Every finding on record at Chateau St. James Rehab and Retirement

Based on observations, interviews, and record reviews, the facility failed to:1. Ensure weighted sandbag (weighted base to prevent something from tipping over) located on a resident's intravenous pole (pole to hold fluids or equipment), and enteral feeding pump (equipment used to deliver liquid nutrition) was maintained in a sanitary manner (Resident #12); and,2. Ensure a resident's wheelchair was maintained in a sanitary manner (Resident #43). This deficient practice was identified for 2 (Resident #12, Resident #43) of 61 sampled resident rooms observed for environmental requirements. Findings:1.Review of Resident #12's quarterly Minimum Data Set with an Assessment Reference Date of 09/24/2025 revealed, in part, Resident #12 received enteral nutrition (liquid/formula going directly into the stomach) through an enteral feeding pump. Observation on 12/08/2025 at 9:53AM revealed several areas of a dried tan colored unknown substance which covered 25% of Resident #12's enteral feeding pump handle and several areas of a dried tan colored unknown substance which covered 25% of Resident #12's left side of the enteral feeding pump. Further observation revealed several areas of a dried tan colored unknown substance which covered 80% of Resident #12's weighted sandbag located on Resident #12's intravenous pole. Observation on 12/09/2025 at 9:05AM revealed several areas of a dried tan colored unknown substance which covered 25% of Resident #12's enteral feeding pump handle and several areas of a dried tan colored unknown substance which covered 25% of Resident #12's left side of the enteral feeding pump. Further observation revealed several areas of a dried tan colored unknown substance which covered 80% of Resident #12's weighted sandbag located on Resident #12's intravenous pole. Observation on 12/09/2025 at 9:29AM revealed several areas of a dried tan colored unknown substance which covered 25% of Resident #12's enteral feeding pump handle and several areas of a dried tan colored unknown substance which covered 25% of Resident #12's left side of the enteral feeding pump. Further observation revealed several areas of a dried tan colored unknown substance which covered 80% of Resident #12's weighted sandbag located on Resident #12's intravenous pole. In an interview on 12/09/2025 at 9:32AM, S4Licensed Practical Nurse further indicated she did not noticed the condition of Resident #12's enteral feeding pump and Resident #12's weighted sandbag located on Resident #12's intravenous pole. S4Licensed Practical Nurse further indicated Resident #12's enteral feeding pump and Resident #12's weighted sandbag located on Resident #12's intravenous pole should have been maintained in a sanitary manner. In an interview on 12/09/2025 at 9:35AM, S2Director of Nursing indicated Resident #12's enteral feeding pump and Resident #12's weighted sandbag located on Resident #12's intravenous pole was not maintained in a sanitary manner, and should have. In an interview on 12/09/2025 at 9:50AM, S1Administrator indicated Resident #12's enteral feeding pump and Resident #12's weighted sandbag located on Resident #12's intravenous pole was not maintained in a sanitary manner, and should have. 2. Review of Resident #43's quarterly Minimum Data Set with and Assessment Reference Date of 10/15/2025 revealed, in part, Resident #43 used a wheelchair for mobility. Review of the facility's Wheelchair Cleaning Assignment Log for the time period of 11/09/2025 to 11/15/2025 revealed, in part, Resident #43's wheelchair was last cleaned on Tuesday during the week of 11/09/2025 to 11/15/2025. Observation on 12/08/2025 at 9:39AM revealed Resident #43's wheelchair had multiple areas of a dried white colored unknown substance which covered 25% on the left side Resident #43's wheelchair seat and multiple areas of a dried white colored unknown substance which covered 25% of the left side of Resident #43's wheelchair leg. Observation on 12/09/2025 at 11:47AM revealed Resident #43's wheelchair had multiple areas of a dried white colored unknown substance which covered 25% on the left side Resident #43's wheelchair seat and multiple areas of a dried white colored unknown substance which covered 25% of the left side of Resident #43's wheelchair leg Observation on 12/10/2025 at 8:55AM revealed Resident #43's wheelchair had multiple areas of a dried white colored unknown substance which covered 25% on the left side Resident #43's wheelchair seat and multiple areas of a dried white colored unknown substance which covered 25% of the left side of Resident #43's wheelchair leg In an interview on 12/09/2025 at 11:47AM Resident #43 indicated her wheelchair was dirty and had not been cleaned. In an interview on 12/10/2025 at 10:52AM, S3Assistant Director of Nursing indicated Resident #43's wheelchair was not cleaned as scheduled, was not maintained in a sanitary manner, and should have been. In an interview on 12/10/2025 at 11:30PM, S1Director of Nursing indicated Resident #43's wheelchair was not maintained in a sanitary manner, and should have.

Based on interviews and record reviews, the facility failed to ensure staff had ongoing communication and collaboration with the resident's dialysis provider regarding the resident's dialysis care and services for 1 (Resident #7) of 1 sampled resident investigated for dialysis requirements. Findings:Review of the facility's End-Stage Renal Disease, Care of a Resident, undated, policy revealed, in part, that agreements between the facility and the end stage renal disease facility should include all aspects of how the resident's care would be managed, including how information would be exchanged between the facility and dialysis center facility's. Review of Resident #7's electronic medical record revealed, in part, Resident #7 had an admission date of 11/18/2025 and a diagnosis of end stage renal disease (loss of kidney function). Review of Resident #7's electronic medical record revealed, in part, an order for Resident #7 to receive dialysis every Monday, Wednesday, and Friday, for the facility staff to review the facility's dialysis communication sheet/form every Monday, Wednesday, and Friday, and for the facility staff to review the dialysis communication sheet/form for any records and/or orders every Monday, Wednesday, and Friday after dialysis care and services. Review of Resident #7's admission Minimum Data Set with an Assessment Reference Date of 11/24/2025 revealed, in part, Resident #7 received dialysis services. Review of provider's dialysis communication binder for Resident #7 revealed, in part, no dialysis communication sheet/forms had been completed since 11/25/2025. In an interview on 12/09/2025 at 9:32AM, S4Licensed Practical Nurse indicated she had not received Resident #7's dialysis communication sheet/form for Monday 12/08/2025 when Resident #7 returned from her scheduled dialysis treatment. S4Licensed Practical Nurse further indicated she had not called the dialysis provider for Resident #7's dialysis communication sheet/form, and should have. In a telephone interview on 12/09/2025 at 11:39AM, Resident #7's dialysis provider's administrator indicated he had not received a dialysis communication sheet/form from the facility to complete for Resident #7 after Resident #7 received dialysis on Monday, 12/08/2025. In an interview on 12/09/2025 at 12:54PM, S2Direcctor of Nursing indicated the facility's nursing staff were responsible to ensure a dialysis communication sheet/form was completed prior to the resident's scheduled dialysis service and when a resident returned from their scheduled dialysis service. S2Director of Nursing further indicated Resident #7 should have had a dialysis communication sheet/form for Sunday 11/23/2025, Wednesday 11/26/2025, Friday 11/28/2025, Friday 12/05/2025, and Monday 12/08/2025 when Resident #7 received dialysis services. In an interview on 12/10/2025 at 8:34AM, S7Licensed Practical Nurse indicated it was the nursing staff's responsibility to call the dialysis provider if a resident did not have a dialysis communication sheet/form when the resident returned to the facility after receiving dialysis treatment. In an interview on 12/10/2025 at 8:48AM, S6Ward Clerk indicated it was the nursing staff's responsibility to ensure the dialysis communication sheet/form was received from the dialysis provider after their scheduled dialysis treatment.

Based on observations, interviews, and records review, the facility failed to administer a resident's enteral feeding (intake of food through a tube placed in the stomach) as ordered by the physician for 1 (Resident #25) of 1 sampled resident investigated for enteral nutritional requirements. Findings:Review of the facility's Enteral Tube Feeding via Continuous Pump policy with a revision date of 08/04/2019, revealed, in part, the enteral nutritional label and rate of administration (milliliters per hour) should be checked against the order before administration.Review of Resident #25's Quarterly Minimum Data Set with an Assessment Reference Date of 11/02/2025 revealed, in part, Resident #25 had a feeding tube placed directly into his stomach.Review of Resident #25's December 2025 order listing report revealed, in part, an order with a start date of 11/28/2025 for Isosource 1.5 at 50 milliliters per hour via feeding tube continuously.Observation on 12/08/2025 at 1:17PM revealed Resident #25's continuous tube feeding was infusing at 53 milliliters per hour via pump.Observation on 12/09/2025 at 8:55AM revealed Resident #25's continuous tube feeding was infusing 53 milliliters per hour via pump.In an interview on 12/09/2025 at 9:00AM, S5Licensed Practical Nurse indicated Resident #25's tube feeding should not have been infusing at 53 milliliters per hour and should have been infusing at 50 milliliters per hour as ordered.In an interview on 12/09/2025 at 9:14AM, S2Director of Nursing indicated Resident #25's tube feeding should not have been infusing at 53 milliliters/hour and should have been infusing at 50 milliliters per hour as ordered.

Based on observations, interviews, and record reviews the facility failed to ensure a resident's care plan was revised to reflect a resident's individualized needs following a significant change in condition. This deficient practice was identified for 1 (Resident #2) of 5 (Resident #1, Resident #2, Resident #3, Resident #4, Resident #5) sampled residents reviewed for quality of care. Findings: Review of Resident #2's Quarterly MDS (Minimum Data Set) with ARD (Assessment Reference Date) of 03/20/2025 revealed, in part, Resident #2 no wandering behaviors noted and required a walker or wheelchair for locomotion. Further review revealed Resident #2 required supervision or touching assistance with eating, performing oral hygiene, personal hygiene, bathing or showering, and partial and moderate assistance with toileting hygiene. Review of Resident #2's Significant change MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 05/02/205 revealed, in part, Resident #2 had no wandering behaviors noted and required substantial or maximal assistance performing personal hygiene, bathing or showering, chair to bed transfers, toileting transfers, and toileting hygiene. Review of Resident #2's Physician's Orders revealed, in part, on 01/02/2025 Resident #2 had an order to place a wander guard to Resident #2's right ankle due to wandering and exit seeking. Further review revealed on 04/24/2025 Resident #2 had an order to remove his wander guard due to Resident #2's status changed to being bedbound. Resident #2 was at risk for falls which included interventions for a fall mat at bedside, encourage Resident #2 to utilize walker while ambulating, ensure resident has on proper footwear when up out of bed, and ensure the call light was within reach. Review of Resident #2's Care Plan header revealed, in part, a special instructions warning which indicated Resident #2 was a fall risk and required rounding every hour, a fall mat at the bedside while Resident #2 was in bed, and that Resident #2 was a wanderer and had a wander guard on Resident #2's right ankle. Further review revealed, this care plan header was also visible to nursing staff on Resident #2's profile in his electronic record. Observation on 05/27/2025 at 3:23PM, Resident was noted lying in bed and had no fall mat at bedside and call light/button was on the floor behind Resident #2's bed on the floor out of reach. Resident #2 was unable to state if he had any falls recently or how to call for staff when he needs assistance, Resident #2 could not say where his call light/button was. In an interview on 05/27/2025 at 3:25PM, S6Certified Nursing Assistant (CNA) indicated Resident #2 did not remember to ask for assistance, she stated he use to have a fall mat but was unsure if he still required one. In an interview on 05/27/2025 at 4:05PM, S2Assistant Director of Nursing (ADON) indicated Resident #2's order for a fall mat by bedside while Resident #2 was in bed should have been discontinued because Resident #2 was now bed bound and was no longer mobile. In an interview on 05/28/2025 at 2:55PM, S4Licensed Practical Nurse indicated that Resident #2 was unable to use the call bell to call for assistance, and will call out for assistance and was bedbound now. In an interview on 05/28/2025 at 3:51PM, S5Licensed Practical Nurse indicated Resident #2's care plan should be updated and revised with all significant changes and quarterly assessments. S5 Licensed Practical Nurse further indicated Resident #2's care plan should have been updated and revised with individual interventions.

