Every finding on record at City Park Healthcare and Rehabilitation Center

Based on observations and interviews, the facility failed to maintain an infection control program designed to provide a safe, sanitary, and comfortable environment to prevent the development and transmission of diseases and infection on two of five units. Specifically, the facility failed to;-Ensure housekeeping staff followed proper cleaning procedures for cleaning and disinfecting resident rooms and high-frequency touched areas (door handles, call lights, and bedside tables);-Ensure areas were cleaned from clean to dirty areas;-Ensure surface disinfectant dwell times (the amount of time a disinfectant needs to remain wet on a surface to effectively kill germs) were followed;-Ensure hand hygiene was performed appropriately during the cleaning of residents' rooms; and, -Failure to use appropriate PPE during wound care for enhanced barrier precautions.Findings include: I. Housekeeping failures A. Professional reference According to The Centers for Disease Control (CDC) Environment Cleaning Procedures (3/19/24), retrieved on 1/20/26 from https://www.cdc.gov.healthcare-associated-infections/hcp/cleaning-global/procedures.html. Wipe surfaces using the general strategies, such as cleaning from dirty areas, high to low, in a systematic manner, making sure to use mechanical action for cleaning steps, and making sure that the surface is thoroughly wetted to allow the required contact time. According to The Centers for Disease Control (CDC) Clinical Safety Hand Hygiene for Healthcare Workers (2/27/24), retrieved on 1/20/26 from https:/www.cdc.gov/clean-hands/hcp/clincial-safety/ Hand hygiene protects both healthcare personnel and patients. Hand hygiene means cleaning your hands with soap and water, alcohol-based foam, or alcohol-based hand sanitizer. Cleaning your hands reduces the potential spread of deadly germs to patients, including those resistant to antibiotics. Gloves are not a substitute for hand hygiene. If your task requires gloves, perform hand hygiene before donning gloves and touching the patient or patient's surroundings. Always clean your hands after removing gloves. The identification of high-touch surfaces and items in each patient care area is a necessary prerequisite to the development of cleaning procedures, as these will often differ by room, ward, and facility. Examples of high-touch surfaces include bedrails, intravenous poles, sink handles, bedside edges, privacy edges, call bells, light switches, and doorknobs. B. Manufacturer's recommendations The Sunburst product specification document for Sani-Clean 2 disinfectant was provided by the housekeeping supervisor on 1/15/26 at 3:28 p.m. It read in pertinent part, Wet all surfaces thoroughly with a mop, cloth, or sprayer. Allow surface to remain wet for the required time (1 to 10 minutes). C. Facility policy and procedure The Safe and Homelike Environment policy, dated 10/25/25, was provided by the nursing home administrator (NHA) on 1/15/26 at 4:45 p.m. It read in pertinent part, In accordance with residents' rights, the facility will provide a safe, clean, comfortable, and homelike environment. Sanitary includes, but is not limited to, preventing the spread of disease-causing organisms by keeping resident care equipment clean and properly stored. Resident care equipment includes, but is not limited to, equipment used to complete activities of daily living. The Daily Room Checklist, not dated, was provided by the housekeeping supervisor on 1/15/26 at 3:28 p.m. It read in pertinent part, Clean and disinfect the bathroom thoroughly, including the toilet, sink, and other fixtures. Follow proper dwell times for each chemical used. Clean and disinfect all reachable flat surfaces, avoiding moving the resident's personal items unless requested. D. Observations On 1/14/26 at 8:45 a.m., housekeeper (HK) #1 was observed cleaning a double occupancy room on the fourth floor. HK #1 donned (put on) gloves without performing hand hygiene and entered the resident's room with two spray bottle containers labeled Sani-Clean 2, and Spray Kleen. She placed the Sani-Clean disinfectant on the sink counter, sprayed the mirror with the Spray Kleen, and immediately wiped it with a small blue towel from her pocket. HK #1 went to her cart, disposed of the blue cleaning