #3 should have cleaned the blood pressure cuff and vital signs equipment between each use. The IP said there were disinfectant purple top wipes to clean the vital signs equipment and the equipment should have been cleaned to prevent any spread of bacteria or germs.The IP said the nursing staff or CNAs needed to clean residents' reusable cold packs and the packs should be kept in the medication room freezer, labeled with residents' names and in separate plastic bags for each resident. The IP said Resident #36 was provided education on 6/23/26 (during the survey) of the need for staff to clean and change out her cold packs. The IP said if a medication vial was dropped and rolled across the floor, it should be checked for breakage and the vial cleaned completely. The IP said the tuberculin PPD vial should not have been placed back into the box and into the medication refrigerator if it was not cleaned after it was on the floor. The IP said if anything was dropped on the floor, including wrappers, she would expect staff to change gloves and perform hand hygiene.

Based on record review and interviews, the facility failed to ensure residents were provided prompt efforts by the facility to resolve grievances for one (#81) of three residents reviewed for grievances out of 37 sample residents.Specifically, the facility failed to ensure Resident #81's grievance concerning late administration of as-needed (PRN) pain medication was documented, investigated, and resolved.Findings include:I. Facility policy and procedure The Grievances policy and procedure, revised 1/8/24, was provided by the nursing home administrator (NHA) on 6/24/26 at 4:56 p.m. It read in pertinent part, The purpose of this policy is to ensure all patients, legal representatives/responsible parties, staff, and visitors are aware of the facility's grievance procedure. Each resident, resident's representative and his or her responsible parties, family members, staff, and visitors have the right to voice complaints and/or grievances without discrimination or the fear of reprisal. Such grievances include those regarding care, treatment, or other matters related to the quality of care or quality of life. Grievances can be communicated to a staff member either verbally or in writing. The facility would make every effort to promptly investigate and resolve any grievances.II. Resident #81A. Resident status Resident #81, age greater than 65, was admitted on [DATE]. According to the June 2026 computerized physician orders (CPO), diagnoses included sepsis due to methicillin susceptible staphylococcus aureus (a severe life threatening medical emergency that occurs when a localized infection caused by a specific strain of bacteria enters the bloodstream and triggers a violent, body wide immune response, type 2 diabetes mellitus, metabolic encephalopathy (a temporary or permanent brain dysfunction caused by a chemical imbalance in the body) and muscle weakness.The 4/22/26 minimum data set (MDS) assessment revealed the resident had a moderate cognitive impairment with a brief interview for mental status (BIMS) score of 12 out of 15. He was dependent with toileting and transfers, required supervision or touch assistance with personal hygiene and was independent with eating.B. Resident interviewResident #81 was interviewed on 6/23/26 at approximately 12:00 p.m. Resident #81 said he had waited over four hours to receive his requested PRN pain medication a few days ago. Resident #81 said he was deeply unhappy with the situation because he was in constant pain and did not receive his medication when it was needed. Resident #81 said he reported the incident to the facility case manager the following morning, but he had not received any feedback regarding his concern. According to Resident #81, the case manager told him he was not the only resident she had heard express concerns about late medications that morning. Resident #81 said that no formal grievance form was completed at the time of the initial report or during the subsequent days. Resident #81 said that due to the delay in receiving his PRN medication, his pain increased from a pain level of 5 to a pain level of 7 on a pain scale of 1-10.C. Record reviewA review of Resident #81's June 2026 CPO revealed the following physician's orders for PRN pain medications:Ibuprofen oral tablet 400 milligrams (mg). Give one tablet by mouth every six hours for pain, ordered4/29/26 and discontinued 6/1/26.Ibuprofen oral tablet 600 mg by mouth every six hours as needed for pain and comfort with, ordered 6/1/26.Oxycodone HCI oral tablet 15 mg. Give 15 mg orally every six hours PRN for pain level 1 to 10; give 10 mg for pain level 1 to 6; give 15 mg for pain level 7 to 10, ordered 4/15/26.Review of Resident #81's pain management care plan, initiated 4/15/26, revealed the resident had acute and chronic pain related to infection, type two diabetes mellitus, deep vein thrombosis, and muscle spasm. Interventions included actively listening to Resident #81's concerns as needed; administering pain medications according to physician's orders and monitoring for effectiveness.-A review of the facility's Grievance Log, from 1/1/26 through 6/24/26, revealed that no entry had been documented regarding Resident #81's reported concern about his late PRN pain medication.III. Staff interviewsLicensed practical nurse (LPN) #3 was interviewed on 6/24/26 at 3:51 p.m. LPN #3 said Resident #81 had chronic pain and his PRN pain medications should be given on time when requested. LPN #3 said the grievances were followed for any concerns expressed by a resident orally or in writing. LPN #3 said that, as the unit manager, she documented all concerns brought to her attention and followed up on them. LPN #3 said she was not aware of any delay in receiving pain medications for Resident #81.The case manager was interviewed on 6/25/26 at 9:45 a.m. The case manager said the facility's grievance process was that when a resident had a concern, the resident was encouraged to report the concern to any staff member, and staff ensured that the social services consultant was informed. The case manager said the department manager, who was responsible for the department, would handle the grievance to ensure a resolution was reached. The case manager said Resident #81 informed her of his concerns about not receiving his PRN pain medication timely when requested. The case manager said she did not remember the exact date the resident reported the incident to her. The case manager said she did not complete a grievance form and did not inform the unit manager of the incident.The NHA was interviewed on 6/25/26 at 10:15 a.m. The NHA said staff members filled out the grievance forms whenever a resident reported concerns with their stay at the facility. The NHA said concerns about care needed to be addressed immediately by the department heads. The NHA said he would then review the grievance forms to ensure the resolution was reached to the resident's satisfaction. The NHA said the case manager should have reported and documented Resident #81's concerns regarding the resident's delay in receiving his PRN medication when it was requested. He said he did not understand why the case manager failed to document and follow up on the resident's pain concerns. The NHA said he would immediately provide education on the grievance process to all the facility staff members.

Based on observations, record review and interviews, the facility failed to ensure two (#18 and #36) of three residents reviewed for medication administration out of 37 sample residents were kept free from significant medication errors.Specifically the facility failed to:-Ensure the insulin pen was primed prior to an insulin medication administration for Resident #18; and,-Ensure pain medications documented on Resident #36's allergy list were not ordered and available for administration to the resident.Findings include:I. Failed to ensure the insulin pen was primed prior to insulin administration for Resident #18A. Professional referenceAccording to the manufacturer [NAME] Lilly and Company, Instructions for Use, Insulin Lispro Kwik Pen, July 2023, retrieved on 6/29/26 from https://pi.lilly.com/insulin-lispro-kwikpen-us-ifu.pdf, Prime before each injection. Priming your pen means removing the air from the needle and cartridge that may collect during normal use and ensures that the pen is working correctly. If you do not prime before each injection, you may get too much or too little insulin. To prime your pen, turn the dose knob to select two units. Hold your pen with the needle pointing up. Tap the cartridge holder gently to collect air bubbles at the top. Continue holding your pen with the needle pointing up. Push the dose knob in until it stops and 0 is seen in the dose window. Hold the dose knob and count to five slowly. You should see insulin at the tip of the needle.B. Facility policy and procedureThe Insulin Pen Injections policy, revised 6/14/22, was provided by the director of nursing (DON) on 6/24/26 at 11:45 a.m. It read in pertinent part, Remove the cap of the insulin pen. If the insulin in the pen appears cloudy, roll the pen in your hands and turn it from side to side until mixed. You do not have to roll the pen if the insulin is completely clear. Wipe the rubber stopper with an alcohol wipe. Attach a new pen needle onto the insulin pen. Prime the insulin pen. Priming means removing air bubbles from the needle, and ensures that the needle is open and working. The pen must be primed before each injection. To prime the insulin pen, turn the dosage knob to the two units indicator. With the pen pointing upward, push the knob all the way. At least one drop of insulin should appear. You may need to repeat this step until a drop appears.C. Resident #181. Resident statusResident #18, age greater than 65, was admitted on [DATE]. According to the June 2026 computerized physician orders (CPO), diagnoses included displaced fracture of right humerus (upper arm), diabetes, kidney disease and atrial fibrillation (an irregular, rapid heart rate).The 6/16/26 minimum data set (MDS) assessment identified Resident #18 had moderate cognitive impairment with a brief interview for mental status (BIMS) score of eight out of 15. The MDS assessment revealed the resident was independent with eating, required substantial assistance with personal hygiene, toileting, showering and transferring.2. ObservationOn 6/24/26 at 10:20 a.m. registered nurse (RN) #2 was in Resident #18's room preparing to administer insulin Lispro to the resident. RN #2 cleaned the tip of the insulin Lispro pen with an alcohol pad, applied a new needle and then dialed the insulin pen to four units. RN #2 showed Resident #18 the pen dialed to four units, cleaned the resident's abdomen on the left side with an alcohol swab, removed the safety cap and administered the injected medication. -RN #2 failed to prime the resident's insulin pen per manufacturer's directions (see professional reference above) prior to administering the medication to the resident.3. Record reviewReview of Resident #18's June 2026 CPO revealed the following physician's order:Insulin Lispro solution pen-injector 100 units per milliliter (ml). Inject four units subcutaneously (SQ) three times a day, ordered 6/24/26.D. Staff interviewsRN #2 was interviewed on 6/24/26 at 10:24 a.m. RN #2 said she did not prime the insulin pen prior to administering insulin to Resident #18. RN #2 said she was an agency nurse and some of the nursing facilities she worked at primed insulin pens, and others did not. RN #2 said she did not know if she needed to prime the insulin pen at this facility. RN #2 said she did not know if Resident #18 received all of the insulin dose that was ordered.The DON was interviewed on 6/24/26 at 10:37 a.m. The DON said all insulin pens should be primed prior to the administration of insulin. The DON said RN #2 should have primed the insulin pen to ensure the entire dose of insulin was administered to Resident #18.II. Failed to ensure pain medications documented on Resident #36's allergy list were not ordered and available for administration to the residentA. Facility policy and procedureThe Allergy Identification and Management policy, initiated 1/1/24, was provided by the nursing home administrator (NHA) on 6/25/26 at 3:30 p.m. It read in pertinent part, Patient allergy and adverse reaction information should be obtained, documented, and communicated as part of the assessment and care process. Allergy information may be reviewed and updated as new information becomes available or when clinically appropriate. Allergy information should be available in the medical record to support safe care and medication administration. Review allergy information during medication reconciliation and before administering medications or treatments, as appropriate.B. Resident #361. Resident statusResident #36, age greater than 65, was admitted on [DATE]. According to the June 2026 CPO, diagnoses included compression fractures of vertebrae (spine), respiratory failure, heart disease and dementia.The 5/4/26 MDS assessment identified Resident #36 was cognitively intact with a BIMS score of 15 out of 15. The MDS assessment revealed the resident required set- up assistance with eating, moderate assistance with dressing and substantial assistance with toileting, showering and transferring. 2. Resident interviewResident #36 was interviewed on 6/22/26 at 2:35 p.m. Resident #36 said earlier that day (6/22/26), the nurse offered to give her oxycodone for her pain. Resident #36 said she told the nurse she could not take the oxycodone medication because she was allergic to it. Resident #36 said oxycodone made her very sick in the past and she could not tolerate it. Resident #36 said she could take hydrocodone, but not oxycodone.3. Record reviewA review of Resident #36's electronic medical record (EMR) on 6/22/26 at 2:45 p.m. revealed she had allergies to oxycodone, Percocet (oxycodone combined with acetaminophen), and Vicodin (hydrocodone combined with acetaminophen).Review of Resident #36's June 2026 CPO revealed the following physician's orders:Hydrocodone-acetaminophen oral tablet, 5-325 milligrams (mg). Give one tablet by mouth every four hours as needed for moderate pain, ordered 5/5/26.Hydrocodone-acetaminophen oral tablet, 5-325 mg. Give two tablets by mouth every four hours as needed for severe pain, ordered 5/5/26.Oxycodone hydrochloride (HCL) tablet 5 mg. Give one tablet by mouth every four hours as needed for pain, one to 10 out of 10 (rating of pain), ordered 6/16/26 and discontinued 6/22/26 at 5:56 p.m. (during the survey)Review of Resident #36's June 2026 medication administration record (MAR) revealed hydrocodone-acetaminophen was administered to the resident 43 times in June 2026. -However, hydrocodone-acetaminophen was listed in the resident's EMR as an allergy until 6/22/26 at 6:00 p.m., when the DON updated and removed the hydrocodone (Vicodin) allergy from the EMR (see interview below).Review of Resident #36's June 2026 MAR revealed the resident had not received any administrations of oxycodone, including l on 6/22/26, when the resident refused the medication (see resident interview above). -However, the medication was available for administration to Resident #36 from 6/16/26 to 6/22/26, even though it was listed as an allergy, creating the likelihood for the medication to be erroneously administered to the resident, who had a history of a reaction to the medication. The oxycodone medication continued to be listed as an allergy after the hydrocodone allergy was removed on 6/22/26.C. Staff interviewsLicensed practical nurse (LPN) #2 was interviewed on 6/22/26 at 5:55 p.m. LPN #2 said he had offered the oxycodone medication to Resident #36 earlier that day (6/22/26) because it was ordered as a medication that could be administered to her. LPN #2 said he should have checked Resident #36's EMR for her allergies prior to asking her if she wanted the oxycodone.The DON was interviewed on 6/22/26 at 6:05 p.m. The DON said LPN #2 should have checked Resident #36's allergies prior to offering the oxycodone medication to the resident. The DON said the physician was contacted about the allergy and the order for oxycodone was discontinued (a few minutes prior to the interview). The DON said nursing staff should have checked Resident #36's allergies prior to administering hydrocodone to the resident. The DON said he did not know why the hydrocodone medication had been administered to Resident #36 since May 2026 when it had been listed as an allergy in the resident's EMR. He said the physician was contacted that afternoon (6/22/26) and had determined Resident #36 was not allergic to hydrocodone. The DON said the hydrocodone allergy was removed from Resident #36's list of allergies. The consultant pharmacist was interviewed on 6/25/26 at 5:14 p.m. The consultant pharmacist said one of the pharmacist's contacted the nurse (identified later as the DON) at the facility on 6/16/26, the date the oxycodone was ordered, regarding the oxycodone and hydrocodone allergies. The consultant pharmacist said the DON told the pharmacist the medications were not allergies for Resident #36 and the EMR would be updated to reflect this information. The consultant pharmacist said the pharmacist would expect the nurse to have updated the allergies at that time. The consultant pharmacist was interviewed again on 6/26/26 at 12:56 p.m. The consultant pharmacist said the pharmacy had also contacted the facility's nursing staff on 4/29/26 to confirm whether hydrocodone was an allergy for Resident #36. The consultant pharmacist said she would expect the pharmacist to confirm Resident #36 did not have the hydrocodone allergy if the facility was administering the medication. The consultant pharmacist said she would expect nursing staff at the facility to confirm residents did not have allergies to medications with each medication that was administered.