Based on observations, interviews, and record reviews, the facility failed to: 1) obtain settings for Continuous Positive Airway Pressure (CPAP) administration (Resident #1); and, 2) follow a physician's order for oxygen administration (Resident #2). This deficient practice was identified for 2 (Resident #1, Resident #2) of 3 (Resident #1, Resident #2, Resident #5) sampled residents reviewed for respiratory care in a total sample of 5. Findings: 1. Review of the facility's CPAP/bi-level positive airway pressure (BPAP) Support policy and procedure revised on 03/2015 revealed, in part, the purpose was to improve oxygenation in residents with respiratory insufficiency, obstructive sleep apnea, or obstructive lung disease. Further review revealed staff was to review the physician's order to determine the oxygen concentration and flow, and the positive end-expiratory pressure (PEEP). Further review revealed staff was to set mode for CPAP settings on the machine as prescribed. Review of Resident #1's Minimum Data Set with an assessment reference date of 03/09/2025 revealed, in part, Resident #1 had a medical history of chronic respiratory failure, chronic obstructive pulmonary disease (a group of lung diseases that block airflow and make it difficult to breathe) and received oxygen therapy. Review of Resident #1's May 2025 Physician's Orders revealed, in part, staff were to check and fill Resident #1's CPAP canister with distilled water at bedtime. Further review revealed no documented evidence, and the facility was unable to present any evidence Resident #1 had a physician order which included settings for oxygen concentration, flow, and pressure for the CPAP to be administered. In an interview on 05/28/2025 at 1:19PM, S1Quality Improvement (QI) Nurse confirmed Resident #1 did not have a physician order which included settings for oxygen concentration, flow, and pressure for CPAP administration as required. 2. Review of facility's Oxygen Administration policy and procedure with a revision date of February 2025, revealed, in part, staff was to review physician's orders to determine the proper flow of oxygen to be administered for safe oxygen administration, and infection prevention associated with respiratory therapy tasks. Review of Resident #2's Physician's Orders dated 05/15/2025 revealed, in part, Resident #2's oxygen was to be administered at 2 Liters per minute (LPM) via nasal cannula (a device that gives you additional oxygen through your nose). Observation on 05/27/2025 at 3:23PM revealed, Resident #2 was lying in bed with oxygen set to be administered at 3LPM via nasal cannula. Observation on 05/27/2025 at 4:02PM revealed, Resident #2 was lying in bed with oxygen set to be administered at 3LPM via nasal cannula. Further observation revealed Resident #2's nasal cannula was not positioned correctly over both nares. In an interview on 05/27/2025 at 4:05PM, S2Assistant Director of Nursing (ADON) verified that Resident #2's oxygen was not set at 2LPM via nasal cannula. In an interview on 05/27/2025 at 4:07PM, S3Licensed Practical Nurse confirmed Resident #2's oxygen was to be administered at 2LPM via nasal cannula, and was not.

Based on observations, interviews, and record reviews, the facility failed to: 1. Ensure residents identified as unsafe smokers did not have access to smoking materials while not being supervised (Resident #36); and, 2.Implement new individualized fall prevention interventions and/or increase supervision to prevent future falls for 1 (Resident #1) of 4 (Resident #1, Resident #34, Resident #35, and Resident #56) sampled residents reviewed for falls. Findings: Resident #36 Review of the facility's Resident's Smoking Policy dated 03/08/2023 revealed, in part, residents were not be permitted to keep cigarettes, e-cigarettes, pipes, tobacco, and other smoking articles in their possession if they were determined to have smoking restrictions or identified as an unsafe smoker unless under supervision. Further review revealed the facility maintained the right to confiscate smoking articles found in violation of the smoking policies. Review of Resident #36's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 09/17/2024 revealed, in part, a Brief Interview for Mental Status (BIMS) score of 14, which indicated Resident #36 was cognitively intact. Review of Resident #36's Care Plan revealed, in part, Resident #36 was assessed and identified as being an unsafe smoker with an intervention for Resident #36 to follow the facility's protocol for safe smoking. Review of Resident #36's Safe Smoking assessment dated [DATE] revealed, in part, Resident #36 was assessed as being an unsafe smoker and required supervision by staff while smoking. Further review revealed Resident #36's cigarettes and lighters were to be secured at the nurse's station. Observation on 11/06/2024 at 10:37 a.m. revealed Resident #36's purple cigarette lighter was located on the top of his bedside dresser in his room. Observation on 11/06/2024 at 11:06 a.m. revealed Resident #36's purple cigarette lighter was located on the top of his bedside dresser in his room. Observation on 11/06/2024 at 3:06 p.m. revealed Resident #36's purple cigarette lighter was located on the top of his bedside dresser in his room. Observation on 11/07/2024 at 10:07 a.m. revealed Resident #36's purple cigarette lighter was located on the top of his bedside table in his room. Observation on 11/08/2024 at 8:28 a.m. revealed Resident #36's purple cigarette lighter was located on the top of his bedside table in his room. Observation on 11/08/2024 at 8:34 a.m. with S2Director of Nursing (DON) present, revealed Resident #36's purple cigarette lighter was located on top of his bedside table in his room. In an interview on 11/08/2024 at 8:35 a.m., S2DON indicated Resident #36 was an unsafe smoker. S2DON further indicated Resident #36's cigarette lighter was unattended in an accessible area, and should not have been available for use. In an interview on 11/08/2024 at 10:14 a.m., when S4Clinical Quality Assurance (QA) Nurse was presented with the facility's smoking policy, S4Clinical QA Nurse indicated Resident #36's smoking materials were not to be kept with Resident #36 if he was assessed as being an unsafe smoker unless under supervision. In an interview on 11/08/2024 at 10:45 a.m., S1Administrator indicated Resident #36 having his cigarette lighter nearby in his room was not a safety concern since Resident #36 did not have access to his cigarettes. S1Administrator indicated Resident #36 did not have one on one supervision while he stayed inside his room with his cigarette lighter. S1Administrator did not offer an explanation as to why the above mentioned policy did not apply to Resident #36. Resident #1 Review of Resident #1's medical record revealed, in part, Resident #1 was admitted to the facility on [DATE] with diagnoses of, in part, mixed incontinence and cognitive communication deficit. Review of Resident #1 Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 10/05/2024 revealed, in part, Resident #1 had a brief interview for mental status (BIMS) score of 00, which revealed Resident #1 had severe cognitive impairment. Further review revealed Resident #1 used a manual wheelchair for ambulation and was totally dependent on staff for all activities of daily living. Review of the facility's Incident Log dated 04/05/2024 revealed, in part, Resident #1 had an un-witnessed fall with injury on 04/05/2024 and unwitnessed falls on 05/12/2024, 05/27/2024, 07/14/2024, 08/16/2024, 09/11/2024, and 10/18/2024. Review of Resident #1's Care Plan revealed, in part, Resident #1 was at risk for falls related to impaired mobility, cognitive impairment, and required extensive to total assistance with transfers. Further review revealed Resident #1's care plans were not updated with new individualized interventions and/or had supervision increased to prevent future falls after the above mentioned falls occurred. In an interview on 11/07/2024 at 8:56 a.m., S2DON indicated Resident #1's care plan for falls which occurred was not updated with a new fall prevention intervention following Resident #1's falls on 04/05/2024, 5/12/2024, 05/27/2024, 08/16/2024, 09/11/2024, and 10/18/2024, but should have been. In an interview on 11/07/2024 at 1:30 a.m., S4Clinical QA Nurse indicated Resident #1's care plan should have been updated with new individualized interventions after the above mentioned falls to prevent future falls. 48855

Based on interview, observation, and record review, the facility failed to perform proper hand hygiene while preparing coffee for residents. Findings: Review of the facility's Policy and Procedure for Preventing Foodborne Illness - Employee Hygiene and Sanitary Practice, last updated October 2008, revealed, in part, all employees who handled, prepared, or served food were trained in the practice of safe food handling and preventing foodborne illness by performing hand hygiene before coming into contact with any food surfaces and after being engaged in other activities that contaminate their hands. Observation on 11/06/2024 at 11:00 a.m., revealed S13Dietary Aide (DA) performed hand hygiene in the facility's kitchen sink, obtained paper towels, used the paper towels to dry her hands, and then lifted kitchen garbage bin lid with her bare hands to dispose of the above mentioned paper towels. Further observation revealed S13DA did not perform hand hygiene after touching the garbage can lid, picked up a container of coffee, brought the coffee to the facility dining room, and then proceeded to prepare coffee for resident consumption without performing hand hygiene. In an interview on 11/06/2024 at 11:01 a.m., S13DA indicated she should not have lifted the facility's kitchen garbage bin lid with her bare hands after she performed hand hygiene and should not have touched the container of coffee without performing hand hygiene. In an interview on 11/06/2024 at 11:05 a.m., S12Dietary Manager indicated S13DA should not have lifted the facility's kitchen garbage bin lid with her bare hands after she performed hand hygiene and should not have touched the container of coffee without performing hand hygiene. In an interview on 11/06/2024 at 11:25 a.m., S1Administrator indicated S13DA should have used proper hand hygiene before she touched the container of coffee.

