Every finding on record at Cherrydale Health & Rehabilitation Center

Based on observation, staff interview, clinical record review, and facility documentation review, the facility staff failed to implement transmission-based precautions to prevent the spread of infections on two of four nursing units, fourth and fifth floors. The findings included:On 11/13/25 at 8:21 AM, licensed practical nurse #2 (LPN #2) was accompanying the surveyor to Resident #6's (R6) room for an observation. While LPN #2 were outside of the room donning necessary personal protective equipment, since the resident was on enhanced barrier precautions, it was observed that two staff members were in the room at the bedside assisting the resident and were only wearing procedure masks and gloves. When the surveyor questioned LPN #2 about the staff in the room, LPN #2 confirmed that they were to have an isolation gown on as well and she called the staff members to the doorway to discuss this. The two staff were identified as licensed practical nursing students. Interviews were conducted with the staff/students, and they reported they had been told last week if there was a yellow sign (pointing to the signage outside the room that was on yellow paper and noted enhanced barrier precautions), they only had to wear a mask. The surveyor asked if they read the sign because it indicated that a mask, gloves and isolation gown were to be worn, neither responded. On 11/13/25, during a clinical record review of R6's chart, it was noted that an active physician order read, Enhanced Barrier Precautions related to g-tube and tracheostomy tube. On 11/13/25 at 8:46 AM, observations were made of a certified nursing assistant #2 (CNA #2) in the room with Resident #9 (R9), the staff member was only wearing gloves and a procedure mask and was at the bedside adjusting the bedlinen. According to the signage outside of R9's room, it indicated the resident was on contact isolation and gloves, mask, and isolation gowns were required prior to entering the room. Observations of the supply bin outside of R9's room revealed an adequate supply of isolation gowns were available. When CNA #2 was exiting the room, they were noted to be carrying two bags, one that had soiled linen and the other with trash. CNA #2 was interviewed and reported he had pulled R9 up in the bed. When asked about the lack of an isolation gown, CNA #2 stated he had not seen the sign. CNA #2 proceeded to exit the room, had not removed the isolation gown or gloves and went to a soiled utility room to discard the bags. On 11/13/25, during a clinical record review of R9's chart, it was noted that the resident had an active physician order that read, Contact precaution r/t [related to] ESBL [extended spectrum beta-lactamase] [a bacteria] in urine. On 11/13/25 at 8:50 AM, while observations were being conducted of medication administration on the fifth floor, two nurses were noted to be working on a medication cart. Licensed practical nurse #3 (LPN #3) was observed removing medications from their package, putting them into the palm of her hand and then placing them into a medication cup. An interview was conducted with LPN #3 and she confirmed she should not be touching medications with her bare hands. On 11/13/25 at 9 AM, a staff member was observed to exit Resident #10's room, wearing a procedure mask, gloves, and isolation gown. The staff member started going through items in the cart with her gloved hands and removing various items from a supply cart in the hallway, while wearing the personal protective equipment (PPE). The employee then re-entered the resident's room. Prior to exiting the room, the employee doffed the PPE and performed handwashing. Upon the employee's exit from the room, an interview was conducted. The employee identified themself as a respiratory therapist (RT). When asked about wearing the PPE into the hall and accessing the supply cart with her gloved hands and then returning to the room, the RT explained that she had gone into the room to retrieve supplies and returned to get them and I didn't touch anything. I work in a hospital and understand infection control. On 11/13/25 at 9:15 AM, during walk-through observations were made on the fourth-floor resident care unit. A nurse was observed in the hallway at a medication cart, the nurse donned gloves and administered eye drops to a resident in the hallway. The nurse then removed her gloves, performed no hand hygiene and began using the computer and then handled medication cards that were on top of the medication cart and returned the medication cards to a drawer within the cart. Upon closing the drawer, the nurse then used hand sanitizer. On 11/13/25 an interview was conducted with LPN #3. LPN #3 explained that PPE is important to protect yourself and also protect the patient whose immune system has been compromised, and we don't want to spread infection around. On 11/13/25 at 10:42 AM, an interview was conducted with the Director of Nursing (DON). The DON was asked to explain the use of PPE with enhance barrier precautions and contact isolation. The DON said, on contact-based precautions you have to put on gloves, mask, and gown up before entering the room. She explained with enhanced barrier precautions, If you provide care you have to wear a gown. When asked if changing bed linen would require use of an isolation gown, the DON said, yes. During the interview, the DON was made aware of the above findings. When asked about the RT who entered the hallway in full PPE and then re-entered the patient's room, she said, We have plenty of PPE to get a new set if you exit and re-enter the room. It still puts the patient at risk. I always tell them no gloves or gowns in the hall. Regarding the administration of eye drops in the hallway, the DON said, No, they shouldn't be administering medications in the hallway. The facility policy titled, Enhanced Barrier Precautions (EBPs), which had an effective date of 3/26/24, was reviewed. The policy read in part, . 3. EBPs require the use of gown and gloves by staff during high-contact patient care activities as defined below: a. Dressing, b. bathing/showering, c. transferring, d. changing linen, e. providing hygiene, f. changing briefs or assisting with toileting, g. device care or use, h. wound care for chronic wounds. 4. Post Enhanced Barrier Precaution signage on the wall outside the patient(s) room. 5. Ensure PPE is available. The facility policy titled, Transmission Based Precautions- General Practice, with an effective date of 12/1/21, was reviewed. The policy read in part, 1. Standard precautions combine the major features of universal precautions and body substance isolation and are based on the principle that all blood, body fluids, secretions, excretions, (except sweat), non-intact skin, and mucous membranes may contain transmissible infectious agents. Standard precautions are to be used during the care of all patients . 4. a. TBPs will be instituted when it is necessary to be especially wary of protecting select patients from infections. b. TBPs will be instituted if there is a risk of spreading infection. e. The health care team and visitors will be instructed on the importance and necessity of maintaining TBPs before entering the patient's room. 5. Fundamental protective measures must be maintained. a. Hand Hygiene and Gloving. 6. Masks, Respiratory Protection, Eye Protection, Face Shields. 7. Gowns and Protective Apparel. On 11/13/25 at 12:30 PM, the above findings were reviewed with the facility's administrator, assistant administrator, director of nursing and regional director of clinical services. No additional information was provided.

Based on resident interview, staff interview, clinical record review and facility documentation review, the facility staff failed to protect the resident's right to be free from neglect for one resident (Resident #4- R4), in a survey sample of eight residents. The findings included:On 11/13/25, a clinical record review was conducted of R4's electronic health record. According to a minimum data set assessment with an assessment reference date of 8/25/25, the resident had a brief interview for mental status score of 15/15, which indicated they were cognitively intact. According to R4's care plan, there were no indications of any cognitive impairments or behavioral problems. On 11/13/25 at 10:30 AM, an interview was conducted with R4. R4 was asked about an incident that occurred on 4/9/25. R4 reported that initially she didn't recall the details of the incident and said, There's always something. When management is not here on weekends, it's pure hell. I don't get care; I lay in feces for hours. You think you are going to get care, and you don't. R4 reported they texted their child daily and gave details of the happenings. The resident requested the opportunity to reference text communication with their child on that day. R4's accessed text messages which stated that the resident had also texted the director of nursing. R4 reported that staff did not respond to the call light for assistance for incontinence care and felt threatened by the certified nursing assistant (later identified as CNA #1) and called the police. According to the text communication sent to the director of nursing (DON) [who was no longer employed by the facility at the time of survey], the resident reported that CNA #1 did not respond to the call bell and the resident was left to lay in feces. When the resident called the police, while the dispatcher was on the phone CNA #1 was asked to leave the room and did not adhere to the resident's request. The nurse then responded to the room with CNA #1, but the resident did not want CNA #1 to provide care and the nurse reported there was no one else to provide the care. CNA #1 later became argumentative with R4 and began displaying aggressive behavior. The details in the message to the DON were stated as, .When she finally realized I wasn't going to allow her to change me, she finally took her gloves off. As she was taking the gloves, she smacked her hands with the gloves, she rolled her hands into a fist with the gloves. I personally felt she was going to physically attack me. Her demeanor had gotten worse. The anger in her eyes & face had dramatically changed. Her erratic behavior was unsettling to me. The resident reported the police did arrive, she talked with them, the officer talked to the nurse and then returned to talk with R4 and the resident reported, . He [police officer] informed me that the CNA who I was working with had gone home. A new shift had just started & someone would be in shortly to take care of me . On 11/13/25, the facility administrator provided the surveyor with the incident summary and facility synopsis. According to the facility records, a nurse working the night of 4/9/25 provided a statement that she had to awaken CNA #1 to answer R4's call light. The nurse reported that CNA #4 was challenging to awaken. The nurse was not available at the time of survey for interview. The facility's conclusion in the incident synopsis read in part, Conclusion: Based on the investigation and interviews, we are substantiating an allegation of neglect. According to the facility synopsis, CNA #1 was noted prior to the incident to be at the nursing station and not responding to resident's requests for assistance/call lights. Review of CNA #1's personnel file, revealed termination of employment was effective 4/17/25. The facility policy titled, Administrative Reference Guide, with an effective date of 1/23/20, was reviewed. The policy read in part, . b. Neglect means a repeated or willful failure to provide timely and consistent services, treatment or care to a patient which are necessary to obtain or maintain a patient's health, safety or comfort; or a repeated or willful failure to provide timely and consistent goods and services necessary to avoid physical harm, mental anguish, or emotional distress, including but not limited to acts that cause, or could cause, pain or injury to a patient or death of a patient; acts that substantially disregard a Center's duties and obligations to a patient; acts that cause or could significantly or likely be expected to cause, mental or emotional damage to a patient. Examples include but are not limited to: . iii. Disregard of physical needs including, but not limited to, toileting and bathing, or continued omission in providing daily care and/or failure to address the omission. On 11/14/25 at 12:30 PM, the above findings were reviewed with the facility Administrator, Assistant Administrator, Director of nursing and Regional Director of Clinical Services. No additional information was provided.

Based on observation, staff interview, clinical record review, and facility documentation review, the facility staff failed to maintain a complete and accurate clinical record for three residents (Resident #5- R5, Resident #6-R6, and Resident #8-R8) in a survey sample of eight residents.The findings included:1. For R5 and R6, the facility staff signed off on a peg tube anchor device was in place that was not being utilized. On 11/13/25 at 8:21 AM, licensed practical nurse #2 (LPN #2) accompanied the surveyor to the room of R6, so that observations of the peg tube (percutaneous endoscopic gastrostomy tube) (tube used for delivering nutrition to patient) could be made. Observations revealed that no anchor to secure the tube was in place. When LPN #2 was questioned about the use of an anchor, LPN #2 stated that the facility only uses anchors for foley/urinary catheters. On 11/13/25 at 8:40 AM, registered nurse #1 (RN #1) accompanied the surveyor to the room of R5. Observations of R5's peg tube revealed that no anchor/securing device was in place. On 11/13/25, a clinical record review was conducted of R5 and R6's physician orders. R5 had an active order dated 11/3/25 that read, Anchor feeding tube every shift for tx [treatment]. R5 also had a prior physician order from 6/2/25-11/2/25, that read, Anchor feeding tube every shift for tx. According to the treatment administration record (TAR), facility staff had signed off each shift three times daily from 11/7/25-11/12/25, that the anchor device was in place. According to R6's physician orders, an order was entered 10/30/25 and remained an active order at the time of review that read, Anchor feeding tube every shift for tx. According to R6's TAR, the anchor device was signed off three times daily, at each shift for the month of November, except for first shift on 11/6/25. The review revealed that on 11/11/25 and 11/12/25, LPN #2 had signed off as the anchor device having been in place. On 11/13/25 at 10:42 AM, an interview was conducted with the director of nursing (DON). When asked about the use of anchor devices for peg tubes, the DON said, we don't use an anchor, we clean it daily and use tape to secure the gauze [gauze dressing placed between the skin and tube bumper]. The surveyor notified the DON of R5 and R6 of having orders for anchor devices to be used and observations that morning revealed they were not in place, the DON stated she would have to get with central supply about an anchor device and if they could order them. The DON stated she was not aware of the physician's order, but if an order was present, they should be following the order. On 11/13/25 at 11:15 AM, a follow-up interview was conducted with LPN #2. LPN #2 was made aware of the physician order for the anchor device for the PEG tube and was asked about her signing off the two days prior that the device was in place. LPN #2 reported that she thought she was signing off that the yankauer [plastic suction tip used to suction a patient] was present in the drawer. On 11/13/25 at 12:30 PM, the facility Administrator, Assistant Administrator, DON and Regional Director of Clinical Services were made aware of the above findings. No additional information was provided. 2. For R8, who went to dialysis at an off-site location three days a week, the facility staff failed to document when the resident left and returned to the facility and failed to include Dialysis Communication Forms into the clinical record. On 11/13/25, R8 was identified as the only resident receiving dialysis services at the facility. According to R8's clinical record, there was no documentation of when the resident left the facility or returned from scheduled dialysis treatment sessions. According to R8's physician orders, the order read, Dialysis 3x weekly [name and address of dialysis site redacted]. There was no indication of when the resident's scheduled dialysis treatments were. On 11/13/25, a review of the facility's sign out book at the nursing station revealed no documentation with regards to R8's departures for dialysis. Review of R8's dialysis book used to communicate between the nursing facility and dialysis clinic was reviewed and didn't include any details of when the resident left or returned to the facility. On 11/13/25 at 12:30 PM, during a meeting with the facility's Administrator, Assistant Administrator, Director of Nursing, and Regional Director of Clinical Services, the above concerns was discussed. The Administrator confirmed that he would expect there to be documentation within R8's clinical record of when the resident left and returned. Review of the facility policy titled, Hemodialysis with an effective date of 1/29/24, was conducted. The policy read in part, . 1. The Dialysis Communication Form will be initiated prior to sending patient for dialysis. A dialysis center's designated form may be used in place of the center's Dialysis Communication Form. 2. Patient reports received from dialysis center will be uploaded to the medical record. A follow-up review of R8's clinical record revealed that no Dialysis Communication Forms had been uploaded into the clinical record for the month of November. No additional information was provided.

Based on observation, staff interview, clinical record review, and facility documentation review, the facility staff failed to follow physician orders for three residents (Resident #1- R1, Resident #5-R5, and Resident #6-R6), in a survey sample of eight residents.The findings included:1. For R1, the facility staff failed to transcribe an order for antifungal medication, which resulted in the resident not receiving the physician ordered medication for two days. On 11/12/25, a closed record review was conducted of R1's chart. This review revealed that R1 was admitted to the facility on [DATE], following hospitalization. According to the hospital discharge summary, while hospitalized , R1 was diagnosed with candida UTI [urinary tract infection]. The hospital discharge summary read in part, . Given his complaint of worsening symptoms of abdominal pain and nausea, fluconazole was initiated . Discharge Medication List: Start taking these medications: fluconazole 200 mg Tabs, Start date: 8/2/25, Take 1 tab by mouth once a day. Indications: a fungal urinary tract infection. Dispense 13 tab. According to R1's physician orders, the order for fluconazole was not transcribed on admission to the nursing facility. The order for fluconazole was entered on 8/4/25, at which time the order read, Fluconazole Oral Tablet 200 mg. Give 200 mg by mouth one time a day for fungal urinary tract infection for 10 days. On 11/12/25 at 4:10 PM, an interview was conducted with licensed practical nurse #1 (LPN #1). LPN #1 explained the process when a resident is admitted and stated, The hospital will call report, we will get the orders, and the orders are put in by the unit manager. If the medication is not available in the Pyxis [automated medication dispensing system/emergency supply of medications], we will call the pharmacy, and they will deliver it before the time it is due/scheduled. LPN #2 reported that the pharmacy delivers to the facility multiple times a day, so getting mediations is not an issue. When asked if there is any reason it would take three-four days for a medication to start, LPN #2 said, Oh no, I don't know of any reason, we have most antibiotics and other medications in the Pyxis, but it doesn't take three days, no. On 11/12/25 at 4:25 PM, during an end of day meeting with the facility administrator, assistant administrator, and director of nursing (DON), the above concerns was discussed. The DON was asked to research why R1 was delayed in receiving the fluconazole medication. The facility staff were asked to provide any policies regarding the admission process and physician orders. On 11/13/25 at 10:42 AM, the DON was asked if she had any additional information regarding R1's fluconazole medication concerns shared the day prior. The DON said, Unfortunately we looked yesterday and there was nothing. It [the order] was put in on the fourth. I talked to the unit manager, and she said when she did her chart check she had identified they [the staff] had not put the order in. We looked under discontinued medications and it wasn't there. The DON confirmed that the medication should have been started on admission as ordered to start on 8/2/25. When asked what the risks are of R1 not receiving the medication as ordered, the DON said, Because it is a kind of antibiotic for fungal, the risk is that what's there [the bacteria] is multiplying and there is a greater risk of the infection going elsewhere. According to the facility policy titled, Physician's Orders, which had an effective date of 1/29/24, it read, 1. Upon every patient's admission or readmission or re-entry to the Center, a licensed nurse will notify the physician requesting and/or verifying physician's orders. The policy went on to read, 2. Upon receiving admission physician's orders from the physician, the nurse will record the order to include: a. Orders- medication and treatment orders must include: 1. Right name of patient. 2. Right name of medication. 3. Right dosage. 4. Right route. 5. Right time. 6. Include diagnosis/reason for use. On 11/13/25 at 12:30 PM, the above findings were again reviewed with the facility Administrator, Assistant Administrator, DON, and Regional Director of Clinical Services. No additional information was provided. 2. For R5 and R6, the facility staff failed to follow physician orders and implement the use of a anchor for the feeding tube. On 11/13/25 at 8:21 AM, licensed practical nurse #2 (LPN #2) accompanied the surveyor to the room of R6, so that observations of the peg tube (percutaneous endoscopic gastrostomy tube) (tube used for delivering nutrition to patient) could be made. Observations revealed that no anchor to secure the tube was in place. When LPN #2 was questioned about the use of an anchor, LPN #2 stated that the facility only uses anchors for foley/urinary catheters. On 11/13/25 at 8:40 AM, registered nurse #1 (RN #1) accompanied the surveyor to the room of R5. Observations of R5's peg tube revealed that no anchor/securing device was in place. No other concerns were noted. On 11/13/25, a clinical record review was conducted of R5 and R6's physician orders. R5 had an active order dated 11/3/25 that read, Anchor feeding tube every shift for tx [treatment]. R5 also had a prior physician order from 6/2/25-11/2/25, that read, Anchor feeding tube every shift for tx. According to the treatment administration record (TAR), facility staff had signed off each shift three times daily from 11/7/25-11/12/25, that the anchor device was in place. According to R6's physician orders, an order was entered 10/30/25 and remained an active order at the time of review that read, Anchor feeding tube every shift for tx. According to R6's TAR, the anchor device was signed off three times daily, at each shift for the month of November, except for first shift on 11/6/25. The review revealed that on 11/11/25 and 11/12/25, LPN #2 had signed off as the anchor device having been in place. On 11/13/25 at 10:42 AM, an interview was conducted with the director of nursing (DON). When asked about the use of anchor devices for peg tubes, the DON said, we don't use an anchor, we clean it daily and use tape to secure the gauze [gauze dressing placed between the skin and tube bumper]. The surveyor notified the DON of R5 and R6 of having orders for anchor devices to be used and observations that morning revealed they were not in place, the DON stated she would have to get with central supply about an anchor device and if they could order them. The DON stated she was not aware of the physician's order, but if an order was present, they should be following the order. On 11/13/25 at 11:15 AM, a follow-up interview was conducted with LPN #2. LPN #2 was made aware of the physician order for the anchor device for the PEG tube and was asked about her signing off the two days prior that the device was in place. LPN #2 reported that she thought she was signing off that the yankauer [plastic suction tip used to suction a patient] was present in the drawer. According to the facility policy titled, Enteral Feeding Tubes with an effective date of 1/29/24, it did not address the use of an anchor device. On 11/13/25 at 12:30 PM, the facility Administrator, Assistant Administrator, DON and Regional Director of Clinical Services were made aware of the above findings. No additional information was provided.