Based on record review and interviews, the facility failed to provide treatment and care in accordance with professional standards of practice for two (#1 and #5) of six residents out of 17 sample residents.Specifically, the facility failed to:-Provide timely, consistent and effective monitoring and appropriate documentation for Resident #1's left lower leg amputation surgical incision, which resulted in the resident's transfer to the hospital where she was hospitalized for 10 days with a diagnosis of a left below the knee amputation incision infection; and,-Obtain wound care orders for Resident #5's skin tear in a timely manner. Resident #1 was admitted to the facility on [DATE] after a hospital stay for a surgical amputation of her left lower leg. Resident #1 had an initial skin assessment completed at the facility on 8/27/25 which documented the staples to the incision were intact and the wound was well approximated (edges of the skin were closed together). An 8/27/25 wound care evaluation assessment did not address the resident's amputation site incision wound. On 8/29/25 the physician documented Resident #1 was worried the incision was getting infected. The physician documented the resident had an amputation site incision infection and ordered doxycycline (antibiotic) 100 milligrams (mg) twice a day (bid) for seven days and Rocephin (antibiotic given by injection) 1 gram (gm) one time dose and monitor the incision.-However, the Rocephin and doxycycline medications were not entered into the resident's electronic medical record (EMR) until 8/31/25. The Rocephin was administered on 8/31/25 and the doxycycline was started on 9/1/25. The resident was not started on any antibiotics until two days after the physician noted an infection to the amputation site incision on 8/29/25.Despite the physician noting the incision site had an infection and antibiotics being ordered, there was no nursing documentation to indicate staff were consistently monitoring the resident's infected incision for signs of a worsening infection. On 9/5/25 Resident #1 went to an appointment with the vascular surgeon who performed the left lower leg amputation. The resident was advised during that visit to go to the emergency room due to an infected amputation site incision. Resident #1 returned to the facility after the appointment and then was transferred to the hospital via non-emergent ambulance. Due to the facility's failure to closely monitor and document the condition of Resident #1's lower left leg amputation site incision. The resident was hospitalized for 10 days for a diagnosis of left below the knee amputation site infection and underwent washout debridement (procedure to remove infected or damaged tissue from wounds). She had a wound vacuum assisted closure (VAC) (promotes wound healing) of the incision site during her hospitalization. The infectious disease specialist was consulted during her hospital admission and a course of intravenous (IV) ertapenem (antibiotic) was ordered and completed with subsequent improvement to the resident's amputation incision site. Resident #1 did not return to the facility.Additionally, the facility failed to obtain timely wound care orders for Resident #5, who was admitted from home with a skin tear to her left lower leg.Findings include: I. Resident #1 A. Resident status Resident #1, age less than 65, was admitted on [DATE] and discharged to the hospital on 9/5/25. According to the August 2025 computerized physician orders (CPO), diagnoses included encounter for orthopedic aftercare following surgical amputation, osteomyelitis (infection of the bone), chronic obstructive pulmonary disease, depression and type 2 diabetes mellitus. The 9/5/25 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 dependent on staff for dressing upper and lower body and substantial to maximal assistance with chair to bed transfers. The MDS assessment revealed the resident did not have any behaviors. The MDS assessment revealed the resident did not refuse care. B. Resident interview Resident #1 was interviewed via phone on 10/22/25 at 2:27 p.m. Resident #1 said when she was admitted to the facility she was no longer on antibiotics for her osteomyelitis because her infection had healed following the amputation of her left lower leg. She said her amputation site incision needed wound care daily, and during the nine day stay at the facility, her wound care was missed being completed twice. She said her hospital discharge orders to the facility said to run water and soap over the incision, but she said that was not done and she only received one shower during her admission at the facility. She said the shower in her room did not accommodate her due to the amputation because of the position of the shower bench. Resident #1 said during the visit with the physician on 8/29/25 she told the physician she thought the amputation incision site was getting infected and he ordered antibiotics. Resident #1 said she voiced the same concern to a nurse a few days later and asked for her incision to be cleaned, but she said she was told the antibiotic would be enough for the infection and the nurse did not clean the incision as she asked. C. Record review The skin care plan, initiated 8/26/25, documented Resident #1 had actual/potential skin breakdown or a surgical wound related to the left below the knee amputation. Pertinent interventions included dressing changes per physician's orders, monitoring the incision everyday and as needed (PRN) and notifying the physician of any signs and symptoms of infections. -The skin care plan did not include any of the specific orders pertinent to the healing of the wound. The amputation care plan, initiated 9/5/25, documented Resident #1 had an amputation of the left lower extremity related to diabetes and infection. Pertinent interventions included checking and documenting on the wound daily for signs and symptoms of infection (excessive drainage, any breakdown of skin and impaired circulation, including edema or pain), encouraging compliance with treatment regimen, monitoring for bleeding, documenting amount of bloody drainage on dressing and in drainage system, and wound care daily as ordered by the physician to include rewrapping the leg stump as ordered and PRN. The 8/27/25 new admission skin progress note documented Resident #1 had a left below the knee amputation (BKA) site with intact staples and the wound was well approximated. -However, the 8/27/25 skin/wound evaluation assessment note documented the resident had a right foot diabetic ulcer wound but did not document any information regarding the resident's left BKA site. The 8/28/25 order administration note, documented at 2:07 p.m., revealed the abdominal pad (ABD - absorbent pads used for drainage of wounds) covering Resident #1's amputation incision site was saturated with serous sanguineous fluid (pink-tinged bodily fluid typically found in wounds) and the area to the suture line was macerated (a softening and breakdown of the skin caused by prolonged exposure to moisture). The stump shrinker (compression garment worn on the residual limb after an amputation) was put back on the stump but the brace was not applied for a couple of hours to allow the surgical site to dry out. -There was no further documentation on 8/28/25 to indicate the incision site was monitored further following the discovery of the macerated suture line or to indicate the physician or surgeon were notified regarding the condition of Resident #1's incision site. The 8/29/25 skilled progress note documented Resident #1 had a left lower extremity amputation. However, the note did not document any information regarding the condition of the resident's amputation incision site. The resident had no mood or behavioral problems. The 8/29/25 physician's progress note documented Resident #1 was worried the amputation incision site was getting infected and she needed dressing changes daily. The note documented there was an infection to the resident's left stump incision and the plan included administering doxycycline 100 mg twice a day and Rocephin 1 gm and wound care was to follow-up. The resident had no mood or behavior issues. The 8/31/25 progress note, documented at 2:02 p.m., revealed Resident #1 felt her leg was not healing well. She requested an antibiotic and to move up her follow-up appointment. -However, according to the physician's progress note, the physician had ordered two antibiotic medications for an infection of the resident's amputation site infection on 8/29/25, two days prior (see above). The 8/31/25 skilled progress note, documented at 2:05 p.m., revealed there were no concerns with Resident #1's mood or behavior and she had been cooperative. The progress note did not document any information regarding the condition of the resident's amputation incision site. The physician was notified the resident requested a new appointment day and an antibiotic. -However, according to the physician's progress note, the physician had ordered two antibiotic medications for an infection of the resident's amputation site infection on 8/29/25, two days prior (see above). The 8/31/25 progress note, documented at 6:35 p.m., revealed Resident #1 the nurse informed the physician that Resident #1 was concerned her incision site was infected. The physician ordered a one time dose of Rocephin 1 gm and doxycycline 100 mg twice a day for seven days. The note documented the incision site appeared more red and irritated. -However, the progress note did not document if the resident had received a one-time dose of Rocephin on 8/31/25. The 9/1/25 skilled progress note, documented at 6:57 a.m., did not indicate the resident was receiving antibiotics. The progress note did not document any information regarding the condition of the resident's amputation incision site. There were no mood or behavior problems documented and the resident had been pleasant. -The progress note did not document the resident had received a one-time dose of Rocephin on 8/31/25 or that she was to start a seven-day course of antibiotics. The 9/2/25 skilled progress note, documented at 3:07 p.m., did not indicate the resident was receiving antibiotics. The progress note did not document any information regarding the condition of the resident's amputation incision site. There were no mood or behavior problems documented and the resident had been pleasant. -There was no daily skilled progress note documented for 9/3/25. The 9/4/25 skin/wound progress note documented Resident #1 had a diabetic ulcer to the bottom of her right foot, however, the note failed to document any information regarding the condition of the resident's amputation incision site, despite the fact the resident was receiving antibiotics for an amputation incision site. The 9/4/25 daily skilled progress note, documented at 5:50 p.m., did not indicate Resident #1 was receiving antibiotics. The progress note did not document any information regarding the condition of the resident's amputation incision site. There were no mood or behavior problems documented and the resident had been pleasant. The 9/4/25 progress note, documented at 6:12 p.m., revealed Resident #1 spoke with the assistant director of nursing (ADON) and reported showers were not being offered to her, her wound care had been missed for one and a half days and she was being treated for an incision infection. The ADON documented he communicated to the wound care nurse (WCN) to evaluate the resident's incision wound and add it to weekly rounds. The 9/5/25 transfer to the hospital progress note documented Resident #1 had a change of condition related to an infection to her BKA site. Review of Resident #1's August 2025 and September 2025 (from 8/1/25 to 9/5/25)medication administration records (MAR) revealed the following: -The resident received a one-time dose of Rocephin 1 gm on 8/31/25 at 7:57 p.m.; -The resident received doxycycline 100 mg two times a day on 9/1/25, 9/2/25, 9/3/25, 9/4/25; and, -The resident received doxycycline 100 mg on the morning of 9/5/25 (prior to being transferred to the hospital). -However, the progress notes failed to indicate that the facility was monitoring the resident's amputation site infection for signs/symptoms the infection was worsening, despite the resident being administered the antibiotics (see progress notes above). Review of Resident #1's August 2025 and September 2025 (from 8/26/25 to 9/5/25) treatment administration records (TAR) revealed the resident's BKA incision was to be monitored every shift and staff were to report any concerns to the physician or surgeon. Documentation revealed there was a problem (documented as a P) noted with the incision on 8/28/25, but the other dates during the time frame were documented as no concerns (documented as a 0). -However, Resident #1 began receiving antibiotics for an infected amputation site incision on the evening of 8/31/25. -Additionally, Resident #1 was transferred to the hospital for evaluation of her infected amputation site infection on 9/5/25, per the recommendation of the vascular surgeon following the resident's appointment on 9/5/25. D. Staff interviews Nurse practitioner (NP) #1 was interviewed on 10/22/25 at 12:50 p.m. NP #1 said it was important to monitor residents' skin integrity at least daily as changes could happen quickly. NP #1 said when she was in the facility, she would follow up with the wound care nurse (WCN) and discuss wounds for her residents. She said she did not always look at a resident's wound but would review documents, such as the progress notes and laboratory results to determine if there were any complications. She said she trusted the facility to be providing accurate wound care assessments and she would be notified if there were concerns. The director of nursing (DON) was interviewed on 10/22/25 at 4:28 p.m. The DON said if there was a change in a wound or skin condition, such as an infection, the resident's TAR would be marked under skin monitoring and the WCN would be notified via text. The DON and WCN #1 were interviewed together on 10/23/25 at 10:29 a.m. WCN #1 said she did not follow wounds or surgical incisions if there were no issues. She said when Resident #1 was admitted to the facility, there were no concerns regarding her BKA incision She said she was not notified of any changes to the resident's incision site during the resident's stay. Licensed practical nurse (LPN) #1 was interviewed on 10/23/25 at 1:45 p.m. LPN #1 said surgical wounds were monitored for signs of infection, such as excessive drainage, and if the wound was red or warm to the touch. She said if there was a problem, the nurse should write a progress note and notify the physician. She said the WCN should also be notified if there were any changes to a surgical wound. She said the resident's TAR wound monitoring would be documented with a P until the change or infection had cleared. LPN #1 said the skilled nursing progress notes should include if a resident was on an antibiotic and include the wound treatments being utilized. II. Resident #5 A. Resident status Resident #5, age greater than 65, was admitted on [DATE]. According to the October 2025 CPO, diagnoses included dementia. The 10/22/25 MDS assessment revealed the resident had significant cognitive impairment with a BIMS score of three out of 15. She required extensive assistance with activities of daily living (ADL). B. Observations On 10/21/25 at 5:03 p.m. Resident #5 was observed with an undated loose bandage wrap sparsely covering a large gauze pad on her left lower leg. On 10/22/25 at 11:05 a.m. two hospice nurses came to check on Resident #5. They noticed the bandage to Resident #5's leg had come undone, and proceeded to change it. The hospice nurses said Resident #5 had sustained the skin tear on her leg from a fall at her home prior to being admitted to the facility. On 10/23/25 at 9:30 a.m. WCN #1 was observed changing Resident #5's dressing to her left lower leg skin tear. The wound was a golf-ball size skin tear on the mid-upper lateral side of her calf with a large amount of red and purple discoloration. There was an additional skin tear on the lower section of her calf that was smaller in size, but with the same dark red and purple discoloration. The skin tears were not actively bleeding and were partially scabbed over. C. Record review The 10/20/25 nursing admission note documented that Resident #5 had a single wound on her left ankle. The note specified that the wound was a skin tear on her lower calf, however, the note did not address the larger skin tear on her left upper-mid calf. The note documented that the skin tear dressing was changed. -However, according to registered nurse (RN) #1 (see interview below), she did not change Resident #5's dressing on the day the resident admitted to the facility (10/20/25), but only looked under the dressing that was already on the wound prior to her admission. -The facility failed to obtain physician's orders for a dressing change until 10/22/25 at 11:44 a.m., two days after Resident #5 had been admitted to the facility. D. Hospice RN interview The hospice RN was interviewed on 10/22/25 at 11:05 a.m. The hospice RN said Resident #5 was on hospice services and was at the facility for respite care. The hospice RN said the resident had fallen while at home and sustained a skin tear to her left lower leg. The hospice RN said that the old bandage she removed had adhered to Resident #5's skin and she had to use a wound cleaner to moisten the bandage in order to remove it. E. Staff interviews RN #1 was interviewed on 10/22/25 at 5:40 p.m. RN #1 said she had admitted Resident #5 to the facility on [DATE]. RN #1 said she had peeked under Resident #5's wound dressing on her lower left leg upon her admission, but she said she did not change the dressing because she was waiting for official wound care orders. She said she expected the WCN would have put in wound care orders the following day after the resident's admission. WCN #1 was interviewed on 10/23/25 at 10:29 a.m. WCN #1 said she saw Resident #5 on 10/21/25 but forgot to enter the wound care orders from the physician into the resident's electronic medical record (EMR). She said she forgot to document the wound care she completed on Resident #5's leg on 10/21/25. The DON was interviewed on 10/23/25 at 12:56 p.m. The DON said she had provided WCN #1 with education regarding correct and timely documentation of resident care.

Based on observations, record review and interviews, the facility failed to provide the necessary treatment and services to prevent pressure injuries to prevent or heal pressure injuries for two (#9 and #7) of six residents out of 17 sample residents.Specifically, the facility failed to:- Accurately identify, document, evaluate and monitor a pressure ulcer for Resident #9;- Ensure Resident #9's weekly skin assessments were documented thoroughly and accurately; and,- Ensure appropriate wound prevention interventions, including an air mattress, were implemented timely and consistently monitored for function and settings for Resident #9 and Resident #7.Resident #9, who was at risk for skin breakdown, was admitted to the facility on [DATE] following a hospitalization for a right hip fracture. The admission skin assessment documented she had scattered bruising to her abdomen and a bruise to her right ear. On 9/9/25 the facility documented the resident had moisture-associated skin damage (MASD) to her coccyx and treated the area of skin damage with barrier cream.On 9/15/25 the facility documented the resident had an abrasion to her coccyx related to MASD and put a treatment order of a foam border dressing in place. However, the facility failed to identify the area of skin breakdown as a pressure injury.On 9/18/25 the facility continued to identify the area of skin breakdown to Resident #9's coccyx as an abrasion and added medihoney (a wound treatment that can be used to get rid of slough (whitish non-viable tissue which commonly develops in Stage 3 or Stage 4 pressure wounds - see professional reference below) or necrotic (dead) tissue that can develop in wounds) the treatment order. However, the facility failed to identify the area of skin breakdown as a pressure injury.Resident #9's skin breakdown care plan failed to include an intervention of an air mattress until 9/12/25, after the resident had already developed the skin issue. Additionally, the resident's weekly skin assessments conducted by the nursing staff were inconsistent and incomplete, frequently failing to identify the skin issue to the resident's coccyx.On 9/22/25 Resident #9 discharged to another long-term care facility. The facility identified the resident had an unidentified wound to her coccyx upon discharge.Upon Resident #9's admission to the receiving facility, the staff at the receiving facility documented the resident had an open area to her coccyx with slough present in the wound.-The facility failed to accurately identify a pressure wound to Resident #9's coccyx, which developed during the resident's stay at the facility from 8/30/25 to 9/22/25.Additionally, the facility failed to ensure staff were consistently following and/or documenting appropriate interventions, including ensuring low air loss mattress settings were in place, for Resident #7, who had a Stage 4 pressure injury to his right buttock.Findings include: I. Professional reference According to the National Pressure Injury Advisory Panel, European Pressure Injury Advisory Panel and Pan Pacific Pressure Injury Alliance Prevention and Treatment of Pressure Injuries: Clinical Practice Guideline, third edition, [NAME] Haesler (Ed.), EPUAP/NPIAP/PPPIA (2019), retrieved from https://www.internationalguideline.com/guideline on 2/10/25, Pressure ulcer classification is as follows: Category/Stage 1: Non-blanchable Erythema (discoloration of the skin that does not turn white when pressed, early sign of tissue damage) Intact skin with non-blanchable redness of a localized area usually over a bony prominence. Darkly pigmented skin may not have visible blanching; its color may differ from the surrounding area. The area may be painful, firm, soft, warmer or cooler as compared to adjacent tissue. Category/Stage 1 may be difficult to detect in individuals with dark skin tones. May indicate 'at risk' individuals (a heralding sign of risk). Category/Stage 2: Partial Thickness Skin Loss Partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough. May also present as an intact or open/ruptured serum filled blister. Presents as a shiny or dry shallow ulcer without slough or bruising. This Category/Stage should not be used to describe skin tears, tape burns, perineal dermatitis, maceration or excoriation. Category/Stage 3: Full Thickness Skin Loss Full thickness tissue loss. Subcutaneous fat may be visible, but bone, tendon or muscle are not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling. The depth of a Category/ Stage 3 pressure ulcer varies by anatomical location. The bridge of the nose, ear, occiput and malleolus do not have subcutaneous tissue and Category/ Stage 3 ulcers can be shallow. In contrast, areas of significant adiposity can develop extremely deep Category/Stage 3 pressure ulcers. Bone/tendon is not visible or directly palpable. Category/Stage 4: Full Thickness Tissue Loss Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the wound bed. Often include undermining and tunneling. The depth of a Category/Stage 4 pressure ulcer varies by anatomical location. The bridge of the nose, ear, occiput and malleolus do not have subcutaneous tissue and these ulcers can be shallow. Category/ Stage 4 ulcers can extend into muscle and/ or supporting structures ( fascia, tendon or joint capsule) making osteomyelitis possible. Exposed bone/tendon is visible or directly palpable Unstageable: Depth Unknown Full thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed. Until enough slough and/or eschar is removed to expose the base of the wound, the true depth, and therefore Category/ Stage, cannot be determined. Stable (dry, adherent, intact without erythema or fluctuance) eschar on the heels serves as 'the body's natural (biological) cover' and should not be removed. Suspected Deep Tissue Injury: Depth Unknown Purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear. The area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue. Deep tissue injury may be difficult to detect in individuals with dark skin tones. Evolution may include a thin blister over a dark wound bed. The wound may further evolve and become covered by thin eschar. Evolution may be rapid, exposing additional layers of tissue even with optimal treatment. II. Facility policy and procedure The Pressure Ulcer policy and procedure, dated 3/14/24, was provided by the nursing home administrator (NHA) on 10/23/25 at 3:30 p.m., it read in pertinent part, The [Facility] will provide the necessary requirements to ensure that a patient receives the treatment and care in accordance with professional standards of practice. Upon admission, the nursing staff will complete a full skin evaluation and examine for any ulcerations or alterations in skin. The following is documented; full evaluation of pressure sore including description of the wound, pain evaluation, patients mobility status, current treatments, if applicable. The physician will assist in identifying factors contributing or predisposing patients to skin breakdown, help clarify relevant medical issues and will authorize pertinent orders related to wound treatments. The physician will assist the staff with reviewing current orders when wounds are not healing as anticipated or new wounds develop despite existing interventions. III. Resident #9 A. Resident status Resident #9, age [AGE], was admitted on [DATE] and discharged on 9/22/25 to another long-term care facility. According to the September 2025 computerized physician orders (CPO), diagnoses included fracture of the superior rim of the right pubic (hip bone), subsequent encounter for fracture with routine healing, type 2 diabetes mellitus with diabetic neuropathy (damages the nerves typically in the feet, legs, hands and arms), chronic kidney disease stage 4, cardiomyopathy (chronic disease of the heart muscle), coronary angioplasty implant and graft (a surgical procedure that bypasses a blocked coronary artery by using a healthy blood vessel from another part of the body), essential hypertension (high blood pressure) and acute respiratory failure with hypoxia (lack of oxygen to the body's tissues). According to the 9/22/25 minimum data set (MDS) assessment, the resident had moderate cognitive impairment with a brief interview for mental status (BIMS) score of 10 out of 15. The resident required supervision with oral hygiene and personal hygiene and maximal assistance with toileting, showering and dressing. The assessment revealed the resident did not have a pressure ulcer. B. Resident #9's representative interview Resident #9's representative was interviewed on 10/21/25 at 4:43 p.m. He said Resident #9 was admitted to the facility after she fell at home and was hospitalized . He said once Resident #9 was at the facility, she acquired a pressure injury on her buttock. He said the facility discovered the pressure injury because she complained of pain on her buttocks so they moved her from one side to the other to relieve her pain and then discovered the pressure injury. He said it took several days for the facility to provide a pressure-relieving mattress. He said Resident #9 received a pressure-relieving mattress two days before she was discharged . He said Resident #9's care at the facility was terrible. He said the nurses were always too busy to help Resident #9 and that was why he moved her to another nursing facility. He said he felt uncomfortable since the first day he visited Resident #9 because he did not think Resident #9 was receiving the correct care and services. C. Record review A review of Resident #9's abrasion to the coccyx care plan, initiated 9/12/25 and revised 9/29/25, revealed the resident had an abrasion to her coccyx. Interventions included determining the cause of the wound and ensuring preventative interventions were in place, documenting a wound evaluation weekly and as needed, notifying the physician of any changes, administering pain medications as ordered before the wound treatments and providing wound treatments as ordered by the physician. Review of Resident #9's skin breakdown care plan, initiated 9/12/25 and revised 9/29/25, revealed she had the potential for skin breakdown related to impaired mobility secondary to weakness, impaired mobility, pain, malnutrition, end stage renal disease (ESRD), pubic fracture recent fall, respiratory problems, muscle spasms, anemia, type 2 diabetes mellitus, incontinence, side effect of medications and debility. Interventions included applying moisturizer to her skin, not massaging over bony prominences and using mild cleansers for peri-care/washing, Braden scale assessment every week per protocol, skin evaluation as ordered and as needed, dressing changes per physician order, encouraging proper nutrition and hydration, monitoring lab values, monitoring, reminding and assisting to turn and reposition frequently as needed and as requested, and toileting as needed. Additional interventions included administering medications per the physician's orders, providing an air mattress and/or air mattress overlay as indicated, providing pressure-reducing devices as needed for the mattress and wheelchair cushion, and a wound nurse was to evaluate and treat the wound as indicated. -The care plan did not identify Resident #9's pressure ulcer to the coccyx (see receiving facility's admission record below). Review of Resident #9's September 2025 CPO revealed the following physician's orders: Moisture-associated skin damage (MASD) to the buttocks. Cleanse the affected area with wound cleanser. Pat dry, apply a thin layer of triad barrier cream every shift. Ordered 9/9/25 and discontinued 9/15/25. Treatment: Abrasion to coccyx related to MASD. Cleanse with wound cleanser, pat dry, apply skin prep to wound bed, and cover with border foam dressing every day shift. Ordered 9/15/25 and discontinued 9/18/25. Treatment: Abrasion to coccyx related to MASD. Cleanse with wound cleanser, pat dry, apply medihoney to wound bed, cover with border foam dressing every day shift every Monday, Wednesday and Friday. Ordered 9/18/25 and discontinued 9/21/25. Treatment: Abrasion to coccyx related to MASD. Cleanse with wound cleanser pat dry, apply medihoney to wound bed, cover with border foam dressing every day shift related to open area to coccyx. Clean, dry, apply medihoney and mepilex (foam dressing). Ordered 9/21/25 and discontinued 9/22/25. A review of the September 2025 CPO did not reveal a physician's order to monitor the resident's coccyx wound on the days the wound treatment was not provided (see director of nursing (DON) interview below) or a physician's order to check the function and settings of the resident's air mattress. A review of the September 2025 CPO revealed there was a physician's order to provide an air mattress related to Resident #9's right hip fracture. -However, the order did not specify what the air mattress function or setting should have been. A review of Resident #9's electronic medical record (EMR) did not reveal the facility monitored the mattress function or setting. A Braden scale (pressure sore assessment risk) assessment, dated 9/6/25 (completed seven days after the resident's admission to the facility), revealed Resident #9 was at low risk for pressure ulcers. Braden scale (pressure sore assessment risk) assessments, dated 9/13/25 and 9/21/25, did not document any changes from the assessment completed on 9/6/25. -However, the Braden scale assessment did not identify the skin injury that had developed to Resident #9's coccyx. The 8/31/25 skin evaluation revealed Resident #9 had right ear bruising with scab formation and scattered bruising on the abdomen. The 9/6/25, 9/13/25 and 9/21/25 skin evaluations revealed the resident had scattered ecchymosis on the abdomen due to heparin shots. -However the skin evaluations did not document the skin condition of MASD of the resident's buttocks which was identified on 9/4/24 (see below wound nurse progress note). The 9/4/25 wound nurse progress note revealed Resident #9 had bruising to the lower abdomen related to injections and MASD to the bilateral buttocks related to incontinence-associated dermatitis (IAD). There was no indication for wound rounds to be completed. The 9/8/25, 9/10/25, 9/11/25, 9/12/25, 9/15/25 and 9/18/25 daily skilled nurse notes revealed the resident's skin was fragile and dry and the coccyx was reddened. The 9/20/25 daily skilled nurse note revealed there was an open wound to Resident #9's coccyx. -No additional information was documented, such as physician notification, measurements and staging of the skin issue to the resident's coccyx. The 9/22/25 discharge progress note documented Resident #9 had an identified wound to the coccyx and an ear with a scab and a small bruise. -A review of Resident #9's EMR failed to document the description, including the size, the characteristic, stage and progress of the wound on the coccyx, if there were complications and if there were signs of infection, despite the fact the wound was identified as open on 9/20/25. D. Receiving facility's documentation The receiving nursing facility's 9/22/25 admission skin evaluation revealed Resident #9 had a pressure injury on the coccyx. The 9/22/25 nurse progress note from the receiving facility revealed that a skin assessment was completed. The resident had an open area to the coccyx. The open area was sloughy, off white in color and punchy. The 9/23/25 nurse progress note revealed there was an open wound on Resident #9's coccyx. The area was approximately 2.5 centimeters (cm) in length and 2.5 cm in width and tunneling (burrowing under the skin) at six o'clock by about 2 cm. Slough mostly covered the area except for a hole in the center. The nurse practitioner was notified for wound rounds. The 9/23/25 wound treatment order documented to cleanse Resident #9's wound with wound cleanser and pat dry. Apply calcium alginate with silver and cover with border gauze dressing every day shift and as needed if the dressing was dislodged or soiled for the coccyx wound. The 9/29/25 wound care physician (WCP) note revealed Resident #9 moved from another facility after a fall. She came to the current receiving facility with a pressure injury that was documented by the transferring facility as a red spot. Resident #9 reported pain at all times, worse with movement. The facility nurse stated the wound was covered in slough but had a pinpoint opening that tunneled deeply. The note revealed the dressing was changed on 9/28/25 but the foam was stuck. The slough had rolled back quite a bit, revealing a Stage 4 pressure ulcer probed to the bone. The WCP debrided the wound and Resident #9 had quite a bit of pain. A culture was taken of the wound, Santyl (prescription ointment used to remove dead or damaged tissue from wounds) was ordered, the wound was packed with iodosorb packing, and covered with a foam dressing. The wound dressing was to be changed daily. The 10/6/25 WCP wound assessment report revealed Resident #9 had a Stage 4 pressure injury on the sacrum. The undermining was from 12 o'clock to 12 o'clock with 60 percent (%) granulation (new, pink or red, moist tissue that forms in the healing process of wounds) and 40% slough. There was exposed bone and the attached wound edges had heavy serosanguinous (a combination of serous fluid and blood, usually a light pink to red color) exudate (drainage that seeps out of wounds). E. Staff interviews Licensed practical nurse (LPN) #1 was interviewed on 10/22/25 at 3:35 p.m. LPN #1 said residents' skin was assessed upon admission, 24 hours after admission and as needed. LPN #1 said the physician should be notified if treatment orders were required based on those skin assessments. LPN #1 said a risk management should be completed, the physician should be notified and a treatment order obtained when a new skin condition was identified. She said skin assessments should be completed weekly. The director of nursing (DON) was interviewed on 10/22/25 at 4:28 p.m. The DON said air mattresses should be monitored if it was being used as a preventative measure. She said the facility did not do an assessment when a resident first had an air mattress. The DON said the facility did not check the manufacturer's recommendations on what the function and settings should be based on the resident's weight. The DON said if a resident had a physician's order to check the resident's air mattress, it meant to check how firm or soft the mattress was to touch. The DON said the staff did not check the function or setting. The DON was interviewed a second time on 10/23/25 at 5:54 p.m. The DON said a resident's skin was assessed upon admission, every seven days and as needed, along with a Braden scale assessment. She said the certified nurse aides (CNA) notified the nurse if they observed anything abnormal. The DON said the nurse documented their findings on the skin evaluation form. She said if a skin condition was identified, then a treatment order and a monitoring order were obtained from the physician. The DON said when a new skin condition was identified, the floor nurse should complete a risk assessment and include a nurse progress note. The DON said measurements were obtained when the wound nurse was involved with the resident's skin treatment. The DON said when a resident was discharged , the nurse should describe the resident's skin condition and provide the treatment orders to the receiving facility. She said a head-to-toe assessment was not completed upon discharge. The DON said she was familiar with Resident #9. She said there should have been a skin monitoring order in place for the days the skin treatment order was not provided to ensure the treatment area was covered, clean and there were no signs of infection. The DON said there should be an incident report for Resident #9's abrasion to her coccyx. The DON said she knew Resident #9 transferred to another nursing facility. The DON said she was not aware Resident #9 had been discharged with a pressure injury to her coccyx. She said she was informed it was an abrasion. The DON was interviewed a third time on 10/23/25 at 6:15 p.m. The DON said an incident report was not completed for Resident #9's skin breakdown to her coccyx and the wound care nurse was not notified of the open area to Resident #9's coccyx prior to her discharge from the facility on 9/22/25. IV. Resident #7 A. Resident status Resident #7, age less than 65, was admitted on [DATE]. According to the October 2025 CPO, diagnoses included multiple sclerosis (MS), quadriplegia (paralysis that affects all a person's limbs) and pressure ulcer of the right buttock stage 4 (severe wound with tissue loss exposing bone, muscles or tendons). According to the 7/28/25 MDS assessment the resident was cognitively intact with a BIMS score of 15 out of 15. The resident was dependent on staff for all activities of daily living (ADL). B. Observations On 10/21/25, at 3:30 p.m., Resident #7 was lying on an air mattress with the head of the bed upright with heel boots in place. His mattress and floor were covered with flakes of skin and there was a strong unpleasant odor in the room. A white board used to pass on information had position changes every two hours written on it and indicated the resident received bathing assistance twice a week in the evening. On 10/22/25 wound care nurse (WCN) #1 and the assistant director of nursing (ADON) completed wound care on Resident #7. The room had a strong foul smell that was observable from the hallway outside of Resident #7's room. Resident #7 had a wound vacuum (vac) covering his wound with a dressing that was intact. A small smear of a brown substance was observed on the corner of the dressing. The dressing was not labeled with the initials of the last staff member to change the dressing or the time and date of the last dressing change. The dressing was removed and revealed a deep, tunneled wound with a moderate amount of brownish-yellowish drainage. The wound bed had a slimly yellowish-brownish film covering it. The walls of the wound were beefy red. The opening of the wound appeared to have a dime-sized black spot on it. WCN #1 said the wound had improved significantly since Resident #7 had been admitted to the facility. A large reddened and peeling area along the inside and back of Resident #7's thigh and buttocks was observed, just below the wound. The ADON glanced at it and said it was probably moisture associated skin damage (MASD). WCN #1 said the area used to be much more macerated but had improved significantly. WCN #1 dressed the wound and labeled the new dressing with her initials, and the time and date of the dressing change. During the wound care observation, the wound was not measured and barrier cream was not applied to the skin around the wound. C. Resident interview Resident #7 was interviewed on 10/21/25 at 3:30 p.m. Resident #7 said he preferred to stay in bed. He said he used to get into a chair but it was uncomfortable for him to sit up. He said he was dependent on staff for all ADLs. Resident #7 said the facility staff repositioned him when he asked for it, but did not come into his room every two hours to offer repositioning. He said he would refuse repositioning at times because he might have just eaten and did not want to lay back further. Resident #7 said he had not had a bed bath in a few weeks. He said facility staff would tell him they were getting ready to give him a bath, but then they would get too busy and never come back. He said he did not refuse bed baths. Resident #7 said he understood the importance of repositioning and bathing. D. Record review The skin care plan, initiated 7/18/25, documented Resident #7 had potential for skin breakdown related to impaired mobility due to weakness and debility. The pertinent interventions included an air mattress to his bed per facility guidelines, dressing changes per physician's order, monitoring and assisting the resident to reposition frequently, as needed or requested, and notifying the physician of any signs and symptoms of infections. -However, the October 2025 CPO documented to reposition Resident #7 throughout the shift and the October 2025 treatment administration record (TAR) documented repositioning was done twice a day. The wound care plan, initiated 7/24/25 and revised 7/29/25, documented Resident #7 had a Stage 4 pressure injury to his right buttock due to MS, quadriplegia, need for assistance for personal care, nutritional problems and staff must assist the resident with meals. The pertinent interventions included administering treatments as ordered and monitoring for effectiveness - if the resident refused treatment, conferring with the resident, the interdisciplinary team (IDT) and family to determine why and to try alternative methods to gain compliance and to document alternative methods; and documenting weekly treatments, including measurements of each area of skin breakdown's width, length, depth, type of tissue and exudate and any other notable changes or observations. The decision care plan, initiated 7/31/25 and revised on 10/23/25 during the survey, documented Resident #7 was non-compliant with care, such as bathing, repositioning of his right buttock and refusals to work with therapy. Pertinent interventions included changing approach and recording approaches which were successful and documenting non-compliance and reporting it to the physician. -Resident #7's care plan, diagnosis list, and July 2025 through October 2025 TARs did not include MASD or interventions to treat MASD. However, WCN #1's assessments, from 8/19/25 and 10/22/25, documented maceration around Resident #7's wound (see observation above for identified MASD). Review of Resident #7's electronic medical record (EMR) and the July 2025 through October 2025 TARs revealed missing treatment documentation from 7/18/25 to 10/23/25. The following was not charted per orders: Wound VAC to right buttock, dressing change every Monday, Wednesday, Friday and PRN was not documented as being completed five times (7/21/25, 9/10/25,10/3/25, 10/10/25 and 10/13/25). Barrier cream to coccyx, periarea every shift and as needed (PRN) was not documented as being completed nine times (8/3/25, 8/11/25, 8/26/25, 9/6/25, 9/9/25, 10/1/25, 10/3/25, 10/4/25 and 10/10/25). Wound Vac check settings and function every shift was not documented as being completed 11 times (7/20/25, 7/21/25, 8/3/25, 8/11/25, 8/26/25, 9/6/25, 9/9/25, 10/1/25, 10/3/25, 10/4/25 and 10/10/25). Reposition side-to-side was not documented as being completed 11 times (8/3/25, 8/11/25, 8/18/25, 8/21/25, 8/26/25, 9/6/25, 9/9/25, 10/1/25, 10/3/25, 10/4/25 and 10/10/25). Low-air-loss mattress check settings was not documented as being completed nine times (8/3/25, 8/11/25, 8/26/25, 9/6/25, 9/9/25, 10/1/25, 10/2/25, 10/3/25 and 10/10/25). The October 2025 CPO revealed a physician's order to check the settings and function of the low-air-loss mattress every shift. However the settings for the mattress were not documented in the physician's order. The October 2025 TAR documented to check settings and function of the low-air-loss mattress every shift. Document with a plus sign or a dash. -There was no further documentation on what the settings should be set at or what the plus sign and dash were to indicate. The 8/12/25 skin/wound note documented Resident #7's periwound (skin surrounding a wound) was healthy and presented with no signs or symptoms of skin breakdown or infection. The 8/15/25 skilled note documented the outer wound area was macerated. The 8/18/25 nurse practitioner (NP) progress note did not document the new finding of the macerated skin to the periwound. The 8/19/25 physician's progress note did not document the new finding of the macerated skin to the periwound. The 8/19/25 skin/wound progress note, documented at 12:24 p.m., revealed the periwound was macerated and had a denuded (loss of the skin's protective layer) area of 3 cm (centimeters). -There was no documentation to indicate the physician had been notified. -However the progress note dated 8/15/25 documented signs of macerated skin but WCN #1 did not assess until 8/19/25, five days later. The daily skilled progress notes through October 2025 did not document the macerated periwound. The skin/wound progress notes continued to document macerated skin to the periwound through October 2025. The progress notes did not indicate the physician had been notified of the resident's skin deterioration. E. Staff interviews NP #1 was interviewed on 10/22/25 at 12:50 p.m. NP #1 said she was not notified of any changes in Resident #7's wound. She said she did not know about, and was not notified about, any concern for MASD. NP #1 said the provider should be notified of any changes to the skin or a wound. She said she relied on staff assessments, progress notes, signs and symptoms of infection and laboratory results for any changes in the treatment of the wounds. LPN #2 was interviewed on 10/22/25 at 3:30 p.m LPN #2 said she would check the air mattress settings by asking the resident if they were comfortable and push on the mattress to check the air pressure. She said she did not check the air mattress settings and thought she was verbally told the settings of the bed. LPN #2 said if there was a change in a resident's skin condition she would notify the WCN. She said the WCN was responsible for notifying the physician. She said Resident #7 was particular about his care but she was not aware that he refused bed baths. She said the daily skilled note should indicate if a resident refused care. The DON was interviewed on 10/22/25 at 4:28 p.m. The DON said the floor nurse should notify the WCN of any skin concerns. She said the CNAs were educated to notify the nurse of anything abnormal to a resident's skin. She said the nurses should document all skin conditions in the skin evaluation. The DON said if the TAR was not marked, the assumption would be that the task was not completed. WCN #1 was interviewed on 10/23/25 at 10:29 a.m. WCN #1 said she completed wound care on Resident #7 once a week and measured the wound once a week when she completed the wound care. She said if she forgot to measure a wound, then she would remove the wound dressing and redo the wound care so the wound could be measured. She said she had only changed Resident #7's wound dressing once, on 10/22/25, although she had not obtained measurements at that time (see observations above). WCN #1 said she had changed Resident #7's wound vac on 10/20/25, but did not document the wound care. She said the measurements she documented on 10/22/25 were actually obtained on 10/20/25. She said she did not document wound care on 10/20/25 or label the wound dressing at that time. F. Facility follow up On 10/23/25 at 12:56 p.m. the DON said she had provided WCN #1 with education on correct documentation. She said documentation on wound care was completed and back-dated for 10/20/25 when WCN #1 said she had measured