Based on record reviews, and interviews the facility failed to identify and include the infection-causing organism for resident infections into their infection control surveillance for 4 (Resident #38, Resident #41, Resident #66, and Resident #75) of 5 (Resident #30, Resident #38, Resident #41, Resident #66, and Resident #75) sampled resident reviewed for infection surveillance. Findings: Review of the facility's Surveillance for Infections policy and procedure with a revision date of September 2017, revealed, in part, the purpose of the surveillance of infections was to identify individual cases and trends of epidemiologically significant organisms and Healthcare-Associated Infections. Further review of the policy revealed infections included in routine surveillance include evidence of transmissibility, processes, and procedures which prevent the spread of infection, and pathogens associated with serious outbreaks. Review revealed the surveillance should include a review of all information to identify possible indicators of infections: laboratory records, infection documentation records, and antibiotic review. Review further revealed the surveillance system was designed to capture epidemiologically. Review further revealed to collect the following data: identifying information, diagnosis, the date of onset of the infection, date of the positive diagnostic test, infection site, pathogens, and risk. Review of the facility's September 2024 infection tracking and trending documentation revealed, in part, four residents (Resident #38, Resident #41, Resident #66, and Resident #75) resided on hall A whom received care from the same assigned staff, and was diagnosed with a urinary tract infection (UTI). Further review revealed no documented evidence, and the facility presented no documented evidence, that the infection-causing organism was identified in the facility's infection surveillance documentation. Review of Resident #38's Urine Analysis (UA) Culture and Sensitivity (C/S) report dated 08/28/2024, revealed a diagnosis of urinary tract infection (UTI) with Staphylococcus (S. Aureus) (bacteria which causes urinary tract infections) identified as the primary pathogen. Review of Resident #41's UA C/S report dated 09/16/2024 revealed gram negative rods were identified as the pathogen. Review of Resident #66's UA C/S report dated 09/30/2024 revealed UTI with Klebsiella Pneumonia (bacteria associated with pneumonia) was identified as the pathogen. Review of Resident #75's UA C/S report dated 09/26/2024 revealed Resident #75 was admitted to a local hospital with a diagnosis of UTI and Klebsiella Pneumonia was identified as the pathogen. There was no documented evidence, and the facility did not produce any documented evidence, infection-causing organisms for resident infections were included as part of the facility's infection control surveillance for 4 (Resident #38, Resident #41, Resident #66, and Resident #75) of 5 (Resident #30, Resident #38, Resident #41, Resident #66, and Resident #75) residents reviewed for infection surveillance. In an interview on 11/07/2024 at 8:30 a.m., S6Infection Preventionist (IP) indicated she had not received any culture results for the above mentioned residents, and was unaware the results were placed in the resident's medical records. S6IP further indicated she was unaware the facility had placed the results in the residents' medical records, and S6IP further indicated she failed to follow-up on culture results as part of the infection surveillance process. In an interview on 11/07/2024 at 8:45 a.m. S2Director of Nursing (DON) indicated she had instructed S6IP on multiple occasions to follow-up on culture results and incorporate the final results into the infection surveillance program. S2DON confirmed the pathogens should have been identified on the Facility Infection Report: Tracking and Trending and it was not.

Based on interviews and record review, the facility failed to publicly post the required contact information for the current State Long-Term Care Ombudsman. Findings: In an interview on [DATE] at 10:10 a.m., Resident #66, the Resident Council President, indicated the facility's Ombudsman had died many months ago. Resident #66 further indicated she did not know the name of, or how to contact, the facility's newly assigned Ombudsman. Review of publicly posted contact information for the facility's Ombudsman revealed the name and contact information of the facility's previously assigned Ombudsman. There was no evidence, and the facility could not provide any documented evidence, the name or contact information had been publically posted for the facility's currently assigned Ombudsman. In an interview on [DATE] at 11:10 a.m., S1Administrator confirmed that information for the facility's current Ombudsman was not posted, and it should have been.

Based on observation, record review, and interview, the facility failed to post the results of previous surveys in an area accessible to residents and/or resident's responsible parties. Findings: In an interview on 11/06/2024 at 10:10 a.m., Resident #66, the Resident Council President, indicated she did not know where the results of previous state surveys were posted or how to access them. Observation on 11/06/2024 at 11:15 a.m. revealed the facility's previous survey results were located in a binder behind the receptionist's desk, not accessible to residents and/or residents' representatives. There was no evidence, and the facility did not present evidence, the previous survey results had been posted in an area readily accessible to residents, family members and legal representatives. In an interview on 11/07/2024 at 2:06 p.m., S1 Administrator indicated the previous survey results with plans of corrections were kept in a binder on a counter behind the front desk inaccessible to the public, and confirmed they were available only upon request.

Based on observation and interview, the facility failed to ensure their daily posted nurse staffing information included the required information for 5 of 5 daily nurse staffing information postings revealed for nurse staffing information requirements. Findings: Observation on 11/04/2024 at 9:18 a.m. revealed the facility's nurse staffing information was posted on a document entitled Daily Staff Report. Further observation revealed it did not include the facility's name or the facility's daily census. Review of the facility's Daily Staff Reports for November 2024 revealed no documented evidence, and the facility did not produce any evidence, the above daily nurse staffing information posted included the name of the facility, the facility's daily census, and/or the total nursing hours provided on 11/02/2024, 11/03/2024, 11/04/2024, 11/05/2024 and 11/06/2024. In an interview on 11/07/2024 at 10:42 a.m., S8Certified Nursing Assistant indicated she was responsible for documenting and posting the daily nurse staffing information on week days. S8CNA indicated she did not document the total nursing hours provided by the facility on the Daily Staff Reports on 11/04/2024, 11/05/2024, and 11/06/2024 as required, and should have. In an interview on 11/07/2024 at 12:20 p.m., S1Administrator further indicated he was not aware the Daily Staff Report did not include the required information.

Based on observation, record review, and interviews, the facility failed to ensure a resident dependent on staff for activities of daily living (ADL) received nail care. This deficient practice was identified for 1 (Resident #3) of 3 (Resident #1, Resident #2, and Resident #3) sampled residents. Findings: Review of Resident #3's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 03/26/2024 revealed, in part, Resident #3 had a Brief Interview for Mental Status (BIMS) score of 00, which indicated severe cognitive impairment. Further review revealed, Resident #3 was dependent upon staff with personal hygiene. Review of Resident #3's care plan revealed, in part, Resident #3 required assistance from staff with all ADLs (activities related to personal care). Observation on 04/22/2024 at 12:18 p.m. revealed, Resident #3's left thumb nail and left second finger nail were approximately one-fourth of an inch long. Further observation revealed, Resident #3's right first finger nail was also long. In an interview on 04/24/2024 at 8:36 a.m., S2CNA indicated she has never attempted to trim or clean Resident #3's fingernails due to Resident #3 sometimes having combative behaviors. Observation with S1Assistant Director of Nursing (ADON) on 04/24/2024 at 10:10 a.m., revealed, in part, Resident #3 had a black unknown substance under her left first finger nail. Further observation revealed, Resident #3's left thumb nail and left second finger nail were approximately one-fourth of an inch long, and Resident #3's right thumb nail was about one-half of an inch long. Further observation revealed, Resident #3's right first finger nail and right third finger nail had an unknown brown substance underneath the nails. In an interview on 04/24/2024 at 10:10 a.m., S1ADON indicated Resident #3's finger nails should not have appeared as they currently did.

47500 Based on record reviews and interviews, the facility failed to ensure the Ombudsman was notified of hospital transfers/discharges by failing to complete and submit the Emergency (ER) Transfer Log to the Ombudsman in a timely manner as required for 2 (Resident #44 and Resident #50) of 3 (Resident #44, Resident #50, and Resident #73) residents reviewed for hospitalization s. Findings: Resident #44 Review of Resident #44's medical record revealed Resident #44 was transferred to an acute care hospital from 04/20/2023 to 04/23/2023. Review of the facility's Emergency Transfer Log dated April 2023 revealed, in part, a notification of hospital transfers/discharges was sent to the Ombudsman on 06/12/2023. In an interview on 12/14/2023 at 12:15 p.m., S13SocialWorker stated the emergency transfer logs should be sent to the Ombudsman by the 15th of the following month. S13SocialWorker stated April 2023's log should have been sent in May 2023 and it was not. In an interview on 12/14/2023 at 12:48 p.m., S1Administrator stated he did not have any additional information on the April 2023 transfer log being sent to the Ombudsman in May 2023. Resident #50 Review of Resident #50's MDS (Minimum Data Set) tracker revealed, in part, Resident #50 was discharged from the facility to an acute care hospital on 10/6/2023 and returned to the facility on [DATE] from an acute care hospital. Review of the facility's October 2023 Emergency Transfer Log revealed there was no documented proof the Ombudsman was notified of transfers/discharges for October 2023. In an interview on 12/13/2023 at 2:40 p.m., S13SocialWorker stated he did not have verification of e-mail notification of the Ombudsman of the facility's transfers/discharges for October 2023. S13SocialWorker further stated the Emergency Transfer Logs had not been sent to the Ombudsman as required since August 2023, and they should have been sent by the 15th of each month. In an interview on 12/13/2023 at 2:50 p.m. S1Administrator confirmed the Ombudsman had not been notified by the facility of the facility's transfers/discharges due to a change in staff. S1Administrator confirmed the Ombudsman should have been notified in writing of transfers/discharges by the 15th of each month. In an interview on 12/14/2023 at 7:42 a.m. S14Ombudsman confirmed she had not received e-mail notifications of transfers/discharges from the facility in about 2 months.

Based on record review and interviews, the facility failed to: 1. Administer a resident's insulin per physician's order for 1 (Resident #44) of 5 (Resident #12, Resident #27, Resident #40, Resident #44, and Resident #75) sampled residents reviewed for unnecessary medications, and 2. Coordinate care and communicate changes in a resident's condition for 1 (Resident #140) of the 1 (Resident #140) residents sampled residents reviewed for hospice care services. Findings: Resident #44 Review of Resident #44's Care Plan revealed, in part, Resident #44 was care planned for the potential of hyperglycemia (high blood sugar) and hypoglycemia (low blood sugar) related to Diabetes and to perform blood glucose levels daily. Review of Resident #44 October, November, and December 2023 Physician's Orders revealed, in part, an order dated 07/06/2023 for Novolog (a medication used to lower blood sugar levels) 100 units/mL (units per milliliter) subcutaneous (injection under the skin) sliding scale administer 0 units and give orange juice for a blood glucose of 0-60 mg/dL (milligrams per deciliter); administer 0 units for blood glucose of 61-150 mg/dL; administer 2 units for blood glucose of 151-200 mg/dL; administer 4 units for a blood glucose level of 201-250 mg/dL; administer 6 units for blood glucose level of 251-300 mg/dL; administer 8 units for blood glucose level of 301-350 mg/dL; administer 12 units for blood glucose level of 351-400 mg/dL; and administer 14 units for blood glucose level of 401mg/dL. Review of Resident #44's EMAR (Electronic Medication Administration Record) for October, November, and December 2023 revealed, in part, Resident #44 was administered Novolog insulin subcutaneously on the following dates as a result of Resident #44's capillary blood glucose reading: On 10/15/2023 at 4:30 p.m. Resident #44 capillary blood glucose reading: 376 mg/dl, and Resident #44 was administered 10 Units of Novolog insulin; On 10/28/2023 at 4:30 p.m. Resident #44 capillary blood glucose reading: 373 mg/dl, and Resident #44 was administered 10 Units of Novolog insulin; On 10/30/2023 at 4:30 p.m. Resident #44 capillary blood glucose reading: 400 mg/dl, and Resident #44 was administered 10 Units of Novolog insulin; and On 11/03/2023 at 4:30 p.m. Resident #44 capillary blood glucose reading: 154 mg/dl, and Resident #44 was not administered Novolog insulin per physician order sliding scale; and On 11/04/2023 at 11:30 a.m. Resident #44 capillary blood glucose reading: 391 mg/dl, and Resident #44 was administered 10 Units of Novolog insulin. In an interview on 12/14/2023 at 9:45 a.m., S11Director of Nursing stated Resident #44's Novolog insulin was not administered as ordered and Resident #44's should have received 2 units of Novolog for capillary blood glucose level of 154 on 11/03/2023. S11Director of Nursing further confirmed the nurse should be administering insulin per the physician's sliding scale for Novolog. Resident #140 Review of Resident #140's Admission Minimum Data Set (MDS) with an Assessment Reference Date of 10/10/2023 revealed, in part, Resident #140's Brief Interview Mental Status (BIMS) was unable to be assessed due to cognitive status and Resident #140 received hospice care. Review of Resident #140's comprehensive care plan developed by the facility on 09/29/2023 revealed, in part, a plan of care was developed for the selection of hospice care with an intervention for the facility to coordinate care with the hospice team. In an interview on 12/13/2023 at 9:15 a.m., S15LicensedPracticalNurse (LPN) stated Resident #140 received hospice care. S15LPN further stated she was not sure how often or what disciplines Resident #140 received from hospice. She further stated she could not locate Resident #140's hospice binder or plan of care. In an interview on 12/13/2023 at 9:20 a.m., S16NurseAuditor stated she could not locate Resident #140's hospice binder and the only information she had was Resident #140's hospice admission paperwork from 09/29/2023. In an interview on 12/13/2023 at 9:30 a.m., S17Certified Nursing Assistant (CNA) stated Resident #140 received ADL (activities of daily living) care from hospice services 3 days per week. S17CNA further stated she did not know the scheduled times of hospice visits. She stated she did not get a report and did not give a report to the hospice staff. Review of Resident #140's record revealed there was no documentation from the hospice company regarding Resident #140's plan of care or on-going treatment. In an interview on 12/13/2023 at 11:48 a.m., S19HospiceLiaison stated the hospice company meets as a team every 2 weeks regarding Resident #140's care. S19HospiceLiasson further stated the nursing facility staff did not participate in Resident #140's care meetings. The facility was unable to locate or present Resident #140's hospice binder, hospice nursing notes, certified aide documentation, or a current hospice plan of care. There was no documented evidence and the facility did not present any documented evidence that facility and hospice staff coordinated Resident #140's care for current care, skin assessments, treatments, and frequency of hospice staff visits. In an interview on 12/13/2023 at 3:10 p.m., S11Director of Nursing confirmed Resident #140's care was not being coordinated by facility and hospice staff and it should have been.