Based on staff interview, clinical record review, and facility documentation review, the facility staff failed to ensure a resident was free from significant medication errors affecting one resident (Resident #1- R1) in a survey sample of eight residents. The findings included:For R1, the facility staff failed to transcribe a physician's order for an antifungal medication to be given for thirteen days, which delayed the initiation of treatment for three days. On 11/12/25, a closed record review was conducted of R1's chart. This review revealed that R1 was admitted to the facility on [DATE], following hospitalization. According to the hospital discharge summary, while hospitalized , R1 was diagnosed with candida UTI [urinary tract infection]. The hospital discharge summary read in part, . Given his complaint of worsening symptoms of abdominal pain and nausea, fluconazole was initiated . Discharge Medication List: Start taking these medications: fluconazole 200 mg Tabs, Start date: 8/2/25, Take 1 tab by mouth once a day. Indications: a fungal urinary tract infection. Dispense 13 tab. According to R1's physician orders, the order for fluconazole was not transcribed on admission to the nursing facility. The order for fluconazole was not initiated until 8/4/25, at which time the order read, Fluconazole Oral Tablet 200 mg. Give 200 mg by mouth one time a day for fungal urinary tract infection for 10 days. According to the medication administration record, R1 was administered the fluconazole from 8/4/25-8/13/25. On 11/12/25 at 4:10 PM, an interview was conducted with licensed practical nurse #1 (LPN #1). LPN #1 explained the process when a resident is admitted and stated, The hospital will call report, we will get the orders, and the orders are put in by the unit manager. If the medication is not available in the Pyxis [automated medication dispensing system/emergency supply of medications], we will call the pharmacy, and they will deliver it before the time it is due/scheduled. LPN #2 reported that the pharmacy delivers to the facility multiple times a day, so getting mediations is not an issue. When asked if there is any reason it would take three-four days for a medication to start, LPN #2 said, Oh no, I don't know of any reason, we have most antibiotics and other medications in the Pyxis, but it doesn't take three days, no. On 11/12/25 at 4:25 PM, during an end of day meeting with the facility administrator, assistant administrator, and director of nursing (DON), the above concerns was discussed. The DON was asked to research why R1 was delayed in receiving the fluconazole medication. The facility staff were asked to provide any policies regarding the admission process and physician orders. On 11/13/25 at 10:42 AM, the DON was asked if she had any additional information regarding R1's fluconazole medication concerns shared the day prior. The DON said, Unfortunately we looked yesterday and there was nothing. It [the order] was put in on the fourth. I talked to the unit manager, and she said when she did her chart check she had identified they [the staff] had not put the order in. We looked under discontinued medications and it wasn't there. The DON confirmed that the medication should have been started on admission as ordered to start on 8/2/25. When asked what the risks are of R1 not receiving the medication as ordered, the DON said, Because it is a kind of antibiotic for fungal, the risk is that what's there [the bacteria] is multiplying and there is a greater risk of the infection going elsewhere. The facility staff provided a policy titled, admission Assessment with an effective date of 1/29/24. The policy did not address admission orders. According to the facility policy titled, Physician's Orders, which had an effective date of 1/29/24, it read, 1. Upon every patient's admission or readmission or re-entry to the Center, a licensed nurse will notify the physician requesting and/or verifying physician's orders. The policy went on to read, 2. Upon receiving admission physician's orders from the physician, the nurse will record the order to include: a. Orders- medication and treatment orders must include: 1. Right name of patient. 2. Right name of medication. 3. Right dosage. 4. Right route. 5. Right time. 6. Include diagnosis/reason for use. On 11/13/25 at 12:30 PM, the above findings were again reviewed with the facility Administrator, Assistant Administrator, DON, and Regional Director of Clinical Services. No additional information was provided.

Based on resident interview, staff interview, clinical record review, and facility documentation review, the facility staff failed to implement their abuse policy for one staff member, which affected one resident (Resident #4-R4) in a survey sample of eight residents. The findings included:For Resident #4, who was a victim of neglect, the facility staff failed to implement their abuse policy for a certified nursing assistant (CNA #1), who was the perpetrator. On 11/13/25, a clinical record review was conducted of R4's electronic health record. According to a minimum data set assessment with an assessment reference date of 8/25/25, the resident had a brief interview for mental status score of 15/15, which indicated they were cognitively intact. According to R4's care plan, there were no indications of any cognitive impairments or behavioral problems. On 11/13/25 at 10:30 AM, an interview was conducted with R4. R4 was asked about an incident that occurred on 4/9/25. R4 reported that initially she didn't recall the details of the incident and said, There's always something. When management is not here on weekends, it's pure hell. I don't get care; I lay in feces for hours. You think you are going to get care, and you don't. R4 reported they texted their child daily and gave details of the events of the day. The resident requested the opportunity to reference text communication with their child on that day. R4's accessed text messages which stated that the resident had also texted the director of nursing. R4 reported that staff did not respond to the call light for assistance for incontinence care and felt threatened by the certified nursing assistant (later identified as CNA #1) and called the police. According to the text communication sent to the director of nursing (DON) [who was no longer employed by the facility at the time of survey], the resident reported that CNA #1 neglected to respond to the resident's request/ call bell for incontinence care and then became aggressive. R4 reported to the DON, .When she [CNA #1] finally realized I wasn't going to allow her to change me, she finally took her gloves off. As she was taking the gloves, she smacked her hands with the gloves, she rolled her hands into a fist with the gloves. I personally felt she was going to physically attack me. Her demeanor had gotten worse. The anger in her eyes & face had dramatically changed. Her erratic behavior was unsettling to me. On 11/13/25, the facility administrator provided the surveyor with the incident summary and facility synopsis. According to the facility records, a nurse working the night of 4/9/25 provided a statement that she had to awaken CNA #1 to answer R4's call light. The nurse reported that CNA #4 was challenging to awaken. The nurse was not available at the time of survey for interview. The facility's conclusion in the incident synopsis read in part, Conclusion: Based on the investigation and interviews, we are substantiating an allegation of neglect. According to the facility synopsis, CNA #1 was noted prior to the incident to be at the nursing station and not responding to resident's requests for assistance/call lights. The charge nurses/supervisor for the shift was aware of CNA #1's actions, lack of attention to resident care, R4's concern which resulted in her calling the police, who responded but took no measures to remove CNA #1. On 11/13/25 a review of certified nursing assistant #1's (CNA #1) personnel file was conducted. This review revealed that the employee was hired on 3/31/25 and was terminated on 4/17/25. The facility staff failed to verify CNA #1 held an active and unencumbered certification to work as a certified nursing assistant until 4/8/25. The facility staff also failed to obtain a criminal background check on CNA #1 until 5/12/25, which was a month after the employee's termination. On 11/13/25 at 10:36 AM, an interview was conducted with the facility's human resources director (HRD). The HRD explained the hiring process and stated that prior to hire/employment the facility obtains a criminal background check and verifies their nursing license/certification. The HRD went on to state that this was important to make sure they have a license and to ensure they don't have any violent offenses or other offenses. During the above interview, the HRD was shown CNA #1's personnel file and confirmed that a criminal background check was not in the file and there was no evidence of a license verification in the personnel file. The HRD stated she would go look and see what she could find. On 11/13/25 at 12:20 PM, the HRD returned and reported that CNA #1 had previously worked for the facility from 9/5/23-11/1/24. With respect to the criminal background check, the HRD said, I'm not sure what happened here. With the license verification, the HRD stated that because she had worked at the facility previously and her license was still active, they did not pull it again. On 11/13/25 at 12:25 PM, the facility administrator confirmed that despite the fact that CNA #1 had previously worked for the facility and they had evidence at the time of her termination that her license remained active at the time of re-hire, they should have checked it again to ensure there were no adverse actions against the license and that it had not been suspended for any reason. According to the facility's policy titled, Prevention/Screening/Training, which read in part, 1. Criminal background and reference checks are performed on all employees. On 11/13/25 at 12:30 PM, the above findings were reviewed with the facility's administrator, assistant administrator, director of nursing and regional director of clinical services. No additional information was provided.

Based on resident interview, staff interview, clinical record review and facility documentation review, the facility staff failed to take measures to prevent further potential abuse, neglect, exploitation, or mistreatment while the investigation was conducted for two residents (Resident #4- R4 and Resident #2-R2), in a survey sample of eight residents.The findings included:1. For R2 who reported an allegation of abuse, the facility staff did not remove the alleged perpetrator and permitted the employee to work the remainder of their shift, therefore having access to other residents. On 11/13/25, a review of facility documentation revealed that on 6/20/25 R2 reported to the facility administrator that a housekeeper (other staff #7- OS #7) said he would beat him [the resident] up. The facility administrator completed an incident summary which was sent to the state regulatory agency at 1:50 PM and noted that the employee had been suspended pending investigation. Review of the timecard for OS #7 revealed that on 6/20/25, the employee worked the remainder of his shift and did not clock out until 4:30 PM. Therefore, the facility failed to protect other residents from an alleged perpetrator while they investigated the allegation of abuse. 2. For R4, who reported an allegation of neglect and intimidation by a staff member, the facility staff failed to remove the alleged perpetrator and allowed the employee to work the following day for an entire shift providing direct resident care to other residents, therefore putting them at risk. On 11/13/25, a clinical record review was conducted of R4's electronic health record. According to a minimum data set assessment with an assessment reference date of 8/25/25, the resident had a brief interview for mental status score of 15/15, which indicated they were cognitively intact. According to R4's care plan, there were no indications of any cognitive impairments or behavioral problems. On 11/13/25 at 10:30 AM, an interview was conducted with R4. R4 was asked about an incident that occurred on 4/9/25. R4 reported that initially she didn't recall the details of the incident and said, There's always something. When management is not here on weekends, it's pure hell. I don't get care; I lay in feces for hours. You think you are going to get care, and you don't. R4 reported they texted their child daily and gave details of the happenings. The resident requested the opportunity to reference text communication with their child on that day. R4's accessed text messages which stated that the resident had also texted the director of nursing. R4 reported that staff did not respond to the call light for assistance for incontinence care and felt threatened by the certified nursing assistant (later identified as CNA #1) and called the police. According to the text communication sent to the director of nursing (DON) [who was no longer employed by the facility at the time of survey], the resident reported that CNA #1 neglected to respond to the resident's request/ call bell for incontinence care and then became aggressive. R4 reported to the DON, .When she [CNA #1] finally realized I wasn't going to allow her to change me, she finally took her gloves off. As she was taking the gloves, she smacked her hands with the gloves, she rolled her hands into a fist with the gloves. I personally felt she was going to physically attack me. Her demeanor had gotten worse. The anger in her eyes & face had dramatically changed. Her erratic behavior was unsettling to me. On 11/13/25, the facility administrator provided the surveyor with the incident summary and facility synopsis. According to the facility records, a nurse working the night of 4/9/25 provided a statement that she had to awaken CNA #1 to answer R4's call light. The nurse reported that CNA #4 was challenging to awaken. The nurse was not available at the time of survey for interview. The facility's conclusion in the incident synopsis read in part, Conclusion: Based on the investigation and interviews, we are substantiating an allegation of neglect. According to the facility synopsis, CNA #1 was noted prior to the incident to be at the nursing station and not responding to resident's requests for assistance/call lights. The charge nurses/supervisor for the shift was aware of CNA #1's actions, lack of attention to resident care, R4's concern which resulted in her calling the police, who responded but took no measures to remove CNA #1. Review of CNA #1's personnel file and timecard revealed that following the incident on 4/9/25, she was permitted to work a full shift on 4/10/25 from 7:05 AM until 3:34 PM, providing direct resident care. The facility policies titled, Prevention/Screening/Training, Reporting Requirements/Investigations, and Administrative Reference Guide, were reviewed. None of the policies addressed protection of residents from alleged perpetrators during an investigation regarding allegations of abuse or neglect. On 11/14/25 at 12:30 PM, the above findings were reviewed with the facility Administrator, Assistant Administrator, Director of nursing and Regional Director of Clinical Services. The administrator confirmed that OS #7 should have left the facility when the allegation was made and not permitted to work the remainder of the shift. On 11/14/25 at 1 PM, the facility administrator confirmed that nurses are the unit supervisors and responsible for the supervision of CNA's and should be taking measures to protect residents when allegations of abuse/neglect are made. No additional information was provided.

Based on observation, resident interview, staff interview, and facility documentation review, the facility failed to maintain an effective pest control program affecting four of four resident units. The findings included: On 6/24/25 at 12:10 p.m., while touring the facility and making observations, the surveyor entered a dually occupied resident room on the fourth floor. In the bathroom observations were made of multiple cockroaches crawling around on the floor. On 6/24/25 at 12:15 p.m., an interview was conducted with the maintenance assistant (Other Employee #5-OE#5). OE#5 was asked about pests within the facility and reported it is a problem. He reported a pest control contractor comes and has bait stations in the ceiling that chemicals are put in. OE #5 accompanied the surveyor to the resident room and confirmed the cockroaches crawling around the floor in the bathroom and stated they were coming from the corner and kicked the wall. When he kicked the wall approximately twenty cockroaches emerged from the wall and began crawling around. OED#5 stated he would caulk the baseboard. On 6/25/25 at 10:05 a.m., an interview was conducted with resident #121 (R121). R121 reported, Roaches are all over the place and mice too. The roaches are terrible, I would say this place is infested, ever since I came here a year ago, I see them, it is getting worse. They run across the floor quite often. On 6/25/25 at 10:10 a.m., an interview was conducted with resident #122 (R122) who resided in the room where the cockroaches were observed on 6/24/25. R122 reported that they have been having trouble with cockroaches, and he sees them crawling on the wall. On 6/25/25 at 1:32 p.m., an interview was conducted with the facility's maintenance director (Other Employee #1- OE#1). OE #1 reported to the survey team that he has certificates in pest control, but they have a company that comes in to provide pest control services weekly. OE #1 reported that prior to him starting at the facility they had a huge rodent problem. OE #1 went on to report that pest control is more of an issue in a building like this because it is extremely hard to treat a problem like that because we can't fumigate, the best we can do is schedule a time to bring residents out the room and he can spray the rooms. We have bait traps in the ceiling. To effectively treat a building like this you need to fumigate, and we don't have the empty space to move residents to do that. On 6/25/25 at 2:15 p.m., during an interview with resident #103 (R103), he reported seeing cockroaches all the time. On 6/25/25 at 2:30 p.m., an interview was conducted with a licensed practical nurse (LPN #4). When asked about pest issues within the facility LPN #4 failed to answer and reported they have books on each unit where they write down when they see pests. On 6/25/25 a review of the pest control logs on each unit was reviewed as well as the pest control company's service reports. This review revealed that on the 200 unit, in the past three months four entries were made in the pest sighting/evidence log and all four noted roaches in resident rooms. The pest sighting log from the third floor noted nine entries in the past two months and all of which noted roaches. The fourth-floor unit logbook had six entries from 5/28/25-6/25/25, all of which noted roaches except for one, which did not indicate what type of pest was observed. The fifth-floor logbooks most recent three entries were all related to roaches. According to the pest control company's service reports the facility was on a cockroach/rodent program. During the technicians' visits he treated cockroaches and, in several reports, specifically 4/8/25 and 5/6/25, the report indicated he observed cockroaches in resident rooms. According to the facility policy titled, Pest Control with an effective date of 5/1/22, it read, the center environment will be inspected monthly and treated for pests by a corporate approved contractor. The policy referenced the pest sighting logbook, notification to the vendor of sightings, vendor provides services as per the corporate-approved agreement. On 6/25/25 at 4:30 p.m., during an end of day meeting, the facility administrator and director of nursing were made aware of the concern that their pest control program was not effective. No additional information was provided.

Based on observations, staff interview, resident interview, clinical record review and facility document review the facility staff failed to ensure staff followed proper infection control practices to include hand hygiene and handling of table linens to prevent contamination during meal service on two of four units ( Unit 4 and Unit 5) and failed to wear the proper personal protective equipment (PPE) for enhanced barrier precautions for Resident #108. The findings included: 1. The facility staff failed to change gloves between tasks and placed clean table linens on the floor before use in the dining room on Unit 4. On 6/24/25 at 12 noon, observations were conducted of the lunch meal service in the fifth-floor dining room. Facility staff were observed wearing gloves to prepare the beverages for resident's trays and while handling and distributing meals to residents in the dining room. The surveyor observed the dietary manager go to the handwashing sink but then leave the dining room. Because the surveyor was going to be observing food temperatures, the plating of food and partaking in a test tray, the surveyor also went to the hand washing sink in the dining room to wash her hands and noted that the soap dispenser was not working. When the dietary manager was asked about a handwashing location, he directed her to a staff area on the unit. Throughout the entire meal service of residents in the dining room, certified nursing assistants were wearing gloves, to distribute food and beverages, touching multiple surfaces and at no point performing any hand hygiene or changing of gloves. On 6/24/25 at 12:15 p.m., an observation was made in the dining room on Unit 4 during the lunch meal. During the entire meal service, the certified nursing assistants were wearing gloves to serve food and beverages, touching multiple surfaces without changing gloves or performing hand hygiene. One aide was observed placing a bag of clean table linens on the floor before placing them on the tables. On two tables she placed the table linens on the table after the tablecloth had touched the floor. On 6/24/25 an interview was conducted with a certified nursing assistant, CNA#3. When asked about wearing of the same gloves in the dining room during the lunch meal CNA#3 said, hand sanitizer not in the dining area yet and with the silver wear we should take gloves off to do that. It contaminates if you wear the same gloves and don't wash your hands. On 6/24/25 at 12:30 p.m., an interview was conducted with CNA#4 When asked about the clean table linen being placed on the floor in the dining room CNA#4 said, table clothes should not have been on floor or touched the floor causes cross contamination, I wear gloves to help with germs but not helping with germs when touching everything with same gloves. On 6/25/25 at 10:00 a.m., a review of facility document was conducted. The document titled, Standard Precautions, read in part, .change gloves between tasks and procedures. Perform hand hygiene upon removing gloves. Handle, transport and process used linen in a manner that prevents contamination of clothing and avoids transfer of microorganisms to other patients. On 6/25/25 at 4:30 p.m., an end of day meeting was held with the administrator and regional nurse consultant. They were informed of the above concerns. No additional information was provided prior to the exit conference. 2. For Resident #108 (R108), who was on enhanced barrier precautions, the facility staff failed to wear appropriate personal protective equipment (PPE) prior to providing direct care. On 6/24/25 at 12:18 p.m., during observations on the resident care unit, it was noted that R108's room had a sign outside the door that stated enhanced barrier precautions and staff were to wear an isolation gown and gloves during any high-contact activity. A staff member (other employee #7-OE#7) was observed in the room providing care/range of motion to the resident's legs/feet and then moved to his upper body, hands/arms and was noted to be only wearing gloves. On 6/24/25 at 12:30 p.m., the staff member OE #7 exited R108's room. OE #7 was interviewed by the surveyor and stated she was with the therapy department and was providing passive range of motion on his lower extremities and upper extremities, performed wrist and fingers range of motion, ankle pumps, and hip flexion. When asked why she wasn't wearing the proper PPE, OE #7 said, He has PPE precautions? I didn't see a sign. Usually, I have on all my stuff. When asked why it is important to wear PPE during care, OE #7 said, To keep any kind of infection from spreading and it has to stay in the room. OE #7 accompanied the surveyor back to R108's room and confirmed the signage for enhanced barrier precautions being present and a bin of PPE outside the room door. On 6/24/25-6/25/25, a clinical record review was conducted of R108's medical record. This review revealed that R108 had a physician order dated 6/24/25 that read, Enhanced barrier precaution r/t [related to] to enteral feeding and wounds. The facility policy titled, Enhanced Barrier Precautions (EBPs) with an effective date of 3/26/24, was reviewed. The policy read in part, Employees providing high-contact patient care activities will follow Enhanced Barrier Precautions (EBPs) for patients who meet the criteria . 3. EBPs require the use of gown and gloves by staff during high-contact patient care activities as defined below: a. Dressing, b. Bathing/showering, c. Transferring, d. Changing linens, e. Providing hygiene, f. Changing briefs or assisting with toileting, g. device care or use, h. wound care for chronic wounds. 4. Post Enhanced Barrier Precaution signage on wall outside the patient room. 5. Ensure PPE is available . On 6/25/25, during an end of day meeting, the facility administrator and director of nursing were made aware of the above findings. No additional information was provided.

Based on observation, staff interview, and facility documentation review, the facility staff failed to store, prepare and distribute food in a sanitary manner in accordance with food service safety standards in the main kitchen. The findings included: In the main kitchen the facility staff failed to label food and store in a way to prevent contamination and to protect the integrity of the food. On 6/24/25 at 11:25 a.m., a tour of the main kitchen was conducted with the dietary manager in attendance. In the walk-in cooler there was a bag of green peas that had been opened and was not labeled with the open date or use by date. There was also a full case of green peas that the bag was open to air. The dietary manager was asked about the storage of opened items and stated, I had cases for each meal, they put that little bit back, I will have to ask why, we don't use partial cases because we have 200 residents. I would expect the bags to be tied up and the box closed. When asked about the date of open items, the dietary manager said, The date is important to know if they rotated it. Also in the walk-in freezer was a silver pan with saran wrap on top that was not covering the entire surface area, leaving the food exposed. The contents had ice build-up on the food. The dietary manager identified the food as turkey meatloaf and said, I will throw that out. There was a bag of bread dough that the dietary manager identified as Caribbean bread, which had a hole in the bag exposing the contents. There was a bag of four fish filets that were open to air, no label to identify the contents, when opened or to be used by and the dietary manager said was [NAME] and was opened two days ago when we served [NAME], it should have been wrapped up. There was a box of sausage patties that had a hole in the bag leaving the contents exposed. The case of bacon was open, the box was not closed, and the contents were easily seen and exposed and had no identification when it was opened or to be used by. In the stand-alone coolers there were three plates of garden salads that had no label to indicate when it was prepared or to be used by. There were three pitchers of a red liquid that had no dates or label to indicate the contents. The dietary manager stated it was juice that had been prepared for the meal. Review of the facility policy titled, Food Storage: Cold with a revision date of October 2019, was conducted. This policy read in part, . 5. The Dining Services Director/Cook(s) insures that all food items are stored properly in covered containers, labeled and dated and arranged in a manner to prevent cross contamination. The CFR [Federal code] read, 3-305.11 Food Storage .D. A date marking system that meets the criteria . (2) Marking the date or day of preparation, with a procedure to discard the food on or before the last date or day by which the food must be consumed on the premises, sold, or discarded . According to the 2017 Food Code published by the U.S. Public Health Service, FDA U.S. Food & Drug Administration chapter 3, section 3-302.15, page 64 stated: Package Integrity. Food packages shall be in good condition and protect the integrity of the contents so that the food is not exposed to adulteration or potential contaminants. On 6/25/25, during an end of day meeting the above findings were shared with the facility administrator and director of nursing. No additional information was provided. 2. The facility staff were stacking stainless steel pans and meal trays wet, which had the potential for bacteria growth. On 6/24/25 at 11:45 a.m., observations within the dish room were conducted which revealed a stack of stainless-steel sheet pans. The dietary manager removed several of the pans which were noted to have standing water and moisture. There were also stacks of meal trays and observation revealed they were also stacked wet and had significant food residue on them. When asked the dietary manager stated that stacking wet/wet nesting can cause bacteria to grow. According to the 2017 Food Code published by the U.S. Public Health Service, FDA U.S. Food & Drug Administration chapter 4, section 4-901.11, titled Equipment and Utensils, Air-Drying Required pages 151-152 stated: After cleaning and sanitizing, equipment, and utensils: (A) Shall be air-dried or used after adequate draining as specified in the first paragraph of 40 CFR 180.940 Tolerance exemptions for active and inert ingredients for use in antimicrobial formulations (food-contact surface sanitizing solutions), before contact with food; and (B) May not be cloth dried except that utensils that have been air-dried may be polished with cloths that are maintained clean and dry. According to the facility policy with a revision date of October 2019, which was titled, Ware Washing, which read in part, 1. The Dining Services Director insures that the nutrition service staff is knowledgeable in proper technique for processing dirty dishware to clean through the dish machine and proper handling of sanitized dish ware . 4. The Dining Services Director ensures that all dishware is air dried and properly stored. On 6/25/25, during an end of day meeting the above findings were shared with the facility administrator and director of nursing. No additional information was provided.