Based on record review and interviews, the facility failed to develop and implement a baseline care plan that included the instructions needed to provide effective and person-centered care for the resident that met professional standards of quality care for three (#2, #8 and #17) of five residents out of 17 sample residents. Specifically, the facility failed to fully develop, review with the resident and/or his responsible party and implement a person-centered baseline care plan within 48 hours of admission for Resident #2, Resident #8 and Resident #17.Findings include: I. Facility policy and procedure The Baseline Care Plan policy and procedure, revised 3/28/24, was provided by the director of nursing (DON) on 10/23/25 at 6:49 p.m. It read in pertinent part, The baseline care plan must be developed within 48 hours of a patient's admission. The facility must provide the patient and their representative, if applicable, with a summary of the baseline care plan. II. Resident #2 A. Resident status Resident #2, age [AGE], was admitted on [DATE]. According to the October 2025 computerized physician orders (CPO), diagnoses included Alzheimer's disease, fracture of left femur, essential hypertension (high blood pressure), psychotic disturbance, mood disturbance and anxiety. The 9/22/25 minimum data set (MDS) assessment revealed the resident had moderate cognitive impairments with a brief interview for mental status (BIMS) score of nine out of 15. The MDS assessment revealed the resident was taking anticoagulant medications, antipsychotic medications, required a mechanically altered diet, and the resident's goal was to be discharged to the community. B. Resident #2's representative interview Resident #2's representative was interviewed on 10/22/25 at 4:30 p.m. Resident #2's representative said he was really frustrated with the facility because they did not communicate when Resident #2 was admitted . He said there was miscommunication on the resident's discharge plans, diet and physical therapy plans. He said it was even more frustrating when the facility said Resident #2 was ready to be discharged because he thought she did not have enough physical therapy. He said he had to tell the facility to cut up the resident's food and she needed assistance. He said he wished the facility had provided more communication when she was first admitted so they could have been on the same page. C. Record review Review of Resident #2's October 2025 CPO revealed the resident had a physician's order for Seroquel (antipsychotic medication) 25 milligrams (mg) one time per day at bedtime for depression, ordered 9/16/25. Review of Resident #2's baseline care plan, dated 9/16/25, revealed the following: -There was no baseline care plan, including a focus, a goal, and an intervention for psychotropic medication. -The baseline care plan identified the resident was to receive a carbohydrate-controlled diabetic diet, however it did not identify that Resident #2 required a mechanical soft diet texture. -The baseline care plan identified Resident #2 received anticoagulant medications, however, the focus, goal, and interventions for anticoagulants were not identified. -The baseline care plan for discharge planning was incomplete and the intervention for the location of where the resident wanted to be discharged to was not identified. -Review of Resident #2's EMR on 10/23/25 did not reveal documentation of a signed Acknowledgement of Care Plan form to acknowledge the resident or the resident's responsible party was provided with a copy of the resident's baseline care plan. The 9/19/25 social services progress note revealed the social services director (SSD) met with Resident #2. The note documented the admission assessments were completed. The SSD explained the discharge plan process and progress updates were conducted on Wednesdays and Thursdays after Tuesday's interdisciplinary team (IDT) discharge meetings. The note documented the resident was aware her discharge date was determined by insurance, therapy progress and her medical status. The resident reported no concerns at the time and the SSD would continue to follow. -However, the SSD did not meet with Resident #2 until three days after her admission to the facility. -Additionally, the progress note did not indicate that the resident's baseline care plan was reviewed with the resident during the meeting with the SSD or that the resident was provided with a copy of her baseline care plan. III. Resident #8 A. Resident status Resident #8 was admitted on [DATE]. According to the October 2025 CPO, diagnoses included acute hematogenous osteomyelitis (an infection of the bone caused by bacteria that travel through the bloodstream) and creation of a bypass arterial graft (a medical procedure to improve blood flow to the heart). The 10/11/25 MDS assessment revealed the resident was cognitively intact with a BIMS score of 15 out of 15. He required moderate assistance with activities of daily living (ADL). B. Resident interview Resident #8 was interviewed on 10/23/25 at 1:00 p.m. Resident #8 said he was planning to return to the community upon discharge. He said he did not understand the reason for why he was still at the facility. The resident said he had surgical staples in his abdomen and once the staples were removed, he would like to return to the community. He said he did not review or receive a copy of his baseline care plan. C. Record review The progress note, dated 10/6/25, revealed Resident #8 was admitted from the hospital after undergoing a coronary artery bypass graft (CABG). The resident had a surgical wound. The resident also had a left toe amputation. -Resident #8's 10/6/25 baseline care plan addressed the left toe amputation, however it did not address the surgical wound from the CABG surgical procedure. -A review of Resident #8's electronic medical record (EMR) on 10/23/25 did not reveal documentation of a signed Acknowledgement of Care Plan form to acknowledge the resident and/or responsible party were provided with a copy of the baseline care plan, which was identified by the director of nursing (DON) as the facility's process (see DON interview below). IV. Resident #17 A. Resident status Resident #17, age [AGE], was admitted on [DATE]. According to the October 2025 CPO, diagnoses included mild neurocognitive disorder due to known physiological condition with behavioral disturbance. The 10/22/25 MDS assessment revealed the resident had severe cognitive impairment and the BIMS assessment was not completed. The staff assessment for mental status revealed the resident had both long and short term memory deficits. He had moderate cognitive impairments. The MDS assessment indicated the resident did not have any behaviors. B. Record review The October 2025 CPO revealed the resident was prescribed Seroquel (antipsychotic medication) oral tablet 25 mg. -The 10/16/25 baseline care plan revealed the use of psychotropic medications, however the baseline care plan did not indicate that the psychotropic medication was an antipsychotic medication and did not include interventions for the use of the antipsychotic medication. -Review of Resident #17's EMR on 10/23/25 did not reveal documentation of a signed Acknowledgement of Care Plan form to acknowledge the resident's responsible party was provided with a copy of the resident's baseline care plan. V. Staff interviews The SSD was interviewed on 10/23/25 at 9:32 a.m. The SSD said when residents were admitted to the facility, a care conference was held within 72 hours of admission. She said the admitting nurse started the baseline care plan. She said she was not responsible for getting the baseline care plan signed by the resident or the resident's responsible party. The DON was interviewed on 10/23/25 at approximately 6:00 p.m. The DON said the admitting nurse was responsible for reviewing the baseline care plan with the resident and/or the resident's responsible party and getting the baseline care plan signed by the resident or the responsible party. The DON said after the Acknowledgement of Care Plan form (for the receipt of the baseline care plan) was signed by the resident or the responsible party, the form was uploaded into the resident's EMR.