Based on observations, interviews, and record reviews, the facility failed to ensure: 1. Hot water temperatures were maintained below 120 degrees Fahrenheit for 4 (Room r, Room t, Room u, Room v) of 20 (Room a', Room b, Room c, Room d, Room e, Room f, Room g, Room h, Room i, Room j, Room k, Room l, Room m, Room r, Room s, Room t, Room u, Room v, Room aa, and Room bb) resident rooms observed for hot water temperatures; and 2. Hot water temperatures were maintained below 120 degrees Fahrenheit for 1 (Shower Room p) of 3 (Shower Room n, Shower Room o, and Shower Room p) facility shower rooms observed. Findings: Review of the facility's policy and procedure titled, Safety of Water Temperatures last revised in December 2009, revealed, in part, water heaters that service resident rooms, bathrooms, common areas, and tub/shower areas shall be set to temperatures of no more than 120 degrees Fahrenheit. Review of the census prepared by the facility on 12/11/2023 revealed, in part, Resident #35 was capable of washing their hands in the sink of Room v, Resident #45 was capable of washing their hands in the sink of Room t, and Resident #81 were capable of washing their hands in the sink of Room s. Further review revealed Resident #7, Resident #83, Resident #191, Resident #192, Resident #193, and Resident #194 had impaired skin. Review of Resident #7's Annual Review Assessment with a reference date of 10/03/2023 revealed, in part, that Resident #7 had severe cognitive impairment and was assessed as being at high risk for pressure ulcer development. Review of Resident #35's Quarterly Review Assessment with a reference date of 10/19/2023 revealed, in part, Resident #35 was assessed as being at high risk for pressure ulcer development. Further review revealed Resident #35 had an active diagnosis of Diabetes Mellitus (medical condition which can cause a decrease in pain sensation to the lower limbs). Review of Resident #45's Quarterly Review Assessment with a reference date of 10/06/2023 revealed, in part, that Resident #45 was assessed as being at high risk for pressure ulcer development. Review of Resident #81's Quarterly Review Assessment with a reference date of 10/24/2023 revealed, in part, that Resident #81 was assessed as being at high risk for pressure ulcer development. Further review revealed Resident #81 had an active diagnosis of Peripheral Vascular Disease and/or Peripheral Artery Disease, and Diabetes Mellitus (medical conditions which can cause a decrease in pain sensation to the lower limbs). Review of Resident #83's Quarterly Review Assessment with a reference date of 11/12/2023 revealed, in part, that Resident #83 had severe cognitive impairment, and had four unstageable pressure ulcers. Review of Resident #191's Entry Tracking Record revealed, in part, that she was admitted to the facility on [DATE]. Observation on 12/11/2023 at 11:05 a.m., revealed Resident #191 was not interviewable during screening. Review of Resident #192's Entry Tracking Record revealed, in part, that she was admitted to the facility on [DATE]. Observation on 12/11/2023 at 10:40 a.m., revealed Resident #192 was not interviewable during screening. Review of Resident #193's Admission Assessment with a reference date of 12/06/2023 revealed, in part, that Resident #193 was assessed as being at high risk for pressure ulcer development. Further review revealed Resident #193 had an active diagnosis of Hemiplegia or Hemiparesis (a condition which can result in a decrease in pain sensation to the affected area). Review of Resident #194's Admission Review Assessment with a reference date of 11/21/2023 revealed, in part, that Resident #194 had moderate cognitive impairment and was assessed as being at high risk for pressure ulcer development. Review of the Facility's weekly inspection checklist dated 09/08/2023 revealed, in part, one of the facility's shower rooms had a hot water temperature of 121 degrees Fahrenheit. Further review revealed the weekly inspection checklist did not identify which shower room had the above mentioned temperature. In an interview on 12/11/2023 at 1:25 p.m., S2Maintenance Director stated hot water temperatures should be below 120 degrees Fahrenheit to prevent burns to resident's skin. In an interview on 12/11/2023 at 4:25 p.m., S3Cluster Leader confirmed the new thermometer being used had been calibrated. Observation on 12/11/2023 at 4:27 p.m., revealed S1Administrator tested the hot water temperature in the sink of Shower Room p. Further observation revealed the temperature of the hot water in the sink of Shower Room p was 126.3 degrees Fahrenheit. In interview on 12/11/2023 at 5:00 p.m., S3Cluster Leader acknowledged that he could not say with certainty that Shower Room p was not being used because it was unlocked, had no signage, and was accessible for resident use. In interview on 12/11/2023 at 5:02 p.m., S4Regional [NAME] President acknowledged that she could not ensure that Shower Room p was not currently being used by the residents that resided on the same hall as Shower Room p. Observation on 12/11/2023 at 4:29 p.m. revealed S1Administrator tested the hot water temperature in the sink of Room r. Further observation revealed the temperature of the hot water in the sink of Room r was 130.6 degrees Fahrenheit. Observation on 12/11/2023 at 4:32 p.m., revealed S1Administrator tested the hot water temperature in the sink of Room u. Further observation revealed the temperature of the hot water in the sink of Room u was 131.1 degrees Fahrenheit. Observation on 12/11/2023 at 4:36 p.m., revealed S1Administrator tested the hot water temperature in the sink of Room t. Further observation revealed the temperature of the hot water in the sink of Room t was 131.6 degrees Fahrenheit. Observation on 12/11/2023 at 4:44 p.m., revealed S1Administrator tested the hot water temperature in the sink of Room v. Further observation revealed the temperature of the hot water in the sink of Room v was 125.5 degrees Fahrenheit. In an interview on 12/11/2023 at 4:29 p.m., S1Administrator stated the hot water temperatures in Shower Room p, Room r, Room s, Room t, Room u, and Room v were too hot, and could cause burns to residents.

Based on observations and interviews the facility failed to ensure: 1. Linen was handled and stored per facility policy; 2. Staff performed hand hygiene during peri-care for 1 (Resident #59) of 4 (Resident #3, Resident #18, Resident #59, and Resident #75) sampled residents observed for peri-care; and 3. Staff performed hand hygiene during medication administration for 1 (S10Agency Licensed Practical Nurse) of 2 (S10Agency Licensed Practical Nurse and S28Licensed Practical Nurse) nurses observed for medication administration. Findings: 1. Review of the facility's Laundry and Bedding, Soiled Policy revealed, in part, clean linen should be stored separately, away from soiled linens, at all times. Observation of the laundry room on 12/11/2023 at 10:26 a.m. revealed clean clothes were being stored on a rack in the same room where dirty linen/clothing was being stored. In an interview on 12/11/2023 at 10:45 a.m., S5Laundry stated clean clothes should not be stored in the same room where dirty linen/clothing was being stored. Observation of the laundry room on 12/13/2023 at 9:21 a.m. revealed clean clothes were being stored on a rack in the same room where dirty linen/clothing was being stored. In an interview on 12/13/2023 at 9:21 a.m., S7Laundry stated clean clothes should not be stored in the same room where dirty linen/clothing was being stored. In an interview on 12/13/2023 at 9:26 a.m., S8Housekeeping Laundry Supervisor confirmed clean clothing was being stored in the same room as dirty linen/clothing and this should not happen. Review of the facility's Laundry and Bedding, Soiled Policy revealed, in part, all used laundry should be handled as potentially contaminated using standard precautions (which means gloves and gowns need to be used when sorting). Observation on 12/11/2023 at 10:48 a.m. revealed S6Housekeeping was carrying dirty clothing with her bare hands, and without a laundry bag or a pair of gloves on. In an interview on 12/11/2023 at 10:48 a.m., S6Housekeeping stated she should have had on gloves and the clothing should have been in a laundry bag. In an interview on 12/13/2023 at 9:26 a.m., S8Housekeeping Laundry Supervisor confirmed housekeepers should not transport dirty clothing without gloves. S8Housekeeping Laundry Supervisor further confirmed dirty laundry should be transported in a laundry bag. 2. Observation on 12/12/2023 at 12:15 p.m. revealed S17Certified Nursing Assistant (CNA) entered Resident #59's room to provide peri-care. Observation further revealed S17CNA did not perform hand hygiene prior to applying clean gloves. S17CNA then opened Resident #59's brief, cleansed the suprapubic site with a wipe, then obtained a clean wipe, and cleansed catheter tubing. Observation further revealed S17CNA disposed of soiled wipe, obtained a clean wipe, and cleansed the left groin. Observation further revealed S17CNA disposed of the soiled wipe, obtained a clean wipe, and cleansed the right groin. Observation further revealed S17CNA disposed of soiled wipe, obtained a clean wipe, cleansed head of penis by pulling the foreskin back, then cleansed shaft of penis, and disposed of the soiled wipe. S17CNA then turned Resident #59, obtained a clean wipe, cleansed sacrum, disposed of the soiled wipe, obtained clean wipe, cleansed buttocks, disposed of wipe, removed brief and disposed of brief, then removed gloves without performing hand hygiene. Observation further revealed S17CNA applied clean gloves without performing hand hygiene, placed a clean brief under resident, repositioned Resident #59, and secured the brief. Observation further revealed S17CNA removed gloves, removed garbage bag with soiled brief and wipes, exited Resident #59's room without performing hand hygiene. In an interview on 12/12/2023 at 12:20 p.m., S17CNA stated she should have performed hand hygiene before and after she completed peri-care. In an interview on 12/14/2023 at 9:52 a.m., S11Director of Nursing (DON) stated during peri-care hand hygiene should be performed prior to starting care, between glove changes, and after care was completed. S11DON confirmed S17CNA should have performed hand hygiene between glove changes during peri-care. 3. Review of the facility's Hand Hygiene Policy revealed, in part, use an alcohol-based hand rub containing at least 62% alcohol; or, alternatively, soap (antimicrobial or non-antimicrobial) and water before preparing or handling medications. Observation on 12/13/2023 at 5:21 a.m. revealed S10Agency Licensed Practical Nurse (LPN) prepared medication for Resident #56, entered Resident #56's room, administered medication, then exited Resident #56's room without performing hand hygiene. Observation on 12/13/2023 at 5:25 a.m. revealed S10Agency LPN prepared medication for Resident #12 without performing hand hygiene, administered medication to Resident #12, then exited room without performing hand hygiene. Observation on 12/13/2023 at 5:29 a.m. revealed S10Agency LPN prepared medication for Resident #71 without performing hand hygiene, entered Resident #71's room, administered medication, then exited Resident #71's room without performing hand hygiene. Observation on 12/13/2023 at 5:33 a.m. revealed S10Agency LPN prepared medication for Resident #49 without performing hand hygiene. Observation further revealed, S10Agency LPN provided Resident #49 with a cup to spit mouth wash in, applied gloves without performing hand hygiene, then cleansed Resident #49's mouth after she spit the mouthwash in the cup. Further observation revealed, S10Agency LPN removed gloves and exited Resident #49's room without performing hand hygiene. Observation on 12/13/2023 at 5:37 a.m. revealed S10Agency LPN prepared medication for Resident #53 without performing hand hygiene. Further observation revealed, S10Agency LPN entered Resident #53's room, administered medication, and then exited Resident #53's room without performing hand hygiene. In an interview on 12/13/2023 at 6:00 a.m., S10Agency LPN stated she should have performed hand hygiene after administering medication to residents. In an interview on 12/13/2023 at 10:30 a.m., S11DON stated during medication administration hand hygiene should be performed prior to medication preparation and after administering medication to a resident.