Based on observations, resident interview, staff interview, clinical record review and facility documentation review the facility staff failed to provide beverages to include, but not limited to milk, in accordance with meal tickets to maintain resident hydration for multiple residents on two units out of four units (Unit 4 and Unit 5). The findings included: 1. The facility staff failed to serve milk according to the planned menu for Resident #102, Resident #128, Resident #129 and Resident #130. On 6/24/25 at 12:40 p.m., an observation was made of the lunch meal being served in the dining room on Unit 4. There were approximately 15 residents in the dining room for lunch. The residents were served their meals and four of the residents, Resident #102, Resident #128, Resident #129 and Resident #130 were not served their milk according to their menu. There was a gallon of 2% milk available to be served to the residents in the dining room. On 6/24/25 at 1:00 p.m., Resident #129 said, I like my milk. He asked a staff member for milk and was never served the milk during the lunch meal. On 6/24/25 at 1:15 p.m., an interview was conducted with the dietary aide (OS12). She stated that the meal ticket had what the residents liked and disliked and whatever is listed on the meal ticket was supposed to be served to the residents. OS12 stated that the aides in the dining room were to serve the beverages, should read the ticket, and was to serve everything on the ticket. On 6/24/25 at 1:28 p.m., Resident 102 said, I like milk anytime, but I don't get my milk. I am in my 70's and I need that extra calcium. He was not served milk during the lunch meal. On 6/24/25 at 1:30 p.m., Resident #128 said, I like milk. Her ticket had Lactaid milk, and this milk was not available in the dining room for her to be served. On 6/24/25 at 1:35 p.m., Resident #130 said, I like milk with my coffee and my cereal in the mornings. He was not served any milk during the lunch meal. On 6/25/25 at 2:30 p.m., a facility document was reviewed. The document was titled, Dining and Food Preferences, read in part, .the individual tray assembly ticket will identify allergies, food and beverage preferences or special request, and adaptive equipment as appropriate. On 6/25/25 at 4:30 p.m., an end of day meeting was held with the administrator and regional nurse consultant. They were informed of the above concerns. No additional information was provided prior to the exit conference. 2. For five of eight residents eating lunch in the eating in the fifth-floor dining room, the facility failed to serve beverages in accordance with meal tickets to maintain proper hydration (Resident #111 (R111), Resident #123 (R123), Resident #124 (R124), Resident #125 (R125), and Resident #126 (R126). On 6/24/25 at 12:40 p.m., observations were conducted of the lunch meal service in the fifth-floor dining room. There were eight residents eating lunch in the dining room and four had milk listed on their meal ticket to be served. Neither of the three residents, Resident #111 (R111), Resident #124 (R124), or Resident #125 (R125), were provided with milk. On 6/24/25 at 12:45 p.m., an interview was conducted with R111. The resident reported that she can't drink tea, it makes me sick. I need milk, I'm supposed to have 8 ounces of whole milk once a day, it would be a miracle if I get it. I don't know what the problem is, why they have no juice, ice water, or anything other than tea with meals. According to resident #111's meal ticket it read, . NO ICED TEA. Listed as the items the resident was to receive was 2% milk- 8 oz, hot coffee or hot tea- 8 oz, neither of which were provided. According to R124's meal ticket, he was to receive 2% milk- 8 oz, and eight ounces of iced tea. R124 only received tea with no ice. R125's meal ticket read in part, . Milk with every meal 2% milk- 8 oz, hot coffee or hot tea- 8 oz. R125 was served one cup of tea with her meal. During an interview with R125 when asked about the meals and beverages, the resident said, I don't get any milk or coffee, we get tea, that's it. You never get what's on the ticket, that's why I ask for a salad, I can't go wrong with a chef salad. On 6/24/25 at approximately 1 p.m., the dietary manager was approached and asked about the lack of milk provided to residents eating in the dining room and was shown Resident #111's meal ticket that said no iced tea and to serve milk and hot coffee or hot tea. He immediately began asking the certified nursing assistants who had provided the resident her tray and why she didn't receive the milk as per the meal ticket. After a few minutes and him stating he would take care of it moving forward, the surveyor had to ask if resident #111 could be given a cup of milk so that she had some form of beverage to consume with her meal. The dietary manager began telling the surveyor that he wanted to change the dining process so that the dietary staff handled all of the food service to include the beverages so that they could ensure accuracy versus nursing providing the beverages. Following the surveyor having to ask, a certified nursing assistant then poured and provided resident #111 with a cup of milk. Resident #123's meal ticket indicated she was to have received eight ounces of hot coffee or hot tea and listed coffee a second time in the quantity of eight ounces. R123 only received a cup of tea with her meal. Resident #126 was supposed to receive 8 oz of milk and 8 oz of hot coffee or hot tea with her lunch meal. R126 was only provided with one small cup of milk. The facility policy titled, Dining and Food Preferences with a revision date of October 2019, was reviewed. The policy read in part, . 5. The Registered Dietitian/Nutritionist (RDN) or other clinically qualified nutrition professional will review, and after consultation with the resident, adjust the individual meal plan to insure adequate fluid volume and appropriate nutritional content for residents that do not consume certain foods or food groups . On 6/25/25, during an end of day meeting, the facility administrator and director of nursing were made aware of the above findings. No additional information was provided.

3. Resident #103's lunch was supposed to be grilled chicken salad and milk for his beverage and was not served according to his preferences on his meal ticket. On 6/24/25 at 12:45 p.m., an observation was conducted with residents' meal trays in the resident's room. Resident #103 was being served lunch in his room and had requested a grilled chicken salad for lunch. His meal ticket had grilled chicken salad, crackers, apple crisp, tea and milk, and there was no apple crisp, grilled chicken or milk on his lunch tray. On 6/24/25 at 1:00 p.m., an interview was conducted with Resident #103. He stated that it was many times that he did not receive what was on his meal tickets. Resident #103 said, When I request the salads most of the time the meat that is supposed to be on the salad isn't there, sometimes they bring it and sometimes not. He stated it was supposed to be apple crisp with lunch today and there was none. Resident #103 requested milk with his meals and stated milk was very seldom on his meal tray. On 6/24/25 at 1:15 p.m., an interview was conducted with the dietary aide (OS12). She stated that the meal ticket had what the residents liked and disliked and whatever is listed on the meal ticket was supposed to be served to the residents. OS12 stated that the aides in the dining room were to serve the beverages, should read the ticket, and was to serve everything on the ticket. On 6/25/25 at 2:30 p.m., a facility document was reviewed. The document was titled, Dining and Food Preferences, read in part, .the individual tray assembly ticket will identify allergies, food and beverage preferences or special request, and adaptive equipment as appropriate. On 6/25/25 at 4:30 p.m., an end of day meeting was held with the administrator and regional nurse consultant. They were informed of the above concerns. No additional information was provided prior to the exit conference. Based on observation, resident interview, staff interview, and facility documentation review, the facility staff failed to serve meals in accordance with resident's meals preferences for five of twenty residents (Resident #111-R111, Resident #124- R124, Resident #125- R125, Resident #121- R121, and Resident #103-R103). The findings included: 1. For R111 R124, and R125, the facility staff failed to provide milk in accordance with the residents' preference. On 6/24/25 at 12:50 p.m., R111 was served her lunch meal in the dining room and her beverages consisted of one cup of tea. According to the resident's meal ticket, it read, 2. For five of eight residents eating lunch in the eating in the fifth-floor dining room, the facility failed to serve beverages in accordance with meal tickets to maintain proper hydration (Resident #111 (R111), Resident #123 (R123), Resident #124 (R124), Resident #125 (R125), and Resident #126 (R126). On 6/24/25 at 12:40 p.m., observations were conducted of the lunch meal service in the fifth-floor dining room. There were eight residents eating lunch in the dining room and four had milk listed on their meal ticket to be served. Neither of the three residents, Resident #111 (R111), Resident #124 (R124), or Resident #125 (R125), were provided with milk. On 6/24/25 at 12:45 p.m., an interview was conducted with R111. The resident reported that she can't drink tea, it makes me sick. I need milk, I'm supposed to have 8 ounces of whole milk once a day, it would be a miracle if I get it. I don't know what the problem is, why they have no juice, ice water, or anything other than tea with meals. According to resident #111's meal ticket it read, . NO ICED TEA. Listed as the items the resident was to receive was 2% milk- 8 oz, hot coffee or hot tea- 8 oz, neither of which were provided. On 6/24/25 at approximately 1 p.m., the dietary manager was approached and asked about the lack of milk provided to residents eating in the dining room and was shown Resident #111's meal ticket that said no iced tea and to serve milk and hot coffee or hot tea. He immediately began asking the certified nursing assistants who had provided the resident her tray and why she didn't receive the milk as per the meal ticket. After a few minutes and him stating he would take care of it moving forward, the surveyor had to ask if resident #111 could be given a cup of milk so that she had some form of beverage to consume with her meal. The dietary manager began telling the surveyor that he wanted to change the dining process so that the dietary staff handled all the food service to include the beverages so that they could ensure accuracy versus nursing providing the beverages. Following the surveyor having to ask, a certified nursing assistant then poured and provided resident #111 with a cup of milk. On 6/24/25, in the afternoon, an interview was conducted with the registered dietician (RD). The RD reported that she had been on-site since the prior survey and had conducted interviews with residents to obtain food/meal preferences and completed forms for each resident. The RD provided the surveyor with a binder containing the resident preference forms. Review of this revealed that R111 had no preference form on file, which the RD confirmed. The RD did provide the surveyor with a printout of the meal tracker form and said, I didn't find a preference form, but this has preferences listed. The meal tracker form for R111 read, NO FISH, NO ICED TEA. According to R124's meal ticket, he was to receive 2% milk- 8 oz, and eight ounces of iced tea. R124 only received tea with no ice. According to R124's Food Preferences Interview, which was not dated, the resident was to receive iced tea and milk with lunch daily. R125's meal ticket read in part, . Milk with every meal 2% milk- 8 oz, hot coffee or hot tea- 8 oz. R125 was served one cup of tea with her meal. During an interview with R125 when asked about the meals and beverages, the resident said, I don't get any milk or coffee, we get tea, that's it. You never get what's on the ticket, that's why I ask for a salad, I can't go wrong with a chef salad. R125's Food Preference Interview dated 6/18/25, indicated she was to receive milk at all meals. According to the meal tracker diet information it listed Milk with every meal. 2. For R121, whose preference was to receive oatmeal, the facility staff failed to provide it. On 6/25/25 at 10:05 a.m., an interview was conducted with R121. R121 was in bed and while conversing with the surveyor, a staff member entered the room and provided R121 with his breakfast tray. The certified nursing assistant delivering R121's tray reported that he liked to sleep late in the mornings, so she will heat his breakfast tray and provide it once he awakens. With R121's permission the surveyor reviewed the meal ticket and compared it to the tray contents. R121 received cheerios cereal, and the meal ticket indicated he was to have received oatmeal. When asked, R121 said, I would like to have oatmeal. On 6/25/25 at approximately 10:10 a.m., the surveyor asked the unit manager, who was a registered nurse (RN #1) to accompany her to R121's room. When asked about the cold cereal versus the oatmeal, RN #1 said, If oatmeal is on his ticket, he should have received oatmeal. The resident again confirmed he would like oatmeal. RN #1 returned to her office and called the kitchen via telephone but with no response. RN #1 then went downstairs to the kitchen. Upon her return, RN #1 stated, They do have oatmeal but was able to give no reason why R121 had not received the oatmeal in accordance with his meal ticket and preference. The facility policy titled, Dining and Food Preferences with a revision date of October 2019, was reviewed. The policy read in part, . 2. The Dining Services Director or designee will interview the resident or resident representative to complete a Food Preference Interview within 48 hours of admission. The purpose of identifying individual preferences for dining location, mealtimes, including times outside of the routine schedule, food, and beverage preferences. 3. The food preference interview will be entered into the medical record. 4. Food allergies, food intolerance, food dislikes, and food and fluid preferences will be entered into the resident profile in the menu management software system. 5. The Registered Dietitian/Nutritionist (RDN) or other clinically qualified nutrition professional will review, and after consultation with the resident, adjust the individual meal plan to insure adequate fluid volume and appropriate nutritional content for residents that do not consume certain foods or food groups . On 6/25/25, during an end of day meeting, the facility administrator and director of nursing were made aware of the above findings. No additional information was provided.

Based on observation, staff interview and facility documentation review, the facility staff failed to prepare and serve meals in accordance with the menu, affecting residents on four of four units. The findings included: For the lunch meal on 6/24/25, the facility staff failed to prepare the dessert on the menu. On 6/24/25 at 11:25 a.m., observations were conducted in the main kitchen. The facility dietary staff were observed preparing food to take to the steam table on each unit to distribute. On 6/24/25 at 12:31 p.m., the food arrived in the fifth-floor dining room accompanied by a dietary aide and the dietary manager. The entire meal service of residents on the fifth floor was observed and it was noted that each resident's meal ticket displayed that an apple crisp was the dessert being served. However, residents were served mixed fruit instead. The dietary manager was observed to compare each plate served in the dining room and permitted the plates to be served with no apple crisp served. On 6/24/25 at approximately 1 p.m., the dietary manager was asked about the apple crisp and showed a meal ticket, he said, I will have to check on that when I go back downstairs [referring to the kitchen]. At approximately 1:20 p.m., the dietary manager confirmed that the cook did not prepare the dessert apple crisp due to a call out and he ran out of time. According to the facility menu, the lunch meal was to include apple crisp. According to the facility policy titled, Menus with a revision date of October 2019, it read in part, . 6. Menus are served as written, unless changed in response to preference, unavailability of an item, or special meal. On 6/25/25, during an end of day meeting, the facility administrator and director of nursing were made aware of the above concerns. No additional information was provided.

Based on observation, staff interview and facility documentation review, the facility staff failed to prepare and serve food at an appetizing/palatable temperature on one of four units. The findings included: On the fifth floor the facility staff failed to serve food at a palatable temperature. On 6/24/25 observations were conducted of the noon meal. On 6/24/25 at 11:25 a.m., observations in the main kitchen revealed the staff transferring pans of food to insulated transport boxes to be distributed to each unit. On 6/24/25 at 12 noon, observations on the fifth-floor dining room revealed tray racks that had food trays with plate/pellet bottoms on each tray. On 6/24/25 at 12:31 p.m., the food arrived in the fifth-floor dining room. The dietary aide removed the food from the insulated transport box and placed the pans of food into the steam table. The dietary manager obtained temperatures of the food items which were as follows (all temperatures recorded in Fahrenheit): green beans 197 degrees, macaroni/pasta 143.9 degrees, chicken 148 degrees, pureed chicken 119 degrees, pureed potatoes 146 degrees, pureed macaroni 145 degrees, mechanical soft chicken 150 degrees and pureed green beans 156 degrees. The temperature was not taken of garden salads covered in saran wrap that were sitting on an open to air tray, without any mechanism to maintain a chilled temperature. Staff distributed food to residents in the dining room and then began putting prepared plates onto the plate/pellet bottoms on the trays for distribution to resident rooms. On 6/24/25, during the lunch meal, interviews were conducted with Resident #111, Resident #123, and Resident #124, all expressed concerns that the food is not usually warm when received. On 6/24/25 at 1:10 p.m., the last resident meal tray was placed on a cart, which also included a test tray, which was being distributed to residents on the unit. On 6/24/25 at 1:21 p.m., the last resident was served their tray, at which time the dietary manager began taking temperatures of each food item on the test tray with the surveyor observing. The chicken measured 127.7 degrees, green beans 115 degrees, macaroni and cheese 120 degrees, milk 44 degrees, fruit cocktail 79.5 degrees and tea 74.1 degrees. The dietary manager and surveyor sampled each food item, and the dietary manager stated the chicken was lukewarm and dry, green beans were bland and should be hotter, the macaroni and cheese was bland and barely had any warmth. The fruit cocktail was described by the dietary manager as not cool. The tea was at room temperature and had no ice. The dietary manager confirmed that the food was not palatable. According to the facility policy titled, Meal Distribution with a revision date of October 2019, it read, . 2. The Dining Services Director will ensure that all food items are transported promptly for appropriate temperature maintenance On 6/25/25 at 4:30 p.m., during an end of day meeting, the facility administrator and director of nursing were made aware of the above findings. No additional information was provided.

Based on resident interviews, staff interviews, clinical record review, and facility documentation review, the facility staff failed to ensure medications were available for administration to one of twenty residents (Resident #111- R111). The findings included: On 6/24/25 at 12:45 p.m., while in the dining room, R111 reported, I've never been in a facility that runs out of medications like this one, and runs out of pain medicine so often, why do they have such a problem getting meds to the patients? On 6/25/25, a clinical record review was conducted of R111's chart. According to the physician orders, R111 had orders that included, but were not limited to, Fluticasone Propionate Suspension to be administered with two sprays in each nostril in the morning. According to R111's medication administration record (MAR) on 6/21/25, the scheduled administration for 9 a.m., was noted with a 9, which according to the chart code legend indicated, Other/See progress notes. According to the progress note dated 6/21/25, it read, on order. On 6/25/25 at 2:15 p.m., an interview was conducted with a registered nurse, who was the unit manager (RN #3). RN #3 accessed R111's MAR and progress notes confirming that the resident did not receive the nasal spray as ordered due to it not being available. RN #3 explained the importance of residents receiving their medications as ordered is, RN #3 said, Because they need it and you don't want them to have a heart attack or make them sicker. You don't want them to have adverse actions from not receiving medications for their condition. RN #3 also explained that when a nurse notices the supply is low, should be ordering the medications to prevent them from running out and so they are available for administration as ordered. On 6/25/25 at 3:37 p.m., an interview was conducted with the facility's director of nursing (DON). The DON stated that he expects staff to follow the policy on when medications are not available and the resident and family should be informed that the medication was not available as well as the provider. The DON was informed of the above findings and reviewed R111's MAR and confirmed the above finding. The facility policy titled, Medication Unavailability with an effective date of 1/29/2024, was reviewed. The policy read, .A licensed nurse discovering a mediation on order that is unavailable will initiate appropriate steps to ensu8re medical treatment is provided as ordered. Procedure: 1. A licensed nurse will notify the provider of the unavailability of medication and discuss an alternative order, if necessary. 2. If alternate medication is ordered and is not available, the licensed nurse will activate the backup pharmacy process and procedures. 3. A licensed nurse will documentation notification to the provider of the unavailability in the medical record. 4. A licensed nurse will notify the responsible party of any new orders and document notification in the medical record. On 6/25/25 at 4:30 p.m., during an end of day meeting, the facility administrator, DON and corporate nurse consultant were made aware of the above findings. No additional information was provided.