Based on observations, record review and interviews the facility failed to provide appropriate treatment and services to residents diagnosed with dementia for three (#17, #5 and #3) of five residents out of 17 sample residents.Specifically the facility failed to:-Develop a person-centered care plan to meet Resident #17's dementia care needs;-Ensure Resident #5 was provided activities to meet her preferences; and,-Develop and implement a person-centered care plan to meet Resident #3's dementia care needs.Findings include: I. Facility policy and procedure The Care of the Cognitively Impaired policy, reviewed on 9/22/25, was provided by the director of nursing (DON) on 10/23/25 at approximately 3:00 p.m. Ensuring adequate medical care, diagnosis, and supports based on diagnosis; Ensuring that the necessary care and services are person-centered and reflect the resident's goals, while maximizing the resident's dignity, autonomy, privacy, socialization, independence, choice, and safety; and, Utilizing individualized, non-pharmacological approaches to care (purposeful and meaningful activities). Meaningful activities are those that address the resident's customary routines, interests, preferences, and choices to enhance the resident's well-being. Identify, address, and/or obtain necessary services for the dementia care needs of residents; Develop and implement person-centered care plans that include and support the dementia care needs, identified in the comprehensive assessment; Develop individualized interventions related to the resident's symptomology and rate of progression (providing verbal, behavioral, or environmental prompts to assist a resident with dementia in the completion of specific tasks); Review and revise care plans that have not been effective and/or when the resident has a change in condition; Modify the environment to accommodate resident care needs; and, Achieve expected improvements or maintain the expected stable rate of decline. II. Resident #17 A. Resident status Resident #17, age [AGE], was admitted on [DATE]. According to the October 2025 computerized physician orders (CPO), diagnoses included mild neurocognitive disorder due to known physiological conditions with behavioral disturbance. The 10/22/25 minimum data set (MDS) assessment revealed the resident had short term memory problems and had moderately impaired cognition per staff assessment. The MDS indicated the resident did not have any behaviors. B. Observations On 10/21/25 around 10:00 a.m. Resident #17 sat at the nurse's station next to a staff member. The resident and staff member chatted while the staff charted on her computer. She encouraged the resident to stay seated with her and utilize a busy board. -The staff did not provide Resident #17 with his preferred activities that were listed on the care plan (see care plan below). On 10/21/25 at approximately 11:00 a.m. Resident #17 was walking around the nurses' station by himself. He entered another resident's room. The other resident shrieked, the staff immediately went over to Resident #17 and asked him to leave the other resident's room. He left the room. The staff walked and talked with him around the nurses' station. -The staff did not provide Resident #17 with any person-centered interventions to prevent him from wandering into other resident's rooms. C. Record review Resident #17's cognitive deficit care plan, revised on 10/17/25, revealed the following pertinent interventions: allowing the resident ample time to absorb and respond to information, allowing the resident to make as many choices as possible with his care, assisting the resident in performing and/or completing a task or activity that they can not do, avoiding changes in the resident's environment, explaining all procedures and treatments prior to completing them, providing a calm environment and structured routine, reorienting the resident as needed. Residents #17's activity care plan, revised 10/17/25, revealed the resident had problems or concerns that may affect the resident's involvement in activities. Pertinent interventions included encouraging the resident to participate in group and individual activities. The care plan documented the resident enjoyed arts and crafts, games and puzzles, television (TV) and movies, listening to music, being outdoors, visits with family and friends, and physical activity. -However, observations revealed the staff did not offer the resident his preferred activities (see observations above). D. Staff interviews The social services director (SSD) was interviewed on 10/23/25 at 9:32 a.m. The SSD said Resident #17's daughter lived out of state. The SSD said the facility had a meeting scheduled for that day (10/23/25) to discuss the resident's placement. The SSD said the resident was placed on a one-to-one care giver to ensure he was safe. She said she was not aware if there had been a care plan developed to address the resident's dementia needs. She said having a one-to-one caregiver sit with him was not the best way to address the resident's dementia needs. She said she was not sure how new staff were provided dementia training. LPN #1 was interviewed on 10/23/25 at 3:20 p.m. She said another resident, Resident #3, had to be moved to a different floor of the building because he and Resident #17 did not get along. She said that on 10/22/25 and 10/23/25 Resident #3 became agitated and yelled at the nurses' station, which triggered Resident #17. She said Resident #17 threw objects, yelled at the resident and staff and made threats. She said on both occasions they were able to redirect the residents away from each other. She said they redirected Resident #17 by having staff talk with him. The activities director (AD) was interviewed on 10/23/25 at approximately 5:30 p.m. The AD said when a resident was admitted to the facility, he conducted an assessment to determine what the resident liked to do. He said he invited the residents to group activities. He said some of the residents preferred individual activities such as puzzles or reading in their rooms. The AD said Resident #17 did not do well in group activities. He said Resident #17 often became agitated and did not stay. He said Resident #17 did not have a special care plan to meet his dementia needs. Registered nurse (RN) #2 was interviewed on 10/23/25 at 5:45 p.m. She said that typical interventions for dementia care were to offer assistance with the restroom, check for incontinence, offer food and fluids, let the resident sit at the nurse's station and to redirect the resident. She said sometimes they will offer books, magazines, word puzzles, the busy board which is a board with a fidget [NAME], locks and other miscellaneous items designed for dementia patients to occupy their time. She said the main focus was to redirect the residents. She said when Resident #17 tried to go into another resident's room, they would try to redirect him by encouraging him to walk and talk with staff, or by offering him soda. Licensed practical nurse (LPN) #3 was interviewed on 10/23/25 at 5:47 p.m. LPN #3 said Resident #17 often walked around the nurses' station and halls. He said Resident #17 had tried to leave the unit before, but had never made it out of the building to his knowledge. He said if the resident did try to leave, a staff member would hopefully see him and bring him back. He said if he made it as far as the lobby, then the receptionist would bring him back. He said Resident #17 was well known by everyone in the building. The DON was interviewed on 10/23/25 at 6:00 p.m. The DON said Resident #17 was placed on a one-to-one caregiver, since he was really agitated and going into other residents' rooms. She said the one-to-one caregiver was helping with the resident's agitation. The DON said the staff gave Resident #17 a Rubik's cube yesterday and he threw it. The DON said they had tried fidget boxes too. The DON said Resident #17 did not staff in the activities. The DON said Resident #17 had a lot of hallucinations. The DON said the staff were provided dementia training at the yearly skills fair. III. Resident #5 A. Resident status Resident #5, age greater than 65, was admitted on [DATE]. According to the October 2025 CPO, diagnoses included dementia. The 10/22/25 MDS revealed the resident had severe cognitive impairments with a BIMS score of three out of 15. She required extensive assistance with activities of daily living (ADLs). The MDs indicated the resident spoke English. B. Observations On 10/21/25 at approximately 10:40 a.m. Resident #5 was lying in bed on her back trying to get out of bed. She was yelling help. A few minutes later a staff member went into the room to assist her. She was seen later that day, around lunchtime, idly sitting in a wheelchair at the nurses station staring downwards. She was seated away from the counters and appeared to have no activities nearby At 5:03 p.m. Resident #5 was yelling for help while she laid in her bed. The unidentified staff member at the nurses' station said it was Resident #5 yelling again, and did not immediately get up to help. Resident #5 yelled for help for approximately five minutes before the staff member assisted her. During a continuous observation on 10/22/25, beginning at 9:35 a.m. and ending at 1:35 p.m. the following was observed: At 9:35 a.m. Resident #5 was sleeping in her bed. At 10:15 she was sleeping in her recliner with the TV on a Spanish speaking channel. -However, Resident #5 did not speak Spanish. At approximately 11:05 a.m. a registered nurse (RN) from an outside hospice provider checked on the resident. At 11:28 a.m. the hospice RN changed the TV channel to an English channel. -The resident was lying in bed with a Spanish speaking channel playing for over an hour. The facility failed to provide person-centered interventions for Resident #5. C. Record review Resident #5's activity care plan, initiated on 10/21/25, revealed she enjoyed listening to music, social events and activities, spiritual activities, arts and crafts, and being outdoors. Pertinent interventions were to provide her assistance with her activity supplies, to make sure that they are convenient for her to use and to encourage her to participate in her activities of interest. Resident #5's social isolation care plan, initiated on 10/21/25, revealed the following pertinent interventions assisting Resident #5 to and from activities and encouraging her to participate in activities of interest with others. III. Resident #3 A. Resident status Resident #3, age greater than 65, was admitted to the facility on [DATE]. According to the October 2025 CPO, diagnoses included anxiety disorder, other symptoms and signs involving cognitive functions and awareness and benign prostatic hyperplasia (non-cancerous enlargement of the prostate gland) with lower urinary tract symptoms. The 9/30/25 MDS assessment revealed the resident had severely impaired cognition with a BIMS score of three out of 15. The resident was dependent on staff for most of the activities of daily living (ADL). The assessment revealed the resident had behavior for difficulty focusing attention, being easily distractible or having difficulty keeping track of what was said, and the resident's thinking disorganized or incoherent. B. Observations During a continuous observation on 10/22/25, beginning at 9:30 a.m. and ending at 1:15 p.m., the following was observed: At 9:30 a.m. Resident #3 was lying in bed with his door open. At 10:10 a.m. an unidentified certified nurse aide (CNA) stood at the room entrance, looked into Resident #3's room for less than 30 seconds, and then left. At 11:02 a.m. LPN #1 entered Resident #3's and provided care to the resident. Then LPN #1 assisted Resident #3 to the lobby by the elevators on the third floor and offered him a cup of drink. At 11:18 a.m. an unidentified CNA sat with Resident #3 at the lobby for a few minutes. At 12:07 p.m. an unidentified CNA brought the resident his lunch. -During the observation, Resident #3 was not provided with any person-centered activities to meet his dementia care needs. During a continuous observation on 10/22/25, beginning at 3:50 p.m. and ending at 6:00 p.m., the following was observed: At 3:50 p.m. Resident #3 was talking with an unidentified staff in the lobby on the first floor. Then they went upstairs on the third floor and Resident #3 stayed a bit in the nurse station talking with staff. At 4:04 p.m. the unidentified CNA assisted Resident #3 to his room. The unidentified CNA assisted Resident #3 in shaving and grooming. Resident #3 later wheeled himself to the hallway and was observed talking to the staff for a while before going back to his room. He stayed in his room sitting in his wheelchair until dinner time. At 5:05 p.m. an unidentified CNA brought the resident dinner. -During the observation, Resident #3 was not provided with any person-centered activities to meet his dementia care needs. At 5:19 p.m. Resident #3 finished eating dinner. On 10/23/25 at 9:10 a.m. Resident #3 was observed sitting by the window with his pants down to the knee. Resident #3 said he had breakfast. At 9:21 a.m. Resident #3 came into the hallway and became combative with staff when they attempted to assist him in pulling up his pants. The staff just walked away at that time. At 10:57 a.m. Resident #3 was moved to the second floor for safety reasons because another resident tried to fight him. -The facility did not provide Resident #3 with any person-centered activities. B. Record review The activities care plan, initiated 9/19/25 and revised 10/7/25, included a care focus for social isolation. Pertinent interventions included one-to-one visits from activities as needed, allowing/encouraging resident to communicate his feelings regarding attended activities, assisting the resident to and from activities of choice and encouraging resident to participate in activities of interest with others. The behavior care plan, initiated 9/19/25 and revised 10/7/25, documented Resident #3 had a potential for mood disturbances. Pertinent interventions included administering medications as per physician's orders, providing distraction/redirection as needed, and providing support and reassurance. The wandering care plan, initiated 9/21/25 and revised 10/7/25, revealed Resident #3 had a history of wandering in a new environment and elopement. Pertinent interventions included reorienting and redirecting resident as needed, providing and involving resident in activities directed at resident's specific interests, monitoring resident's whereabouts regularly as needed to ensure safety and documenting any attempts at elopement and notifying physician and responsible party. -The care plan did not document any person-centered interventions to address Resident #3's dementia care needs. The 10/4/25 nursing note revealed Resident #3 was verbally aggressive to the nurse while passing medications. Resident #3 attempted to strike at the nurse. The nurse asked Resident #3 to refrain from his behavior and redirect him. The weekly activity progress note, dated 10/20/25, revealed Resident #3 had been watching television, exercising as directed by therapy staff/resting to recover, ambulating in his wheelchair and participating in coffee cart and check-in visits. He had declined additional activity supplies and was offered activities this week. Resident #3 had not expressed satisfaction or dissatisfaction with his recreational needs being met. The 10/21/25 physician assistant (PA) note revealed an assessment of dementia with behavioral disturbances/ psychosis for Resident #3. Resident #3 hit a CNA, was verbally aggressive, his behaviors were difficult to control and displayed exit seeking behaviors. The 10/23/25 progress note revealed Resident #3 was moved to the second floor for safety reasons. D. Staff interviews CNA #1 was interviewed on 10/23/25 at 2:10 p.m. CNA #1 said Resident #3 often became combative with the CNAs when they were providing care. CNA #1 said Resident #3 did not let staff assist him with toileting or hygiene. CNA #1 said Resident #3 sometimes wore briefs, but Resident #3 would not allow staff to physically check the briefs during their rounds. CNA #1 said Resident #3 was moved to the second floor for safety reasons on 10/23/25 because another resident tried to fight him. LPN #1 was interviewed on 10/23/25 at 3:25 p.m. LPN #1 said Resident #3 required supervision while allowing Resident #3 to clean himself. She said on 10/23/25 Resident #3 allowed them to clean him as he was very unkempt. LPN #1 said Resident #3 sometimes did not wear briefs during daytime as he was able to use the toilet, but he wore briefs at night. LPN #1 said Resident #3 was yelling at her, which upset another resident. She said that resident attempted to confront Resident #3. LPN #1 said she notified her manager who decided to move Resident #3 to the second floor for safety reasons. The AD was interviewed on 10/23/25 at approximately 5:30 p.m. The AD said Resident #3 spoke Spanish and English. He said he had offered Resident #3 puzzles, but he did not like them. The AD said he had tried to keep Resident #3 busy, but had not found anything that he liked so far. The AD said the facility did not have any Spanish speaking activities. The DON was interviewed on 10/23/25 at 6:00 p.m. The DON said Resident #3 became combative during care and resisted care if he did not recognize the staff member. He said to de-escalate the situation, he would show Resident #3 his badge, explain the care that was going to be provided, and offer Resident #3 a cup of coffee. The DON said the staff needed to approach Resident #3 at his level and he was more willing to listen and allow staff to assist him.

Based on interviews and record review, the facility failed to ensure one (#2) of six residents out of 17 sample residents were provided prompt efforts by the facility to resolve grievances. Specifically, the facility failed to effectively resolve and demonstrate the facility's response to individual grievances for Resident #2.Findings include:I. Facility policy and procedureThe Grievance policy, revised 1/8/24, was provided by the director of nursing (DON) on 10/23/25 at 3:36 p.m. It read in pertinent part, If the complaint is verbal, it is the responsibility of the staff member who received the complaint to properly complete the grievance form on behalf of the complainant. The completed form must be provided to the executive director or designee immediately. The grievance will be given to the appropriate department manager for follow up and resolution. All grievances will be reviewed in the morning meeting with interdisciplinary (IDT) members. The department managers are responsible for the resolution of all complaints within his or her department. The department managers will note the disposition of the grievance in writing to the executive director or designee. It is the responsibility of the department manager in coordination with the executive director, when appropriate, to develop a process and plan for the resolution of the grievance and notify the complainant about the resolution plan. All actions taken on the grievance, including meetings with the patient, telephone calls, action plans, revisions to care plans, etc., must be documented on the grievance form. If the complainant or aggrieved party is dissatisfied with the finding and/or remedies, the executive director will make reasonable attempts to resolve the grievance. The ombudsman will be notified if the grievance is not resolved per the resident/family representative's request.II. Resident #2A. Resident statusResident #2, age [AGE], was admitted on [DATE]. According to the October computerized physician orders (CPO), diagnoses included Alzheimer's disease, fracture of left femur, essential hypertension (high blood pressure), psychotic disturbance, mood disturbance and anxiety.The 9/22/25 minimum data set (MDS) assessment revealed the resident had moderate cognitive impairments with a brief interview for mental status (BIMS) score of nine out of 15. B. Resident #2's representative interviewResident #2's representative was interviewed on 10/22/25 at 4:30 p.m. He said he had filed grievances with the facility regarding Resident #2's physical therapy. The representative said he was concerned the weight bearing status communicated by the orthopedic surgeon was not being followed. The representative said he had not received a response to the grievance he filed. He said the director of rehabilitation (DOR) met with him but he was not satisfied with her explanation. The representative said he emailed the nursing home administrator (NHA), but he had not received a response. He said he had other concerns with the care Resident #2 received. He said he felt the facility did not resolve his concerns for Resident #2's care. C. Record reviewA grievance form for Resident #2 was provided by the director of nursing (DON) on 10/23/25 at 2:28 p.m.The grievance form, completed by the DOR on 10/7/25, documented Resident #2's representative was upset about the new weight-bearing order. The resident's representative felt the therapy department changed Resident #2's weight bearing status and not the orthopedic surgeon. The grievance form documented the therapy team provided education to the resident's representative indicating the resident was not fully weight-bearing and Resident #2 was able to bear weight as tolerated. The grievance form documented the date the grievance was received by social services, the signature line, the substantiated and unsubstantiated line, and the NHA's signature were left blank. It revealed Resident #2's satisfaction was hesitant, concerned, and the comments read that the representative still believed therapy had changed the resident's weight bearing status order. III. Staff interviewsThe NHA was interviewed on 10/23/25 at 6:48 p.m. The NHA said anyone could fill out a grievance form. He said residents and family members can turn in the grievance form to any staff or put it in the box in front of the social services office. He said once a grievance was turned in, the facility had 48 hours to resolve the grievance. He said if a resident was discharged prior to the grievance being resolved, the facility should contact the resident or representative to resolve the grievance. The NHA said based on the format of the grievance form, he was unable to show when any grievance was resolved, including the grievances filed for Resident #2, because there was no section on the form with a date when the grievance was resolved. The NHA said the words cautiously optimistic, doubtful, hesitant and concerned did not reveal if the grievance was resolved to the resident or family's satisfaction. The NHA said before October 2025, nursing documented resident concerns as a progress note. The NHA said resident's concerns documented as a progress note should have been documented on a grievance form to ensure the grievance was resolved.

Based on observations, record review and interviews the facility failed to ensure residents who were unable to carry out activities of daily living (ADL) received the necessary services to maintain proper personal hygiene and good nutrition for two (#3 and #7) of five residents reviewed for ADLs out of 17 sample residents.Specifically, the facility failed to:-Ensure Resident #3 consistently received assistance with meals and showers; and, -Ensure Resident #7 received assistance with showers. Findings include: I. Resident #3 A. Resident status Resident #3, age greater than 65, was admitted to the facility on [DATE]. According to the October 2025 computerized physician orders (CPO), diagnoses included cellulitis (skin infection caused when germs enter through a crack in the skin) of left lower limb, lymphedema (a condition where fluid called lymph builds up in the body's tissues causing swelling usually in the arms and legs) and benign prostatic hyperplasia (non-cancerous enlargement of the prostate gland) with lower urinary tract symptoms. The 9/30/25 minimum data set (MDS) assessment revealed the resident had severely impaired cognition with a brief interview for mental status (BIMS) score of three out of 15. The assessment revealed the resident was dependent on staff assistance with toileting hygiene, showering/bathing, upper and lower body dressing, putting on/taking off footwear and personal hygiene. The assessment revealed the resident required supervision or touching assistance while eating. B. Observations During a continuous observation on 10/22/25, beginning at 9:30 a.m. and ending at 1:15 p.m., the following was observed: At 12:07 p.m. an unidentified certified nurse aide (CNA) delivered Resident #3 his lunch. The unidentified CNA provided a few cues before Resident #3 began to feed himself. The unidentified CNA left the room. At 12:30 p.m. Resident #3 finished eating lunch. He ate approximately 25 percent of the meal and drank one cup of coffee. At 12:50 p.m. the same unidentified CNA returned to remove the meal tray. She asked Resident #3 if he was done eating. She did not encourage the resident to eat more, despite Resident #3 having eaten only 25 percent of the meal. During a continuous observation on 10/22/25, beginning at 3:50 p.m. and ending at 6:00 p.m., the following was observed: At 5:05 p.m. an unidentified CNA delivered Resident #3's dinner. She set up the meal tray and provided a few cues to Resident #3. Resident #3 began to feed himself. The unidentified CNA left the room. At 5:19 p.m. Resident #3 finished eating dinner. He ate less than 25 percent of the food. He drank all of the coffee. No staff went into Resident #3's room since his dinner was delivered to encourage him to eat. -During the observation, the staff failed to provide meal assistance by encouraging Resident #3 to eat more food. C. Record review The baseline care plan, created 9/17/25, documented Resident #3 was dependent on staff for bathing. Interventions included providing the resident bathing per his preference, providing assistance as needed with grooming, bathing and personal hygiene and encouraging the resident to do as much as possible for himself as able. The nutrition care plan, initiated 9/22/25 and revised 10/6/25, documented Resident #3 had a potential and/or was at risk for inability to maintain his nutrition due to potential for increased needs for healing. Pertinent interventions included providing and serving diet and supplements as ordered, and the registered dietitian (RD) to evaluate and making nutritional recommendations as needed. The visual/bedside Kardex (staff directive tool), dated 10/23/25, revealed Resident #3 was scheduled for bathing on Monday and Thursday evenings. Review of the October 2025 (10/1/25 to 10/21/25) shower records revealed Resident #3 received bathing on 10/1/25, 10/4/25, 10/6/25, 10/8/25, 10/11/25, and 10/21/25. Resident #3 did not receive bathing for nine days from 10/11/25 to 10/21/25. There was no documentation indicating Resident #3 refused shower at that period of time as the facility did not provide the shower sheets when requested. D. Staff interviews CNA #1 was interviewed on 10/23/25 at 2:10 p.m. CNA #1 said Resident #3 was scheduled to receive showers on Monday and Thursday evenings. CNA #1 said Resident #3 often became combative with the evening shift CNAs, so he would not receive a full shower. He said instead, CNAs offered him a sponge bath as an alternative. CNA #1 said when he started his shift on 10/23/25, Resident #3 needed a shower, so he provided a sponge bath to Resident #3. CNA #1 said when Resident #3 refused both shower and the sponge bath, CNAs notified the nurse and documented the refusal. CNA #1 said he had Resident #3 sign the shower sheet when he refused showers. CNA #1 said Resident #3 did not let staff assist him with toileting or hygiene and often became combative. CNA #1 said he encouraged Resident #3 to eat more if he noticed Resident #3 did not eat much. CNA #1 said when Resident #3 refused to eat, he notified the nurse and documented that the resident refused. Licensed practical nurse (LPN) #1 was interviewed on 10/23/25 at 3:25 p.m. LPN #1 said she consulted with the RD when she was notified by the CNAs that a resident ate poorly. LPN #1 said the dietitian could determine what to offer as alternative food options. LPN #1 said she could offer nutritional supplements such as Boost or Ensure to the resident and notify the physician who would then provide the order. LPN #1 said Resident #3 needed cues and guidance while allowing Resident #3 to clean himself. She said she had not worked with Resident #3 much, so she was not aware of his eating habits. She said on 10/23/25 Resident #3 allowed them to bathe him. The RD was interviewed on 10/23/25 at 6:35 p.m. The RD said she had not assessed Resident #3 since her first assessment upon admission. She said Resident #3 would rather benefit from a restorative program if the facility had one. II. Resident #7 A. Resident status Resident #7, age less than 65, was admitted on [DATE]. According to the July 2025 CPO, diagnoses included multiple sclerosis (MS), quadriplegia (paralysis that affects all a person's limbs) and pressure ulcer of right buttock stage 4 (severe wound with tissue loss exposing bone, muscles or tendons). According to the 7/28/25 MDS assessment the resident was cognitively intact with a BIMS score of 15 out of 15. The resident was dependent on staff for all activities of daily living (ADL). B. Resident interview and observation Resident #7 was interviewed on 10/21/25 at 3:30 p.m. During the interview, Resident #7 was lying in bed. His mattress and floor were covered with dry, white flakes. There was a strong unpleasant odor in the room. There was a white board in the room that indicated Resident #7 was to receive baths twice a week in the evening. He said he was dependent on staff for all ADLs. Resident #7 said he had not had a bed bath in a few weeks. He said the staff would tell him they would get to his bath and then get too busy and never come back. He said he did not refuse bed baths. D. Record review The bathing care plan, initiated 7/18/25 and revised 10/22/25, documented the resident agreed to receiving a shower or bed bath. Interventions included Resident #7 preferred a bed bath, frequency was two times a week. The decision care plan, initiated 7/31/25 and revised 10/23/25 (during the survey), documented the resident was non-compliant with cares such as bathing, repositioning of right buttock and refusals to work with therapy. Pertinent interventions included changing the approach and recording approaches which were successful, documenting non-compliance and reporting to the physician. -However, review of the EMR revealed there was no documentation of non-compliant behavior or successful approaches. The 8/9/25 skilled nursing note documented the resident verbalized to the nurse that he had not had a bath since his admission on [DATE]. The October 2025 look back period (9/25/25 to 10/19/25) bathing task record revealed Resident #7 had a bath documented 9/25/25, a bath on 10/2/25 and a refusal documented 10/10/25. -It indicated Resident #7 received two out of eight opportunities. -Review of the daily skilled notes from admission to 10/21/25 did not reveal any refusals of bed baths. E. Staff interviews Wound care nurse (WCN) #1 was interviewed on 10/22/25 at 10:50 a.m. WCN #1 said it was important to bathe residents with skin conditions. She said the odor coming from Resident #7's room has not changed since she started in July 2025. WCN #1 said she did not believe the odor was from the wound and said he may need more hygiene care and bathing. She said the staff may not be cleaning him well enough after a bowel movement. She said she saw feces on the dressing while she changed it on 10/22/25. WCN #1 said she was not aware Resident #7 had refused bed baths. LPN #2 was interviewed on 10/22/25 at 3:30 p.m. LPN #2 said Resident #7 was particular about his care but she was not aware he had refused bed baths. LPN #2 said if a resident refused any care, treatment or medication, the refusal should be documented in the daily skilled note. The director of nursing (DON) was interviewed on 10/22/25 at 4:28 p.m. The DON said the IDT monitors the bathing schedule about every two weeks. She said if a resident refused they are not offered another bath until their next scheduled bath day. The DON said if a resident refused a bath they would fill out a shower form. -However, there were no shower forms for Resident #7 during that time period.