Based on observations and interviews, the facility failed to protect a resident's dignity during personal care for 3 (Resident #18, Resident #59, Resident #75) of 3 (Resident #18, Resident #59, Resident #75) sampled residents investigated for resident privacy. Findings: Observation on 12/11/23 at 10:00 a.m., revealed Resident #75, who resided in semi-private room, had her incontinence brief (diaper) changed by a Certified Nursing Assistant (CNA). Further observation revealed the privacy curtain to one side of Resident #75's bed and the half-wall to the other side of Resident #75's bed did not completely block visualization of Resident #75's personal care, and a CNA could be seen fastening Resident #75's incontinence brief and pulling up her pants from the entrance of the room. In an interview on 12/12/2023 at 9:42 a.m., S21CNA stated she provided for a resident's dignity by ensuring privacy when personal care was being performed. Observation on 12/12/2023 at 10:10 a.m., revealed Resident #18, who resided in a semi-private room, did not have a curtain to provide privacy when he received personal care. In an interview on 12/12/2023 at 10:10 a.m., Resident #18 non-verbally confirmed through gestures and sounds, that he did not have a privacy curtain. Resident #18 further non-verbally confirmed through gestures and sound, the facility's staff only closed the door to the hallway when providing him with personal care. Resident #18 further shrugged his shoulders in a I don't know manner, when questioned how staff provide him with privacy and respect his dignity during personal care, since he has a roommate and no privacy curtain. In an interview on 12/12/2023 at 10:10 a.m., Resident #18's caregiver stated the residents did not have privacy in Resident #18's room. Resident #18's caregiver further stated was uncomfortable when she would go to visit Resident #18, and she could see other resident's in the room receiving personal care. Observation on 12/12/2023 at 11:57 a.m., revealed S21CNA was preparing to perform incontinence care to Resident #75, and Resident #75's nightgown was pulled up, exposing her incontinence brief. Further observation revealed there was no barrier or curtain preventing visualization of Resident #75's personal care if someone were to enter the semi-private room. Observation on 12/12/2023 at 12:02 p.m., revealed S7Laundry opened the door to Resident #75's room and walked into Resident #75's section of her semi-private room to hang clothes. Further observation revealed as S7Laundry was hanging clothes in Resident #75's closet, Resident #75's vaginal area was exposed. Further observation revealed, at no point did S21CNA stop to cover Resident #75's vaginal area while S7Laundry was in Resident #75's room or ask S7Laundry to wait outside until she was done performing incontinence care for Resident #75. Observation on 12/12/2023 at 12:15 p.m. revealed no curtain was pulled around Resident #59's bed while S17CNA was providing catheter and peri-care to Resident #59. Observation on 12/12/2023 at 2:10 p.m., revealed S21CNA performed incontinence care for Resident #18. Further observation revealed, there was no privacy curtain to block visualization of Resident #18's incontinence care being performed from anyone entering Resident #18's room. Further observation revealed S22CNA opened the door to Resident #18's room and poked her head into the room to speak to S21CNA while she was performing Resident #18's incontinence care. Further observation revealed at no point did S21CNA stop to cover Resident #18 while S22CNA was speaking to her or ask S22CNA to wait outside until she was done performing incontinence care for Resident #18. In an interview on 12/12/2023 at 2:15 p.m., S21CNA confirmed that anyone could see into Resident #75's and Resident #18's rooms during their personal care because their privacy curtains do not provide total visual privacy. S21CNA further stated that S7Laundry and S22CNA should not have been able to visualize the resident's while she was providing incontinence care. In an interview on 12/12/2023 at 2:50 p.m., S20Quality Improvement Nurse stated the CNAs should have ensured residents had privacy to maintain their dignity when they were providing personal care, and other staff members should not be going into resident's room while residents were receiving personal care unless absolutely necessary. In an interview on 12/12/2023 at 2:52 p.m., S27Resource Staff confirmed that Resident #18 did not have a curtain to provide privacy during personal care in his room. In an interview on 12/12/2023 at 3:20 p.m., S1Administrator stated CNAs should maintain a resident's dignity and privacy when they performed catheter and incontinence care.

Based on observation, interview, and record review, the facility failed to ensure a dependent resident was provided with incontinence care for 1 (Resident #18) of 6 (Resident #9, Resident #18, Resident #19, Resident #20, Resident #27, and Resident #140) sampled residents investigated for activities of daily living. Review of Resident #18's Electronic Medical Record (EMR) revealed, in part, Resident #18 had hemiplegia (paralysis to one side of the body) following a cerebral infarction (disruption in blood supply to a part of the brain causing tissue to die) affecting the right dominant side and hemiplegia following cerebral infarction affecting the left non dominant side. Review of Resident #18's Minimum Date Set (MDS) with an Assessment Reference Date (ARD) of 11/21/2023 revealed, in part, Resident #18 had a Brief Interview for Mental Status (BIMS) score of 14 which indicated he was cognitively intact. Further review revealed Resident #18 was dependent on staff for toileting hygiene, dependent on staff for personal hygiene, and was always incontinent of bowel and bladder. Review of Resident #18's plan of care revealed, in part, an intervention that staff were to provide incontinence care every two hours and as needed to Resident #18. In an interview on 12/11/2023 at 10:41 a.m., Resident #18's caregiver stated Resident #18 was unable to independently perform his own personal care due to being paralyzed. Resident #18's caregiver further stated Resident #18 was lucky if staff would come to change him two times a day. In an interview on 12/12/2023 at 12:15 p.m., S21Certified Nursing Assistant (CNA) stated she had not changed Resident #18 incontinence brief yet today and would be changing him after lunch. Review of S21CNA's time sheet revealed, in part, S21CNA's start time was 5:25 a.m. on 12/12/2023. In an interview on 12/13/2023 at 9:50 a.m., Resident #18 communicated non-verbally through gestures, sounds, and pointing to the clock, the facility's staff had not changed his incontinence brief since before 8 a.m. Observation on 12/13/2023 from 10:00 a.m. until 12:20 p.m. revealed no staff went into Resident #18's room to change his incontinence brief or to ask if Resident #18 wanted his incontinence brief to be changed. In an interview on 12/13/2023 at 10:45 a.m., Resident #18's caregiver stated there was a problem with the CNAs not changing Resident #18 often enough. Resident #18's caregiver further stated she knew staff did not change Resident #18 as often as they should because she washes his clothes, and sometimes, they [NAME] of urine. In an interview on 12/13/2023 at 1:10 p.m., Resident #18 communicated non-verbally through gestures and sounds, he still had not had his incontinence brief changed today, and no one had come to check if his incontinence brief was wet. Resident #18 further communicated non-verbally through gestures and sounds, he was upset that no one had come to change him despite Resident #18 communicating to a staff member in the hall that he wanted to be changed. In an interview on 12/13/2023 at 1:34 p.m., Resident #18 communicated non-verbally through gestures and sounds, he had not had his incontinence brief changed. In an interview on 12/13/2023 at 1:50 p.m., S21CNA stated she had not changed Resident #18's incontinence brief since she had started her shift today. S21CNA further stated she had not asked Resident #18 if he needed his incontinence brief to be changed today. S21CNA confirmed she had not provided incontinence care and/or had not checked to see if Resident #18 was in need of incontinence care at least every two hours. Review of S21CNA's time sheet revealed, in part, S21CNA's start time was 6:08 a.m. on 12/13/2023. In an interview on 12/13/2023 at 2:27 p.m., S20Quality Improvement Nurse stated if Resident #18 was care planned for incontinence care every two hours, and Resident #18 had communicated to a staff member that he wanted to be changed, then Resident #18 should have been changed. S20Quality Improvement Nurse further stated the CNA's should at least be asking residents if they need to have their incontinence briefs changed every two hours.