Based on staff interview, clinical record review, and facility documentation review, the facility failed to notify the resident and the resident's legal representative of a medication change for one of twenty residents (Resident #112- R112). The findings included: On 6/24/25, during a clinical record review, it was noted that R112 was out of the facility on an extended leave of absence and was not available for interview during the survey. R112's clinical record included a power of attorney, which appointed his wife as his legal representative. According to R112's admission record/face sheet, it noted that R112's wife was his A/R [accounts receivable] guarantor, responsible party, and POA [power of attorney]- financial. The wife alleged that the facility started the resident on a muscle relaxer that she was not aware of. On 6/24/25-6/25/25, during a clinical record review it was noted that on admission, R112 was ordered cyclobenzaprine, which was a muscle relaxer, to be administered every eight hours as needed for muscle spasms. Then on 3/8/25, the order was changed to only be for fourteen days. There was no documentation within the clinical record to indicate that the initial order or the revised order dated 3/8/25, was reviewed and/or discussed with the resident or his legal representative. On 6/25/25 at 11:01 a.m., an interview was conducted with a registered nurse, who was the unit manager (RN #3). When asked to explain the process if they receive a new order from the medical provider, RN #3 explained that the nurse transcribes the order into the electronic health record. RN #3 went on to say, You can't assume the doctor told the patient, so you make sure to tell the resident the medication is starting, what it is for and contact the RP [responsible party] if the resident isn't their own RP. RN #3 further confirmed that R112's wife was his responsible party. RN #3 confirmed in the electronic health record of R112 that on 3/8/25, an order for cyclobenzaprine was received and there was no evidence that the resident or RP were made aware of the order. On 6/25/25 at 11:31 a.m., during an interview with the facility's Director of Nursing (DON), the above findings were discussed and reviewed. On 6/25/25 at 3:37 p.m., during a follow-up interview, the DON confirmed the above findings and that he had no supporting evidence that the resident and/or responsible party were made aware of the order for cyclobenzaprine. He stated that he would expect the nursing staff to review all orders and order changes with the resident and/or responsible party. On 6/25/25, the facility policy titled, General Guidelines for Medication Administration was reviewed. This policy did not address physician orders other than indicating medications are administered in accordance with physician orders. On 6/25/25 at 4:30 p.m., during an end of day meeting, the facility administrator, director of nursing and corporate nurse consultant were made aware of the above findings. On 6/26/25, the facility staff were asked to provide the survey team with the facility policy regarding physician orders or changes in plan of care. The facility supplied a policy titled, Significant Change of Condition, which did not specifically address new orders other than in the event a resident has a status change. In which case the policy read, . 3. Responsible party will be notified of a change of condition . No additional information was provided.

Based on staff interview, clinical record review and facility documentation review, the facility staff failed to provide a resident with written notice and reason for a room change for one of twenty residents (Resident #112- R112). The findings included: On 6/24/25, during a clinical record review, it was noted that R112 was on leave of absence and was not scheduled to return prior to completion of the survey, therefore he was not able to be interviewed. On 6/24/25-6/25/25, during a clinical record review, according to the census tab, R112 was admitted to a room on the fifth floor. On 3/6/25, R112's room was changed to a different room on the fifth floor. On 5/22/25 R112 was moved from the fifth floor to a room on the fourth floor. Then on 6/13/25, R112 was again moved to another room on the fourth floor. According to the nursing progress notes there were no entries dated 3/6/25, to document the room change. There was a progress note dated 3/8/25, that read in part, . notified of room change on 03/08/2025 12:00 AM. [R112's wife's name redacted] notified on 03/08/2025. Reason for change: Medical management (i.e. isolation, acuity, treatments, symptoms mgmt, etc.). [R112's wife's name redacted] consented to room change. Nursing initiated room change. SW will continue to monitor as resident adjust to his new setting. According to a progress note dated 5/22/25 at 3 p.m., the note read, Resident was moved from 512A to 423A with skin intact and stable. Another note dated 6/13/25, read, Resident alert and verbally responsive. Resident is aware of the move. Resident was moved from 423A to 412B with skin intact and stable. NP notified and called place to wife but no answer. There were no details noted to indicate the reason for the room changes, nor that the room change was provided to the resident in writing. On 6/25/25, interviews were conducted with the nurse managers on the fourth and fifth floors and admissions director, none of which were able to explain why the room change from the fifth floor to the fourth floor was performed. On 6/25/25 at 3 p.m., an interview was conducted with the social worker, who explained that the room change was for bed management. The social worker stated that R112 was notified the day prior, but confirmed she had no evidence that he was provided information in writing of the room change. On 6/25/25 at 4:30 p.m., during an end of day meeting, the facility administrator, director of nursing and corporate nurse consultant were made aware of the above findings. On 6/26/25, the facility policy titled, Room to Room Transfer was reviewed. The policy read, The center will complete the transfer of a patient to a different room efficiently and without incident for the patient. Procedure: 1. Nursing will notify the Social Services Department of room change requests. 2. The Social Services Department will initiate appropriate documents, notify patient(s) and/or responsible parties, and obtain signatures as indicated. 3. The Interdisciplinary Team will work collaboratively to ensure all room transfers are handled efficiently. 4. Ensure all medical records are transferred appropriately. 5. Transfer all patient's belongings. 6. Orient patient to new room and location in the center. 7. Introduce patient to new roommate, if applicable. No additional information was provided.

Based on observation, resident interview, staff interview, clinical record review and facility documentation the facility staff failed to ensure that one resident (Resident #102) out of a survey sample of 20 residents, was treated with respect and dignity by performing personal grooming without the resident's consent. The findings included: The facility staff shaved off Resident #102's full beard without first obtaining permission. On 6/24/25 at 11:30 a.m., during the initial tour of unit four of the facility an observation was made of Resident #102 standing at the nurse's station very upset about his beard being shaved off this morning. Resident #102 was observed with a redness and razor burn appearance to his face. Resident #102 had beard hair that was still on his neck area. He was very anxious and pacing on the unit. Resident #102 was saying that something needs to be done now for this hurting and burning on my face. On 6/24/25 at 11:35 a.m., an interview was conducted with Resident #102. Resident #102 said, I was anxious to be getting a shower and when in the shower room the girl just started shaving my mustache first then my beard. I was trying to stop her, but she just kept going and shaving my beard. I only have use of one arm and was unable to push her away, but I was going to try. Resident #102 was upset about his beard being shaved and said, I hope they will let it grow back. On 6/24/25 at 11:40 a.m., an interview was conducted with a certified nursing assistant, CNA#3. CNA#3 stated that Resident #102 was just shaved, and his face just became that red. She stated that she applied aftershave lotion after he was shaved. On 6/24/25 at 11:45 a.m., an interview was conducted with a licensed practical nurse, LPN#6. LPN#6 said, [Resident #102's name was redacted] family wanted his beard shaved off and hair trimmed. His sister had trimmed his beard and then requested it to be shaved off. On 6/25/25 at 1:45 p.m., an interview was conducted with Resident 102's sister. She was visiting with her brother today and agreed to answer some questions about his care. Resident 102's sister said, I never asked anyone to shave his beard. He has had that beard a very long time. I asked the staff here if they would make sure to clean his beard and so no food would be in his beard after he ate his meals. She stated Resident 102 was upset about the beard being shaved off because he has had it for a long time. On 6/25/25 at 2:30 p.m., a clinical record review was conducted. There was no documentation of consent or refusal noted for shaving Resident 102's beard, and his care plan was not updated to reflect the resident's grooming preferences. The nurse practitioner saw Resident 102 the day he was shaven. She ordered hydrocortisone cream to be applied to his razor burn on his face. On 6/25/25 at 3:00 p.m., a review of facility documentation was conducted. The facility document titled, Resident Rights Annual Review, read in part, .be treated with consideration, respect, and full recognition of his/her dignity and individuality, including privacy in treatment and in care for his/her personal needs. On 6/25/25 at 4:30 p.m., an end of day meeting was held with the administrator and regional nurse consultant. They were informed of the above concerns. No additional information was provided prior to the exit conference.

Based on resident interviews, staff interview, clinical record review, and facility documentation review, the facility staff failed to administer medications to one of twenty residents (Resident #111- R111). The findings included: On 6/24/25 at 12:45 p.m., while in the dining room, R111 reported, I've never been in a facility that runs out of medications like this one, and runs out of pain medicine so often, why do they have such a problem getting meds to the patients? On 6/25/25, a clinical record review was conducted of R111's chart. According to the physician orders, R111 had orders that included, but were not limited to, Atorvastatin Calcium 40 mg tablet, that was to be given at bedtime daily and Apixaban 5 mg tablet that was to be administered every 12 hours. According to R111's medication administration record (MAR) on 6/19/25, the scheduled administration for 9 p.m., was blank with no indication that the medications were administered. R111's chart had no progress notes dated 6/19/25, that addressed why the medications were not administered. R111's chart contained no progress notes dated 6/19/25, to explain why medications were not administered. According to the census tab and progress notes, there was no indication that R111 was not at the facility at the time of scheduled administration. On 6/25/25 at 2:15 p.m., an interview was conducted with a registered nurse, who was the unit manager (RN #3). RN #3 explained that when medications are given, they are signed off on the MAR. RN #3 accessed R111's MAR and confirmed the above findings and stated that she can't say that R111 received the medications as ordered and the nurse that was assigned to R111 on the evening of 6/19/25, was an agency nurse that no longer works at the facility. RN #3 added, If it is not documented, it was not done. When asked what the importance of residents receiving their medications as ordered is, RN #3 said, Because they need it and you don't want them to have a heart attack or make them sicker. You don't want them to have adverse actions from not receiving medications for their condition. On 6/25/25 at 3:37 p.m., an interview was conducted with the facility's director of nursing (DON). The DON stated that he expects staff to sign off on medications following the administration. When asked what a blank on the MAR indicates, he stated that They didn't give or accidentally didn't sign off. If we see a blank hole we should call and address, it. The DON was informed of the above findings and reviewed R111's MAR and confirmed the above findings. He stated he had no evidence that R111 received the medications as ordered by the provider on the evening of 6/19/25. The facility policy titled, General Guidelines for Medication Administration with an effective date of 09/2018, was reviewed. The policy read in part, .IV. Documentation (including electronic). 1. The individual who administers the medication dose records the administration on the resident's MAR directly after the medication is given. At the end of each medication pass, the person administering the medications reviews the MAR to ensure that necessary doses were administered and documented. In no case should the individual who administered the medication report off-duty without first recording the administration of any medications . On 6/25/25 at 4:30 p.m., during an end of day meeting, the facility administrator, DON and corporate nurse consultant were made aware of the above findings. No additional information was provided.

Based on observations, interviews, record review and policy review, the facility failed to ensure that staff followed the Infection Control and Prevention Program standards, policies, and procedures affecting five residents (Resident (R) 346, R56, R3, R145, and R178) of 46 sampled residents. Immediate Jeopardy (IJ) was determined related to the failure to disinfect multi-use glucometers with a manufacturer approved disinfectant when performing fingerstick blood glucose testing between residents, with the IJ start date identified as 4/22/25 at 8:14 AM. Following the facility's provision of an acceptable Immediate Jeopardy Removal Plan, the survey team verified full implementation of the removal plan, and the Immediate Jeopardy was subsequently removed on 04/23/25 at 11:20 AM. After the removal of the Immediate Jeopardy, the remaining noncompliance was determined to be at the scope and severity of Level Two - Pattern, with potential for more than minimal harm. Findings include: 1. For Resident (R) 346, R56, R3, and R145, the facility failed to ensure that multi-use glucometers were properly disinfected with an approved environmental protection agency (EPA) disinfectant when performing fingerstick blood glucose testing between residents. During medication administration on 04/22/25 at 8:14 AM, Registered Nurse (RN) 1 obtained R346's blood sugar (BS) and did not disinfect the glucometer prior to placing it back into the caddy. At 8:17 AM, RN1 obtained R56's BS with the same glucometer without it being disinfected prior to use. At 8:28 AM, RN1 finished and cleaned the glucometer with a germicidal wipe; however, RN1 did not allow it to dry before placing it back into the caddy. Review of R346's Admission Record under the tab Profile located in the Electronic Medical Record (EMR) indicated R346 was admitted to the facility on [DATE] with a diagnosis of type two diabetes mellitus. Review of R346's Order Summary under the tab Orders located in the EMR, dated 04/12/25 indicated, Fingerstick BS every six hours. Review of R56's Admission Record under the tab Profile located in the EMR indicated R56 was readmitted to the facility on [DATE] with a diagnosis of type two diabetes mellitus. Review of R56's Order Summary under the tab Orders located in the EMR dated 09/15/24 indicated, AccuCheck's before meals and at bedtime. Interview on 04/22/25 at 1:00 PM, RN1 confirmed that she did not disinfect the glucometer between residents and indicated that she should have. RN1 verbalized that the glucometer can be disinfected with either the germicidal wipes or with alcohol wipes if the germicidal wipes are not available. During another medication observation on 04/22/25 at 11:00 AM, LPN2 wiped the glucometer with alcohol wipes before and after use to obtain the BS results for R3. LPN2 verbalized that this was the process that the facility uses to clean the glucometer. During a third medication observation on 04/22/25 at 12:15 PM, Licensed Practical Nurse (LPN) 1 verbalized that the glucometers are cleaned with alcohol pads. LPN1 was observed completing R145's BS check and then afterwards, LPN1 cleaned the glucometer with alcohol pads and allowed the glucometer to dry. Review of R145's Admission Record under the tab Profile located in the EMR indicated, R145 was readmitted to the facility on [DATE] with a diagnosis of type two diabetes mellitus. During an interview on 04/22/25 at 2:20 PM, the DON stated that the glucometers should be sanitized with a germicidal wipe, left wet to dry one to five minutes, then put up, and this was to be done between residents. He stated that it depended on the type of wipes they get from the manufacturer. The DON explained that white bottom container of wipes with red top are five minutes and the white bottom container of wipes with purple top is one minute. The DON confirmed that alcohol wipes should not be used. Review of facility's policy titled, Patient Care Equipment dated 04/06/23 indicated, It is the center's policy to maintain an environment that reduces the risk of transmitting and acquiring infections, therefore all clinical equipment shall be handled in such a manner as to eliminate, reduce or minimize the spread of disease. Procedure .13. Glucometers: a. Clean the outside of the meter using a lint-free cloth. Clean in accordance with the manufacturer's recommendation. Review of the facility provided User's Guide for the Meter Memory glucometers, which were used to obtain the blood sugars, revealed that the glucometers should be cleaned and disinfected between each patient and requires a germicidal wipe disinfectant, which alcohol is not. The survey team discussed the potential for this facility's failure to disinfect multi-glucometers with an appropriate disinfectant increases the likelihood of transmission of bloodborne pathogens among all residents requiring this point-of-care testing. It was determined that immediate action was needed to prevent the likelihood of transmission of bloodborne pathogens between residents. Following consultation with the SA to confirm that immediate Jeopardy (IJ) exists, the facility's Administrator, Administrator in Training (AIT), Director of Nursing (DON), Regional Director of Clinical Services, and [NAME] President of Operations were informed on 04/22/25 at 3:44 PM that the facility was in IJ. The facility provided the following Immediate Jeopardy Removal Plan, that was accepted on 04/22/25 at 5:22 PM. Plan Corrective Action for those residents found to be affected by the deficient practice: A. R346, R56, and R145 had no negative outcomes related to the deficient practice. Corrective Actions taken for residents with potential to be affected by deficient practice: A. Residents who require blood sugar monitoring will have their glucometers cleaned after each use with the appropriate disinfectant that will kill bloodborne pathogens and kept out until the dry time has completed. Two glucometers will be placed in each nurses cart to allow for time in-between use to allow for proper disinfection. Systemic Changes put into place to ensure the deficient practice does not recur: A. The Interdisciplinary Team (Administrator, Director of Nursing, Assistant Director of Nursing, Director of Social Work, Activities Director, Dietary Manager, Business Office Manager, Director of Maintenance, Director of Housekeeping and Laundry, Human Resources, and Unit Managers) will be educated by the Regional Director of Clinical Services on the facility policy for using glucometers to maintain infection control standards. This education will cover how to disinfect the glucometer after use on each patient and the required dry time to prevent the spread of bloodborne infections. All licensed nursing staff will be educated by the DON or designee on the glucometer cleaning policy per manufacturer guidelines to include the steps to take to use and disinfect after each patient. This education will be provided to agency nurses prior to starting with the facility. Any nurse who hasn't completed will be educated before the start of their next shift. The Administrator to conduct an ADHOC Quality Assurance Performance Improvement Meeting on 4/22/25 including the Administrator, Director of Nursing, Assistant Director of Nursing, MDS Coordinator, Director of Social Work, Activities Director, Dietary Manager, Business Office Manager, Director of Housekeeping and Laundry, and Unit Managers to review the policy for the use of glucometers. Monitoring of corrective action to ensure the deficient practice does not recur. A. DON or designee will monitor the procedure for disinfecting the glucometer between residents by random observations of glucometer usage/use five times per week for four weeks and weekly for four weeks. Completion of removal plan 4/22/25 at 9:00pm. The Administrator made the Medical Director aware of the Immediate Jeopardy via telephone on 4/22/25 at 4:14pm The survey team reviewed the in-service training documentation/signature sheets for nursing staff and verified procedures were in place to educate the remaining staff prior to the start of their next shift. All staff educated had a competency checklist completed, that included indications of return demonstration of proper disinfecting procedure. No concerns were noted. The survey team reviewed education of interdisciplinary team regarding disinfection procedure of glucometers, reviewed documentation of ad hoc QAPI meeting held by administrator on 4/22/25 regarding F880 IJ, interviewed all nurses providing direct care and medication administration on units 2, 3, 4, and 5, with all able to describe/verbalize steps for proper disinfection of glucometers using germicidal wipes. The survey team also verified that two glucometers and supply of germicidal wipes were available on all medication carts in use in the facility. No concerns were noted. The survey team reviewed the form that had been developed for monitoring the disinfecting procedure for glucometers in coming weeks, as listed in removal plan. No concerns were noted. After consulting with the SA, the survey team determined that the removal plan was fully implemented and that the likelihood of serious injury, serious harm, serious impairment, or death no longer existed, the facility was notified that the Immediate Jeopardy had been removed on 04/23/25 at 11:20 AM. 2. For R178, who was on Enhanced Barrier Precautions (EBP), facility staff failed to wear personal protective equipment (PPE) during catheter care. Review of facility policy titled, EBP dated 03/26/24 indicated, Employees providing high-contact patient care activities will follow EBP for patients who meet the criteria. Procedure: 1. May be indicated for patients .with indwelling medical devices ( .urinary catheter) .3. EBP require the use of gown and gloves by staff during high contact patient care activities as defined below .g. device care or use ( .urinary catheter) Review of facility policy titled, Personal Protective Equipment, dated 05/27/21, indicated, PPE is provided to employees at no cost to them. Procedure .2. Gloves .Disposable gloves are to be replaced if contaminated, if torn or punctured, or if the gloves' ability to function as a barrier is compromised. Review of R178's Admission Record under the tab Profile located in the EMR indicated R178 was admitted to the facility on [DATE] with a diagnosis of obstructive and reflux uropathy. Review of R178's Order Summary under the tab Orders located in the EMR dated 03/27/25 indicated, EBP related to Foley and trach, every shift for precaution. 3. For R178, facility staff failed to ensure that soap was used during catheter care, and failed to ensure that gloves were changed before going from a dirty area to a clean area, along with appropriate hand hygiene. During catheter care observation on 04/23/25 at 11:07 AM, Certified Nursing Assistant (CNA) 2 was observed gathering two washcloths, and one towel which he brought into R178's room without putting on any PPE prior to entering room. After putting on gloves, one washcloth dropped on the floor. CNA2 picked the washcloth up off the floor with a gloved hand and placed it on the overbed table. With the same gloves, CNA2 went through R178's dresser drawers and found a gray wash basin. CNA2 added a small amount of water in the basin without soap and placed the basin on the overbed table. At this time, CNA2 removed his gloves and emptied R178's Foley catheter. CNA2 applied gloves again, wiped the catheter tubing with the wet washcloth, in a downward motion, changed the direction of the washcloth, and dried the tubing while wearing the same gloves. CNA2 refastened the incontinent brief on R178. During an interview on 04/23/25 at 11:15 AM, CNA2 stated that PPE (gown, gloves, and mask) should have been worn because he is on EBP related to catheter care. He confirmed that he did not wear the appropriate PPE. CNA2 stated that gloves should be changed when going from a dirty area to a clean area. CNA2 said that he did not change his gloves when going from a dirty area to a clean area. CNA2 explained that he did not put soap into the water because he thought it was just a demonstration, so he .just left it out. During an interview on 04/23/25 at 2:00 PM, RN3 indicated that PPE (gown, gloves, mask) should have been worn due to R178 being on EBP. RN3 indicated that CNA2 should have used soap in the water and should have changed gloves when going from dirty area to clean area. During an interview on 04/23/25 at 3:00 PM, the DON stated that he expected that CNA2 to wear appropriate PPE (gown, gloves, mask) due to R178 being on EBP. The DON stated that he expected CNA2 to add soap to the water and change his gloves when going from a dirty area to a clean area. No additional information was provided prior to survey exit. 21875 4. For Resident #56, staff failed to follow infection control practices for proper positioning of a urinary catheter bag. R56's clinical record documented that Resident #56 (R56) was admitted to the facility with diagnoses that included cerebral infarction with hemiplegia, diabetes, hypertension, anemia, obstructive uropathy, and cognitive communication deficit. The minimum data set (MDS) dated [DATE] assessed R56 with moderately impaired cognitive skills. The record also included a physician's order dated 9/17/24 for a Foley urinary catheter for management of urinary retention due to obstructive uropathy. On 4/21/25 at 2:53 p.m., R56 was observed in bed. The urine collection bag for R56's catheter was positioned with the bottom part of the bag resting on the floor. The bag was strapped to the bed frame but was not positioned or strapped to ensure the bag was off the floor. On 4/22/25 at 7:51 a.m., R56 was observed in bed. The urinary catheter bag was observed positioned with the bottom part of the bag resting on the floor. On 4/23/25 at 8:52 a.m., the registered nurse (RN #1) caring for R56 was interviewed about the catheter bag seen resting on the floor. RN #1 stated the catheter bag was not supposed to be on the floor but was supposed to be attached to the bed frame so that the bag remained off the floor. On 4/23/25 at 9:02 a.m., the unit manager (RN #3) was interviewed about R56's catheter bag observed on the floor. RN #3 stated catheter bags should be positioned below the bladder and without contact with the floor for infection prevention. The facility's policy titled Urinary Catheterizations (effective 1/29/24) documented under procedures for management of urinary catheters, .Maintain drainage bags below the level of the bladder .Ensure drainage bags are not touching the floor . This finding was reviewed with the administrator, director of nursing and regional nurse consultants during a meeting on 4/23/25 at 4:45 p.m., with no further information provided prior to the end of the survey.