rag, took a new cleaning rag, and returned to the residents' room. She sprayed the sink area with the disinfectant labeled Sani Clean 2, and immediately wiped it with a clean blue rag. She went back to her cart and placed the glass cleaner back on the cart. HK #1 removed her gloves and donned a new pair of gloves without performing hand hygiene. She grabbed a container with a cleaning brush labeled Tub and Tile Cleaner and the Sani-Clean spray bottle and went to the residents' bathroom. She placed the container with the brush on the floor and sprayed the surfaces of the toilet with Sani-Clean 2, then immediately used a purple cleaning rag to wipe it down from top to bottom. HK #1 picked up the brush from the container and began cleaning the inside of the toilet bowl. She continued cleaning the inside of the bowl, the top of the seat and the outside around the back of the toilet with the same brush. She sprayed two grab bars in the residents' bathroom. She returned to her cart, placed the tub and tile container, and Sani-Clean 2 sprayer into it. She removed her gloves and donned a new pair. HK #1 retrieved her broom and dustpan from her cart. She swept the floor on side two of the room with the broom. She swept under the bed and around the resident's bedside, then moved the bedside table and swept the corner of the bed between the bed and the bedside dresser. HK #1 then proceeded to side one of the room and swept the floor. -HK #1 did not perform hand hygiene before and after removing gloves. -HK #1 did not allow the disinfectant solution to remain wet on the surfaces for the manufacturer's recommended dwell time (1 to 10 minutes). HK #1 obtained a clean mop rag and mop stick from the cleaning cart and mopped the floor under the bed and towards the second side of the room. She continued to mop the floor towards the first side of the residents' room with the same mop head. HK #1 removed the mop head and stored it in a rag plastic bag alongside the mop stick. She removed her gloves and placed a wet floor sign in front of the resident's door. The HK then applied alcohol based hand sanitizer. -HK #1 used the same mop head to mop sides one and two of the residents' room. -HK #1 failed to disinfect and clean high-frequency touched areas, such as call lights, door handles, light switches and headboards of the residents' room. On 1/15/26 at 11:28 a.m. HK #2 was observed cleaning room [ROOM NUMBER], a double occupancy room. HK #2 donned gloves without performing hand hygiene. HK #2 entered room [ROOM NUMBER] and began spraying the entire surface of the toilet with Sani-Clean disinfectant cleaner, then immediately wiped it down with a purple cleaning rag she had in her hand. HK #2 removed a toilet riser from the resident's toilet and placed it in the middle of the resident's room to make room to clean other parts of the resident's toilet. She returned to the cleaning cart and grabbed a container labeled tub and tile all-purpose cleaner and a container with two cleaning brushes. HK #2 held the bathroom door handle to return to the bathroom to finish cleaning it. HK #2 grabbed a long green brush from the container and began cleaning the toilet bowl. She cleaned the inside and used the same brush to clean the outside of the toilet bowl. She placed the brush in the tub and tile container and continued to wipe down with the same cleaning rag. She used the same rag to clean the underside of the toilet seat, the rim of the toilet, then the top of the toilet seat, and the basin. HK #2 placed the toilet brush back in the cleaning cart without disinfecting it. -HK #2 failed to clean from the cleanest area to the dirtiest -HK failed to perform hand hygiene after her hands became contaminated. HK #2 grabbed a mop head and placed it on the floor by the bedside of bed two and began mopping that side. HK #2 used the same mop pad to mop the first side of the room. HK #2 retrieved a new mop head and put it on the bathroom floor, and mopped the bathroom. She returned to her cart, placed the mop head and stick away, removed her gloves and performed hand hygiene. After finishing the room, HK #2 realized the toilet commode was sitting in the middle of the resident's room. HK #2 retrieved the Sani-Clean disinfectant, without wearing gloves she sprayed the commode and immediately wiped it down with a cleaning