Based observation, interview, and record review the facility failed to ensure staff was available at all times to provide care and services to meet the residents' needs for 1 [S23Certfied Nursing Assistant (CNA)] of 4 (S23CNA, S24CNA, S25CNA, and S26CNA) CNAs observed on the night shift from 10:00 p.m. to 6:00 a.m. on 12/12/2023. Findings: Review of the Shift Assignment Sheet dated 12/12/2023 revealed, in part, S23CNA was assigned to provide services to residents on the night shift from 10:00 p.m. to 6:00 a.m. on 12/12/2023. Observation on 12/13/2023 at 5:05 a.m. revealed S23CNA was sitting in the chair in Resident #25's room with her head leaned against the wall, with her eyes closed, and snoring. Further observation revealed Resident #25 was sleeping and in no distress. Observation on 12/13/2023 at 5:07 a.m. revealed the white female dressed in a maroon polo shirt with S23CNA embroidered on the shirt that was sitting in the chair with her head leaned against the wall and eyes closed snoring in Resident #25's room jumped up and stated oh shit! In an interview on 12/13/2023 at 5:08 a.m., S23CNA was asked why she was snoring in Resident #25's room, and S23CNA did not respond/answer the surveyor's questions. In an interview on 12/13/2023 at 1:35 p.m., S1Administrator stated staff should not have been asleep in any resident rooms. S1Administrator further stated he would review the surveillance footage to determine the length of time S23CNA spent in Resident #25's room on 12/12/2023 during the 10:00 p.m. to 6:00 a.m. shift. Review of S23CNA Employee Warning Report dated 12/13/2023 revealed, in part, S23CNA was found sleeping in a resident's room on 12/13/2023 at 5:05 a.m. In an interview on 12/14/2023 at 8:45 a.m., S1Administrator stated he reviewed the surveillance footage and was not able to identify how long S23CNA was in Resident #25's room on 12/12/2023 during the 10:00 p.m. to 6:00 a.m. shift, but S23CNA was terminated due to sleeping in a resident's room on 12/12/2023 during the 10:00 p.m. to 6:00 a.m. shift.

Based on observation, interview, and record review, the facility failed to ensure a medication cart was locked when unattended for 1 (Medication Cart w) out of 3 medication carts (Medication Cart w, Medication Cart x, and Medication Cart y) observed. Findings: Review of the facility's Storage of Medications Policy revealed, in part, unlocked medication carts should not be left unattended. Observation on 12/13/2023 at 5:21 a.m. revealed Medication Cart w was unlocked and unattended while S10Agency Licensed Practical Nurse (LPN) was in Resident #56's room. Observation on 12/13/2023 at 5:25 a.m. revealed Medication Cart w unlocked and unattended while S10Agency LPN was in Resident #12's room. Observation on 12/13/2023 at 5:29 a.m. revealed Medication Cart w was unlocked and unattended while S10Agency LPN was in Resident #71's room. Observation on 12/13/2023 at 5:33 a.m. revealed Medication Cart w was unlocked and unattended while S10Agency LPN was in Resident #49's room. Observation on 12/13/2023 at 5:37 a.m. revealed S10Agency LPN left Medication Cart w unlocked and unattended when she entered Resident #53's room. In an interview on 12/13/2023 at 6:00 a.m., S10Agency LPN stated she should have locked Medication Cart w every time she walked away from Medication Cart w. In an interview on 12/13/2023 at 10:30 a.m., S11Director of Nursing (DON) stated medication carts should be locked when the carts were unattended.

Based on interview and record review the facility failed to ensure a resident was free from accident after S4Certified Nursing Assistant (CNA) failed to ensure a client's safety while turning a resident in order to provide personal care per facility policy for 1 (Resident #1) of 5 sampled residents (Resident #1, Resident #2, Resident #3, Resident #4, and Resident #5) reviewed for accident. This deficient practice resulted in an actual harm on 02/08/2023 when S4CNA disregarded Resident #1's request to stop turning him in bed due to safety concerns and failed to position a resident properly in the bed prior to turning a resident. This caused Resident #1 to roll out of bed onto the floor where Resident #1 sustained a fractured tooth. Resident #1 required dental services, lost a tooth, received stiches to his mouth, sustained pain, required antibiotic use, sustained a contusion to the head, a cut lip, and skin tears to both arms. Resident #1 indicated he had difficulty eating, and was cautious for a while when CNAs were assisting him with turning/personal care after the incident. Findings: Review of the facility's Abuse and Neglect policy revealed, in part, neglect means the failure of the facility, its employees, or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish or emotional distress. Further review revealed, in part, neglect includes cases where the facility's disregard for resident care, comfort, or safety, resulted in or could have resulted in, physical harm, pain, mental anguish, or emotional distress. Review of the facility's turning a resident on his side procedure revealed, in part, slide the resident's shoulders, buttocks, and feet toward you then cross the resident's arms over his chest and the resident's leg nearest you over the leg farthest from you to gently turn the resident away from you. Review of Resident #1's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 03/07/2023 revealed, in part, Resident #1 had a Brief Interview for Mental Status score (BIMS) of 7, which indicated Resident #1had severe cognitive impairment. Further review revealed, in part, Resident #1 required extensive assistance with bed mobility Review of the facility's incident report dated 02/08/2023 revealed, in part, staff were called to Resident #1's room and observed Resident #1 was bleeding from his nose and mouth with skin tears to right and left arm. Further review revealed, in part, during care S4CNA rolled Resident #1 to the edge of the bed, where Resident #1 rolled off the bed onto the floor sustaining skin tears to the right and left arm, and hitting his mouth causing him to lose a tooth. Further review revealed, Resident #1 was provided wound care to skin tears, oral hygiene and nasal cleansing then sent to a hospital emergency room . Resident #1 returned to the facility on an antibiotic due to the missing tooth. Further review revealed, in part, Resident #1 stated S4CNA did not stop turning him when he asked and was rushing while providing care. Review of Resident #1's Nursing Home Visit note dated 02/09/2023 revealed, in part, Resident #1 had upper lip swelling and scabbing, bandages to both arms with skin tears, and discharged from the emergency room with an antibiotic due to a dental fracture. Further review revealed, Resident #1 presented with a diagnosis of fracture of tooth (traumatic), a contusion to the head, and an abrasion of the forearm. In a telephone interview on 04/04/2023 at 1:42 p.m., S4CNA stated she went in to Resident #1's room to assist with changing Resident #1's brief and turned him onto his side. S4CNA stated Resident #1was holding onto the bedside dresser. S4CNA stated Resident #1 told her she was pushing too hard. S4CNA stated she held Resident #1's hip to attempt to prevent him from falling, but Resident #1 rolled out of bed. S4CNA further stated she did not reposition Resident #1 in bed before turning him. In an interview on 04/03/2023 at 12:19 p.m., Resident #1 stated S4CNA rolled him to his side and he fell out of bed. Resident #1 stated he requested S4CNA stop rolling him and she did not. Resident #1 further stated he had skin tears to his right and left arm, discoloration to his right and left eye, and a broken tooth after the fall. In an interview on 04/05/2023 at 9:08 a.m., Resident #1 stated immediately after the fall he had severe pain in his mouth. Resident #1 stated when he returned to the facility the severe pain in his mouth was still present. In an interview on 04/05/2023 at 10:27 a.m., S3Licensed Practical Nurse (LPN) stated she cared for Resident #1 the day after the incident of him falling out of bed. S3LPN also Resident #1 was awake, alert, and oriented and able to make his needs known. S3LPN stated the day after the incident she sent Resident #1 out to the dentist on 02/09/2023 with his daughter. S3LPN stated Resident #1 received prescribed pain medication on 02/10/2023, 02/13/2023, and 02/14/2023 for pain related to his fractured tooth and a laceration to his lip. In an interview on 04/05/2023 at 10:07 a.m., S2Director of Nursing (DON) stated S4CNA should have stopped and assessed Resident #1's position in bed or called for assistance before continuing to care for Resident #1. Review of S4CNA's personnel file revealed, in part, an employee warning report dated 02/09/2023. Further review of type of violation revealed, carelessness and failure to listen to resident. In an interview on 04/05/2023 at 11:20 a.m., S5Regional Nurse Consultant (RNC) stated she was the DON at time of Resident #1's above mentioned incident. S5RNC stated S4CNA disregarded Resident #1's request to stop turning him due to safety concerns which caused Resident #1 to roll out of bed onto the floor which resulted in a fractured tooth. S5RNC further stated Resident #1 experienced harm as a result of the incident.