Based on observation, resident interview, staff interview and clinical record review, the facility staff failed to obtain and/or follow physician orders for five of thirty-seven residents in the survey sample. 1. Resident #78 was not administered the medication epoetin alfa-epbx (Epogen) as ordered by the physician for treatment of anemia. After missing eight consecutive doses of the medication over a period of eight weeks, Resident #78 experienced critically low hemoglobin levels of 6.8 g/dL (grams per deciliter) and 6.7 g/dL and required treatment with a blood transfusion. 2. Resident #46 did not have a dressing applied to a forehead lesion as prescribed by the physician. 3. The facility failed to obtain a physician's order for the care and treatment of a midline (intravenous) catheter for Resident #136. 4. During the medication pass and pour observation physician orders were not followed for the administration of Propranolol (medication given for hypertension) for Resident #92. 5. There were no physician orders obtained for the care of a midline (an intravenous line inserted into the upper arm, usually used for the treatment of antibiotics) for Resident #20. The findings include: 1. Resident #78 was admitted to the facility with diagnoses that included anemia in chronic kidney disease, diabetes, osteomyelitis, multiple myeloma in remission, peripheral vascular disease, dysphagia, cerebrovascular disease, COPD (chronic obstructive pulmonary disease), hypertension, hyperlipidemia, major depressive disorder, gout and urinary retention. The minimum data set (MDS) date 6/27/22 assessed Resident #78 as cognitively intact. Resident #78's clinical record documented a physician's order dated 1/18/22 for epoetin alfa-epbx 4000 units/milliliter with instructions to administer 1 ml (milliliter) intramuscularly once every 7 days for treatment of anemia. Resident #78's medication administration record (MAR) documented no administration of the epoetin alfa-epbx during the next eight weeks following the order. The MAR documented doses of epoetin alfa-epbx were scheduled but not administered on 1/27/22, 2/3/22, 2/10/22, 2/17/22, 2/24/22, 3/3/22, 3/10/22 and 3/14/22. Nursing notes documented the epoetin alfa-epbx was not administered because the medication was not available from the pharmacy. Nursing notes documented the following regarding missed doses of the epoetin alfa-epbx. 2/3/22 - .med [medication] is not available Epoetin Alfa-epbx Solution 4000 unit/ml . 2/10/22 - .non available labs to be faxed to pharmacy . 2/17/22 - Waiting for pharmacy to deliver Epoetin Alfa-epbx Solution 4000 unit/ml . 2/24/22 - non available 3/10/22 - awaiting delivery 3/14/22 - no available labs faxed . (sic) 3/15/22 - .Hg [hemoglobin] 6.8. Epoetin Alfa-epbx Solution 4000 unit/ml and order fax to pharmacy waiting for med . Prior to and during the weeks of missed epoetin alfa-epbx, Resident #78's hemoglobin was tested and documented as follows. The resident was identified with critically low hemoglobin on 3/14/22 after missing the ordered epoetin alfa-epbx injections for two months. Lab reports listed the hemoglobin in g/dL and documented a reference/normal range of 11.0 to 15.3 g/dL. 11/19/21 - 8.6 (low) 12/16/21 - 11.2 (in range) 1/31/22 - 8.6 (low) 2/28/22 - 7.1 (low) 3/3/22 - 7.3 (low) 3/7/22 - 7.4 (low) 3/14/22 - 6.8 (critically low) A nurse practitioner (other staff #4) assessed Resident #78 two times prior to the critically low hemoglobin level of 3/14/22. The NP notes listed the resident was receiving epoetin alfa-epbx as treatment for anemia and made no mention of the resident not receiving the injections as ordered or that the medication was not available. The NP (other staff #4) documented the following assessments of Resident #78. 1/24/22 - .Pt asked to be seen per nursing request for abnormal lab review .Assessment and Plan .Anemia Epoetin 1 ml IM [intramuscularly] inj [injection] Q 7D [every 7 days] . 3/2/22 - .Pt asked to be seen per nursing request for blood streaks in foley catheter, fever, and tachycardia .Assessment and Plan .Anemia Epoetin 1 ml IM inj Q 7D . A different NP (other staff #13) assessed the resident on 3/11/22 and diagnosed a urinary tract infection, started antibiotics and increased the frequency of the epoetin alfa-epbx from once per week to three times per week. There was no mention in the note that the resident had not received prescribed weekly doses of epoetin alfa-epbx or that the medicine had not been provided by the pharmacy. The lab report listing the critically low hemoglobin of 6.8 on 3/14/22 documented the physician was notified of the abnormal value on 3/15/22. A nursing note dated 3/15/22 documented, .Lab result received Hg [hemoglobin] 6.8. Epoetin Alfa-epbx 4000 unit/ml and order fax to pharmacy waiting for med. NP .notified. Continue Cefuroxime Axetil Tablet 500 mg .for UTI [urinary tract infection] . An additional dose of epoetin alfa-epbx scheduled for Wednesday 3/16/22 was not administered as ordered. A nursing note dated 3/16/22 at 10:22 a.m. documented, Pending pharmacy delivery and another note dated 3/16/22 at 10:55 p.m. documented, Waiting for med Epoetin Alfa-epbx Solution 4000 unit/ml . There was no documented notification to the physician or NP about the unavailable epoetin alfa-epbx until 3/17/22. A nursing note dated 3/17/22 documented, NP [nurse practitioner] .was notified of Epogen still pending deliver from pharmacy . (sic) The NP ordered a repeat lab test for 3/18/22. The resident's hemoglobin was checked on 3/18/22 with results reported on 3/19/22 indicating another critically low value at 6.7 g/dL. A nursing note dated 3/19/22 documented, .NP Notified of critical labs and order received to send pt [patient] out to . [hospital] for blood transfusion . The emergency department report dated 3/19/22 documented, .presents from .nursing facility, after being found to have severe anemia, hemoglobin of 6.7. She reports no significant symptoms .upon being informed of her decreased hemoglobin, she was sent to the ER [emergency room ] for transfusion . The ER report documented the resident's hemoglobin at 6.8. The resident was administered one unit of packed red blood cells and transferred back to the facility on [DATE]. NP (other staff #4) assessed Resident #78 on 3/21/22 after the blood transfusion. The NP note dated 3/21/22 documented, .Assessment and Plan .Anemia critical lab hemoglobin 6.7, send out non-emergent for transfusion, 1 unit PRBCs [packed red blood cells] c/w [continue with] Epo [Epogen] 1 ml mon, wed, fri x 5 weeks . After receiving the blood transfusion, Resident #78's hemoglobin on 3/21/22 was assessed at 8.0 g/dL. The resident continued to miss doses of the epoetin alfa-epbx following the blood transfusion because the medication was not available. Scheduled doses on 3/23/22, 3/25/22 and 3/28/22 were not administered because the medication was not provided by the pharmacy. The first dose documented as administered was on 3/30/22. The record documented no notification to the physician regarding the missed doses of epoetin alfa-epbx from 1/24/22 until 3/17/22. There were no documented attempts to determine the reason for the undelivered medicine, no communication to/from the provider or pharmacy about the medication or of any alternative treatments attempted to prevent the critically low hemoglobin that resulted in a blood transfusion. The resident was prescribed Vitron-C (iron-vitamin C) for anemia starting on 1/21/22 and this supplement was ongoing during the time with the critically low hemoglobin values. Nurse practitioner assessments on 1/24/22 and 3/2/22 listed the epoetin alfa-epbx as treatment for anemia and made no mention the medication was not administered to the resident as ordered. Another NP assessment on 3/11/22 made no mention of missed/unavailable epoetin alfa-epbx and increased the frequency of the medication from once per week to three times per week. Monthly medication regimen reviews conducted by the consultant pharmacist on 2/22/22 and 3/20/22 documented no new irregularities with Resident #28's medicines and made no mention of the weeks of missed epoetin alfa-epbx injections. On 8/17/22 at 10:06 a.m., the licensed practical nurse unit manager (LPN #1) was interviewed about Resident #78's missed doses of epoetin alfa-epbx. LPN #1 stated he did not work on Resident #78's unit until May 2022 and he did not know anything about the missed epoetin alfa-epbx or the critically low hemoglobin. On 8/17/22 at 11:10 a.m., the regional director of clinical services (other staff #3) stated she reviewed Resident #78's medication records and the epoetin alfa-epbx was not administered as ordered and nursing should have notified the physician regarding the missed medication. The regional director stated nursing notes listed the medication had not been supplied by the pharmacy. On 8/17/22 at 11:10 a.m., the unit manager (LPN #1) was interviewed again about the protocol when medications were not available. LPN #1 stated if medications were not available, the nurse should call pharmacy requesting delivery, notify the physician and seek alternate treatments if appropriate. On 8/17/22 at 2:08 a.m., the nurse practitioner (other staff #4) that routinely cared for Resident #78 was interviewed about epoetin alfa-epbx and the missed doses prior to critically low hemoglobin values. The NP stated the Epogen (epoetin alfa-epbx) was a medication used to stimulate production of red blood cells for patients with anemia. The NP stated Resident #79 had anemia due to chronic kidney disease. The NP stated the resident's baseline hemoglobin was low and ran in the high 7's. The NP stated she got a couple of contacts from nursing about the medication not available but she did not recall specific dates of the notifications. The NP stated patients with chronic kidney disease may have low hemoglobin readings even when taking Epogen. The NP stated sometimes there was no reason why something triggered a drop in hemoglobin. The NP stated her colleague (NP - other staff #13) increased the Epogen to three times per day so she was unable to comment on the increased dosage. The NP stated she had no information about why the epoetin alfa-epbx was not provided by the pharmacy and she had experienced problems getting Epogen for other residents in the facility. The NP stated there could be other reasons for the drop in hemoglobin such as dehydration or infection. When asked about any interventions implemented other than the Epogen to maintain the resident's hemoglobin, the NP stated the resident was already taking Vitron-C (iron-vitamin C). On 8/17/22 at 5:10 p.m., these findings were discussed with the administrator, regional director of clinical services and the corporate nursing consultant. The administrator stated at this time that nursing should contact the pharmacy when medicines were not available and notify the physician about any missed medicines. On 8/18/22 at 10:00 a.m., the regional nurse consultant (other staff #2) stated there was no notification documented regarding the unavailable Epogen for Resident #78. The nurse consultant stated she talked with the nurses and they reported some communication back and forth about the issue but there was nothing documented. The nurse consultant stated it was protocol to send a resident out for transfusion/treatment when hemoglobin dropped below 7.0. On 8/18/22 at 10:03 a.m., the NP (other staff #13) that assessed Resident #78 on 3/11/22 and increased the Epogen dose to three times per week was interviewed. This NP stated she was on-call and nursing notified her about abnormal labs. This NP stated she was not aware the resident was not getting the prescribed weekly doses of Epogen. This NP stated she increased the dose to three times per week because, based on her calculations, the previous dose was not adequate for the resident's condition and weight. This NP stated again she was not aware the resident had missed weeks of the Epogen injections. This NP stated she provided on-call coverage on 3/11/22 and did not assess the resident again after this visit. On 8/17/22 at 3:46 p.m., the registered pharmacist/director of quality (other staff #5) was interviewed about why Resident #78's Epogen was not provided. The pharmacist director stated the order was received by the pharmacy on 1/18/22 with a start date assigned as 1/24/22. The pharmacist director stated at this time that Epogen required permission to send and an email was sent to a facility distribution on 1/20/22 requesting this permission/approval from the provider. The pharmacist director stated no response was received to the email so the medication was never released. The pharmacist director stated a second email was sent on 1/24/22 with no response received from the facility so the medication was not dispensed. The pharmacist director stated Epogen (epoetin alfa-epbx) was a medication that stimulated production of red blood cells and helped maintain and/or increase hemoglobin levels for patients with anemia. The pharmacist director stated Epogen typically took two to six weeks for effect and was not used for immediate treatment of low hemoglobin. On 8/18/22 at 10:56 a.m., the consultant pharmacist (other staff #14) was interviewed about Resident #78's missed doses of Epogen due to unavailability from the pharmacy. The consultant pharmacist stated she performed spot checks of medications administered when she completed monthly medication reviews. The consultant pharmacist stated she did not pick up that Resident #78 missed the weekly Epogen during February and March (2022) reviews. The consultant pharmacist stated nobody from the facility notified her that the Epogen had not administered and/or provided. The consultant pharmacist stated Epogen was a medication that required additional approval before being dispensed. The director of nursing was out on leave and not available for interview during the survey. Resident #78's plan of care (revised 2/15/22) documented the resident had care needs and weakness due to conditions that included kidney failure, anemia and end stage kidney disease. Interventions to prevent complications included, Monitor and notify MD/RP [responsible party] of any critical Lab .Notify MD/RP of any changes in condition .Administer medications as ordered . The Lippincott Manual of Nursing Practice 11th edition on pages 757 and 758 describes anemia as, .the lack of sufficient circulating hemoglobin to deliver oxygen to tissues .Treatments for anemia include nutritional counseling, supplements, RBC [red blood cell] transfusions, and, for some patients, administration of exogenous erythropoietin (epoetin alfa or darbepoetin alfa), a growth factor stimulating production and maturation of erythrocytes .Severe compromise of the oxygen-carrying capacity of the blood may predispose to ischemic organ damage, such as myocardial infarction or stroke . (1) The Nursing 2022 Drug Handbook on page 49 describes epoetin alfa-epbx as a hematopoietic agent used for the treatment of anemia associated with chronic renal failure and cancer chemotherapy by stimulating red blood cell production in the bone marrow. Page 528 of this reference documents concerning epoetin alfa-epbx prescribed for anemia caused by chronic renal disease, .Maintenance dosage is highly individualized. Give the lowest effective dose to gradually increase Hb [hemoglobin] to a level at which blood transfusion isn't necessary . (2) These findings were reviewed with the administrator, regional director of clinical services and corporate nursing consultant during a meeting on 8/17/22 at 4:15 p.m. (1) Nettina, [NAME] M. Lippincott Manual of Nursing Practice. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2019. (2) Woods, Anne Dabrow. Nursing 2022 Drug Handbook. Philadelphia: Wolters Kluwer, 2022. 2. Resident #46 was admitted to the facility with diagnoses that included atypical lesion of left eyebrow, hypertension, rheumatoid arthritis, chronic deep vein embolism, hyperlipidemia, cellulitis, peripheral vascular disease, major depressive disorder and GERD (gastroesophageal reflux disease). The minimum data set (MDS) dated [DATE] assessed Resident #46 as cognitively intact. On 8/16/22 at 10:00 a.m., Resident #46 was observed in bed. The resident had an irregular shaped growth over the left eyebrow. The surface of the growth was red and moist with the lesion hanging partially over the upper portion of the left eyelid. When asked about any concerns with her care, Resident #46 stated a dressing was supposed to be over the growth on her eyebrow. Resident #46 stated the dressing fell off earlier in the morning and she reported this to her nurse around 7:30 a.m. or 8:00 a.m. Resident #46 stated her nurse had been in the room and still had not replaced the dressing. Resident #46 stated she did not like having the lesion exposed to air. On 8/16/22 at 11:08 a.m., Resident #46 was observed in bed with no dressing in place over the eyebrow growth. Resident #46 stated the nurse had not returned to replace the dressing yet. On 8/16/22 at 12:00 p.m., Resident #46 was observed with a dressing in place over the eyebrow growth. Resident #46 stated a nurse had just applied the dressing. Resident #46 stated she was concerned that the dressing had been off all morning. Resident #46's clinical record documented a physician's order dated 7/3/22 to cleanse the atypical lesion on the left eyebrow with wound cleanser, apply Xeroform, calcium alginate and cover with a border gauze every day shift and as needed for loose dressing. On 8/16/22 at 12:03 p.m., the registered nurse (RN #3) caring for Resident #46 was interviewed about the eyebrow lesion without a dressing. RN #3 stated he was assigned to Resident #46 today and she told him earlier in the shift that the dressing was off. RN #3 stated he reported the missing dressing to the unit manager. RN #3 stated he did not know why the unit manager did not replace the dressing earlier. On 8/16/22 at 12:05 p.m., the licensed practical nurse (LPN #1) unit manager was interviewed about Resident #46's lesion without a dressing. LPN #1 stated he had just reapplied the dressing to Resident #46's eyebrow growth. LPN #1 stated it had not been reported to him earlier that the dressing was off. LPN #1 stated, No one told me the dressing was off. LPN #1 stated the lesion was supposed to have a dressing in place as ordered. This finding was reviewed with the administrator, regional director of clinical services and corporate nursing consultant during a meeting on 8/17/22 at 4:15 p.m. 27353 3. The facility failed to obtain a physician's orders for the care and treatment of a midline (intravenous) catheter for Resident #136. Resident #136's diagnoses included, but were not limited to: muscle weakness, high blood pressure, diabetes mellitus, and osteomyelitis of the left ankle/foot with partial amputation of the left foot. Resident #136's most recent MDS (minimum data set) was an admission assessment dated [DATE]. This MDS assessed the resident with a cognitive score of 14, indicating the resident was intact for daily decision making skills. The resident was also assessed as requiring extensive assistance with most ADL's (activities of daily living). Resident #136 was interviewed on 08/16/22 at approximately 10:00 AM. The resident stated that he had an infection in his foot and that staff were giving him IV (intravenous) medications for the treatment. An IV pump/pole was observed in the corner of the room. The resident had a midline catheter in the right upper arm, a clear occlusive dressing was covering the catheter. There was no date, no time and no initials on the dressing. The resident's clinical records were reviewed. The resident had an order to, Insert midline one time only for IV abx [antibiotics] .order date: 08/03/22 start date: 08/03/2022 . There were no other orders found for the care and/or of the midline IV catheter. The resident's CCP (comprehensive care plan) was then reviewed. The CCP documented, .care needs related to osteomyelitis .meds as ordered . There was no information on the resident's care plan regarding a midline or care interventions for an intravenous catheter. The resident's MARs/TARs (medication administration/treatment administration records) were reviewed for July and August 2022. There was no information regarding the care and/or treatment of a midline IV catheter for Resident #136. On 08/17/22 at approximately 1:30 PM, Resident #136 was again interviewed. The resident's midline IV catheter dressing was intact (as observed the day before) no date, no time, and no initials were on the dressing. The midline, single lumen IV catheter was observed without a protective cap. RN #4 was in the room at the time and was interviewed. The RN stated that it should have a cap on the lumen hub and further stated that resident was no longer getting medication through the midline. The RN was asked how do the nurse's know how to care for a midline. The RN stated that they follow the physician's orders. The RN was made aware that there were no orders for the care of the midline. The RN stated that there should be orders. On 08/17/22 at 2:19 PM, in a meeting with the survey team, the NP (nurse practitioner) and the administrator were interviewed regarding the residents midline catheter and made aware of concerns regarding no care orders and/or instructions on how to manage the midline. The NP stated, I don't think I have specific orders for a midline, I think there is a standard, flush every 7 days, they [nurses] do the dressing change. You flush it everyday, with normal saline. I don't put in those orders, the nurses put them in and I would sign. The NP stated, that she thought it was a common practice for nurses to care for a midline and that she does review her orders. The NP was made aware that this resident did not have any care orders. The NP stated that when she was in nursing school that they had protocols they could use without physician's orders in the hospital. The NP was made aware that this is not a hospital and that resident's have to have specific care orders. The administrator nodded her head in agreement. On 08/17/22 at approximately 4:30 PM, in a meeting with the survey team, the administrator and corporate consultants were again made aware of the concerns regarding the lack of physician's orders for the care and treatment of Resident #136's midline. No further information and/or documentation was presented prior to the exit conference on 08/19/22 at noon. 28106 4. During the medication pass and pour observation, physician orders were not followed for the administration of Propranolol (medication given for hypertension) for Resident #92. Diagnoses for Resident #92 included: Hemiplegia, dementia, Hypertension, and hyperlipidemia. The most current MDS (minimum data set) was a quarterly assessment with an ARD (assessment reference date) of 7/7/22. Resident #92's cognitive score was a 6 indicating moderately cognitively intact. On 08/16/22 at 8:26 AM a medication pass and pour was conducted with license practical nurse (LPN #3 ). LPN #3 began pulling Resident #92 's medications from the medication cart and handing them to the surveyor for review. One of the medications (Propranolol) instructed to give two 10 Mg (milligrams) tablets equaling 20 Mg. After reviewing the medications the surveyor handed the medication back to LPN #3 , and LPN #3 began popping the medications out into a medication cup. LPN #3 picked up the Propranolol medication card and only popped one pill into the cup (equaling 10 MG). LPN #3 then put all the medication back into the medication cart, locked the cart, turned and started to go into Resident #92's room. Upon entering the resident's room, LPN #3 was asked to come back to the cart and review the instructions for the Propranolol. LPN #3 pulled the medication from the medication cart and reviewed the instructions on the medication with the instructions on the medication administration record (MAR) and was asked, what is the dosage of each Propranolol tablet and how much is supposed to be given. LPN #3 realized that 2 Propranolol pills should have been dispensed and said You're right I will get another. Review of the physician's orders for Propranolol read: Propranolol 10 MG tablet Give 20 mg orally two times a day [ .] On 8/17/22 at 4:45 PM the above information was presented to the administrator and nurse consultant. No other information was presented prior to exit conference on 8/18/22. 5. The facility staff failed to obtain physician orders for the care of a midline (an intravenous line inserted into the upper arm, usually used for the treatment of antibiotics) for Resident #20. Diagnoses for Resident #20 included: Sepsis, stenosis of left carotid artery, depression, and urinary tract infection. The most current MDS (minimum data set) was a quarterly assessment with an ARD (assessment reference date) of 7/30/22. Resident #20's cognitive score was a 15 indicating cognitively intact. On 08/16/22 at 8:54 AM during an interview, Resident #20 was asked about the Midline inserted into the left upper arm. Resident # 20 verbalized that he recently had an infection and was being given a antibiotics, but is no longer on antibiotics. On 8/16/22 Resident #20's medical record was reviewed. An order to insert a midline was dated 7/25/22, however there were no orders placed for care of the Midline (such as flushing to ensure patency). On 8/17/22 at 8:36 AM nurse consultant (administrative staff, AS #2) was interviewed. AS #2 reviewed Resident #20's physician orders and verbalized orders should have been placed for the care of the Midline. On 8/17/22 at 4:45 PM the above information was presented to the administrator and nurse consultant. On 8/18/22 at 8:30 AM AS #2 was asked if there are any nursing protocals regarding the care and treatment of a Midline. AS #2 said there is a protocol and those orders should have been placed on the medical chart. No other information was presented prior to exit conference on 8/18/22.