rag. She placed it back in the bathroom. She returned to her cart and performed hand hygiene with alcohol-based hand sanitizer. -HK #2 failed to clean high-frequency touched areas. -Failed to sweep the resident's room before mopping the bedroom floor. The floor had debris on it. -HK #2 failed to follow the dwell time for the Sani-Clean 2 and the tub and tile disinfectant E. Staff interviews HK #2 was interviewed on 1/15/26 at 12:15 p.m. HK #2 said it was okay to use the same brush to clean the inside of the toilet bowl and the outside to remove hard-tickened substances. HK #2 said she should have performed hand hygiene and changed her gloves more often. She said she should perform hand hygiene between tasks, but she forgot. HK #2 said she should have put on gloves to clean the toilet commode. The infection preventionist (IP) was interviewed on 1/15/26 at 12:35 p.m. The IP said HK #1 and HK #2 should have worn gloves at all times while cleaning the residents' rooms. The IP said the housekeepers should have changed gloves frequently and performed hand hygiene between dirty and clean tasks. The IP said HK #2 should have washed her hands with soap and water after cleaning the resident toilet commode without gloves. The IP said HK's should not clean inside the toilet bowl and the outside with the same brush to prevent the spread of harmful germs. The IP said it was important to keep surfaces wet for at least three minutes to allow the chemical to work, according to the manufacturer's recommendation. She said the housekeepers should always clean from the cleanest to the dirtiest. The IP said she would ensure education was provided to the HK's immediately to prevent the spread of harmful germs. The housekeeping supervisor was interviewed on 1/15/26 at 1:20 p.m. The housekeeping supervisor said HK #1 and HK #2 received education and performance evaluation to follow the facility's housekeeping policy and procedures. The housekeeping supervisor said HK #2 should have swept the resident's room before mopping the floor. She said both HK's would immediately receive education to ensure proper hand hygiene and appropriate infection control measures were followed during housekeeping procedures. II. EBP failures A. Professional reference According to the Centers for Disease Control and Prevention's (CDC) Implementation of Personal Protective Equipment (PPE) Use in Nursing Homes to Prevent Spread of Multidrug-resistant Organisms (MDROs), retrieved on 1/27/26 from https://www.cdc.gov/long-term-care-facilities/hcp/prevent-mdro/PPE.html. It read in pertinent part, Enhanced barrier precautions (EBP) are an infection control intervention designed to reduce transmission of resistant organisms that employ targeted gown and glove use during high contact resident care activities. Nursing home residents with wounds and indwelling medical devices are at especially high risk of both acquisition of and colonization with MDROs. The use of gown and gloves for high-contact resident care activities is indicated, when contact precautions do not otherwise apply, for nursing home residents with wounds and/or indwelling medical devices regardless of MDRO colonization, as well as for residents with MDRO infection or colonization. Examples of high-contact resident care activities requiring gown and glove use for enhanced barrier precautions include dressing, bathing/showering, transferring, providing hygiene, changing linens, changing briefs or assisting with toileting, device care or use (central line, urinary catheter, feeding tube, tracheostomy/ventilator) and wound care, any skin opening requiring a dressing. A. Resident interview Resident #5 was interviewed on 1/12/26 at 10:05 a.m. Resident#5 said he had an ulcer on the bottom of his foot. B. Observation On 1/14/26 at 10:10 a.m. the IP entered Resident #5's room to perform wound care. She put on gloves. She did not put on a gown to perform Resident #5's wound care. , C. Staff interviews The IP was interviewed on 1/14/26 at 10:30 a.m. The IP said she forgot to put her gown on. She said she realized she forgot to put her gown on when she left his room. She said she would gown and glove for any treatments for enhanced barrier precautions. The medical director was interviewed on 1/15/26 at 9:30 a.m. The medical director said Resident #5 had a right heel pressure injury.