Based on observations, record review and interviews, the facility failed to keep medical records in a secure and confidential manner. Specifically, the facility failed to ensure nursing staff logged off their workstation when leaving the work area to protect the confidentiality of resident information. Findings include: I. Facility policy and procedure A request for a protected health information policy was requested on 8/1/24, but was not received. II. Observations On 7/30/24 observations were made on the second and third floor units. The second and third floors each had a nurses station in the middle of the unit with five to seven computer monitors. The second and third floor units had three hallways with resident rooms. Each hallway had a computer at a workstation in the middle of the hallway. The second and third floor units had three medication carts with a computer. Residents, visitors and families frequently walked down the hallways and by the nurses station, which enabled the computers to be visible to anybody walking by. At 2:42 p.m. an unidentified nurse left her computer screen, with a resident's electronic medical record (EMR) open, at the third floor nurses station. At 2:47 p.m. an unidentified certified nurse aide (CNA) left her computer screen, with a resident's EMR open, in the hallway at the third floor nurses station. At 3:00 p.m. a computer screen was left unattended, with a resident's EMR open, on a second floor medication cart. At 3:00 p.m. a computer screen was left unattended, with a resident's EMR open, on the second floor hallway desk workstation. An unidentified resident was sitting in a wheelchair next to an unidentified CNA. The unidentified resident was looking at the computer monitor. On 7/31/24 the following observations were made on the third floor unit: At 9:18 a.m. licensed practical nurse (LPN) #1 left her computer screen open, with a resident's EMR visible, at the nurses station. At 11:15 a.m. LPN #1 left her computer screen open, with a resident's EMR visible, at the nurses station. Two family members walked by the nurses station and Resident #99 came out of her room to the nurses station. At 12:41 p.m. LPN #1 left her computer screen open, with a resident's EMR visible, at the nurses station. On 7/31/24 observations were made on the third floor unit with the nursing home administrator (NHA) and the director of nursing (DON). At 2:46 p.m. a computer screen was left open, with a resident's EMR visible, in the hallway. The DON locked the computer screen. At 2:47 p.m. a computer screen was left open, with a resident's EMR visible, at the third floor nurses station. The DON locked the computer screen. III. Staff interviews CNA #5 was interviewed on 8/1/24 at 10:40 a.m. CNA #5 said residents' EMRs should not be left open on the computers where they were easily accessible to non-staff members. She said she needed to log off her workstation when she left the work area. LPN #2 was interviewed on 8/1/24 at 8:54 a.m. LPN #2 said the residents' EMRs with personal health information should not be left open and easily accessible to non-staff members. She said the nurses needed to log off their workstations when leaving the work area. LPN #1 was interviewed on 8/1/24 at 9:26 a.m. LPN #1 said the resident's EMRs with personal health information should not be left open and easily accessible to non-staff members. She said the nurses needed to log off their workstations when leaving the work area. The NHA was interviewed on 7/31/24 at 2:44 p.m. The NHA said the staff needed to log off their workstation when they left their workstation. He said the residents should not sit right next to nurses or CNAs who had resident medical record information visible on the computer monitor. The NHA said it was important to not leave the monitors unattended to keep resident medical information private.

Based on record review and interviews, the facility failed to ensure in-service training for certified nurse aides (CNA) consisted of annual training for dementia management and/or annual abuse training for three of three out of eight sampled staff. Specifically, the facility failed to ensure: -CNA #3, CNA #4 and CNA #5 completed the annual dementia and abuse training. Findings include: I. Facility policy and procedure The Abuse and Dementia Training policy and procedure was requested from the director of nursing (DON) on 8/1/24 at 12:00 p.m. The policy and procedure was not provided. II. Record review A review of the 5/30/24 dementia training sign in sheet failed to reveal documentation that CNA #3, CNA #4 or CNA #5 had attended the dementia training. A review of the dementia and abuse training documentation on 7/31/24 revealed the following: -The training records revealed CNA #5 had not received dementia and abuse training since 5/25/23. -The training records revealed CNA #4 had not received dementia and abuse training since 6/8/23. -The training records revealed CNA #3 had not received dementia and abuse training since 7/13/23. III. Staff interview The DON was interviewed on 8/1/24 at 8:44 a.m. The DON said abuse training was conducted by the nursing home administrator (NHA) because he was the abuse coordinator. She said he had conducted a recent training on abuse but she was unable to find the documentation or the agenda for the training. She spoke with the NHA and he did not have the documentation. She said a dementia training was completed on 5/30/24 but it did not contain the signatures of CNA #3, CNA #4 or CNA #5. She did not know why those staff members did not complete the training. She said the facility did not have a training policy or procedure for dementia or abuse.

Based on record review and interviews, the facility failed to meet all of the requirements for the provision of hospice for one (#19) of one resident reviewed for hospice services out of 40 sample residents. Specifically, the facility failed to ensure a hospice care plan was initiated for Resident #19 to determine who was responsible for resident care. Findings include: I. Facility policy and procedure The Care Plan policy, revised 2/8/21, was received by the director of nursing (DON) on 8/1/24 at 10:54 a.m. The policy read in pertinent part, It is the policy of the facility to promote seamless interdisciplinary care for our residents by utilizing the interdisciplinary plan of care based on assessment, planning, treatment, service and intervention. It is utilized to plan and manage resident care as evidenced by documentation from admission through discharge for each resident. The care plan will identify priority problems and needs to be addressed by the interdisciplinary team, and will reflect the patient's strengths, limitations, and goals. The care plan will be specific and appropriate to the individual needs of each resident. The interdisciplinary care plan will be developed through collaborative efforts of the IDT (interdisciplinary team) and other health care professionals. The care plan will be patient centered emphasizing the resident's and/or family's goals. The care plan will contain information about the physical, emotional/psychological, psychosocial, spiritual, educational and environmental needs as appropriate. It is our purpose to ensure that each resident is provided with individualized, goal-directed care, which is reasonable, measurable and based on resident needs. (Facility name) will develop, implement, and provide care in accordance with a comprehensive person-centered care plan for the resident consistent with regulatory requirements. The care plan will be modified when needed to meet the resident's current needs, problems, and goals. Any revision, additions, or deletion to the plan of care will be dated. II. Resident #19 A. Resident status Resident #19, age greater than 65, was admitted on [DATE]. According to the August 2024 computerized physician orders (CPO), diagnoses included metabolic encephalopathy and unspecified dementia. The 5/24/24 minimum data set (MDS) assessment revealed the resident had severe cognitive impairment with a brief interview for mental status (BIMS) score of six out of 15. He was dependent on staff for assistance with lower body dressing, putting on/taking off footwear, sitting to lying, and sitting to standing, chair/bed to chair transfers, toileting transfers and tub/shower transfers. B. Record review Review of the July 2024 CPO revealed Resident #19 was admitted to hospice services for metabolic encephalopathy, ordered 8/29/24. -Review of Resident #19's comprehensive care plan revealed there was not a care plan for hospice care. The care plan did not indicate which cares the facility would provide versus what cares the hospice services would provide. C. Staff interviews Certified nurse aide (CNA) #2 was interviewed on 8/1/24 at 8:40 a.m. CNA #2 said she knew Resident #19 was receiving hospice care. She said when a resident was receiving hospice care a care plan should be implemented. CNA #2 said she provided basic care for Resident #19 such as repositioning, turning the resident, getting him out of bed and basic hygiene. She said the hospice staff came in on Tuesdays and Fridays. She said if she had any questions or concerns regarding Resident #19 she would call hospice. Registered nurse (RN) #2 was interviewed on 8/1/24 at 8:56 a.m. RN #2 said anytime a resident was receiving hospice care a care plan should be implemented. She said when a resident was admitted to hospice services she would initiate the care plan along with the minimum data set coordinator (MDSC). She said she could add to and update the care plan when she saw any changes. She said she did not know what Resident #19's goals were for care and treatment at the end of life. She said she was not aware that a care plan was not initiated for Resident #19. RN #2 said she was responsible for providing direct patient care, checking on the resident as needed and providing medications and treatments. She said any staff member could communicate with the hospice staff. She said the hospice CNA came in twice a week to shower Resident #19. She said she did not know how often the hospice nurse came in to check on Resident #19. She said the hospice staff came to the facility on a routine basis. She said if she had any concerns regarding Resident #19 she would call the hospice nurse. The director of nursing (DON) was interviewed on 8/1/24 at 9:14 a.m. The DON said when a resident was receiving hospice care a care plan should be implemented. She said the resident should have a hospice initiated care plan and a facility initiated care plan. She said she knew Resident #19 was receiving hospice services. She said she did not know a care plan for the resident's hospice services was not implemented. She said the MDSC and nursing staff were responsible for implementing the care plans. The MDSC was interviewed on 8/1/24 at 9:24 a.m. The MDSC said she was responsible for implementing the comprehensive care plans She said she would look at the physician's orders and go off them to determine what needed to be updated on the residents' care plans. She said the care plans should be updated daily and as needed. She said a team that consisted of the DON, the nursing home administrator (NHA), the case manager (CM), the unit manager (UM) and the MDSC met every morning. She said if there was a change of condition the CM and the UM would notify the team. The MDSC said she was not aware that a care plan for hospice was not initiated for Resident #19. She said she did not know how the care plan was missed. She said a change of condition in the MDS assessment was updated but a care plan was never initiated. She said she would make sure that a care plan would be implemented.

Based on observations, record review and interviews, the facility failed to ensure one (#98) of six residents reviewed for unnecessary medications out of 40 sample residents was free from unnecessary medications. Specifically, the facility failed to: -Ensure Resident #98's hours of sleep were documented for psychotropic medication use; and, -Ensure person-centered interventions to address Resident #98's repetitive statements were identified and attempted prior to ordering an antipsychotic medication for the resident. Findings include: I. Resident #98 A. Resident status Resident #98, age 77, was admitted on [DATE], discharged on [DATE] and readmitted on [DATE]. According to the August 2024 computerized physician orders (CPO), diagnoses included dementia, transient ischemic attack (stroke), cerebral infarction, psychotic disturbance, mood disturbance, insomnia and anxiety. The 5/17/24 minimum data set (MDS) assessment revealed the resident had severe cognitive impairments with a brief interview for mental status (BIMS) score of six out of 15. He required supervision for oral hygiene and toileting. He required partial assistance for transfers. B. Resident observations During a continuous observation on 7/29/24, beginning at 10:54 a.m. and ending at 11:27 a.m., the following was observed: At 10:54 a.m. Resident #98 was in his room. He said can you help me, help me, help me please. At the nurse's station, directly across from the resident's room, an unidentified nurse said it was time to give him medicine. At 10:55 a.m. the unidentified nurse went into the resident's room with medicine. At 11:00 a.m. the resident left his room in his wheelchair with the unidentified nurse. The nurse assisted him to the activity room. At 11:02 a.m. Resident #98 tried to go into Resident #99's room, which was next to Resident 98's room. Resident #98 said he needed help. Resident #99 asked him what he needed help with. An unidentified staff member assisted Resident #98 back to the activity room. -There were no activities being conducted in the activity room and the unidentified staff member did not attempt to interact with the resident to determine what the resident needed or provide him with a meaningful activity to distract the resident from his repetitive statements. At 11:19 a.m. the unidentified staff member assisted Resident #98 to his room. The unidentified staff member provided toileting assistance and assisted Resident #98 to his bed. The unidentified staff member left his room. At 11:20 a.m. Resident #98 said help me. There was a certified nurse aide (CNA) who walked past his room and two staff members at the nurse's station. The nurse's station was directly across from Resident #98's room. The resident continued to say help me fifteen times. -The CNA and the two other staff members did not attempt to interact with the resident to determine what the resident needed or provide him with a meaningful activity to distract the resident from his repetitive statements. At 11:22 a.m. Resident #98 said hello. At 11:22 a.m. an unidentified nurse went into the resident's room and asked the resident if he wanted to watch a sports competition (Olympics). At 11:23 a.m. the nurse left the room. From 11:23 a.m. to 11:27 a.m. the resident said help, I need help, and help me and help me, please help me multiple times until an unidentified CNA went into the resident's room. On 7/30/24, Resident #98 was observed throughout the day. The resident was in his bed asleep. On 7/31/24, the following observations of Resident #98 were made: From 12:33 p.m. to 12:35 p.m. the resident was in his bed. He said please help and help me seven times. There were two nurses at the nurse's station across from the resident's room. -Neither nurse provided assistance to the resident. From 3:28 p.m. to 3:30 p.m. the resident was in his bed. He said help and hello, help me. Registered nurse (RN) #1 went into the resident's room and asked him if he wanted to take a nap. C. Record review Resident #98's antipsychotic medication care plan, revised 7/28/24, revealed the resident was on an antipsychotic medication related to repetitive statements causing agitation, pacing and delusions disturbing to the patient. The resident would yell out after needs were met. Interventions included administering medications per physician orders, considering a gradual dose reduction when necessary, monitoring as needed for fall risk, monitoring and reporting to the physicians for adverse side effects, offering non-pharmacological interventions and pharmacy to review the drug regimen monthly. -The care plan failed to document what type of delusions the resident exhibited which were disturbing to the resident. -The resident's antipsychotic medication care plan did not include effective non-pharmacological interventions when the resident asked for help. -Further review of the resident's comprehensive care plan revealed there was no care plan to monitor for hours of sleep related to the use of Melatonin for insomnia. The July 2024 CPO revealed the following physician's orders: Melatonin one milligram (mg). Take one tablet as needed for insomnia, ordered on 7/19/24. -There was no physician's order to monitor the hours of sleep. Seroquel 25 mg. Take one tablet by mouth every morning and at bedtime for delirium for seven days, ordered on 7/9/24 and discontinued on 7/11/24. Seroquel 25 mg. Take one tablet by mouth every morning and at bedtime for delirium until 7/16/24 for delusions that are disturbing to the resident, ordered on 7/11/24 and discontinued on 7/16/24. Seroquel 25 mg. Take one tablet by mouth every morning and at bedtime for medical illness with psychotic features for seven days for delusions that are disturbing to the resident and pacing to the point of exhaustion, ordered on 7/19/24 and discontinued on 7/24/24. Seroquel 25 mg. Take one tablet by mouth stat (immediately) for delusions and pacing to the point of exhaustion, ordered on 7/19/24 and discontinued on7/19/24. Seroquel 25 mg. Take one tablet by mouth one time a day for repetitive statements causing agitation for one day, ordered on 7/23/24 and discontinued on 7/24/24. Seroquel 25 mg. Take one tablet by mouth three times a day for medical illness with psychotic features due to delusions that are disturbing to the resident and pacing to the point of exhaustion, ordered on 7/24/24. Antipsychotic medication monitoring. Monitor every shift for signs and symptoms of sedation, drowsiness, dry mouth, constipation, blurred vision, weight gain, edema, sweating and loss of appetite, ordered on 7/9/24 and discontinued on 7/18/24. The 7/21/24 nurse progress note revealed melatonin was given and was ineffective. On 7/24/24, 7/25/24, 7/26/24, 7/27/24, 7/28/24 the nurse progress notes revealed the resident called out help me several times after needs were met. It revealed redirection was sometimes effective. -The progress note failed to document if any other interventions were attempted with Resident #98 when redirection was not effective. On 7/29/24 and 7/30/24 the resident called out help me and hello several times after needs were met. It revealed redirection was sometimes effective. -The progress note failed to document if any other interventions were attempted with Resident #98 when redirection was not effective. The 7/27/24 nurse progress note revealed the resident was up at night moving around in his room due to incontinence care that required a bed linen change. The 7/28/24 nurse progress note revealed melatonin was given and was effective. -There were no hours of sleep documented. The 7/31/24 provider progress note revealed the resident had dementia with psychosis. He remained an elopement risk. He required constant supervision and redirection. He was at risk for self harm and wandering into another resident's room. The 8/1/24 provider discharge summary revealed the resident had a challenge during his stay. He continued to have a decline in overall cognitive function. At times, he was redirectable and other times he was not. A few days prior to discharge, nursing noticed increased agitation. The resident continued to yell out for help and had increased restlessness and agitation at night. -A review of the resident's electronic medical record (EMR) did not reveal documentation indicating the resident's hours of sleep were monitored. II. Staff interviews Licensed practical nurse (LPN) #2 was interviewed on 8/1/24 at 8:54 a.m. LPN #2 said she knew a resident had behaviors requiring monitoring based on the diagnosis of dementia, if the psychiatrist saw the resident, at shift change report and monitoring based on protocol. LPN #2 said she was told at shift change if the resident had an active behavior or if the resident was on a psychotropic medication. She said she documented if the resident had behaviors in the resident's EMR. LPN #2 said she knew what interventions to use by asking the resident's physician. She said she tried redirection and guiding as an intervention. She said she would ask the resident what they wanted. LPN #2 said she would ask the family for effective interventions but she said the family did not know what interventions worked most of the time. She said she would notify the MDS coordinator so the care plan was updated. LPN #2 said she was not familiar with Resident #98. LPN #1 was interviewed on 8/1/24 at 9:26 a.m. LPN #1 said she knew a resident had behaviors requiring monitoring based on her assessment, if the behaviors were in the resident's chart, and the resident's hospital summary. LPN #1 said a dementia diagnosis did not mean a resident had behaviors. She said behaviors were based on how staff approached and interacted with residents. LPN #1 said she knew what interventions to use based on the care plan, on the report form, the CNA task list and the nurses shared at shift change what interventions worked for them. LPN #1 said she tried to put new interventions on the care plan but it was hard to do with the other charting responsibilities. She said it was important to have interventions to keep the resident safe and comfortable. LPN #1 said it was important to give a high quality of life so the resident could improve and go home. LPN #1 said Resident #98 constantly said help but it was not a behavior. She said he did not show distress, discomfort or agitation. She said she held his hand and he continued to say help. She said she added a care plan for the resident saying help repeatedly and his needs were met. LPN #1 said there were no interventions to stop him from saying help. She said everyone was responsible for identifying interventions for Resident #98. The director of nursing (DON) was interviewed on 8/1/24 at 11:01 a.m. The DON said certain diagnoses triggered specific behaviors that needed to be monitored. The DON said the staff knew what interventions to use to stop a behavior based on the psychiatrist visits and what the staff saw during their shift. She said a personalized care plan was important. The DON said the interventions used were based on a list of interventions. The DON said the interventions were not personalized for the residents. The DON said sleep should be monitored anytime a resident was on a hypnotic or on an antipsychotic medication. She said the sleep was documented in the medication and treatment administration records. The DON said she was not aware Resident #98's hours of sleep were not monitored. The DON said Resident #98 often said help me. She said sometimes he said what he needed. The DON said if a resident said help consistently, a personalized intervention should be on the resident's care plan to help address the behavior. The DON said it was important to have interventions to monitor behaviors and sleep so the resident had the best care. She said the resident should have personalized care to stay safe and receive good care. The DON said personalized interventions were important because there were different ways to identify the resident's needs.