Based on family interview, staff interview, clinical record review, facility document review, and in the course of a complaint investigation, the facility staff failed ensure care and treatment were provided in a timely manner for one of nine residents, Resident #1, resulting in harm. Resident #1 had an unwitnessed fall on 01/07/22, and was not assessed until two days later on 01/09/22. Resident #1's condition declined in the days after the unwitnessed fall and the resident was sent to the hospital on 01/14/22, and found to have a hematoma to the head with facial bruising, along with fractures to the cervical neck (C1-C3) and a right hip. Findings include: Resident #1 was admitted to the facility on [DATE], with the most current readmission on 12/24/21. The resident was discharged from the facility on 01/14/22 and did not return. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The most recent full MDS (minimum data set) was an admission (5 day/annual) assessment dated [DATE]. This MDS assessed the resident with long and short term memory impairment and severe impairment in daily decision making skills. Resident #1 was also assessed as requiring total assistance from at least one staff person for bed mobility, transfers, dressing, toileting, and extensive assistance for eating and hygiene. This MDS documented that the resident did not ambulate in room or corridor during the look back period. In Section G 0300. Balance during transitions and walking Resident #1 was assessed as activity did not occur for the following: moving from seated to standing position, walking, turning around, and/or moving on and off the toilet. This MDS assessed the resident as having one fall since readmission (12/24/21), not major in injury. This MDS assessed Resident #1 as receiving scheduled and PRN medications for pain and unable to answer pain presence. Resident #1's clinical records were reviewed and included the following: A physician's progress note dated 01/07/22 at 3:01 PM documented, .to be seen .for positive COVID .generalized weakness .cognitive impairment, advanced age, frail .muscle weakness .signed by nurse practitioner (NP). There was no information regarding a fall in the NP's note. A skin assessment dated [DATE] timed 3:42 PM documented, .skin without impairment: no .multiple ecchymosis and bruising to bilateral arms and hands, otherwise skin intact . A progress note dated 01/09/22 at 1:58 AM documented, Patient grimacing and moaning, Tylenol .given, well tolerated .continue to monitor for changes . A post fall assessment dated [DATE] and timed 2:46 PM documented, .date and time of fall: 01/09/22 1:00 AM .date and time physician notified: 01/09/22 1:00 AM .date and time RP (responsible party) notified 01/09/22 1:15 AM .two person assist .chair bound, requires assistance to transfer .pain management/assessment .patient assisted back to bed .staff members assisted .2 .signed LPN (licensed practical nurse) #1. There was no other information on the post fall assessment. A progress note dated 01/09/22 at 3:33 PM, which documented, Patient observed lying on the floor beside her bed face down, hematoma observed on right side of the head close to the forehead VS (vital signs) .ROM (range of motion) within normal limit (sic) .MD (medical doctor) and RP notified .signature of LPN#1. A progress note dated 01/09/22 at 3:54 PM documented, Patient observed lying on the floor beside her bed face down, hematoma observed on right side of the head close to the forehead VS .ROM within normal limit (sic) .MD and RP notified .signature of LPN #1. A physician's progress note dated 01/09/22 at 5:17 PM documented, .S/P (status post [MEDICAL RECORD OR PHYSICIAN ORDER] .generalized weakness .Vital Signs: (Resident #1's blood pressure, pulse and respiration were dated from 12/24/21 on this progress note, and were not current as of the date of 01/09/22 note) cognitive impairment, advanced age, frail .muscle weakness .fall precautions .forehead hematoma start apply ice to hematoma TID (three times daily) Start Tylenol 650 mg for pain .signed by NP. There was no mention of Resident #1 being on an long term anticoagulant therapy (Xalrelto 15 mg daily since June 2020). A progress note dated 01/09/22 at 10:18 PM documented, Situation: Post fall 3-11 .history of .A-Fib .right [CONDITION(S)]. Assessment (RN)/Appearance (LPN): Head to toe assessment done heamatoma (sic) noted on right side of the head close to the forehead, NP and supervisor aware, ROM within normal limit, remain afebrile .continue to monitor .educate resident to call for help, bed in the lowest position .signature of LPN #1. No other documentation was located in Resident #1's clinical record regarding the details of this fall. According to the documentation in the resident's clinical records the resident sustained [MEDICAL RECORD OR PHYSICIAN ORDER] . A progress note dated 01/10/22 at 10:48 AM documented, Situation: S/P fall 7-3 shift Background: .hemi-neglect of right side .AFIB, [CONDITION(S)], Dysphagia. Assessment (RN)/Appearance (LPN): Pt. is alert and verbally responsive. Meds given as ordered, tolerated well. No changes in mental status .Bruise remain on pt. (patient) both knees and hematoma forehead .ROM with in normal limit .No distress noted during shift .signature of RN #3. A progress note dated 01/10/22 at 4:01 PM documented, .Alert and confused. Total assist with ADL (activities of daily living) .fluid encouraged . A progress note dated 01/10/22 at 6:48 PM documented, .A-Fib .[CONDITION(S)] .alert and verbally responsive .meds given .no change in mental status .bruise remain on both knees and on hematoma her forehead (sic) .ate with assist .monitor frequently . Progress note dated 01/11/22 at 8:00 PM documented, .hematoma to the right side of the head .healing in progress, ROM within normal limit .continue with plan of care . A progress noted dated 01/12/22 a 8:23 PM documented, .alert .responsive .bruise remain on both knees and hematoma on her forehead .observed .weak .meals .staff assist .NP notified . A progress noted dated 01/13/22 at 1:46 PM documented, Pt. received in bed this am .care provided by staff with total assist. Meds given as ordered, pt. observed very weak on shift, open her eye (sic) intermittently and fall back to sleep .NP notified .RP updated about pt condition . A progress note dated 01/13/22 at 9:59 PM documented, .VS obtained at this time .daughter came in to visit. Pt. to be send (sic) with non emergency for further eval NP aware (name of transport) called. Resident #1 was sent out to the hospital the following day 01/14/22, at 11:14 AM. Resident #1's current CCP (comprehensive care plan) at the time of the fall documented, .The resident is at risk for falls related to gait/balance problems/poor safety awareness .assist bars for bed mobility, wheelchair for locomotion, pommel cushion for w/c positioning .call light in reach .encourage resident to use it for assistance as needed .educate caregivers about safety reminders and what to do if a fall occurs .rounding and close monitoring, and anticipate to meet the resident's needs .environment free of hazards .is on anticoagulant therapy related to [CONDITION(S)] (created on 05/12/2020) .Lab work as ordered .meds as ordered .Monitor for bleeding such as unusual bruising, bloody or black tarry stool, red or dark brown urine, abdominal pain .swelling .bleeding from eyes, gums, nose .report symptoms to MD .Observe for any signs/symptoms of bleeding related to anticoagulation therapy .SKIN: bruises to bilateral forearms, right head hematoma (revised on 01/09/22) . On 02/15/22 at approximately 10:00 AM, the administrator, DON (director of nursing) and the corporate nurse were made aware of a complaint regarding Resident #1 and were asked for any information or investigation regarding a fall with injury for Resident #1 in January 2022. The administrator stated that the investigation was currently underway and that it would be completed on 02/16/22. The administrator stated they were made aware that Resident #1 had a fall on 01/09/22 by the Unit Manager (LPN #2) in a morning meeting on 01/10/22. The administrator stated that it wasn't until an investigator called and came to the facility on [DATE] that they were made aware of concerns regarding alleged significant injuries. The administrator stated that was when the investigation was initiated and that this information was what prompted the investigation. The administrator stated that there had not been any other investigation regarding Resident #1. On 02/15/22 at approximately 2:30 PM, the hospital medical records obtained by the facility were presented for review. The ED (emergency department) provider note dated 01/14/22 at 11:22 AM documented, Sent to the ER for evaluation of lethargy and mental status change since yesterday .Patient is on Xalrelto. It is reported that patient has been lethargic and sleeping all day since yesterday .report of a fall that occurred last week .Altered mental status, lethargy .patient non verbal, not following commands, lying on stretcher with eyes closed .Ecchymosis (bruises) to forehead and orbital left eye .A-fib at 100 bpm (beats per minute) .Trauma and CNS (central nervous system) failure or compromise .C1 anterior tubercle fracture, right and left posterior arch fracture of C1 with moderate distraction of fracture fragments, non-displaced fracture C3 left facet .left superior articular facet fracture of C2 extending into L (left) vertebral foramen, right impacted fracture of proximal femur .1:20 PM .awake, not following commands .opens eyes on own, pushes away noxious stimuli, moans, makes unintelligible sounds .Right forehead/scalp hematoma .Left peri-orbital ecchymosis .right forearm ecchymosis .HIP, LEG, FOOT: left withdrawals to pain .right .deformity right foot, right leg shortened, yellowing ecchymosis right knee, healing abrasions to right upper thigh .right hip fracture .trauma consulted .hold Xalrelto .C1-C3 fractures .right proximal femur displaced impacted fracture . On 02/16/22 at approximately 9:00 AM, the administrator and corporate nurse presented their final investigation for review. The investigation had an incident report dated, 01/09/22 which documented, .UN-witnessed: (Name of patient) .Nursing Description: observed lying on the floor beside her bed on the floor face down. Patient Description: cannot explain due to dementia .Immediate Action Taken: Head to Toe assessment done, hematoma observed on right side of the head close to forehead, pt (patient) assisted back to bed by two staff .Hematoma top of scalp .alert .oriented to person .Level of consciousness: (blank) .No witness found. Also included in the investigation was LPN #1's statement which documented, .date of incident: 7-3 (shift) 01/07/22 .On 01/07/22 I was the only nurse for 7-3 shift on that day, when my manager (Name of LPN #2/Unit Manager) called me in room (number) with urgency .I was in middle of doing patient care (in another room) but I have to run to him due to the urgency from him .upon getting into the room (number) I saw resident (Name of Resident #1) lying on the floor with my manager in the room told me she fell .manager was suppose (sic) to do the necessary documentation .In report out going nurse reported about (Resident #1) huge swelling on patient head .signed on 02/11/22 by LPN #1. CNA (certified nursing assistant) #6's statement documented, .I was not around when the accident happened, I came back to work I went to patient room to change patient and I saw bump and black eye on patient forehead (sic) and patient daughter came in the room and said patient in a bad condition and she asked me what happened to patient and I told her that I don't know what happened to patient because I was not around .signed on 02/10/22 by CNA #6. The statement by CNA #6 did not provide a date as to when the CNA returned to work or observed the bump and black eye on Resident #1. RN #5's statement documented, .Return to work on Monday (01/10/22). I was told resident had a fall over the weekend .signed RN #5 02/11/22. CNA #8's statement documented, I came to work on 3-11 shift patient was in bed I change her (sic) and seen she had bruises on both knees nurse was notified .signed CNA #8. The statement by CNA #8 did not provide a date as to when the CNA saw the bruising on Resident #1. On 02/16/22 at 10:25 AM, Resident #1's daughter was interviewed. The daughter stated that she was informed of the fall on 01/09/22 and she saw Resident #1 on Monday 01/10/22. She stated that LPN #2 told her not to worry they were taking care of Resident #1. The daughter stated that she asked what happened and no one could tell her what happened to her mother. The daughter stated that bump on her mother's head was So big, I knew it was a head injury. The daughter asked the facility staff to send Resident #1out and stated they acted as though they didn't want to. The daughter stated that she went back on Thursday (01/13/22) and her mother was gone, she wasn't responding, and She was unconscious. The daughter stated that she cried and wanted Resident #1 to go to the hospital and that staff told her, maybe it's time to let her go.' The daughter stated that she was so upset and finally the nurse called to have Resident #1 sent out, but not 911, because it wasn't an emergency. The daughter stated that she left at around 10 PM on 01/13/22 and the facility staff called her around 3:00 AM and told her that transport would pick her mother up between 7 and 8 AM. The daughter stated that Resident #1 went to the hospital and was admitted with a broken neck and broken hip. On 02/16/22 at 1:35 PM, Resident #1's attending physician was interviewed. The physician stated that he did not see Resident #1 after the fall. The physician stated that NP saw Resident #1 and completed an assessment. The physician stated that he was notified, but was unsure of when, and stated, I get so many calls. The physician stated that he was unsure of the details and did not see Resident #1 during this time. On 02/16/22 at 1:55 PM, the NP was interviewed regarding Resident #1's fall. The NP was made aware of the investigation and the statement by LPN #1 that Resident #1's fall occurred on 01/07/22. The NP stated that she was notified of the fall on the 9th and that when she saw Resident #1 she had a hematoma and she was fully assessed. The NP was asked if she knew what happened. The NP stated, .she literally fell out of the wheelchair . The NP was asked where that information came from as the resident's clinical records did not document that information in the notes or the post fall assessment. The NP stated it was documented somewhere. The NP stated that she palpated the resident's head and the resident did show discomfort and stated that Resident #1 had some bruising on both knees. The NP was asked if Resident #1 should have been sent out at that time for an evaluation, as the resident had sustained a head injury and was on Xalrelto 15 mg daily at the time of the fall. The NP stated, In most cases yes, the placement (of the hematoma), I figured it would go away, and based on my assessment didn't show any distress, but probably should have sent her out. The NP was asked if she saw the resident anytime after 01/09/22. The NP stated that she had not, and that staff did not call her all week long with any changes. The NP stated that on 01/13/22 around 9 or 10 PM, she was notified about sending Resident #1 out for an evaluation because she was sleepy. The NP was asked why the resident was not sent via 911, instead of being sent non-emergentl. The NP stated, Yes, sent out non-emergent .the way it was described, the patient is sleepy and vital signs were stable. On 02/16/22 at 2:20 PM, LPN #1 was interviewed via phone. LPN #1 stated, It happened on Friday (01/07/22); I was the only nurse on the floor and around at that time and Resident #1 tested positive and was sent to the COVID positive floor (5th floor). I was in the middle of care and my manager was calling me with urgency to come. I get into the room, patient is lying on the floor face down, he (LPN #2) asked me to help get the patient back to bed. LPN #1 stated that he was not in the room when it happened and that he did not know what happened. LPN #1 stated that LPN #2 didn't say what happened to Resident #1 but it did happen on the 7th (not the 9th as documented). LPN #1 stated that Resident #1 was on the 3rd floor, tested positive and was moved to the 5th floor, it was in the afternoon, and that he worked the 7-3 shift and he wasn't there much longer before he left for the day. LPN #1 stated that he passed it on in report to the oncoming nurse that the resident fell , but did not report it to the physician. LPN #1 stated that LPN #2 was the one who found Resident #1 and was supposed to do all that and the paperwork. LPN #1 stated that the only people in the room were the patient, LPN #1 and LPN #2, and that Resident #1 was put back in bed. LPN #1 stated, I just noticed swelling on the face. LPN #1 stated that he didn't notice any bruising at that time. LPN #1 stated, I did not witness the fall that was on Friday. LPN #1 stated that he was off on Saturday and picked up another shift on Sunday. When he came in on Sunday he noticed there was no documentation regarding the fall, so he called LPN #2 and asked why he didn't document the fall and report for Resident #1. LPN #1 stated that LPN #2 told him that since he wasn't in the facility that LPN #1 needed to do it. LPN #1 then stated that is when he documented the fall on 01/09/22, but it happened on 01/07/22. LPN #1 stated that he texted the NP and informed her of the fall on 01/09/22. LPN #1 was asked if Resident #1 was assessed. LPN #1 stated that he did not assess Resident #1 or notify the physician, and that LPN #2 (the unit manager) must not have either. A policy titled, Falls Management Program documented, .the center considers all patients to be at risk for falls .fall is defined as unintentional change in position coming to rest on the ground or .next lower surface .Notify the physician, responsible party, and/or EMS (emergency medical services), as well as the Supervisor/Administrative personnel .evaluate, monitor and document patient response .include neurological assessment if the fall was unwitnessed and/or the patient hit his/her head . On 02/16/22 at 2:35 PM, the administrator, DON , and corporate nurse were made aware of the concerns regarding the lack of immediate care and assessment for Resident #1 related to the fall that occurred on 01/07/22, but was documented as 01/09/22. Resident #1 was not assessed or seen by the NP until two days later. The facility staff were also made aware that the resident began to have a decline with noticeable changes documented by nursing staff leading up to the notification of the NP on 01/13/22 and Resident #1 was not assessed by the NP or MD or sent out at that time for evaluation. The staff were also made aware of concerns that when nursing contacted the NP on 01/13/22 at 9:59 PM, that the NP agreed to send the resident out for evaluation non-emergently. Resident #1 left the faciity on [DATE] at 11:14 AM, sent to the hospital, and found with altered mental status and lethargy, a right femur fracture, fractures to the neck (C1 through C3), hematoma to the head with bruising to the eyes, and bruising to the knees. The DON stated that she was on vacation when the fall occurred and she was made aware after (on 01/17/22 upon return to work). The administrator stated that she was made aware that the resident had a fall on 01/09/22 in a morning meeting on 01/10/22. The corporate nurse stated, I see missteps in our process, unfortunately there is room for performance improvement. The corporate nurse stated, No one can tell we saw this in this patient (sic) .we base on our own findings and our own review. No further information and/or documentation was presented prior to the exit conference on 02/17/22.