Based on observation, interview, and record review the facility failed to ensure a resident with a known history of choking and severe cognitive impairment was supervised during meals. This deficient practice was identified for 1 (Resident #91) of 2 (Resident #91 and Resident #43) sampled residents identified as having dysphagia, requiring assistance from staff with eating, and that were investigated for accident hazards in a total sample of 26. This deficient practice resulted in an Immediate Jeopardy situation on [DATE] when Resident #91, a resident with severe cognitive impairment and an identified risk for choking and had a habit of grabbing food and placing things into his mouth, was provided a sandwich wrapped in plastic by a Certified Nursing Assistant (CNA) and left unsupervised. Resident #91 was then found choking by staff, the Heimlich maneuver was performed unsuccessfully, and became unresponsive on [DATE] at 7:30 p.m. Cardiopulmonary Resuscitation (CPR) was initiated by facility staff beginning at 7:30 p.m. and ended at 8:34 p.m., by emergency medical services staff. Resident #91 was pronounced dead at 8:34 p.m. The Immediate Jeopardy situation for Resident #91 ended on [DATE] at 8:34 p.m. when Resident #91 expired after CPR was performed. The Immediate Jeopardy situation continued for 24 residents identified as having impaired cognition and dysphagia because the facility failed to take action to identify other cognitively impaired residents at risk for choking and/or provided supervision to ensure their environment was safe from potential accidents and hazards. This deficient practice had the likelihood to cause serious harm to the remaining 24 residents identified with dysphagia and impaired cognition by the facility. S1Administrator was notified of the Immediate Jeopardy on [DATE] at 5:18 p.m. The Immediate Jeopardy was removed on [DATE] at 7:27 p.m., after it was determined through observations, interviews, and record reviews, the facility implemented an acceptable Plan of Removal, prior to the survey exit, which included: IJ Plan of Removal: 1. The identified risk for the alleged deficient practice was no longer active on Resident #91 due to Resident #91's death on [DATE] related to the choking incident. 2. On [DATE] at 5:15 p.m., S2Director of Nursing (DON)/Designee completed facility wide chart audit to identify any other resident at risk due to the facility failing to assist and/or supervise a cognitively impaired resident with eating who had been identified at risk for choking. 24 residents were identified with dysphagia (difficulty swallowing) and impaired cognition, which made them at risk to be affected by facility failing to assist and/or supervise cognitively impaired residents who had dysphagia with eating. 3. On [DATE] at 5:20 p.m., a room sweep was performed by administrative staff for each of the 24 identified residents at risk to ensure there were no accessible items/food items that could pose harm or injury to the residents at risk. No other potential for harm or injury to cognitively impaired residents were identified during the initial room sweeps, which were completed by [DATE] at 7:35 p.m. 4. The deficient practice had the potential to affect 24 residents. 5. On [DATE] at 5:30 p.m. S2DON/Designee initiated an in-service to facility staff regarding a safe environment, free of accidents and hazards, specific to residents with cognitive impairments and dysphagia. Education included the process to improve resident priority rounds (RPP) by including the evaluation of the resident room environment for accessible items that could cause harm. Education also included identifying residents with a new diagnosis of dysphagia or dementia through the daily clinical review. This information will be reviewed by S1Administrator in the Daily Stand up meeting Monday through Friday at 9:00 a.m., by the S2DON or Designee during daily clinical quality assurance on Monday through Friday at 9:30 a.m., and weekly by S2DON in the High Risk on Thursdays at 2:00 p.m. 6. On [DATE] at 5:35 p.m., S16Social Services and the activities department provided education material to residents and families as an added measure to reduce the amount of items brought in that could be made accessible to cognitively impaired residents. This was completed by [DATE] at 7:35 p.m. 7. On [DATE] at 5:40 p.m., the administrative nursing team added to the resident care guide communication and intervention board a risk for choking for the 24 residents identified as at risk. This will continue to be updated by the administrative nursing team as new residents risk are identified. 8. On [DATE] at 4:30p.m., all in-services, audits and education were completed except on employee S27Licensed Practical Nurse (LPN). S27LPN was removed from the schedule and will be in-serviced on [DATE] at 7:00 a.m., prior to the beginning of her shift by S2DON or Designee. S27LPN will not be allowed to work in the event she does not complete the in-service on [DATE] at 7:00 a.m. 9. On [DATE] at 5:13 p.m., S2DON/Designee initiated a Quality Assurance Performance Improvement (QAPI) for assisting and supervising residents with cognitive impairments and an identified risk for choking and reporting and investigating Abuse/Neglect. Monitoring tools for supervising residents with cognitive impairments and identified choking risk were initiated and will be completed 3 times a week for 4 weeks on Mondays, Wednesdays, and Fridays. The monitoring tools for supervising, reporting and investigating Abuse/Neglect were initiated 3 times a week for 4 weeks on Mondays, Wednesdays, and Fridays and will be performed by S1Administrator. The Week Day stand up Facility Administrator Quality Meeting Tool was updated to include the review of residents with a new diagnosis of dementia or dysphagia and this will be performed by S1Administrator Monday through Friday at 9:00 a.m. The Week Day Clinical Quality tool was updated to include the review of residents for a new diagnosis of dementia and dysphagia, and this will be performed every Thursday at 2:00 p.m. by S2DON or Designee. S1Administrator will monitor for new diagnoses of dementia and dysphagia with daily stand up, S2DON to monitor new diagnoses of dementia and dysphagia with Daily Clinical tool and Weekly High Risk. S1Administrator will monitor compliance of verification of new diagnosis of dementia and dysphagia via QAPI monitoring tool. The monitoring was initiated on [DATE] at 4:30 p.m. The Regional [NAME] President will monitor the facility administration for compliance with supervising the investigation and reporting of abuse and neglect 1 time a week for 4 weeks. 10. The likelihood for serious harm or injury to any resident no longer existed as of [DATE] at 4:30 p.m. Findings: 1. Review of Resident #91's face sheet revealed, in part, Resident #91 was admitted to the facility on [DATE] with diagnoses of Dementia without behavioral disturbance, Dysphagia following unspecified cerebrovascular disease, and Hemiplegia (paralysis on one side of the body) following cerebrovascular affecting dominant side. Review of Resident #91's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of [DATE] revealed, in part, a Brief Interview for Mental Status score of 99, which indicated the resident was unable to complete the interview due to cognitive impairment. Further review revealed Resident #91 required extensive assistance of one staff member for eating and a mechanically altered diet. Review of Resident #91's [DATE] Physician's Orders revealed, in part, an order for a Mechanical Soft diet and a nighttime snack. In an interview on [DATE] at 12:10 p.m., S15MDS Nurse verified that Resident #91 had severe cognitive impairment, required extensive assistance by one person for eating, and required a mechanically altered diet. Review of Resident #91's Comprehensive Care Plan initiated on [DATE] with a target date of [DATE] revealed Resident #91 suffered a choking episode on [DATE]. Review revealed, on [DATE], interventions were added that Resident #91 must be in an upright position when eating and staff were in-serviced to follow Resident #91's proper diet texture. Further review revealed interventions that Resident #91 required assistance with meals, required cuing to eat small bites with sips of liquids in between, and required cuing to eat at slower rates. Review of Resident #91's Departmental Notes revealed, in part, on [DATE] at 10:41 p.m., Resident #91 choked on a sandwich which required the Heimlich maneuver, Cardiopulmonary Resuscitation (CPR), and a hospital emergency department evaluation. Review of Resident #91's Nurse's Notes, dated [DATE] revealed, in part, Resident #91 choked on a sandwich, which required an unsuccessful Heimlich maneuver (a first aid procedure for choking). Further review revealed Resident #91 then became unresponsive and CPR was initiated by facility staff at 7:30 p.m. and continued by emergency medical services upon their arrival until Resident #91's time of death was pronounced at 8:34 p.m. In an interview on [DATE] at 10:40 a.m., S8CNA (Certified Nursing Assistant) indicated she was working with Resident #91 on the night on [DATE]. S8CNA indicated she placed a sandwich on the bedside table of Resident #91 and left Resident #91 unattended to assist his roommate with incontinent care. S8CNA indicated the privacy curtain was closed and she was not able to see Resident #91. S8CNA further indicated another staff member entered the room and noticed Resident #91 was chocking. S8CNA further indicated Resident #91 had a history of choking and needed assistance with meals. S8CNA indicated her plan was to assist Resident #91 with eating the sandwich because he required assistance with meals. In an interview on [DATE] at 1:15 p.m., S5LPN indicated she was the nurse assigned to Resident #91 on the night of [DATE]. S5LPN indicated she was notified by a CNA that Resident #91 was choking. S5LPN indicated S8CNA reported that a sandwich was left on Resident #91's bedside table, Resident #91 was left unsupervised, and then Resident #91 ingested the sandwich wrapped in plastic. S5LPN further indicated Resident #91 was at risk for choking and required assistance with meals due to his risk and history of choking. In an interview on [DATE] at 7:38 a.m., S10CNA indicated she entered Resident #91's room on the night of [DATE] and noticed he was choking. S10CNA indicated S8CNA was in the room assisting Resident #91's roommate with incontinent care and could not see Resident #91 due to privacy curtain being closed. S10CNA further indicated S8CNA stated she left a sandwich on Resident #91's bed side table and Resident #91 ate it without assistance. S10CNA indicated Resident #91 had a history of choking and required assistance with meals. In an interview on [DATE] at 4:10 p.m., S1Adminitrator indicated the facility failed to provide supervision to Resident #91 while he was eating even though he was known to have cognitive deficits and a history of choking. In interview on [DATE] at 3:20 p.m., S2DON indicted she was aware of Resident's #91 choking episode. S2DON indicated Resident #91 was at risk for choking and required assistance with meals and a mechanical soft diet. S2DON further indicated S8CNA was aware of Resident's #91 risk for choking and failed to provide assistance with meals. S2DON further indicated S8CNA was reprimanded. Review of Employee Warning Report completed by S2DON for S8CNA dated [DATE] revealed, in part, S8CNA actions on [DATE] resulted in harm for Resident #91. There was no documented evidence and the facility did not present any documented evidence the facility took immediate action after Resident #91 expired on [DATE] to develop and implement a system in place which identified other cognitively impaired residents at risk for choking and provided supervision to ensure their environment was safe from potential accidents and hazards until [DATE]. In interview on [DATE] at 4:10 p.m., S1Administrator indicated the facility failed to provide supervision to Resident #91 while he was eating even though he was known to have cognitive deficits and a history of choking. S1Administrator further indicated a system was not put in place to identify other cognitively impaired residents at risk for choking and provided supervision to ensure their environment was safe from potential accidents and hazards. 2. Based on record review, interviews, and observations, the facility failed to ensure a resident with a known history of falls and severe cognitive impairment was provided an assessment, supervision, and resident centered interventions following falls for 1 (Resident #43) of 3 (Resident #43, Resident #27, and Resident #56) sampled residents investigated for accidents. Findings: Review of Resident #43's medical record revealed she admitted to the facility on [DATE]. Review of Resident #43's Minimum Data Set (MDS) with an Assessment Reference date of [DATE] revealed, in part, Resident #43's Brief Interview of Mental Status score was 99 indicating resident was unable to complete the interview. Staff assessment for mental status revealed, in part, Resident #1 had short and long-term memory problems, poor decision making skills, and disorganized thinking that fluctuated. Further review of Resident #43's MDS revealed, in part, no falls since previous assessment. Review of Resident #43's face sheet revealed, in part, Resident #43 had diagnoses including a history of falling, the need for assistance with personal care, unspecified dementia, and primary generalized osteoarthritis. Review of Resident #43's Care Plan, initiated on [DATE], revealed, in part, Resident #43 was a high risk for falls with an intervention initiated on [DATE] for staff to encourage Resident #43 to use her call light to call for assistance. Review of Resident #43's incident report dated [DATE] revealed, in part, Resident #43 had an unwitnessed fall in her room with no injury. Review of Resident #43's [DATE] flowsheet for neurological observations which was initiated after Resident #43 sustained an unwitnessed fall, revealed, in part, 8 neurological assessments were not documented as being completed for Resident #43. There was no documented evidence and the facility did not present any documented evidence of that the 8 neurological assessments that were missing from the above mentioned flowsheet were performed after [DATE] fall. Review of Resident #43's incident report dated [DATE] revealed, in part, Resident #43 had a witnessed fall from her wheelchair as a CNA was pushing her on the hallway. Further review revealed Resident #43 was leaning forward in her wheelchair when she fell to the floor and a lump was noted to the left side of Resident #43's forehead. Resident #43 was not sent to the emergency room for evaluation. Resident #43 received a range of motion assessment without concerns, ice packs were placed on her forehead, hourly rounds were continued by staff, and staff educated to report any changes in condition. Review of Resident #43's medical record revealed no documented evidence and the facility did not present any documented evidence that neurological assessments were completed on [DATE] after Resident #43's fall with head injury. Review of the facility's Neurological Assessment Policy, revised [DATE], revealed, in part, neurological assessments are indicated following a fall or other accident/injury involving head trauma or when indicated by residents condition. Review of the facility's Falls Clinical Protocol revealed, in part, if underlying causes cannot be readily identified or corrected, staff will try various relevant interventions based on assessment of the nature or category of falling. In an interview on [DATE] at 10:27 a.m., S2DON stated all falls were discussed in the administrative morning meetings, interventions were discussed as a team, and the interventions were placed in the care plan by the MDS nurse. S2DON stated Resident #43 was not able to follow commands or use a call light to ask for assistance, and encouraging the use of the call light was not an appropriate intervention for Resident #43's fall from her wheelchair while in the hallway. S2DON confirmed there were no appropriate interventions for staff to implement for Resident #43's following her fall from her wheelchair on [DATE]. In an interview on [DATE] at 12:15 p.m., S15MDS Nurse stated she was familiar with Resident #43's recent fall from her wheelchair on [DATE], but she was not aware of the interventions that were put in place. S15MDS Nurse confirmed the intervention documented on Resident #43's care plan to encourage the use of the call light was not an appropriate intervention for Resident #43's fall from her wheelchair while in the hallway. S15MDS nurse acknowledged a pommel cushion could have been placed in her wheelchair as a more appropriate intervention following fall. In an interview with [DATE] at 3:29 p.m., S2Director of Nursing confirmed Resident #43's neurological assessment flowsheet documentation following Resident #43's fall on [DATE] was incomplete. S2Director of Nursing also acknowledged Resident #43 should have had neurological assessments completed after Resident #43's fall with a head injury on [DATE]. 3. Based on record review, interviews, and observations, the facility failed to ensure a resident with a known history of unsafe smoking and moderate cognitive impairment was supervised while smoking for 1 (Resident #27) of 2 (Resident #27 and Resident #78) sampled residents investigated for unsafe smoking. Findings: Review of the facility's Smoking Policy revealed, in part, residents will not be permitted to keep cigarettes, e-cigarettes, pipes, tobacco, and other smoking articles in their possession if they are determined to have smoking restrictions or deemed an unsafe smoker unless they were provided direct supervision. Review also revealed residents with smoking restrictions shall have the direct supervision of a staff member, family member, visitor or volunteer worker at all times while smoking. Further review revealed any smoking-related privileges, restrictions, and concerns shall be noted on the care plan, and all personnel caring for the resident shall be alerted to these issues. Review of the Resident #27's MDS with an ARD of [DATE] revealed, in part, Resident #27's BIMS score was 12, which indicated Resident #27 had moderate cognitive impairment. Review of Resident #27's comprehensive Care Plan revealed, in part, Resident #27 had a potential for injury related to her smoking habit, and on [DATE] Resident #27 was determined to be an unsafe smoker. Further review revealed, Resident #27 should smoke in designated smoke areas, be instructed on safe smoking measures, and may need her cigarettes and lighter given to her by facility staff when Resident #27 needed to smoke. Review of Resident #27's Assessment for Safe Smoking dated [DATE] revealed, in part, Resident #27 was an unsafe smoker. Further review revealed Resident #27 had a history of smoking in non-designated smoking areas. Review also revealed Resident #27 required supervision by staff for safety during smoking. Observation on [DATE] at 10:06 a.m. revealed Resident #27 was sitting outside of the temporary main entrance smoking unattended and unsupervised. Observation revealed a red and black sign near the entrance door that read, No smoking in this area, smoking area noted on side of building. Observation revealed a green pack of Kool brand cigarettes and a red lighter in Resident #27's purse. Further Observation revealed, Resident #27 returned into the facility at 10:11 a.m. In an interview on [DATE] at 1:05 p.m., Resident #27 stated she often went into the temporary main entrance to smoke. Resident #27 also stated she was not supervised by staff, and she was allowed to keep her cigarettes and lighter with her. Observation on [DATE] at 10:45 a.m. revealed S4LPN gave Resident #27 a cigarette from the medication cart. Observation then revealed Resident #27 was approached by S28Therapist about attending therapy, and Resident #27 stated she wanted to smoke first. Observation revealed Resident #27 approached the temporary main entrance and was let outside by S14Ward Clerk. Observation also revealed S22Laundry Personnel exited the facility and lit Resident #27's cigarette for her. S22Laundry Personnel then encouraged Resident #27 to go to the facility's designated smoking area and then left Resident #27 unsupervised. Observation then revealed Resident #27 propelled herself down the side walk, unattended and unsupervised, with a visibly lit cigarette in her mouth. Observation revealed S29Corporate MDS approached Resident #27 and asked Resident #27 if she wanted to come with her and Resident #27 stated no. At this time S29Corporate MDS then continued walking on the side walk, leaving Resident #27 unattended and unsupervised. Lastly, observation revealed Resident #27 continued to smoke a visibly lit cigarette unattended and unsupervised while sitting on the side walk near the side parking lot of the facility until 10:52 a.m. In an interview on [DATE] at 11:00 a.m., S16Social Worker confirmed Resident #27 was an unsafe smoker. In an interview on [DATE] at 11:02 a.m., S1Administrator stated the facility only has two unsafe smokers which are, Resident #27 and Resident #78. S1Administrator stated Resident #78 does not get out of bed at this time and is not smoking. S1Administrator stated her definition of supervision was supervision only to ensure Resident #27 made it to the proper smoking area and did not return into the facility with smoking materials. S1Adminstrator stated Resident #27 did not require direct 1 on 1 staff supervision when smoking. S1Administrator stated Resident #27 should not have passed through multiple facility staff members from multiple departments without someone ensuring Resident #27 arrived to the designated smoking area. S1Administrator also stated staff should be aware of Resident #27's unsafe smoking status. 46361 46683