Based on observations, record review and interviews, the facility failed to provide an effective pain management regimen consistent with professional standards of practice, the comprehensive person-centered care plan and the resident's goal for one (#32) of two residents out of 40 sample residents. Specifically, the facility failed to, for Resident #32: -Ensure a pain assessment was completed that identified the type of pain, the effects of pain on the resident, the aggravating factors and the relieving factors; -Ensure person centered non-pharmacological interventions for pain management were offered and monitored for effectiveness; and, -Ensure the administration of pain medications was documented consistently. Findings include: I. Resident #32 A. Resident status Resident #32, age 83, was admitted on [DATE]. According to the August 2024 computerized physician orders (CPO), diagnoses included type 2 diabetes, interstitial pulmonary disease (inflammation and scarring that made it hard for lungs to get oxygen), heart failure, atrial fibrillation (irregular and often rapid heart rhythm), morbid obesity and unsteadiness on her feet. The 6/19/24 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. She required substantial assistance for toileting. She was dependent on staff for showering, dressing and transfers. She required supervision for oral hygiene and personal hygiene. The assessment revealed the resident did not have a pain management regimen. The resident took pain management as needed and received non-medication interventions for pain. The MDS assessment documented the resident had pain frequently, which occasionally affected her sleep and her day-to-day activities. The resident reported her pain as moderate. B. Resident interview Resident #32 was interviewed on 7/29/24 at 2:28 p.m. Resident #32 said she sometimes had pain in different locations on her body. Resident #32 said she did not like to take pain medications. She said the facility did not offer non-pharmacological interventions when she experienced pain. She said if the lighting in her room was lowered, it would help her pain. C. Record review Resident #32's pain care plan, revised 8/1/24 (during the survey), revealed the resident had acute and chronic pain related to joint pain, peripheral vascular disease (blood circulation is reduced to a body part), interstitial lung disease and diabetes. She did not want to take pain medications and preferred non-pharmacological interventions. Interventions included acknowledging the presence of pain and discomfort, administering pain medications and monitoring for effectiveness, implementing non-pharmacological interventions, monitoring for pain every shift and notifying the physician as needed. Resident #32's opioid medication care plan, revised 6/17/24, revealed the resident took opioid medication for pain relief. The intervention was to monitor for side effects of dependence, nausea, vomiting, constipation, itching, respiratory depression and addiction. Resident #32's comfort care plan, revised 6/25/24, revealed the resident was at the facility for comfort care with minimal therapy. She received pain medications as ordered to keep her comfortable. Interventions included administering pain medication as ordered, notifying the physician if pain continued, providing a calm dimly lit environment, providing incontinence care and repositioning throughout the shift. -The care plan did not identify the location of her pain. The 6/13/24 admission pain assessment revealed the resident reported her pain was a 5 on a scale of 1 to 10. Her pain level, based on a verbal scale, was moderate. Her acceptable pain level was a 3 out of 10. She said she had pain in her knees, left arm and shoulders. The assessment documented the pain started years ago and the pain was constant and sharp. Voltaren gel and Advil helped her pain and movement made her pain worse. The 6/17/24 comprehensive pain assessment revealed the resident's pain, based on a verbal scale, was moderate. She had pain in her abdomen. -The type of pain, effects of pain on the resident's life, aggravating factors, relieving factors and associated symptoms portions of the assessment were not documented. The 7/27/24 comprehensive pain assessment revealed the resident's pain, based on a verbal scale, was moderate. She had pain in her abdomen. -The type of pain, effects of pain on the resident's life, aggravating factors, relieving factors and associated symptoms were marked as unable to determine. The August 2024 CPO revealed the following physician's orders: Voltaren gel 1%. Apply two grams transdermally every six hours as needed for chronic joint pain, ordered 6/13/24. Oxycodone five milligrams (mg). Take one tablet by mouth every four hours as needed for a pain level of 6 to 10 on a scale of 1 to 10, ordered 6/14/24. Tramadol 50 mg. Take one tablet by mouth every six hours as needed for a pain level of 1 to 5 on a scale of 1 to 10, ordered 6/14/24. Evaluate pain every shift and document, ordered 6/13/24. -A review of the resident's August 2024 CPO did not reveal a physician's order for non-pharmacological pain interventions and non-pharmacological interventions were not monitored for effectiveness. On 6/28/24, 6/29/24, 6/30/24, 7/3/24, 7/4/24, 7/5/24, 7/6/24 7/7/24, 7/8/24, nurse progress note revealed the resident had pain. She had a pain level of 2 out of 10 on a scale of 1-10. The location of the pain was generalized. The action taken was repositioning, immobilization of the affected area and pain medication. -A review of the resident's electronic medical record (EMR) did not reveal documentation indicating if the non-pharmacological pain interventions were effective. The 7/10/24 nurse progress note revealed the resident had pain. She reported her pain as a 7 out of 10. The location of the pain was generalized. The action taken was repositioning, immobilization of the affected area and pain medication. -A review of the resident's EMR did not reveal documentation indicating if the non-pharmacological pain interventions were effective. On 7/11/24, 7/12/24, 7/14/24, 7/15/24, 7/16/24, 7/18/24, 7/21/24 the nurse progress notes revealed the resident had pain. She had a pain level of 2 out of 10. The location of the pain was generalized. The action taken was repositioning, immobilization of the affected area and pain medication. -A review of the resident's EMR revealed repositioning and immobilization were not determined as a personalized pain management intervention. -A review of the resident's EMR did not reveal the facility followed up to see if the repositioning and immobilization interventions were effective. -A review of the resident's July 2024 medication administration record (MAR) revealed pain medication was not administered. The narcotic log book was reviewed on 7/31/24. Oxycodone and tramadol were not administered in July 2024. -However, the nursing progress notes indicated pain medication was administered (see above). II. Staff interviews Certified nurse aide (CNA) #5 was interviewed on 8/1/24 at 10:40 a.m. CNA #5 said if a resident reported they were in pain, she would ask them what their pain was based on a scale of 1 to 10. CNA #5 said she told the nurse and then the nurse told her what the nurse planned to do. CNA #5 said she told the resident what the nurse's plan was to alleviate the pain. CNA #5 said she provided non-pharmacological interventions if the resident could not have pain medication. CNA #5 said the nurse told her what pain relieving interventions to provide for the resident. CNA #5 said Resident #32's pain plan was not documented. CNA #5 was familiar with Resident #32. She said the resident did not have pain at the moment. CNA #5 said the resident sometimes refused pain medication and the family representative, who was frequently present, helped encourage the resident to take the pain medication. Licensed practical nurse (LPN) #1 was interviewed on 8/1/24 at 9:26 a.m. LPN #1 said she completed pain assessments for residents at admission, during shift change and during medication pass. LPN #1 said she asked the resident where the pain was located, what the level of pain was, if it was acute or chronic pain and what helped the resident's pain improve. Registered nurse (RN) #1 was interviewed on 8/1/24 at 10:32 a.m. RN #1 said a pain assessment was completed every morning during medication pass and as needed throughout the day. She said the residents who had chronic pain told her when they had pain. RN #1 said a pain assessment was completed at admission. She said the pain assessment included what an acceptable pain level was for the resident, where the pain was located and what medication and non-medication interventions relieved the pain. RN #1 said if the resident reported they only wanted pain medications, she documented that in the assessment. RN #1 said she encouraged the residents to use non-pharmacological interventions, such as ice and elevation. RN #1 said typical interventions included ice, elevating, resting and limiting movement. She said she knew if pain medication or non-pharmacological interventions were effective because she followed up with the resident an hour after the medication was administered or an intervention was offered. She said she documented the effectiveness in the progress note. RN #1 said Resident #32 had generalized pain. RN #1 said Resident #32 had pain in her neck, chest and back. RN #1 said the resident used to have little to no pain. She said since the resident received a skin tear on 7/27/24, she had pain more frequently. RN #1 said Advil and tramadol helped the resident when she had pain. She said a calm, quiet and dark environment helped her. The director of nursing (DON) was interviewed on 8/1/24 at 11:01 a.m. The DON said a pain assessment was completed at admission, every seven days and quarterly. The DON said the pain assessment covered the resident's pain level and if the pain was managed. She said non-pharmacological interventions were not personalized to the resident. The DON said the pain assessments were documented in a progress notes. The DON said if the assessment sections were marked as unable to determine, it meant the resident was unable to answer because they were confused. -However, Resident #32 was cognitively intact and was able to answer questions regarding her pain The DON was not aware Resident #32's assessments were marked as unable to determine because the resident was able to answer the questions. The DON said she did not know why the pain assessments revealed the resident had pain in her abdomen. The DON said she was not aware the nurse progress notes documented the resident was administered pain medication but the MAR showed no pain medication was administered. The DON said Resident #32's care plan should have included monitoring if the resident's non-pharmacological interventions were effective and indication that the resident would refuse pain medication. IV. Facility follow up The DON provided the following information on 8/2/24 at approximately 1:54 p.m. (after the survey): Resident #32 had a comprehensive pain evaluation every seven days per protocol. The DON said the pain evaluation addressed the location of pain, if the pain was tolerable and if the pain impacted her day-to-day activities. The 8/1/24 nurse progress note revealed the resident said her pain level was a four. The resident said once pain medication was administered, the pain level decreased. The resident had tramadol available as needed. Non-pharmacological interventions were discussed. The resident said she usually dealt with it or took Advil. The resident was asked if repositioning, distraction, music, or cold helped the pain. The resident said the cold made it worse for her and repositioning did not help. -However, the facility did not update the resident's EMR to identify Advil was an effective intervention for the resident. -The facility did not update the pain assessment to demonstrate the resident was able to answer questions in the pain assessment, specifically the quality of pain, effects of pain on the resident's life, aggravating factors, relieving factors and associated symptoms. -The facility did not update the resident's EMR to monitor if non-pharmacological interventions were offered and if the interventions were effective.

Based on observations, record review and interviews, the facility failed to ensure residents were provided an environment as free of accident hazards as possible for one (#32) of two residents reviewed for accidents and hazards out of 40 sample residents. Specifically, the facility failed to: -Ensure a thorough investigation was conducted after a skin tear was acquired during a staff-assisted transfer for Resident #32; and, -Identify the root cause of Resident #32's skin tear. Findings include: I. Resident #32 A. Resident status Resident #32, age 83, was admitted on [DATE]. According to the August 2024 computerized physician orders (CPO), diagnoses included type 2 diabetes, interstitial pulmonary disease (lung disorder), heart failure, atrial fibrillation, morbid obesity and unsteadiness on her feet. The 6/19/24 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. She required substantial assistance for toileting. She was dependent on staff for showering, dressing and transfers. She required supervision for oral hygiene and personal hygiene. B. Resident interview and observation Resident #32 and the resident's representative were interviewed together on 7/29/24 at 2:28 p.m. Resident #32 said the certified nurse aide (CNA) went too fast during her toileting care on 7/27/24 during the day shift. She said the CNA brought the walker to her while she was seated on the toilet. Resident #32 said she used the walker to transfer from the toilet to her wheelchair. She said the CNA went too fast when she placed the walker in front of her and caused a skin tear on her left shin. Resident #32 said the day shift nurse put a bandaid on the skin tear. She said the skin tear bled through the bandaid. She said she did not have proper skin care until the night shift nurse arrived. She said it was important to her to have good skin care because she had edema in both of her lower extremities. Resident #32 said her doctor told her that her skin was very fragile and she needed to be careful because it was easy to tear her skin. During the interview, Resident #32's left lower leg was observed with a white bandage which was loosely wrapped around the resident's left shin. She had swelling in both of her lower extremities and her legs were dry. C. Skin tear observation On 7/31/24 at 12:07 p.m., wound care of the skin tear was observed. Resident #32 had an L-shaped skin tear on her left lower extremity that was approximately four and a half centimeters (cm) by one cm. The skin tear was on the upper left side of her left shin. D. Record review Resident #32's skin breakdown care plan, revised 6/14/24, revealed the resident had the potential for skin breakdown related to impaired mobility secondary to weakness and debility. Interventions included applying moisturizer to the skin and performing a Braden Scale assessment (a tool used to predict the risk of developing pressure injuries) every week and as needed. Resident #32's edema care plan, revised 7/31/24 (during the survey), revealed the resident was at risk for skin injury due to edema of bilateral lower extremities. Interventions included administering medications per physician's orders, elevating the resident's legs as tolerated, monitoring weight and monitoring for signs and symptoms of fluid overload as needed. Resident #32's skin tear care plan, revised 7/30/24 (during the survey), revealed the resident had a skin tear to the left lower extremity related to assistive device use. Interventions included encouraging good nutrition and hydration, identifying potential causative factors if skin tears occurred, using caution during transfers and bed mobility to prevent striking arms, legs and hands against any sharp and hard surface, placing tennis balls on the resident's walker, treating the skin tear per facility protocol and notifying the physician. The 7/27/24 nurse progress note revealed Resident #32 sustained a skin tear during the day shift on her left lower extremity. The wound was oozing and bleeding. The note documented the wound was cleaned with normal saline, covered with an ABD (abdominal) pad and wrapped with Kerlix (gauze) until the wound nurse was able to put new orders in. The wound nurse was messaged. The 7/28/24 nurse progress note revealed an as needed wound care was provided at the resident's request for a saturated dressing. -A review of the resident's electronic medical record (EMR) revealed there was no documentation by the day shift nurse on 7/27/24 that described how the skin tear occurred, skin assessment, pain assessment, who was notified and what orders were obtained for treatment of the skin tear. -There were no new care plan interventions added to prevent further skin tears for the resident until 7/30/24 (during the survey). The August 2024 CPO revealed the following physician's order: Wound care, cleanse the open area to left lower extremity with normal saline or wound cleanser, pat dry, apply xeroform (a moist wound dressing) to open area, cover with ABD pad, wrap with kerlix daily and as needed, ordered 7/28/24. II. Staff interviews Certified nurse aide (CNA) #5 was interviewed on 8/1/24 at 10:40 a.m. CNA #5 said she knew if a resident required assistance with toileting based on the shift change report, information on the vital signs sheet and on the white board in the resident's room. She knew if a resident needed one or two-person assistance based on the white board and she asked the resident. She said she knew if assistive devices were required with toileting based on the white board and vital signs sheet. CNA #5 said if she noticed a skin injury during toileting care, she finished the care then told the nurse about the skin tear. She said skin injuries included bed sores, weeping of skin, bruises and skin tears. She said she was familiar with Resident #32. CNA #5 said the resident required two-person assistance with toileting. CNA #5 said one person helped the resident stand while the other staff member provided toileting care. She said she saw the bandage on Resident #32's shin but the resident did not tell her what happened. CNA #5 said she was not told what happened to her shin. After the interview, the vital signs sheet was reviewed with CNA #5. The vitals signs sheet document revealed Resident #32 required an extensive two-person assist. Licensed practical nurse (LPN) #1 was interviewed on 8/1/24 at 9:26 a.m. LPN #1 said the CNAs knew if a resident required assistance with toileting based on the report from the hospital when they were admitted . She said the hospital report usually had a physical therapy (PT) and occupational therapy (OT) evaluation. She said the PT/OT evaluation said if assistance was needed and how much assistance. LPN #1 said if there was not an evaluation, she did two-person assistance until the facility's therapists completed an evaluation. LPN #1 said the CNAs asked the nurses if a resident required assistance with personal care. LPN #1 said skin tears happened because accidents happen. She said if a skin injury happened, she called the doctor to obtain an order, referred to the skin protocol and started the risk management module. LPN #1 said the risk management module for a skin tear included a section that described what happened, who was contacted and if physician's orders were obtained. Registered nurse (RN) #1 was interviewed on 7/31/24 at 3:18 p.m. RN #1 said if she noticed a new skin injury, she told the wound nurse. RN #1 said she worked the night after the skin tear occurred for Resident #32. She said she went to the resident's room and saw the skin tear weeping. She said she used her nurse's judgment to clean the wound. She said did not notice a bandaid on the skin tear. RN #1 said Resident #32 told her the skin tear happened when the day shift CNA helped her transfer from the toilet to the wheelchair. RN #1 said the resident told her the day shift nurse placed a band aid on the wound. RN #1 said she did not notify the physician, obtain wound care orders or complete a head to toe assessment. RN #1 said the skin tear happened during the day shift so the day shift nurse was responsible for notifying the physician and obtaining wound care orders. RN #1 said she documented what she did as a progress note in the resident's chart. -However, Resident #32 told RN #1 how she obtained the skin tear and there were no additional measures put in place to prevent the skin tear from occurring again The nursing home administrator (NHA) was interviewed on 7/30/24 at 1:43 p.m. The NHA said the nurse who worked the day shift did not complete an incident report on the day of the incident. The NHA said the nurse was coming in to complete the incident report when he returned from vacation. The NHA said an investigation regarding the skin tear was underway (during the survey) to determine what happened with the resident. The NHA said a request was made to nursing services for what immediate interventions were put in place to prevent the skin tear from occurring again. The director of nursing (DON) and the assistant director of nursing (ADON) were interviewed together on 7/31/24 at 9:44 a.m. The DON reviewed the incident report for Resident #32's skin tear. The DON said the incident revealed the root cause was the walker hit the resident's shin and caused a skin tear. The DON said the intervention was to complete wound care and individual staff education. The DON said the intervention put in place was for wound care but an immediate intervention to prevent the skin tear from occurring again was not completed. The resident's care plan was reviewed with the DON. The DON said the care plan was updated for wound care but the care plan was not updated to include interventions to prevent the skin tear from occurring again. The DON was interviewed again on 7/31/24 at 3:47 p.m. The DON said when the staff noticed a new skin injury,the nurse needed to notify the physician and the resident's representative The DON said the staff needed to notify the DON for risk management to be completed and obtain wound care orders from the physician. The DON said the nurse should add interventions, monitor for signs and symptoms of infection and complete a head to toe assessment, including the actual injury site. The DON said the nurse told the wound nurse about the wound so the wound nurse could determine if she needed to follow the resident's wound. The DON said the nurse documented the skin injury when the risk management module was triggered. The DON said the risk management module was not part of the resident's EMR. She said the risk management module had a section where the nurse was supposed to describe what occurred. She said this section was transferred to the resident's EMR as a progress note. The DON said the 7/27/24 skin tear was not investigated until 7/30/24 (during the survey). The DON said the investigation did not start because the nurse was on vacation and the DON wanted the nurse to complete the investigation report. The DON said she did not identify the skin tear as an accident. The DON was interviewed again on 8/1/24 at 11:01 a.m. The DON said the CNAs knew a resident required assistance with toileting, assistive devices and the type of assistance based on the Kardex (an abbreviated care plan for staff), tasks and the white board in the resident's room. The DON said if a CNA noticed a skin injury they told the nurse. She said Resident #32 required one-person assistance. The DON said the CNAs might have said the resident required two-person assistance because the CNAs preferred the additional assistance. The DON said Resident #32's skin tear happened because the skids on her walker's legs tore the resident's skin on her shin. The DON said she did not interview the nurse or the CNA because the nurse was on vacation and the CNA was not scheduled to work until 8/2/24. The DON said she did not interview any other staff or other residents. The DON said the ADON interviewed the resident. III. Facility follow up The DON provided the following information on 8/2/24. Resident #32 obtained a skin tear on 7/27/24 during a transfer. The CNA moved the walker in front of the resident and hit her left lower extremity, causing the skin tear. The CNA immediately reported the incident to the nurse on duty who assessed the injury and notified the provider. The provider gave verbal orders to cleanse and place a bandage, which the nurse did. The skin tear was passed on in the report so the night shift nurse contacted the wound nurse who collaborated with the provider for the new order due to increased drainage. The day shift nurse performed the original assessment and treatment. The nurse progress note revealed on 7/27/24, the CNA reported a small skin tear on the resident's leg during a transfer. The provider and family were notified. A physician's order was obtained to cleanse and cover the skin tear with a bandage. Treatment was performed and the wound care nurse was notified. The resident denied pain. On 8/2/24, on the spot training and education for safe transfers with a walker was completed with the staff involved in the incident on 7/27/24.