Based on staff interview, facility document review and clinical record review, the facility staff failed to provide a safe transfer for one of 36 residents in the survey sample. Resident #90 was transferred to bed with the assistance of one person when her plan of care required two-person assistance for safe transfers, resulting in a [MEDICAL CONDITION] femur. The findings include: Resident #90 was admitted to the facility on [DATE] with a re-admission on 3/17/19. [DIAGNOSES REDACTED]. The minimum data set ((MDS) dated [DATE] assessed Resident #90 with severely impaired cognitive skills and as totally dependent upon two people for bed mobility. Resident #90's clinical record documented a nursing note dated 3/13/19 at 11:09 p.m. stating the resident complained of left knee pain and was administered Tylenol for pain rated 6 out of 10 (on scale of 0 = no pain, 10 = worst pain) with notification to the physician of the left knee pain. A nursing assessment dated [DATE] documented, .left knee is warm to touch, swollen and c/o (complaint of) pain .Tylenol 650 mg (milligrams) given .MD (physician) order for x-ray of left knee . The physician assessed the resident on 3/14/19 and documented, .Has had bilateral knee replacements. Left knee is warm and swollen. This seems acute . The x-ray report dated 3/14/19 documented the resident was diagnosed with [REDACTED]. The physician was notified of the x-ray results and the resident sent to the hospital for treatment of [REDACTED]. Resident #90 was hospitalized for [REDACTED]. The hospital discharge summary dated 3/17/19 documented, .was sent to the emergency room from the nursing home due to left knee pain and swelling. X-rays was performed earlier today and showed left distal femur fracture .has been nonambulatory for the last several years . (Sic) The emergency room physician's exam documented, The skin is intact about the left leg. There is mild swelling about the left distal femur. There is mild tenderness on palpation of the distal femur. There is motion at the fracture site .She (Resident #90) is unable to give a history or an account of how the leg was injured .X-rays of the left femur which reveal a displaced left long oblique periprosthetic femur fracture .There is significant lateral displacement of the distal fracture fragment . The resident was not a candidate for surgical repair, was treated conservatively with a knee immobilizer and discharged back to the nursing home. Resident #90 was readmitted to the facility following hospitalization for the fracture 3/17/19. The resident was prescribed bedrest, a left knee immobilizer and [MEDICATION NAME] 5/325 milligrams every 6 hours as needed for pain. The resident's Medication Administration Record [REDACTED]. The resident was treated by orthopedics with the knee immobilizer and pain medications. A physician's note dated 12/19/19 documented, .Left femoral fracture is healing but it's not completely healed . A facility reported incident form dated 3/14/19 documented Resident #90 was transferred on the evening of 3/13/19 with the assistance of one person instead of two-person assistance as required in the plan of care, resulting in the fracture femur. The incident form dated 3/14/19 documented, Resident has chronic intermittent pain on left leg, but complained of severe pain during ADL (activities of daily living) care this morning around 7:30 am. X-ray was ordered and results came as an acute [MEDICAL CONDITION] left femur. The facility's internal investigation of Resident #90's femur fracture documented, .On the evening March 13, 2019, (Resident #90) expressed she was in pain. Her Charge Nurse asked her CNA (certified nurses' aide) to assist (Resident #90) back to bed in an attempt to alleviate her pain. Her pain worsened after the transfer to bed. She was offered [MEDICATION NAME] which relieved her pain and she was able to sleep without incident. The morning of March 14, 2019, (Resident #90) complained of pain to her leg. Upon assessment, an X-ray was ordered and the fracture was identified. It is concluded that the fracture inadvertently occurred during her transfer to bed on the evening of March 13, 2019 unknown to the CNA that was performing the task. The facility's investigation dated 3/18/19 documented Resident #90 required two people for safe transfer and that CNA #1 transferred the resident on the evening of 3/13/19 without assistance of a second person. An employee corrective action form dated 3/18/19 documented, Failure to follow patient (Resident #90's) plan of care during transfer. (CNA #1) transferred the patient without a second staff assist on 3/13/19 and that cause possible injury to the patient . (Sic) CNA #1's written statement dated 3/13/19 documented, I worked with (Resident#90) on the 13th of March at 3 - 11 pm shift at about 8:00 (p.m.) after dinner she started complaining pain on the leg. She was saying 'my leg my leg' I took her from the dinning (dining) room to the nurses station for observation and told the nurse about the pain. The nurse asked me to put her in bed. When I undress her she showed me where she is hurting. I called the nurse for observation later the nurse told me she gave her medicine for the pain . (Sic) The MDS dated [DATE] documented the resident was 68 inches tall, weighed 165 pounds and was totally dependent upon two people for bed mobility and transfers. The resident's plan of care in place prior to the fracture (revised 10/23/18) documented the resident was dependent upon staff for all activities of daily living including transfers. Included in interventions for safe transfers was The resident requires 2 staff assistance for transfers. On 1/28/20 at 3:20 p.m., CNA #1 that transferred Resident #90 to bed on the evening of 3/13/19 was interviewed. CNA #1 stated on 3/13/19 around 8:00 p.m., Resident #90 was in a wheelchair in the dining room and complained of leg pain. CNA #1 stated she pushed the resident to the nursing station and told the nurse. CNA #1 stated the nurse told her to put Resident #90 to bed. CNA #1 stated, I just hurried up and put her to bed. CNA #1 stated she lifted the resident by herself and did not get assistance from another person when transferring her from the wheelchair to bed. CNA #1 stated, I lifted her myself, was in a hurry. The nurse said hurry up. CNA #1 stated the resident did not require a mechanical lift but required two people for transfers. When asked how she transferred her alone, CNA #1 stated she put her arms around the resident and just lifted her. CNA #1 stated the nurses were busy giving medications and she did not ask for assistance from the other aides on the floor. CNA #1 stated the resident complained of pain frequently when transferred and she did not realize the resident was hurt when she transferred her. CNA #1 stated the resident did indicate her left knee was hurting after she put her to bed on the evening of 3/13/19. CNA #1 stated she reported this to the nurse and the nurse told her she medicated the resident. On 1/29/20 at 11:30 a.m., the administrator and director of nursing (DON) were interviewed about Resident #90's improper transfer and resulting femur fracture. The administrator stated their investigation revealed that CNA #1 did not follow the protocol requiring a two-person transfer for Resident #90 that resulted in the resident's femur fracture. The DON stated prior to the incident the resident was totally dependent upon staff and required two-person assistance for all transfers. The administrator stated CNA #1 was initially suspended until the investigation was complete and was re-educated about proper transfer assistance prior to her return to work. The administrator stated audits and education were broadened to include all aides with correction date of 5/2/19. The administrator presented a plan of correction regarding the failure to provide required transfer assistance. The plan of correction documented an audit by unit managers dated 3/19/19 verifying each resident's transfer requirements and that care plans documented accurate transfer assistance requirements. A list of residents documented as two-person assistance was provided to each nursing manager. The plan documented education by the staff development coordinator to all certified nurses' aides on 3/19/19 identifying all residents requiring two-person transfer assistance and proper protocols for a two-person transfer. The plan documented education to CNA #1 on 3/20/19 regarding how to reference information about required transfer assistance, education about following the plan of care and online education with a passing test grade regarding safe transfers and positioning. The training also documented a return demonstration by CNA #1 regarding safe transfer techniques. The plan documented audits by the unit managers and/or DON of 10% of current residents on each floor requiring two-person transfer assistance. The audits were documented weekly for four weeks, monthly for two months and then once quarterly following the in-service education on 3/19/19. The date of completion/compliance was 5/2/19. The survey team reviewed and accepted the plan of correction as no new deficiencies were identified regarding accidents since the correction date of 5/2/19. This deficiency was past non-compliance.

Based on complaint investigation, observations, clinical record review, staff interview, family interview, and facility document review, the facility staff failed for one of 34 residents in the survey sample (Resident # 34) to assess, monitor, and provide physician ordered treatment and services to address the resident's [MEDICAL CONDITIONS], and a leg wound on multiple occasions. The failure of the facility to provide assess, monitor, and provide the necessary care and services resulted in the identification of Immediate Jeopardy and Sub-standard Quality of Care. The facility Administration was notified of the finding of Immediate Jeopardy at 3:15 p.m. on 6/30/16. Following the presentation and acceptance of a Plan of Removal, the finding of Immediate Jeopardy was lifted at 5:00 p.m. on 6/30/16. Subsequently, the Scope and Severity of the finding was reduced to Level 2, pattern. In addition, the facility staff failed for one of 34 residents in the survey sample (Resident # 4) to follow physician's orders for the provision of care. The findings include: 1. The facility staff failed to assess and provide physician ordered treatment and services to address the resident's [MEDICAL CONDITIONS], and a leg wound. Resident # 34 in the survey sample, a [AGE] year-old female, was admitted to the facility on [DATE] with [DIAGNOSES REDACTED].**, generalized muscle weakness, cerebral infarction (a type of stroke), [MEDICAL CONDITION]***, [MEDICAL CONDITION], hypertension, vitamin deficiency, overactive bladder, and [MEDICAL CONDITION]****. According to a Medicare 14-Day Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 6/26/16, the resident was assessed under Section AC (Cognitive Patterns) as being moderately cognitively impaired, with a Summary Score of 9 out of 15. *[MEDICAL CONDITION] is an infection of the skin and deep underlying tissues. **[MEDICAL CONDITION] is the name of a type of swelling. It happens when lymph builds up in your body's soft tissues. Lymph is a fluid that contains white blood cells that defend against germs. It can build up when the lymph system is damaged or blocked. It usually happens in the arms or legs. ***[MEDICAL CONDITION] means swelling caused by fluid in your body's tissues ****[MEDICAL CONDITION] is an abnormally high concentration of fats or lipids in the blood Under Section M (Skin Conditions) on the 14-Day MDS, the resident was assessed at Item 1040 (Other Ulcers, Wounds and Skin Problems) as having an infection of the foot. At Item 1200 (Skin and Ulcer Treatments), the resident was assessed as having a pressure reducing device for bed, as having the application of non-surgical dressings, and as having applications of ointments/medications. A thorough review of Resident # 34's Electronic Health Record (EHR) and paper clinical record failed to reveal any documentation that her legs and leg wound were assessed by the facility staff at the time of admission, or at any time prior to 6/30/16, when the legs and wound were first observed by the facility staff and the survey team. Resident # 34's EHR included two Weekly Skin Assessment forms, dated 6/22/16 and 6/29/16. The 6/22/16 Weekly Skin Assessment form included the following notation under Item A (Observations), [MEDICAL CONDITION]. Item 2 (Notes), included the following entry, [MEDICAL CONDITION] present on both legs from feet to upper area of legs. Resident has order for lymphrdema (sic) wraps. There was no further description of the resident's legs or of her leg wound. The 6/29/16 Weekly Skin Assessment form included the following notation under Item A (Observations), [MEDICAL CONDITION]. Item 2 (Notes), included the following entry, Weekly skin assessment completed. [MEDICAL CONDITION] present on both legs from feet to upper area of legs. Patient has order for lymphrdema (sic) wraps that patient prefers to get it wrapped at (name of hospital). There was no further description of the resident's legs or of her leg wound. At approximately 12:30 p.m. on 6/30/16, the resident's daughter came to the facility and met with the survey team. The resident's daughter said she has taken care of her mother's legs at home for eight years. I have been trained to perform leg wraps for [MEDICAL CONDITION]. There is no one here qualified to do them. I told the nurses I would prefer if they don't touch the legs, the resident's daughter said. The daughter went on to say that she will not allow the facility's nursing staff to change the wraps and dressing on her mother's legs. I change them every three days, she said. She admitted she has not told the facility how many times she has changed the wraps. According to the daughter, the Administrator offered to have one of two Physical Therapists who have been trained in [MEDICAL CONDITION] care do the wraps and dressing changes. I refused, she said. The therapist wanted to leave the wound open to the air so it would heal, but that's not what the wound clinic wanted, that's not what I want. Continuing, the daughter said she takes her mother to (name of hospital) wound clinic for dressing and wrap changes, the last time being on 6/16/16. According to the daughter, she does not have an order to go to the wound clinic, but makes an appointment when she wants to take her mother there. To my knowledge, the daughter said, no one here has ever seen the wound. The survey team asked the resident's daughter if she would consent to the removal of the wraps and dressing so the resident's legs and the wound could be assessed. After some discussion, the daughter agreed to remove the dressings from Resident # 34's lower extremities to allow the survey team visualization of the resident's legs as well as the wound. On 06/30/2016 at approximately 1:10 p.m., two members of the survey team accompanied the daughter to Resident # 34's room. This surveyor went to the nurse's station and requested for a staff member to be present during the wound care. LPN (Licensed Practical Nurse) # 7 stated, We don't do her dressing changes, her daughter does them. This surveyor replied, (Name of daughter) is here and agreed to do the dressing change for the survey team. We need a staff member in the room as well. She stated, I will get her nurse, (Name of LPN # 8). The two surveyors went into Resident # 34's room. The daughter was in the room. The resident was observed in her bed, with the head of the bed at approximately 90 degrees. She was covered in blankets and stating that she was cold. The daughter requested a towel which she placed under the resident's leg and she then began unwrapping the right leg. A white geri-leg sleeve was observed with brown, dried, odiferous drainage. The sleeve was pushed up revealing a woolen sock which was taped to the layers of material under it with masking tape. The tape and the sock were removed. Another white geri sleeve was under the sock and taped in the same manner as the sock. Both were removed. The next layer was a foam dressing. The daughter stated that the foam dressing was the [MEDICAL CONDITION] wrap. As each layer was removed the odor from the drainage of the leg increased. When the last layer was removed, a nonstick rectangular gauze was observed over the outer aspect of the right ankle. The gauze had a brown area the approximate size of a fifty cent piece. The skin of the right leg that had been unwrapped was observed. The skin was dry, dark and cracked. The toes of the right foot had been amputated in the past. Folded gauze was observed in the area of amputation. The daughter stated that the gauze was covering a corn. The lower leg from approximately one inch above the still covered wound to the ankle was red. The daughter was asked if the area was hard. She felt it and stated, No, it's soft. The daughter stated, All my supplies are in my car. She requested the LPN's in the room to get her some saline. LPN # 8 brought in bottles of sterile water which the daughter used to clean the leg. As she wiped chunks of dried dead skin came off of the leg. She stated, That's the way they do it at the hospital .they just pull it off. She also stated, .her leg is reeping (sic) .she has the staph infection again .see it's not green (referring to the drainage). The daughter continued to wipe the leg and put the dead skin on the towel under the resident's leg. She then poured sterile water over the nonstick dressing to remove it. Once the nonstick dressing was removed yellow drainage was observed on the outer aspects of where the dressing had been and on the dressing itself. The wound was approximately 3 inches long and approximately 1 inch in the widest part. The borders were irregular. The wound bed was pink with yellow exudate observed. The odor from the wound and the leg was strong and foul. LPN # 7 and LPN # 8 were asked if there were any measurements available for the wound. They both shook their heads side to side, indicating, no. LPN # 7 and LPN # 8 were asked if they had seen the wound before they both stated, No. The daughter was asked when she had last done the dressing change. She stated, Saturday (June 25, 2016). The daughter also stated that she did not always change the gauze over the wound every time she did the [MEDICAL CONDITION] wraps. At approximately 11:30 a.m. on 6/30/16, one of the two Physical Therapists (PT) trained in [MEDICAL CONDITION] treatment was interviewed. The PT acknowledged she had offered to unwrap the legs, and that she had recommended the wound be left open to the air to facilitate healing, but that the daughter had refused. The PT also stated that rewrapping the leg with the wound would be contraindicated by physical therapy standards due to the possibility of spreading the infection. Resident # 34's Electronic Medication Administration Record [REDACTED]. The treatment order was signed off as having been performed daily from 6/13/16 through 6/30/16. The E-MAR also included the following treatment order, dated 6/16/16 for the treatment of [REDACTED]. Wound care was signed off on the E-MAR as having been performed on 6/17/16, 6/20/16, 6/22/16, 6/24/16, 6/27/16 and 6/29/16. Review of the facility's policy General Wound Care/Dressing Changes noted the following: POLICY: A licensed nurse will provide wound care/dressing change(s) as ordered by physician. At 1:10 p.m. on 6/30/16, two of the staff members who signed off the E-MAR as having performed the [MEDICAL CONDITION] wraps and wound care were interviewed. RN # 7 (Registered Nurse) said, We don't do dressing changes, her daughter does them. We are not allowed to. We used to do it but we did not do it correctly. RN # 8 stated, We are just documenting that the dressings are intact, not that we are doing it. Sometimes I document in the Nurses Notes that the dressing is intact. RN # 8 went on to say that the Nurse Practitioner was made aware that staff is not doing dressing changes, but she (the Nurse Practitioner) did not write and new orders. At approximately 3:00 p.m. on 6/30/16, a telephone interview was conducted with the resident's attending physician, who also serves as the Co-Medical Director. The physician admitted he has never seen the resident's leg wound. He also said he did not know the resident's daughter had taken her to the wound clinic. The physician went on to say he was aware the resident and her family were non-compliant with the treatment orders for her [MEDICAL CONDITION] and leg wound. We talked to the family multiple times, the physician said. If the family is going against doctor's wishes for treatment, we just accept it. The physician inferred there was not much he could do to address the family's/resident's non-compliance. Asked if he had any notes of his conversations with the resident and her family, the physician said, I don't recall. Review of the facility policy Refusal of Medication/Treatment Care noted the following: POLICY: A licensed nurse is to document and notify the physician and responsible party when a patient refuses medication(s) and/or treatment. Following the notification of Immediate Jeopardy at 3:15 p.m. on 6/30/16, the facility submitted the following Plan of Removal: The statements made in the following plan of correction are not an admission to and do not constitute an agreement with the alleged deficiencies nor the reported conversations and other information cited in support of the alleged deficiencies. The facility sets forth the following plan of correction to remain in compliance with all federal and state regulations. The facility has taken or will take the actions set forth in the plan of correction. The following plan of correction constitutes the facility's allegation of compliance. All alleged deficiencies cited have been or will be corrected by the date or dates indicated. 1) Patient # 34 will be sent to (name of hospital) for evaluation per MD order, APS referral will be made to ensure patient welfare. 2) All refusals of staff performance of wound care or [MEDICAL CONDITION] wrapping will be reviewed for proper documentation, MD notification, APS referral as appropriate. 3) Nurses will be in serviced on: a. Refusal of care protocols including MD notification. b. Proper treatment documentation. c. Skin/Wound Assessment. 4) Administrator and DON will review audit findings. 5) Date of compliance June 30, 2016. The Plan of Removal was reviewed and accepted by the survey team at 5:00 p.m. on 6/30/16. COMPLAINT DEFICIENCY 2. Resident #4 was not weighed daily per physician orders. Findings were: Resident #4 was most recently readmitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. The most recent MDS (minimum data set) was an annual assessment with an ARD (assessment reference date) of 04/12/2016. Resident #4 was assessed as having a cognitive summary score of 10, indicating moderate impairment with her cognitive status. The clinical record was reviewed on 06/28/216. Observed on the POS (physician order sheet) was an order dated 05/23/2016 for Daily weight in the morning related to HEART FAILURE, UNSPECIFIED 9150.9); FLUID OVERLOAD, UNSPECIFIED (E 87.70) Notify MD (medical doctor) if weight gain is 2-3 lbs (pounds) within 2-3 days, change in SOB (shortness of breath), lower leg swelling, chest pain or pressure. The weight section of the clinical record was reviewed. Daily weights were recorded from 05/24/2016 through 06/08/2016. From 06/09/2016 through 06/28/2016, a total of 20 days 20 opportunities, five weights were recorded. On 06/28/2016 the unit manager, LPN (licensed practical nurse) #1 was interviewed regarding weights for Resident #4. She asked RN (registered nurse) #4 if he had was weighing Resident #4. He stated, Yes. LPN #1 asked RN #4 to go see what weights he could find. He returned with a piece of paper and stated These are her weights from the weekend. The handwritten paper contained two weights dated from the previous weekend .He was asked where the paper came from. He stated, I just wrote them. There was no name on the paper or any other weights LPN #1 and RN #4 were interviewed regarding the weights. RN #4 stated, I weigh her everyday when I am here. I don't write the weights down if they are in the parameters. RN #4 was asked how the next person would know what the weights were and if the doctor needed to be notified if he didn't write the weights down when he got them. He did not answer. LPN #1 stated, The weights should be in the computer not on paper. The administrator, the DON (director of nursing) and the corporate nurse consultant were notified of the above information during and end of the day meeting on 06/28/2016. The administrator stated, We are currently going through pieces of paper to find the weights. Eight additional days of weights were presented on handwritten pieces of paper. Weights were not obtained every day as ordered by the physician. No further information was obtained prior to the exit conference on 06/30/2016.