Based on interview and record review the Administrator failed to: 1.) Take steps to ensure a resident with a known history of choking and severe cognitive impairment was supervised during meals (Resident #91); and 2.) Ensure a system was put in place to identify other cognitively impaired residents at risk for choking and provided supervision to ensure their environment was safe from potential accidents and hazards. to identify other cognitively impaired residents at risk for choking and provided supervision to ensure their environment was safe from potential accidents and hazards (Resident #91). This deficient practice was identified for 1 (Resident #91) of 2 (Resident #91 and Resident #43) sampled residents identified as having dysphagia, requiring assistance from staff with eating, and that were investigated for accident hazards in a total sample of 26. This deficient practice resulted in an Immediate Jeopardy situation on [DATE] when Resident #91, a resident with severe cognitive impairment and an identified risk for choking and had a habit of grabbing food and placing things into his mouth, was provided a sandwich wrapped in plastic by a Certified Nursing Assistant (CNA) and left unsupervised. Resident #91 was then found choking by staff, the Heimlich maneuver was performed unsuccessfully, and became unresponsive on [DATE] at 7:30 p.m. Cardiopulmonary Resuscitation (CPR) was initiated by facility staff beginning at 7:30 p.m. and ended at 8:34 p.m., by emergency medical services staff. Resident #91 was pronounced dead at 8:34 p.m. The Immediate Jeopardy situation for Resident #91 ended on [DATE] at 8:34 p.m. when Resident #91 expired after CPR was performed. The Immediate Jeopardy situation continued for 24 residents identified as having impaired cognition and dysphagia because the facility failed to take action to identify other cognitively impaired residents at risk for choking and/or provided supervision to ensure their environment was safe from potential accidents and hazards. This deficient practice had the likelihood to cause serious harm to the remaining 24 residents identified with dysphagia and impaired cognition by the facility. S1Administrator was notified of the Immediate Jeopardy on [DATE] at 5:18 p.m. The Immediate Jeopardy was removed on [DATE] at 7:27 p.m., after it was determined through observations, interviews, and record reviews, the facility implemented an acceptable Plan of Removal, prior to the survey exit, which included: IJ Plan of Removal: 1. The identified risk for the alleged deficient practice was no longer active on Resident #91 due to Resident #91's death on [DATE] related to the choking incident. 2. On [DATE] at 5:15 p.m., S2Director of Nursing (DON)/Designee completed an audit to identify any other resident at risk due to the facility failing to assist and/or supervise a cognitively impaired resident with eating who had been identified at risk for choking. 24 residents were identified with dysphagia (difficulty swallowing) and impaired cognition, which made them at risk to be affected by facility failing to assist and/or supervise cognitively impaired residents who had dysphagia with eating. 3. On [DATE] at 5:20 p.m., a room sweep was performed by administrative staff for each of the 24 identified residents at risk to ensure there were no accessible items/food items that could pose harm or injury to the residents at risk. No other potential for harm or injury to cognitively impaired residents were identified during the initial room sweeps, which were completed by [DATE] at 7:35 p.m. 4. The deficient practice had the potential to affect 24 residents. 5. On [DATE] at 5:30 p.m. S2DON/Designee initiated an in-service to facility staff regarding a safe environment, free of accidents and hazards, specific to residents with cognitive impairments and dysphagia. Education included the process to improve resident priority rounds (RPP) by including the evaluation of the resident room environment for accessible items that could cause harm. Education also included identifying residents with a new diagnosis of dysphagia or dementia through the daily clinical review. This information will be reviewed by S1Administrator in the Daily Stand up meeting Monday through Friday at 9:00 a.m., by the S2DON or Designee during daily clinical quality assurance on Monday through Friday at 9:30 a.m., and weekly by S2DON in the High Risk on Thursdays at 2:00 p.m. S1Administrator was educated via verbal lecture and handouts regarding supervising, abuse/neglect reporting, and investigation practices. 6. On [DATE] at 5:35 p.m., S16Social Services and the activities department provided education material to residents and families as an added measure to reduce the amount of items brought in that could be made accessible to cognitively impaired residents. This was completed by [DATE] at 7:35 p.m. 7. On [DATE] at 5:40 p.m., the administrative nursing team added to the resident care guide communication and intervention board a risk for choking for the 24 residents identified as at risk. This will continue to be updated by the administrative nursing team as new residents risk are identified. 8. On [DATE] at 4:30p.m., all in-services, audits and education were completed except on employee S27Licensed Practical Nurse (LPN). S27LPN was removed from the schedule and will be in-serviced on [DATE] at 7:00 a.m., prior to the beginning of her shift by S2DON or Designee. S27LPN will not be allowed to work in the event she does not complete the in-service on [DATE] at 7:00 a.m. 9. On [DATE] at 5:13 p.m., S2DON/Designee initiated a Quality Assurance Performance Improvement (QAPI) for assisting and supervising residents with cognitive impairments and an identified risk for choking and reporting and investigating Abuse/Neglect. Monitoring tools for supervising residents with cognitive impairments and identified choking risk were initiated and will be completed 3 times a week for 4 weeks on Mondays, Wednesdays, and Fridays. The monitoring tools for supervising, reporting and investigating Abuse/Neglect were initiated 3 times a week for 4 weeks on Mondays, Wednesdays, and Fridays and will be performed by S1Administrator. The Week Day stand up Facility Administrator Quality Meeting Tool was updated to include the review of residents with a new diagnosis of dementia or dysphagia and this will be performed by S1Administrator Monday through Friday at 9:00 a.m. The Week Day Clinical Quality tool was updated to include the review of residents for a new diagnosis of dementia and dysphagia, and this will be performed every Thursday at 2:00 p.m. by S2DON or Designee. S1Administrator will monitor for new diagnoses of dementia and dysphagia with daily stand up, S2DON to monitor new diagnoses of dementia and dysphagia with Daily Clinical tool and Weekly High Risk. S1Administrator will monitor compliance of verification of new diagnosis of dementia and dysphagia via QAPI monitoring tool. The monitoring was initiated on [DATE] at 4:30 p.m. The Regional [NAME] President will monitor the facility administration for compliance with supervising the investigation and reporting of abuse and neglect 1 time a week for 4 weeks. 10. The likelihood for serious harm or injury to any resident no longer existed as of [DATE] at 4:30 p.m. Findings: Cross Reference F689 There was no documented evidence and the facility did not present any documented evidence S1Administrtor took immediate action after Resident #91 expired on [DATE] to develop and implement a system in place which identified other cognitively impaired residents at risk for choking and provided supervision to ensure their environment was safe from potential accidents and hazards until [DATE]. In interview on [DATE] at 4:10 p.m., S1Administrator indicated failed to provide supervision to Resident #91 while he was eating even though he was known to have cognitive deficits and a history of choking. S1Administrator further indicated she did not take steps to ensure a system was put in place to identify other cognitively impaired residents at risk for choking and provided supervision to ensure their environment was safe from potential accidents and hazards.