Based on observations, interviews, and record review the facility failed to ensure menus were followed to meet the nutritional needs of residents. Specifically the facility failed to follow the menu, menu items were omitted without substitutions being made of the same nutritional value, and did not follow extensions for the pureed and mechanical soft diets. Findings include: I. Menu items were omitted for residents during the survey. Evening meal 1/5/22 -Regular diet: The menu called for eight ounces of 2% milk to be served. Observations at 4:00 p.m., in the kitchen revealed residents were not served or offered milk or a milk substitute. Observations at 4:45 p.m., on the 200 and 300 hall revealed residents were not served or offered milk or a milk substitute when served meal room trays. Noon meal 1/6/22 -Regular diet: The menu called for eight ounces of 2% milk to be served. Observations at 11:00 a.m., in the kitchen revealed the residents were not served or offered milk or a milk substitute. II. Food extensions for pureed and mechanical soft diet Evening meal 1/5/22 -Puree diet: The menu called for a chocolate chip cookie to be pureed and served. -Mechanical soft diet: The menu called for a soft, moist chocolate chip cookie to be served. Observations at 4:00 p.m., in the kitchen revealed residents were served chocolate pudding cups on a pureed diet and mechanical soft diet in place of the chocolate chip cookie on the menu. Noon meal 1/6/22 -Puree diet: The menu called for four ounces of rice pureed to be served or four ounces of buttered noodles pureed for the alternate meal. Observations at 11:00 a.m., in the kitchen revealed the residents were served mashed potatoes on a pureed diet in place of the rice or buttered noodles on the menu. III. Interviews The dietary aide (DA) #1 was interviewed on 1/6/22 at 11:00 a.m. She said the residents were provided a meal ticket every Monday, Wednesday and Friday to choose their meals for the upcoming days. She said each resident filled out their own meal ticket unless they needed help from nursing. She said milk was on the meal ticket as a beverage option for residents to choose from, but it was not served as part of the meal. She said most of the residents did not choose milk for a beverage and preferred juice, soda or water. The dietary manager (DM) was interviewed on 1/6/22 at 11:10 a.m. He said milk was offered as a beverage on the meal ticket. He said it was listed on the menu as part of the meal, however, not every resident chose milk to drink. He said the pureed dessert offered for the evening meal on 1/5/22 was chocolate pudding. He said the menu called for the chocolate chip cookie to be pureed, however, he did not have success in the past pureeing a cookie so he served pudding instead. He said the menu for noon meal on 1/6/22 called for rice or buttered noodles to be pureed, however, he did not have success in the past pureeing rice and chose to serve mashed potatoes instead of what was on the menu. He said he did not have a recipe for pureed extensions and would use the liquid from the meal to add flavor to the puree. He said the puree should have a smoothie consistency. The registered dietitian (RD) was interviewed on 1/6/22 at 1:03 p.m. She said a corporate RD approved the menus and that the milk was part of the calorie count. She said that everything on the menu needed to be served. She said if a resident did not want milk then an alternative needed to be served to replace the calorie count. She said there were recipes for all regular food, however, she was not aware of recipes for the pureed foods. She said the corporate office was rolling out a new dietary program that would provide recipes for all food and would include posters on how to prepare the food extensions. She said the dietary cook should follow the menu and prepare what was listed for each meal. She said substituting mashed potatoes for the menu items could be repetitive and may not have the same nutritional value. She said having recipes for pureed and mechanical soft foods would help the dietary cooks prepare what was on the menu.

Based on observations, record review and interviews, the facility failed to follow infection prevention and control procedures during resident care. Specifically, the facility failed to: -Perform hand hygiene before entering or after leaving resident's rooms and in between tasks; -Perform hand hygiene for residents before meals; and, -Disinfect equipment in between resident use; Findings include: I. Facility policy and procedure The policy and procedure titled Infection prevention, control & immunizations, dated 5/15/2020, revised on 2/8/21, read in pertinent part, 2. Staff will use standard precautions (hand hygiene and appropriate PPE (personal protective equipment). 3. Staff will follow appropriate hand hygiene practice 6. Staff will wash hands and perform hand hygiene even when gloves are used in the following situations: Before and after patient contact, after contact with blood, body fluid, or visibly contaminated or other objects or surfaces in patient's environment, after performing procedures and removing PPE and catheter care (PICC (peripherally inserted central catheter) line, CVC (central venous catheters) / dressing care). II. Lack of handwashing A. Facility policy and procedure The policy and procedure titled Infection prevention, control & immunizations, dated 5/15/2020, revised on 2/8/21, was received by the director of nurses on 1/5/22, read in pertinent part, 2. Staff will use standard precautions (hand hygiene and appropriate PPE (personal protective equipment). 3. Staff will follow appropriate hand hygiene practice 6. Staff will wash hands and perform hand hygiene even when gloves are used in the following situations: Before and after patient contact, after contact with blood, body fluid, or visibly contaminated or other objects or surfaces in patient's environment, after performing procedures and removing PPE and catheter care (PICC (peripherally inserted central catheter) line, CVC (central venous catheters) / dressing care). B. Professional reference The Centers for Disease Control (CDC) Hand Hygiene Guidance updated 1/30/2020, retrieved on 1/13/22 from: https://www.cdc.gov/handhygiene/providers/guideline.html, revealed in part, Healthcare personnel should use an alcohol-based hand rub or wash with soap and water for the following clinical indications: Immediately before touching a patient Before performing an aseptic task (e.g., placing an indwelling device) or handling invasive medical devices Before moving from work on a soiled body site to a clean body site on the same patient After touching a patient or the patient's immediate environment After contact with blood, body fluids, or contaminated surfaces Immediately after glove removal The Centers for Disease Control (CDC) Hand Hygiene updated 5/17/2020, retrieved on 12/19/21 from: https://www.cdc.gov/coronavirus/2019-ncov/hcp/hand-hygiene.html, revealed in part, Hand hygiene is an important part of the U.S. response to the international emergence of COVID-19. Practicing hand hygiene, which includes the use of alcohol-based hand rub (ABHR) or handwashing, is a simple yet effective way to prevent the spread of pathogens and infections in healthcare settings. CDC recommendations reflect this important role. The exact contribution of hand hygiene to the reduction of direct and indirect spread of coronaviruses between people is currently unknown. However, hand washing mechanically removes pathogens, and laboratory data demonstrate that ABHR formulations in the range of alcohol concentrations recommended by CDC, inactivate [CONDITION(S)]-CoV-2. ABHR effectively reduces the number of pathogens that may be present on the hands of healthcare providers after brief interactions with patients or the care environment. The CDC recommends using ABHR with greater than 60% [MEDICATION(S)] or 70% [MEDICATION(S)] in healthcare settings. Unless hands are visibly soiled, an alcohol-based hand rub is preferred over soap and water in most clinical situations due to evidence of better compliance compared to soap and water. Hand rubs are generally less irritating to hands and are effective in the absence of a sink. 1. Observations During the observation on 1/5/22 at 10:00 a.m., certified nursing aide (CNA) #3 entered room [ROOM NUMBER] adjusted Resident #55's nasal cannula. CNA #3 came out of the room without hand hygiene, adjusted her face mask and sat down at the charting station. CNA #3 went through the purse then put it back on the charting station, and started typing on the computer. At 10:10 a.m., noted CNA #3 mask fell below her nose, she adjusted the mask back to the correct position. At 10:11 a.m., CNA #3 went to room [ROOM NUMBER] and did not sanitize or wash her hands prior to entering the room. At 11:08 a.m., CNA # 3 assisted the resident out of room [ROOM NUMBER] and returned to the room for cleaning. She put on a pair of gloves and started cleaning the bed. There was no hand hygiene after assisting the resident out of the room and prior to putting on the gloves. CNA #3 came out of room [ROOM NUMBER] and went to the linen closet to take clean linen with gloves on. At 11:10 a.m., CNA #3 went to room [ROOM NUMBER] while holding clean linen in her gloved hand. She talked to an unidentified nurse then returned to room [ROOM NUMBER]. CNA #3 then started placing a clean sheet over the bed and removed the soiled sheet out of the room and, placed the soiled bed sheet into the linen bin outside of the room by the trash bin. She returned to the room to continue adjusting the clean bed sheet. CNA #3 did not perform hand hygiene or change gloves in between changing sheets or after placing used sheet into the linen bin. -At 11:14 a.m., CNA #3 removed gloves in the room and came out to the charting station. She took the clip board for review then went back into room [ROOM NUMBER] without hand hygiene. CNA#3 took a pair of gloves out from the scrub pocket and donned gloves, she then put a blue blanket over the bed and continue cleaning the room. -At 11:19 a.m., CNA #3 removed gloves in the room and came out with a trash bag in her hand. She discarded the trash bag into the trash bin outside of the room. CNA #3 did not perform hand hygiene after leaving room [ROOM NUMBER] or after discarding the trash bag. -At 11:37 a.m., CNA # 3 returned to the station with a key in her hand. She placed the key in the bag and entered room [ROOM NUMBER] without hand hygiene prior to entering. CNA # 3 left the room at 11:48 a.m. and did not perform hand hygiene after leaving the room. C. Interview The assistant director of inures, and the director of inures were interviewed on 1/5/22 at 2:21 p.m. The ADON said staff were to perform hand hygiene prior to entering a room, after leaving a room, and between tasks. The ADON said hand hygiene training had been provided to all staff. She said she would continue to provide education. 2. Hand hygeine offered to residents A. Observations Second floor At 12:18pm, CNA #5 started passing lunch trays. CNA #5 delivered a tray to room [ROOM NUMBER] and placed the tray on the bedside table. She adjusted the table placement for the resident. CNA #5 did not assist the resident with hand hygiene prior to the resident started eating. CNA #5 came out of the room to deliver another tray to room [ROOM NUMBER]. CNA #5 did not perform hand hygiene after leaving room [ROOM NUMBER] nor prior to taking another lunch tray from the cart and entered room [ROOM NUMBER]. She failed to offer hand hygeine to the resident. On 1/5/22 at 12:28 p.m., meal trays were passed to residents without offering resident's hand hygiene and without staff sanitizing hands between residents. Observations were as follows: An unidentified certified nurse aide (CNA) was observed to deliver a meal tray to the resident in room [ROOM NUMBER]. The resident was not offered hand hygiene. The CNA failed to sanitize her hands prior to entering the room or after exiting the room. The CNA then entered room [ROOM NUMBER] The resident was not offered hand hygiene. The CNA did not sanitize her hands prior to entering the room or after exiting the room. The CNA then entered room [ROOM NUMBER] to deliver the meal tray. The meal tray was left next to the resident who was sleeping. The Unidentified CNA) did not sanitize her when she left the room. A meal tray delivered to room [ROOM NUMBER]. The CNA did not offer hand hygiene to the resident. She also failed to sanitize her hands prior to entering the room or after exiting the room. B. Interview The assistant director of inures, and the director of inures were interviewed on 1/5/22 at 2:21 p.m. The ADON said staff had been trained on assisting residents to wash their hands prior to eating their meal. She said hand sanitizer or hand wipes could be used. She said that it was constant reminders to staff to encourage hand hygeine. III. Cleaning equipment A. Facility policy The policy and procedure titled Medical devices/ equipment - disinfection, dated 3/27/2020, revised on 2/8/21, read in pertinent part, The Centers will follow CDC (Centers for disease control and prevention) guidelines for disinfection of medical devices/ equipment . All non - dedicated, non-disposable medical equipment used for patient care is cleaned and disinfected with EPA (environmental protection agency) approved product/CDC guidelines & recommendations. B. Observations On 1/5/22 at 11:50 a.m., CNA #3 wheeled a resident into room [ROOM NUMBER]. She then brought a weighing chair into room [ROOM NUMBER]. She did not perform hand hygiene or disinfected the portable scale prior to weighing the resident. CNA # 4 was assisting CNA #3 with documentation of weight and vital signs. After CNA #3 took resident's vitals and oxygen level, she handed the thermometer, blood pressure cuff and pulse oximeter to CNA #4. CNA #4 placed the equipment into the bag that she wore across her body. Both CNAs did not disinfect the equipment after use prior to storage. On 1/5/22 at 11:59 a.m., CNA # 5 came in and took the portable scale to weigh another resident in room [ROOM NUMBER]. CNA #5 did not disinfect the weighing chair after taking the chair into room #W221. At 12:06 p.m., CNA #5 and CNA #2 transferred resident from the wheel chair to the weighing chair. The portable scale was not disinfected after use. On 1/6/22 at 3:15 p.m., LPN #6 was handed a pulse oximeter by CNA #7. CNA #7 was observed to take the personal pulse oximeter out of his personal backpack. LPN #6 then proceeded to check the pulse oximeter for Resident #49. She failed to clean it prior to placing it on her finger. When finished, LPN #6 handed it directly back to CNA #7. and CNA #7 was observed placing the pulse oximeter back into a personal backpack without it being sanitized. C. Interview The assistant director of inures, and the director of inures were interviewed on 1/5/22 at 2:21 p.m. The ADON said all equipment needed to be disinfected prior to being used on another residnet. She said it also needed to be disinfected prior to being stored. The staff were provided with disinfecting wipes which were available thoughout the facility. She said she would provide more education on the importance of cleaning the equipment.

Based on observations and interviews, the facility failed to follow the infection control measures to prevent the potential cross contamination of [CONDITION(S)]-CoV-2 COVID-19, during testing procedures on visitors and staff. Specifically, the front desk staff failed to wear proper personal protective equipment (PPE), a protective gown, gloves and N95 mask, consistently when collecting [CONDITION(S)]-CoV-2 COVID-19 specimens from visitors and staff. Findings include: I. Professional reference According to the CDC guidance, Guidance for [CONDITION(S)]-CoV-2 Point-of-Care and Rapid Testing, updated 12/13/21, available from: https://www.cdc.gov/coronavirus/2019-ncov/lab/point-of-care-testing.html#print, accessed on 1/11/22. It read in pertinent part: Rapid point-of-care tests provide results within minutes (depending on the test) and are used to diagnose current or detect past [CONDITION(S)]-CoV-2 infections in various settings, such as: Long-term care facilities and nursing homes. Specimen Collection & Handling of Point-of-Care and Rapid Tests -Proper specimen collection and handling are critical for all COVID-19 testing. For personnel collecting specimens or working within six feet of patients suspected to be infected with [CONDITION(S)]-CoV-2, maintain proper infection control and use recommended personal protective equipment (PPE), which could include an N95 or higher-level respirator (or face mask if a respirator is not available), eye protection, gloves, and a lab coat or gown. II. Facility policy The Center COVID-19 vaccination, exemption and testing policy issued on 9/23/21, provided by the director of nursing (DON) on 1/5/22 at 2:15 p.m., read in pertinent part: All employees, direct contractors and support staff will be required to daily screening upon entering the facility and prior to start of shift. Employees, direct contractors, and support staff who are granted exemptions, but are still working in the facility, will be required to submit to rapid testing prior to every shift and COVID 19 PCR testing 2x (twice) per week. The exemption and testing policy did not provide protocol on how to protect patients and staff during specimen collection and handling of point of care and rapid tests. III. Observations and interviews The receptionist (RCT) was observed on 1/5/22 at 10:47 a.m. She collected a [CONDITION(S)]-CoV-2 rapid test specimen from two visitors entering the building. The RCT wore a surgical mask. She handed the visitors each a swab and placed the collected specimen swabs into the testing card after the visitors self-swabbed. Both visitors stood in the front entrance next to the front desk while they swabbed their nose. The visitors were approximately one to two feet away from the RCT when they self-swabbed The RCT did not wear gloves, a face shield or gown during the rapid testing process. The two visitors wore a surgical mask and sat in the lobby while they waited for the rapid test results. The RCT placed the collected specimens on her desk and set a timer for ten minutes while the tests were processed. During the specimen processing, other visitors and staff entered the building and were screened while the collected specimens sat in the front desk. The tested visitors sat in the lobby while their specimens were processed. Once the tests were processed the RCT discarded the tests in the lobby trash can. The testing was not done in a secured room away from other visitors, staff or residents. During the observation three visitors were provided a rapid test in the lobby area. Proper personal protective equipment (PPE) was not worn by the RCT during the testing process. The RCT was interviewed on 1/5/22 at 11:15 a.m. She said the front desk staff assisted with COVID-19 rapid testing. She said she wore a surgical mask when she assisted with the screening process and testing process. She said all visitors regardless of vaccination status were encouraged to take a rapid test before entering the resident's room. She said all unvaccinated staff are required to take a rapid test prior to working. All staff and visitors are provided a wristband after screening to verify they have completed the screening process before entering the building. She said she would separate visitors in the lobby area if they were not together and try to have them wait 6 feet apart while their rapid test was processed. She said she always wore a surgical mask, but did not always wear a face shield. She said she did not wear gloves or a gown during the testing process. The director of nursing (DON) was interviewed on 1/5/22 at 2:21 p.m. The DON said they did not have any positive COVID-19 cases in the building and did not know the current rapid testing process was out of compliance. She said the visitors and staff tested themselves. She said the RCT did handle the specimen after the visitor or staff member swabbed themselves and agreed the RCT should wear proper PPE during the testing process. She said they would change their current rapid testing process and remove it from the lobby front desk area. She said they would move testing to an office at the front lobby area to provide an enclosed self-testing area for staff and visitors. She said all staff should be wearing N95 masks and face shields when assisting in the rapid testing and specimen collection process.