Based on observation, staff interview, resident interview, family interview, and facility document review the facility staff failed to ensure a safe smoking environment for three of 34 residents in the survey sample: Residents # 19, 11, and 33. For Residents, #19, 11, this resulted in the identification of Immediate Jeopardy and Substandard quality of care. The facility administration was notified of the finding of Immediate Jeopardy on 6/29/16 at 6:30 p.m. Following the presentation and acceptance of a Plan of Removal, the finding of Immediate Jeopardy was removed 6/30/16 at 8:15 p.m. Subsequently, the deficiency was assigned a scope and severity of Level 2, isolated. 1. The facility staff failed to implement safety measures for Resident # 19, a resident with known seizure activity. Resident # 19 was not reassessed for safety and the facility failed to follow the policy for safety by allowing him to keep his lighter at the bedside. 2. Resident #11, with severely impaired cognitive skills and a care plan requirement for supervised smoking, was allowed to smoke unsupervised. After exhibiting increased exit seeking behavior and placement of a Wanderguard safety device, Resident #11 was allowed out of the facility unsupervised without a plan of care for outside safety. 3. Resident #33 was identified as a smoker by the facility on 05/31/2016. An assessment to determine whether or not Resident #33 was safe to smoke without supervision was not conducted until 06/24/2016. Findings include: 1. Resident # 19 was allowed to smoke outside the facility, unsupervised, after having documented seizure activity while smoking. The facility did not put safety interventions in place for Resident # 19, and did not reassess his ability to safely smoke. Resident # 19 was initially admitted to the facility 4/18/15 with a readmission date of [DATE]. [DIAGNOSES REDACTED]. The most recent MDS (minimum data set) was a quarterly review dated 6/1/16 and had the resident as being cognitively intact with a total summary score of 15 out of 15. The electronic medical record (EMR) was reviewed 6/29/16 at 9:00 a.m. Nursing notes documented the following: 4/8/16 06:28(6:28 a.m.) Writer reported to work at 05:45 (5:45 a.m.) and met (name of resident) sitting outside the main entrance smoking. Writer witness (sic) same situation Tuesday 4/5/16 and resident was educated to wait until secretary at lobby to activate door to 'open' so he can be seen by staff. Resident also educated on risk of having a seizure when he is alone with no staff member around. Writer asked resident how he got out and he stated he wait at the lobby for phlebotomist or delivery people coming in and out and also leave and enter. Writer again educated resident about his frequent seizure activity and risk of having seizure with no staff around due to his noncompliance with the facility smoking rules. He verbalized understanding of the risk. 4/19/16 15:46 (3:46 p.m.)- writer and staffs (sic) responded to resident having seizure while smoking downstairs 4/19/16 18:30 (6:30 p.m.)- DON (director of nursing) and charge nurse met with resident to discuss resident's noncompliance with leaving the unit unsupervised due to frequent recurrent seizure activity and associated risks. Resident was offered to have staff accompany him to the patio when he leaves that unit but he declined. Resident waits by the main entrance doors during odd hours and sneaks (out) when someone unfamiliar open the door and when redirected he get agitated (sic). ADT (administrative disciplinary team) suggested setting specific times for staff to supervise resident when he is off unit for seizure activities. Resident staunchly declined staff supervision. He did not want to hear about setting specific times for staff to accompany him from the unit to the patio so that he can know when to anticipate staff assistance. he states he wishes to be left alone. He further stated he will leave the unit and go outside anytime he damn well pleases. I just don't go there to smoke. I want to hang out with my friends and I don't need anybody watching me. Resident's cognitive skills for daily decision making is very intact. He is capable of making an informed educated decision but has chosen to be noncompliant with medical safety interventions. Resident has been educated on the disease process, safety, that his noncompliance is placing him at a very high risk for injuries that may even result in death and he has staunchly chosen not to understand or comply. Resident is self RP (responsible party). NP (nurse practitioner) visiting facility was notified. 4/28/16- Seizure while smoking . 6/21/16- Seizure lasting 10 minutes educated re seizure precautions The current comprehensive care plan (CCP) was then reviewed. Under Focus was documented Resident is a smoker The date the CCP was created was dated 5/21/15 with a revised date of 5/23/16. Under Goals was documented The resident will not suffer injury from unsafe smoking practices through the next review. Under Interventions was documented Instruct resident about smoking hazards and about smoking cessation. Instruct resident about the facility policy on smoking: locations, times, safety concerns. Notify charge nurse immediately if it is suspected resident has violated smoking policy. The resident can smoke UNSUPERVISED (sic). The resident is able to safely light own cigarette and may keep lighter at bedside. The CCP did not include any interventions to reflect the need for supervision while smoking due to seizure activity or the resident's behavior of sneaking out during odd hours. The safe smoking assessment was reviewed. The assessment was dated 4/29/15 and had Resident # 19 assessed as needing no supervision to smoke. On 6/29/16 at 11:30 a.m. the administrator was asked about the frequency of the smoking assessments. The administrator stated he would check on that and get back to me. At 12:50 p.m. the administrator told this surveyor There is no set frequency for when to do an assessment for smoking, just as determined by the IDT (interdisciplinary team). On 6/29/16 beginning at 4:25 p.m. during a meeting with facility staff, the administrator and DON were informed of the above findings. They were asked since Resident # 19 had been witnessed to leave the facility at odd hours by waiting by the door, and having had seizure activity while smoking, should the CCP be updated about those items, and should a smoking assessment be done to ensure the resident was still safe to smoke unsupervised? The DON was also asked how staff were to be aware of the resident's behavior if the plan of care did not address it. The administrator stated The residents who are cognitive and the smoking assessment indicates they are safe to smoke unsupervised are allowed to do so. I don't know about the CCP; it's documented that there was a conversation with the resident about putting safety measures in place and he refused. If he is willing to accept the risks I'm not sure we can make him. ( .)he has rights. I can't just discharge someone for not following smoking rules. The facility policy for smoking was requested from the administrator at that time. The policy titled Patient Smoking was received and reviewed. The policy documented The Center promotes a smoke-free environment to protect the health, safety and well-being of all our patients; therefore the Center maintains a policy of no smoking within the building by anyone at any time. (Bold letters by policy writing). Under Procedure was documented: 1. The Administrator may or may not choose to designate areas outside the building for any smoking activities. 3. A patient may smoke in designated smoking areas that may be established on the grounds of the Center: a. if the patient has been assessed by the interdisciplinary team, and b. it has been determined through the Safe Smoking Assessment that it is safe for the patient to smoke. 4. If a smoking area is administratively designated on the grounds of the Center, any patient who wishes to smoke will be evaluated (see Safe Smoking Assessment) by the Interdisciplinary Team upon admission to determine safety and ability to handle smoking material. The patient must also sign the Patient Smoking Acknowledgement form which is to be maintained in the patient's medical record. If supervision is deemed necessary the patient will be supervised by staff or other appropriate person (i.e. family member) and with any safety device needed(i.e. smoking apron). Ashtrays of noncombustible material and safe design shall be provided . A smoking schedule will be created for patients requiring supervision. All instruments that cause a spark or flame (igniting products) will be kept in a locked location. Smoking is only allowed in designated outside smoking areas and where oxygen is not being used or stored. Sharing of smoking material with patients by patients, staff, family members or other visitors is strictly prohibited. 5. Failure to comply with the use of any smoking and/or igniting products may result in the initiation of the discharge process. The administrator, DON, and corporate nurse consultant were informed of the finding of Immediate Jeopardy 6/29/16 at 6:30 p.m. The administrator presented the survey team with a five point plan for the removal of Immediate Jeopardy 6/29/16 at approximately 8:00 p.m. which included: the smoking area placed on immediate supervision until individualized care plans were developed to provide a safe smoking environment for all active smokers. Per policy all lighters and matches currently in patients' possession will be collected by staff and stored in a locked location. Active smokers would be reassessed to determine competence to smoke unsupervised and develop appropriate safety measures. Re-education of staff and active smokers on the smoking policy, daily protocols on the storage of lighters for those needing supervision, staff monitoring for policy adherence, care planning for smokers assessed to need supervision and scheduled smoking time, and signing of the Patient Smoking Acknowledgement. Administrator and staff will audit Residents 11 and 19 to ensure safety interventions in place. Date of compliance 6/29/16. The survey team, after review of the plan of removal, accepted and removed the Immediate Jeopardy 6/29/16 at 8:15 p.m. On 6/30/16 at 8:00 a.m. the safe smoking reassessment for Resident # 19, and an updated care plan, was provided by the administrator. The safe smoking reassessment dated [DATE] revealed the resident was assessed as needing a smoking apron and supervision. The smoking assessment also documented Resident has [DIAGNOSES REDACTED]. Resident will be provided a smoking apron when smoking as a safety precaution. The CCP was updated to include the safety precautions and supervision for Resident # 19. The signed Patient Smoking Acknowledgement form was also provided. The form was dated 6/29/16. The administrator stated We couldn't locate all the signed forms; some of the residents have been here for [AGE] years or more. We just went ahead and had them signed last night. On 6/30/16 at approximately 9:15 a.m. this surveyor went to the smoking area per the reassessment of Resident # 19, and the smoking schedule developed for him. Resident # 19 was sitting in his wheelchair, smoking, without the smoking apron on his person as the smoking assessment documented he would have. This surveyor asked Resident # 19 if he was aware he was to have the smoking apron on, and he stated Yes. Resident # 19 was then asked if he had a smoking apron, and he reached down to the side of the wheelchair and held up a folded, unused apron. This surveyor then asked if he was going to put it on, and he began unfolding the apron, and attempted to put the apron on. A staff member, who was standing a few feet away, came over and began helping Resident # 19 put the apron on. Resident # 19 voiced his disagreement to wearing the apron, to which the staff member told him This is to make sure you are safe. A few moments later, this surveyor spoke to the staff person, who stated she worked in the business office, and since she occasionally smoked, had agreed to be one of the staff who supervised the smoking area. The staff member was asked if she was aware Resident # 19 was to wear the smoking apron, and asked why the resident did not have it on while smoking. The staff member stated The DON came out earlier and put one on him; I think he must have taken it off The staff member was then made aware the apron the resident presented to this surveyor had been unused, and folded with the tie strings still tied around it. The staff member then stated I tried to encourage him to put it on; I guess he must have gotten another one . During that time, the administrator had walked over and was standing beside the staff member as this surveyor was interviewing her. The administrator stated (name of resident) is somewhat anti-authority. He has stated he does not want to wear the apron, and has signed a statement. The administrator then handed this surveyor a copy of a paper with a paragraph that included the resident accepted all liability for any harm that may occur as a result of not complying with the smoking rules. The paper was signed by the resident and the administrator dated 6/30/16. The resident, as noted above, had signed the Patient Smoking Acknowledgement form 6/29/16, as required by the facility policy, that he would comply with the smoking rules, or his smoking privileges could be suspended, and the discharge process started. 2. Resident #11, with severely impaired cognitive skills and a care plan requirement for supervised smoking, was allowed to smoke unsupervised. After exhibiting increased exit seeking behavior and placement of a Wanderguard safety device, Resident #11 was allowed out of the facility unsupervised without a plan of care for outside safety. Resident #11 was admitted to the facility on [DATE] with a re-admission on 4/24/16. [DIAGNOSES REDACTED]. The minimum data set ((MDS) dated [DATE] assessed Resident #11 with severely impaired cognitive skills and functional limitation in range of motion of his upper and lower extremities on one side. On 6/28/16 at 10:40 a.m. an interview about quality of life in the facility was conducted with the resident's guardian. The guardian stated she routinely visited and spent time with Resident #11 daily but was unable to visit during several weeks in May (2016) due to illness. The guardian stated she was just coming back to the facility after being sick. The guardian stated when she was unable to visit in May 2016 a Wanderguard device was placed on Resident #11's wheelchair causing the door to alarm when Resident #11 attempted to go outside. The guardian stated she accompanied the resident outside during her visits and was concerned that staff members did not take Resident #11 outside when she was unable to visit. The guardian stated the resident routinely smoked in the designated smoking area and she did not understand why the resident had the Wanderguard. Resident #11's clinical record was reviewed on 6/28/16. The clinical record documented the following about smoking. 9/11/15 - Patient is non compliance with smoking. Writer spoke to patient's guardian .regarding the medical disadvantage of smoking especially his head injury. Guardian stated that (Resident #11) has been smoking through out his life and no body will stop him smoking . (sic) 9/14/15 - .DON (director of nursing) and writer explained the adverse effects of smoking and wound healing to guardian. The guardian said he does not matter the medical problems patient may have, he is fine for him to smoke .So she (guardian) authorized two alert and oriented residents to assist patient with smoking when staff are not around. She will provide cigarettes . (sic) 1/18/16 - At around 1930 (7:30 p.m.) resident insisted to go out by himself to smoke. Writer explain to resident he cant (can't) go out by himself and need an escort. Resident got upset and started striking the walls, and his head. Resident family was notified. Resident (Guardian) .stated 'resident can go out and smoke by himself with no escort needed'. A smoking assessment dated [DATE] listed the resident was safe to smoke without supervision or safety devices. A Smoking - Safety Screen for Resident #11 dated 3/29/16 listed the resident had cognitive loss, had dexterity problems, smoked 2 to 5 cigarettes per day and liked to smoke in the morning, afternoon and evening. This assessment stated Resident #11 was able to light his cigarettes, required no apron, no cigarette holder, no supervision or one to one assistance for smoking. In addition, this assessment documented the resident was safe to keep his own lighter and cigarettes. This assessment documented, At this time resident is deemed a safe smoker and so will not need no protective equipment for his safety or other residents' safety . (sic) Resident #11's care plan (revised 5/27/16) listed the resident was a smoker. On 5/25/16 the care plan was updated requiring supervision with smoking. The care plan stated, Resident is a smoker. The care plan goal regarding smoking stated, Resident will not smoke without supervision through the review date. Care plan interventions for smoking stated, Instruct resident about smoking risks and hazards and about smoking cessation aids that are available .Instruct resident about the facility policy on smoking: locations, times, safety concerns .Notify charge nurse immediately if it is suspected resident has violated facility smoking policy .Observe clothing and skin for signs of cigarette burns .Resident requires SUPERVISION while smoking. The clinical record documented a physician's orders [REDACTED].#11's wheelchair due to exit seeking behavior. Resident #11's care plan included no interventions regarding who was responsible to supervise the resident during smoking. The care plan made no mention of the resident's use of the Wanderguard device or of any problems or safety concerns about the resident going outside unsupervised. There were no revisions to the care plan regarding the resident's documented non-compliance with smoking supervision. The care plan documented the resident had poor safety awareness, impaired cognitive function due to traumatic brain injury, impulsive behavior, adverse behaviors that included scratching and removing wound dressings, cursing, hitting and kicking staff and refusal of care. The care plan also documented the resident had communication problems due to speech impairment from a stroke. Resident #11's clinical record documented the resident had a history of [REDACTED]. Nursing notes for May and through 6/27/16 documented the following. 5/9/16 - Resident was found on the floor mat in his room .Resident had an actual fall and at risk for further falls r/t (due to) poor safety awareness, confusion and impulsive behavior secondary to TBI (traumatic brain injury) 5/12/16 - .Resident has history of falls. Resident has contracture of his left arm. Resident is unable to bend his left leg. Resident has history of accident and sustained head injury. Resident has history of seizures. Resident is unable to talk but utters sounds when he needs assistance .Resident exhibits adverse behavioral symptoms namely: Intensely scratching and removing dressing on scalp wound, cursing, hitting, kicking staff, and refusing to be changed . 5/15/16 - .While in the dining room resident was observed trying to hit the sister . 5/16/16 - Resident was observed trying to go (to) the bathroom on his own. Resident lost his balance and fell on the floor . 5/22/15 - Resident behavior is very alarming this morning. As care team was attempting to provide care to resident he started kicking and swearing curse words as well as trying to punch staff. We attempted again to get resident cleaned up from urine accident and he ripped the diaper off and slung it at staff. We immediately left the room before anyone got hurt . 5/23/16 - .Resident easily becomes angry. At first he did not want staff to remove his shoes. Resident started to hit his head . 5/26/16 - During review period resident exhibited increased agitation and aggression as evidenced by hitting and kicking staff and hitting himself in the head . 5/27/16 - .Resident is non-compliant with care. Resident was incontinent of urine this am (morning) and refused to be changed . 5/31/16 - .Resident was not observed but he states he was pointing at his breakfast tray that was left in his room so it seems like he was trying to reach his tray to eat breakfast in the process lost his balance . 6/14/16 - .Resident is very non compliant with keeping dressing on. Removes dressing and picks on wound . 6/16/16 - .Resident continues to remove dressing on scalp and picking on wound . 6/17/16 - .Resident continues to remove dressing on scalp and picking on wound . On 6/28/16 at 1:45 p.m. the facility's activity director was interviewed about Resident #11. The activity director stated Resident #11 routinely went outside and smoked in the designated smoking area without supervision. The activity director stated Resident #11 went outside and there was not always a staff person assigned. The activity director stated the resident liked to sit on the walk near the front entrance and spend time in the designated smoking area. The activity director stated she felt Resident #11's going outside and smoking unsupervised was not safe. The activity director stated the entire smoking area was unsafe because there was no routine supervision of residents smoking. The activity director stated Resident #11 had a Wanderguard placed when his family member was unable to routinely visit and the resident had increasing behaviors of leaving the facility. The activity director stated with the Wanderguard the front entrance door alarmed when Resident #11 approached to exit but that the front desk receptionist deactivated the alarm and let Resident #11 outside. The activity director stated if the resident went out of the front door to the left toward the main highway, the front desk receptionist went after the resident and re-directed him. The activity director stated the resident was allowed to go out the door to the right toward the smoking area unsupervised. The activity director stated Resident #11 was usually accompanied to the smoking area by Resident #19. The activity director stated concerning going outside with activity staff, I'm not taking him (Resident #11) out. The activity director stated when volunteers were available some residents were accompanied outside but Resident #11 had not been included in outside activities. The activity director stated she felt the entire smoking area was unsafe because there was no scheduled supervision of the area or the residents. On 6/28/16 at 2:05 p.m. the designated smoking was observed. The smoking area was located under an awning at the one end of the building accessible from the main parking lot. The smoking area was not visible from the front lobby or reception desk. The area was accessible from the front sidewalk area, front parking lot and a side entrance into the building. There were four residents in the smoking area at the time of this observation. Two of the four residents were actively smoking. One resident was sitting on a bench with a cigarette lighter in her hand. There were no staff members present and no protective aprons in use. On 6/28/16 at 2:15 p.m. the licensed practical nurse (LPN #3) that routinely cared for Resident #11 and completed the smoking assessment dated [DATE] was interviewed. LPN #3 stated the assessment on 3/29/16 listed the resident as safe to smoke without supervision. When asked how the resident was assessed as safe to smoke without supervision when he had severely impaired cognitive skills, LPN #3 stated the guardian usually went with the resident outside. LPN #3 stated the resident had developed exit seeking behaviors during the last several weeks when his guardian was sick and no longer visited daily. LPN #3 stated the Wanderguard was placed on the resident's wheelchair because it was unsafe for the resident to go out toward the garden and highway unsupervised. LPN #3 stated, We (staff) were afraid he was going farther. LPN #3 stated prior to the guardian's illness, the resident had been going outside frequently with the guardian, his cousins and sometimes a therapy aide. LPN #3 stated when the guardian was unable to visit each day the resident made increased attempts to go out alone. When asked how the resident went out of the facility with a Wanderguard device in use, LPN #3 stated the alarm was turned off. When asked how she was sure the resident was supervised when he went out to smoke, LPN #3 had no response. LPN #3 stated the nurses and unit manager were responsible for updating care plans. On 6/28/16 at 2:30 p.m. the registered nurse unit manager (RN #5) was interviewed about Resident #11 smoking and going outside without supervision. RN #5 stated Resident #11 was not supposed to be by himself when smoking. RN #5 stated prior to guardian's illness, the guardian routinely went out with the resident to smoke. RN #5 stated when the guardian became sick and did not visit each day Resident #11 became more agitated and exit seeking. RN #5 stated the Wanderguard device was placed on the resident's wheelchair to prevent him from leaving the facility without staff knowledge. RN #5 stated the receptionist called him from the lobby when Resident #11 was attempting to leave the building and he would go or send staff to redirect or supervise the resident. When asked if he was aware the receptionist was turning off the Wanderguard alarm and allowing Resident #11 to go outside and smoke unsupervised, RN #5 stated, No. When asked about the assessment on 3/29/16 that listed the resident as safe to smoke without supervision, RN #5 stated that assessment was wrong. RN #5 stated the resident had severely impaired cognitive abilities due to his brain injury and required supervision. RN #5 stated the current care plan was correct and the resident required supervision to smoke. On 6/28/16 at 2:40 p.m. the front desk receptionist was interviewed about Resident #11. The receptionist stated that Resident #11 sometimes went out of the facility with Resident #19. When asked how Resident #11 went out of the facility with the Wanderguard device in place, the receptionist stated she deactivated the alarm by swiping her card so Resident #11 could go outside. The receptionist stated she sometimes let Resident #11 sit out on the front walk. The receptionist stated, I eyeball him from in here. The receptionist stated if she saw Resident #11 going left toward the highway she would get him or alert other staff members. The receptionist stated sometimes a staff member went with Resident #11 outside and other times the resident went out with Resident #19. When asked if Resident #11 went to the smoking area supervised, the receptionist stated, Not always. The receptionist stated she deactivated the Wanderguard alarm and allowed Resident #11 to go out of the front door toward the smoking area. The receptionist stated Resident #19 usually accompanied Resident #11 to smoke. The receptionist stated the smoking area was not visible from her desk but that Resident #11 was usually with Resident #19 when he went to smoke. While being interviewed the receptionist answered the telephone switchboard for the facility and greeted and interacted with visitors and residents from behind the front desk. On 6/28/16 at 3:30 p.m. the administrator, nurse consultant and director of nursing (DON) were interviewed about Resident #11 smoking unsupervised when his plan of care required supervision. The administrator stated when the resident was first admitted to the facility the guardian did not want the resident to smoke. The administrator stated the resident enjoyed going outside and wanted to be with other young smokers so a plan was initiated regarding smoking. The nurse consultant stated when the resident originally started smoking he was able to smoke safely. The nurse consultant stated recently the resident had increased behaviors and was considered a possible danger. The nurse consultant stated Resident #11 had declined in condition and there was maybe a need to supervise, to watch him from a distance. The DON stated the Wanderguard was added because Resident #11 was trying to go outside alone. The DON stated sometimes the resident would sit safely near the front entrance and sometimes he attempted to go toward the street. The DON stated the front desk receptionist watched the resident when he went outside. When asked how the resident was supervised when smoking as the smoking area was not visible from the lobby or front desk, the administrator stated the resident's guardian was ok with him going outside and smoking unsupervised. When asked why the resident was allowed to smoke unsupervised when he was assessed with [REDACTED].#11 smoking unattended. On 6/29/16 at 4:40 p.m. the administrator was interviewed about Resident #11 smoking and going outside unsupervised. The administrator stated it was most appropriate for Resident #11 to be a supervised smoker but the guardian wanted the resident to be allowed to smoke. When asked about the resident's care plan that made no mention of interventions allowing the resident to smoke unsupervised or the use of the Wanderguard, the administrator stated the care plan needed to be updated. The administrator stated the Wanderguard alarm was to alert staff the resident was going outside. The administrator stated when Resident #11 went outside the front desk receptionist alerted staff if he was going toward the main highway. The administrator stated, The front desk person is monitoring that (going outside). The administrator stated the resident was allowed to smoke unsupervised because they were trying to maximize the resident's freedom and honor the guardian's wishes for the resident to go outside and smoke independently. When asked why the plan of care made no mention of the Wanderguard, unsupervised smoking or the receptionist's monitoring of the resident, the administrator stated, When the ID (interdisciplinary) team figures out how to handle this we need to update the care plan. Concerning the unsupervised smoking, the administrator stated, We want to honor the guardian's decision to willingly accept the risks (of unsupervised smoking). The administrator stated there were no designated smoking times in the facility and residents were allowed to smoke in the smoking area from 8:00 a.m. until 10:00 p.m. each day. The facility's policy titled Patient Smoking (effective 2/1/15) documented, A patient may smoke in designated smoking area that may be established on the grounds of the Center: a. if the patient has been assessed by the interdisciplinary team, and b. it has been determined through the Saf