Based on observations, record review and interviews, the facility failed to ensure effective fall interventions were in place to prevent resident falls for two (#9 and #7) of four residents reviewed for falls out of 23 sample residents. Record review and interview revealed the facility failed to effectively and consistently investigate the cause of falls, develop and implement sufficient care plan interventions to ensure the residents were provided appropriately assessed levels of supervision as recommended by the IDT to prevent falls and fall related injuries. Resident #9 was admitted on [DATE] from the hospital. The hospital assessed the resident to be confused, hard of hearing and at risk for falls. The resident had two falls with injuries within one month of admission. On 9/15/2020, she sustained a major injury related to one of the falls. The fall resulted in the resident needing to be assessed and treated in an emergency room . The facility failed to reassess the effectiveness of care planned interventions and implement sufficient interventions to prevent the resident from a repeat fall while in the care of the facility. On 9/1/2020, the resident fell and sustained an abrasion to the left scapula (back). The details and outcome of the fall were unclear because the facility did not complete a post-fall investigation form or provide a thorough fall investigation report. On 9/15/2020, the resident fell a second time in the care of the facility and sustained a skin tear to the right wrist and a laceration to the head requiring hospital care and treatment with staple sutures application. The facility failed to reassess, develop, and implement care-planned interventions to effectively prevent the resident from falling and to prevent a fall related major injury. Resident #7 was admitted on [DATE] from the hospital. The hospital assessed the resident to have had an altered mental status with a [DIAGNOSES REDACTED]. The resident had four falls over the course of two months; on 10/16/2020 his fall resulted in a concussion which required assessment and treatment in the emergency room . The facility failed to reassess the effectiveness of care planned interventions and implement sufficient interventions to prevent the resident from repeated unwitnessed falls and a fall resulting in an injury, while in the care of the facility. On 8/24/2020 the resident became restless and fell at the bedside. On 9/9/2020 the resident fell at bedside. On 10/6/2020 the resident fell a third time at meal time and sustained an abrasion to scalp. On 10/16/2020 the resident fell a fourth time and sustained an abrasion to the top of his scalp at the right side of forehead. The resident was assessed to have increased confusion following the fall. The details and effectiveness of interventions were unknown because the facility did not complete a post fall investigation of the fall. Hospital discharge records confirmed the resident sustained [REDACTED]. The facility failed to fully investigate each fall; reassess the effectiveness of the interventions; develop appropriate interventions; and implement an effective plan to prevent falls and fall related injury, as outlined in the facility fall prevention program. The facility failed to report a [MEDICAL CONDITION] (concussion) to the State Agency reporting line per regulation. Findings include: I. Facility policies and procedures The Fall Prevention policy, dated 10/1/18, was provided by the director of nursing (DON) on 10/26/2020 at 11:55 a.m. The policy read in pertinent part: Falls in the skilled nursing setting represent one of the most potentially devastating occurrences that can negatively impact a patient's recovery .It is because of these unfortunate events that the facility implemented a comprehensive program to prevent falls and injury. Any patient deemed to be high risk by nursing and/or therapy staff will have the following interventions implemented immediately or at least considered: -Thorough Physical and Occupational therapy evaluation; -Low bed (or lower our standard bed to its lowest position); -Day time sitter (family member can fill this role); -Routine toileting schedule every two (2) hours; -When not with a sitter increase time spent in common area in line of sight of nursing staff; -Consultant Pharmacist to review medications, labs, considers blood tests and review history; -Consider enrolling patient into restorative dining; -Encourage patient to participate in monitored activities; and, -Move the patient to a room closer to the nurse's station if indicated. A Registered Nurse will assess patient post-fall and document. The DON/designee will complete a follow up investigation and will review findings with the IDT members to determine an appropriate intervention. Patient's care plan will be updated accordingly. The Fall Prevention Program policy, dated 11/1/17, was provided by the DON on 10/26/2020 at 11:55 a.m. The policy read in pertinent part: The fall program will consist of: -Rounding frequently throughout the shift will be tasked. CNAs will ask the four (4) P's: Does the patient have to go to the bathroom? Does the patient need to be repositioned? Are all common used belongings within reach of patients? Is the patient having pain? -All patients on the fall program should be reviewed weekly and taken off of the program as necessary. Neither policy was documented as being reviewed annually (in the past 12 months). II. Resident #9 A. Resident status Resident #9, over the age of 65, admitted on [DATE]. According to the October 2020 computerized physician's orders [REDACTED]. The 9/4/2020 minimum data set (MDS) assessment revealed the resident's hearing was severely impaired, vision was adequate, and she had the ability to express ideas and wants, and understood others in communication. The resident had moderately impaired cognition with a brief interview for mental status (BIMS) score of 12 out of 15. She required extensive physical assistance from two staff with transfers, toileting, bed mobility, and dressing walking in the room and with locomotion on and off the unit. She was not able to stand from a seated position, transfer from surface to surface, walk short distances, or turn around while walking without the use of a walker and assistance from staff. The resident was on daily antidepressants, anticoagulants, antibiotics, diuretics, and opioids. She refused care regularly and had had one fall with injury in the facility at the time of assessment. -The resident last received physical and occupational therapy on 9/3/2020 and was not on a restorative nursing program. B. Resident observations Resident #9 was unable to participate in an interview. On 10/20/2020 at 10:02 a.m. Resident #9 was observed lying in bed. Her bed was up at mid level position and not in the lowest possible position. She was looking for her bed controller and was trying to get up to find it. She was very hard of hearing and kept saying I just need the controller. She could not recall falling earlier in her stay. C. Record review Verbal order given on 8/25/2020 patient is hospice with center care hospice. The resident's comprehensive care plan dated 8/18/2020 revealed the following care focus needs: Falls risk: I have a risk for falls related to: weakness, stutter steps with ambulation, impaired balance/mobility, impaired cognition, medication side effects, history of falling; initiated: 8/18/2020. This care focus was revised on 9/16/2020 to include fall events: 9/1/2020 resident had a fall with abrasion to left scapula/back and 9/15/2020 resident had a fall with a laceration to the head and a skin tear the right wrist; sent to emergency room for evaluation and treatment. Goal: I will not have major injuries from a fall; revised on 9/14/2020. Interventions/tasks: -Call light within reach; initiated 8/18/2020. -Ensure environment is free of clutter; initiated 8/26/2020. -Signage to remind the resident to use call light for assistance; initiated 9/16/2020. Their resident's comprehensive care plan failed to incorporate assessed needs and risk as revealed throughout the resident's medical records. There was no revision to the care plan interventions after the first fall and the only intervention to the care plan after the second intervention was to post a sign to remind the resident to use the call light for assistance. The visual bedside kardex report was reviewed on 10/26/2020, it failed to document the resident was a high risk of falls or provide any related interventions that may prevent future falls care plans. The hospice care plan dated 9/10/2020 read in pertinent part: Safety - Issues: Patient is a fall risk. Goal: Patient will remain free of injury. Interventions under this goal have been coordinated with facility staff. The daily skilled note dated 10/24/2020 revealed the reason for the residents stay was for skilled nursing; pain management; medication management; oxygen therapy; palliative care; safety monitoring and strengthening. A physical therapy evaluation dated 8/18/2020 revealed the resident's risk factors were falls, being hard of hearing, confusion and impaired safety awareness. Fall risk predictors included reduced proactive balance, reduced quad strength, and reduced reactive balance. The resident's comprehensive care plan did not incorporate the physical therapy assessment. An occupational therapy evaluation dated 8/18/2020 revealed the resident's risk factors were due to physical impairments and associated functional deficits, without skilled therapeutic intervention the patient is at risk for falls, decreased ability to return to prior level of assistance and decrease in level of mobility. The resident's comprehensive care plan did not incorporate the physical therapy assessment. D. Falls 1. Nursing progress notes revealed the resident had her first in facility fall on 9/1/2020 at 4:15 a.m. Related progress notes revealed and read in pertinent part: A nursing note revealed resident had a fall on 8/31/2020 at an undocumented time. The note dated (created date) 9/1/2020 at 7:30 a.m., Note text: Late entry effective date: 8/31/2020 at 4:15 a.m. Change of condition: Unwitnessed fall: signs and symptoms: abrasion to left mid-back. Vital signs: temperature 97.6, oxygen situation 90% on room air, respirations 22 breaths per minute, blood pressure 132/83, heart rate 110 beats per minute. Resident response to change: complaints of pain to lower back and mid-back. Physician notification/time/response: nurse practitioner notified on 9/1/2020. Resident's husband was notified of the fall on 9/1/2020 at 7:07 a.m. The post-fall investigation effective date: 9/1/2020 at 4:15 a.m. was only partially completed. Questions to answer regarding the description of fall; injuries sustained from the fall; did the resident hit their head; was the fall witnessed; or were neurological checks initiated per facility protocol were all left blank. Also left blank were questions about: -Resident activity at the time of the fall; location of the fall; equipment used by the resident; -What was the probable cause of fall, based on review and the investigation; -Quality assurance review: Recommendations from review by team (also record in resident medical record); and -Care plan revisions and care plan revision date. The IDT note dated 9/2/2020 read: Resident #9 was found in her room on the floor on 9/1/2020 at 4:14 a.m., after she was self-ambulating without assistance after going to the bathroom. The resident is alert and able to make needs known. The resident is working with therapy. The resident is weight bearing to all extremities. The resident is hard of hearing and has poor safety awareness. Therapy and nursing to continue education with the resident on using call light and locking wheelchair. The resident was encouraged to use the call light for assistance. Abuse and neglect ruled out. The IDT failed to document if they examined the care-planned interventions in place at the time of the fall with the potential interventions that could have been considered, as outlined in the Fall Prevention Policy procedural steps; and document why other interventions were not appropriate or considered. 2. Nursing progress notes revealed the resident had a second fall in the facility on 9/15/2020 at 2:48 p.m. Related progress notes revealed and read in pertinent part: Nursing note dated 9/15/2020 at 1:05 p.m. Note text: Transfer to hospital: Change of condition: unwitnessed fall, sutures need to back of scalp. Interventions attempted: steri-strips applied, kerlix wrapped around head. Injuries included a laceration to the back of the head and a skin tear to the right wrist. Fall progress note dated 9/15/2020 at 9:57 p.m. Note text: Resident is alert and able to voice needs following a fall earlier today. Staple sutures intact to the back of the resident's head. Neurological checks at baseline. No new or delayed injuries observed. The post-fall investigation effective date: 9/15/2020 at 2:46 p.m. revealed in part: Date of current fall: 9/15/2020. Date of last fall in facility: 9/1/2020. Description of fall: This nurse was informed by the physical therapist that she heard a loud noise, when she entered the resident's room the resident was laying on the ground. Upon entering the room, the resident was laying on her back, diagonal to the bed with her feet towards the bed. -The fall was unwitnessed. -The resident was transferred to acute care for a head injury. Injuries included a laceration to the back of the scalp and a skin tear to the right forearm. -The resident did not express pain from the fall and was not medication prior to going to the emergency room . -The probable cause of fall was the resident's impulsiveness, confusion, and weakness. Quality assurance review recommendations: post signs to reinforce call light use. -The care plan was revised on 9/16/2020. emergency room visit report dated 9/15/2020 at 2:13 p.m., revealed the resident's emergency room discharge [DIAGNOSES REDACTED]. Review of the State Agency reporting system revealed the facility failed to report this event to the State reporting line, as required. The IDT note dated 9/15/2020 read: Resident #9 was found in her room on the floor 9/15/2020 at 2:46 p.m. The resident had tried to ambulate to the bathroom without assistance. The resident does have weakness, poor safety awareness, is impulsive, and is confused. The resident was noted with a laceration to the back of her scalp and a skin tear to her right forearm. The resident is currently on hospice care. The resident was transported to the emergency room for evaluation and treatment. The resident returned to the facility with staples sutures. Call light kept within reach. Visual signage to encourage the resident to use call light for assistance. Abuse and neglect ruled out. The IDT failed to add a care plan intervention to address the resident's tendency to get up to the bathroom on her own or examine the care-planned interventions in place at the time of the fall with the potential interventions that could have been considered, as outlined in the Fall Prevention Policy procedural steps. No changes were made to the care plan following this fall in an effort to prevent future fall and fall related injuries. There was no document of why other interventions were not appropriate or considered. III. Resident #7 A. Resident status Resident #7, over the age of 65, admitted on [DATE]. According to the October 2020 computerized physician's orders [REDACTED]. The 8/26/2020 minimum data set (MDS) assessment revealed the resident's hearing was minimally impaired, vision was adequate, and he had the ability to express ideas and wants, and was usually understood and usually understood others in communication. The resident had severely impaired cognition with a brief interview for mental status (BIMS) score of three out of 15. He required extensive physical assistance from two staff with transfers, toileting, bed mobility, and dressing and with locomotion on and off the unit. He was unable to walk and was not able to stand from a seated position, transfer from surface to surface without assistance from staff. The resident was on daily anticoagulants, and opioids. He had had one fall without injury in the facility at the time of assessment. -The resident last received physical and occupational therapy on 8/24/2020 and was not on a restorative nursing program. B. Resident observations Resident #7 was unable to participate in an interview. On 10/20/2020 at 10:45 a.m., Resident #7 was observed sound asleep in bed. He did not wake upon knocking. C. Record review Verbal order given on 9/3/2020 Admit to (name of company) hospice. The resident's comprehensive care plan dated 8/6/2020 revealed the following care focus needs: Falls risk: I have a risk for falls related to: Altered mental status, poor safety awareness, medication side effects, and weakness; initiated: 8/6/2020. -The care plan was revised on 10/9/2020 to include fall history. On 8/21/2020, the resident had an unwitnessed fall with no injuries. On 10/6/2020 the resident had an unwitnessed fall and sustained an abrasion to the scalp. -The resident's fall on 9/8/2020 was not documented. Goal: I will not have major injuries from a fall; revised on 9/10/2020. Interventions/tasks: -Assist patient back to bed after meals; revised on 8/24/2020; -Call light within reach; initiated on 8/6/2020; -Occupational therapy to evaluate and treat, as ordered; initiated 8/6/2020; -Palliative/hospice consult; initiated: 8/24/2020; -Physical therapy to evaluate and treat, as needed; initiated 8/6/2020; -Restorative nursing programs added after fall on 10/6/2020; initiated 10/7/2020. Opioid use: I am taking Opioid medication for pain relief. I had a fall with a fracture. I have chronic pain; initiated 8/21/2020. Interventions/Tasks: Monitor for side effects of dependence, somnolence, nausea, vomiting, constipation, itching, slowed reaction, respiratory depression and addiction; initiated 8/21/2020. Antipsychotic use: I am on [MEDICATION NAME] (antipsychotic medication) related to nausea and vomiting; initiated: 9/10/2020. Goal: I will not have any adverse drug effects; initiated 9/10/2020. Interventions/task: - Administer medications per physician orders; initiated 9/10/2020; -Complete an abnormal involuntary movement scale upon admission and repeat as needed; initiated 9/10/2020; -Monitor, as needed, for fall risk such as unsteady gait, impaired balance, drowsiness, [MEDICAL CONDITIONS], etc.; initiated: 9/10/2020; -Monitor for and report to physician, as needed, any of the following adverse; initiated 9/10/2020; -Pharmacist to review drug regime monthly; initiated: 9/10/2020. A physical therapy evaluation dated 8/6/2020 revealed the resident had poor sitting balance and was unable to balance while standing, he was dependent with transfers and had impaired gross motor coordination. The resident was at risk due to physical impairments and associated functional deficits; without skilled therapeutic intervention, the resident was at risk for further decreased leisure task participation, decreased participation with functional tasks and limited out-of-bed activity. The resident's comprehensive care plan did not incorporate the physical therapy assessment. An occupational therapy evaluation dated 8/6/2020 revealed the resident has poor safety awareness, limited awareness, but was able to follow simple one step instructions. The resident required skilled occupational therapy to assess safety and independence with self-care and functional tasks of choice, facilitate sitting tolerance and postural control, improve rehab potential, increased functional activity tolerance and provision of modalities and strengthening. Without skilled therapeutic intervention, the resident was at risk for falls, decreased ability to return to prior level of supervision and limited out of bed activity. The resident's comprehensive care plan did not incorporate the occupational therapy assessment. D. Falls 1. Nursing progress notes revealed the Resident #7 had his first in facility fall on 8/21/2020 at 10: 27 p.m., since his 8/5/2020 admission. Progress notes read in part: Change in condition note dated 8/22/2020 at 12:07 a.m. Note text: At 8:10 a.m., staff found the resident on the floor in the bathroom doorway. He was facing out into the room. He was lying on his left side. The wheelchair was in the bathroom. The residents did not have any shoes on; however, he did have on the yellow non-skid socks. The call light was not on. The resident's response: Resident was anxious, breathing hard, and fighting against staff to assist him. Hospice-nurse progress note dated 8/25/2020 read in pertinent part: Safety - Fall Risk: Yes. Fall risk scale: seven (7) on a scale of 10 (high) to zero (0) (Low). Had a fall since the last nurse visit: Yes. It appears the resident rolled off the bed although unwitnessed. He was found on the floor next to his bed. Summary of Visit: This resident had a steady decline since admission post hospitalization .He has had multiple falls with increasing fatigue and weakness for the several months per the families report. He is non-ambulatory and totally dependent now for all activities of daily living including feeding. -Resident #7 is a fall risk: related to restlessness and agitation; no environment risks noted. Resident is in an observation room to help monitor him, that is a care needs and fall prevention. Goal: resident/caregiver will verbalize understanding of safety techniques. Interventions under this goal have been coordinated with facility staff. Staff will report any falls or change of condition that could precipitate a fall or other safety concerns. The post-fall investigative report revealed the Resident #7 had an unwitnessed fall on 8/21/2020. The resident was found on the floor at 8:10 p.m. The narrative note read in part: Date of current fall: 8/21/2020, date of last fall in facility: 8/21/2020. At 8:10 p.m., staff found the resident on the floor in the bathroom doorway. He was facing out into the room. He was lying on his left side. The wheelchair was in the bathroom. The resident did not have any shoes on; however, he did have on the yellow non-skid socks. The call light was not on. No injury/no complaints of pain. Neurological checks were initiated per facility protocol. Probable cause of fall: restlessness and impulsiveness. Quality assurance review- recommendations: refer to palliative/hospice consult, and assist the resident to bed after meals. Care plan revised 8/23/2020. Staff were attempting to get patients to bed, howeve just not enought staff to ge it done in a timely manner. The IDT note dated 8/24/2020 read: Resident #7 was noted to be on the floor in his room in the doorway of the bathroom. The resident is in an observation room, had a history of [REDACTED]. The resident was admitted for metabolic [MEDICAL CONDITION]. The resident was noted in the morning and up to about; midday to be calm and easy to redirect. In the later part of the day the resident began to become more impatient, impulsive and restless. The resident was evaluated by the palliative and hospice team. The resident was transitioned from palliative care to hospice. The resident's plan of care was updated to assist the resident back to bed after meals. Abuse and neglect ruled out. 2. Resident #7 had a second unwitnessed fall on 9/8/2020 at 7:55 p.m. Progress notes read in part: Change of condition note dated 9/8/2020 at 9:30 p.m. Resident #7 had an unwitnessed fall. Signs and symptoms: Lying face down on the floor wedged between the wheelchair and the floor. Vital signs: temperature 98.0, heart rate 81 beats per minute, respirations 22 breaths per minute, blood pressure 134/95 and oxygen saturation level 80 percent. Resident's response to change- resident was not able to verbalize. Neurological checks within normal limits for this resident. Hospice-nurse progress note dated 9/9/2020 read in pertinent part: Neurological/Mental/Emotional level of consciousness Score: 10 on a scale of 10 (Awake) to zero (0) (Unresponsive to verbal or painful stimuli). Oriented toward person; recent memory: bad; remote memory: bad; judgment: bad; perception: bad; ability to analyze problems: bad. Mental conditions: memory changes; forgetful; confused; lethargic. Emotional conditions: Peaceful, [MEDICAL CONDITION], and Expressive. Communication status: eight (8) on a scale of 10 (Normal) to zero (0) ([MEDICAL CONDITION]). -Safety: Resident #7 had a fall. It was unreported by the facility. The certified nurse aide (CNA) tells this RN during the visit that the resident fell [DATE] at 7:55 p.m. No injuries assessed. Resident #7 is assessed to be a high risk for falls due to: incontinence; diminished cognition; diminished strength; and other: restlessness and agitation. This: RN will reiterate to facility staff that hospice needs to be notified of all falls. The post-fall investigative report revealed the Resident #7 had an unwitnessed fall on 9/8/2020. The resident was found on the floor in his room at 7:55 p.m. The note read in part: Date of current fall: 9/8/2020, date of last fall in facility: 8/21/2020. Description of fall: Resident #7 noted to be lying on the floor face down in his room. He was wedged between the wheelchair and the wall at the corner of the closet. The call light was not on. The resident had been noted to be sitting in his wheelchair in his room just minutes prior to being noted on the floor. The patient did have on non-skid socks. The resident hit his head; neurological checks initiated per facility protocol. He sustained an abrasion to right lateral knee and first aid was applied. The resident complained of pain and pain medication was administered. The probable cause of fall: Patient must have leaned forward and fell out of the wheelchair. -The quality assurance review recommendations section was left uncompleted and it is unknown from this note if the care plan was revised. The IDT note dated 9/9/2020 read: Resident #7 sustained fall in room. Prior to fall the resident was noted in his room up in a wheelchair. The resident was on hospice and continues to decline medically. Patient is impulsive and has poor safety awareness. Patient care planned to lay down after meals, the resident is a late riser and gets agitated in the evening. -There was no documentation to show if the IDT considered adding care plan intervention based on the resident's continued decline or to address his evening agitation. 3. Resident #7 had a third unwitnessed fall on 10/6/2020 at 12:30 p.m. Progress notes read in part: Change of condition note dated 10/6/2020 at 5:53 p.m. Note text: Staff went to check on the resident while he was eating lunch. When staff walked in the room the resident was lying face done and legs were on top of the wheelchair pedals. Staff immediately assessed the residents for any injuries prior to moving him off the floor. The resident was able to move all extremities without difficulty. Appeared to hit his head on the floor and has an abrasion to right upper forehead. The resident had slurred speech and was unable to tell staff what happened. The post-fall investigative report revealed Resident #7 had an unwitnessed fall on 10/6/2020 and was found on the floor at 12:30 p.m. The narrative note read in part: Date of current fall: 10/6/2020, date of last fall in facility: 9/8/2020. Description of fall: Staff went to check on the resident while he was eating lunch. When staff walked in the room the resident was lying face done and legs were on top of the wheelchair pedals. Staff immediately assessed the resident for any injuries prior to moving him off the floor. The residents appeared to have hit his forehead on the floor causing an abrasion. The resident was able to move all extremities without difficulty. The resident hit his head and sustained a scalp abrasion to the right side of the forehead, neurological checks initiated per facility protocol and first aid and ministered. The residents did not complain of pain and no pain medication was administered. The probable cause of fall was poor safety awareness and cognitive impairment. Quality assurance review recommendations included adding a restorative nursing program. The care plan was updated to added restorative nursing services on 10/7/2020. The IDT note dated 107/2020 read: Resident #7 was noted in his room on the floor during meal time. The resident is currently on hospice services. Patient impaired cognition can be impulsive and is restless at times. Patient has had a previous fall in the facility. Patient is on scheduled pain medication and scheduled antianxiety medication. The resident was noted to have an abrasion to his head. No other injuries noted. The resident was added to a restorative program for meals. Abuse and neglect ruled out. Physician/medical provider note dated 10/8/20 read in pertinent part: Reason for Visit: follow-up fall. [DIAGNOSES REDACTED]. 4. Resident #7 had a fourth unwitnessed fall on 10/16/2020 at 5:15 p.m. Progress notes read in part: Change of condition note dated 10/16/2020 at 5:15 p.m. Note text: Resident #7 was found down in a room sitting on the floor on his buttocks. No complaints of pain. Vital signs: blood pressure 112/80, heart rate 71 beats per minute, respiration 18 breath per minute, temperature 97.5 oxygen saturation level 95 percent on room air. The resident was confused. Review of the resident records revealed the facility failed to complete a post-fall investigative report. A request was made on 10/26/2020 at 11:35 a.m., to the NHA for all fall investigative report finding for all of Resident #7 falls. The DON provided investigative findings as IDT notes falls dated 8/21/2020, 9/8/2020 and 10/6/2020 but was unable to provide an IDT note findings report for Resident #7s fall dated 10/16/2020. IV. Staff interviews RN #4 was interviewed on 10/26/2020 at 12:34 p.m. RN #4 said residents who need more supervision were moved to one of the observation rooms across from the nurses station so nursing staff could keep a closer eye on them. The nurses were responsible to document any ineffective intervention in progress notes and alert the DON so the care plan can be updated appropriately. RN #4 said, the nurses can assess resident needs and implement fall intervention, as needed. Rn #4 said, effective interventions were also to be documented in progress notes. The nurses were responsible to make sure the CNAs were trained to carry out interventions within their scope of practice. If a resident falls, the RN on duty assesses the resident for injuries and completes the post fall investigation report to document what might have caused the resident's fall particularly if the fall was unwitnessed. The main goal is to keep residents safe and prevent falls. CNA #3 was interviewed on 10/26/2020 at 12:45 p.m. CNA #3 said the CNAs follow the resident care plan and assignments boards ported in the resident's room. If the CNA noticed a resident was not safe they were to notify the charge nurse of any concerns. CNAs could only do what was within their scope of practice and were not able