Based on record review and interviews, the facility failed to provide response, action and rational to residents involved in group grievances. Specifically, the facility failed to address and document resolutions to resident concerns brought up in the resident council meetings in a timely manner.Findings include I. Facility policy and procedure The Grievance policy, dated 10/15/25, was provided by the nursing home administrator (NHA) on 1/15/26 at 3:40 p.m. It revealed in pertinent part, It is policy of this facility to establish a grievance process to address resident concerns without fear of discrimination or reprisal. Such grievances include those with respect to care and treatment which has been finished as well as that which has not been furnished, the behavior of staff and of other residents; other concerns regarding their facility stay; and make prompt efforts to resolve grievances the resident may have. General concerns may be voiced at resident and/or family council meetings. II. Group interview A group interview was conducted on 1/14/26 at 2:00 p.m. with six residents (#7, #18, #26, #45, #60 and #68). The residents were interviewable per the facility and assessment. Resident #18, Resident #7 and Resident #60 said they did not feel the facility followed up on their concerns. Resident #18 said she felt like the response time was too long. III. Record review Facility grievances from resident council meetings were provided by the NHA on 1/15/26 at 10:30 a.m. The grievances were reviewed and revealed the following: A 10/25/25 resident council grievance documented a concern that the meat had been hard to cut and requested could the facility work on that. The description of the resolution documented the dietary director would work with the dietary staff to make sure all meats were soft and tender. A 11/19/25 resident council grievance documented a concern the residents voice food had improved but they would like to continue seeing improvements. The resolution documented the dietary manager continued to monitor and improve. A 12/17/25 resident council documented that a resident would like to have the channel TMC on 26 and not ABC, residents would like to have access to [NAME] through Hulu and go to the art museum. The resolution documented maintenance staff changed the channels to TMC and residents had Hulu and [NAME] available now. The aquarium was scheduled on 1/29/26. -However, the 10/25/25, 11/19/25 and 12/17/25 grievances failed to document that the facility followed up with residents regarding the resolutions to the grievances or discussed the resolutions at the next resident council meetings. III. Staff interviews Certified nurse aide (CNA) #5 was interviewed on 1/15/26 at 1:00 p.m. CNA #5 said grievance forms were around the corner from the elevator. CNA #5 said sometimes the residents would tell her they were unhappy with the food. CNA #5 said the kitchen did have alternate items for residents to choose from if they did not like something but she did not typically fill out a grievance for a resident's food complaints. The NHA was interviewed on 1/15/26 at 6:15 p.m. The NHA said grievances were followed up on by department heads. The NHA said the facility did document their resolution and follow up with residents but did not document the resolution for the resident council grievances (see above). The NHA said grievances were reviewed daily at the morning meeting.

Based on observations, record review and interviews, the facility failed to ensure one (#23) of three residents reviewed for accidents out of 46 sample residents received adequate supervision to decrease and/or prevent risk for accident hazards. Specifically, the facility failed to reassess Resident #23 for safe smoking practices. Findings include: I. Resident status Resident #23, age less than 65, was admitted on [DATE] and re-admitted on [DATE]. According to the January 2026 computerized physician orders (CPO), diagnoses included chronic respiratory failure with hypoxia (not enough oxygen in the blood), congestive heart failure, anxiety, chronic kidney disease (kidneys did not effectively filter waste), obstructive sleep apnea (sleeping disorder where breathing stops due to an obstructed airway) and the presence of automatic (implantable) cardiac defibrillator (device to monitor heart rhythms). The 11/11/25 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score of 14 out of 15. She needed substantial or moderate assistance with activities of daily living and was independent at meals. II. Observations On 1/14/26 at 10:19 a.m. Resident #23 was in her room seated in her wheelchair. She placed a blanket over her lap and removed her oxygen cannula (flexible tube that delivers oxygen to the nostrils). She exited her room (while in her wheelchair) and took the elevator to the first floor. At 10:25 a.m. Resident #23 was talking to an unidentified staff member inside near the facility exit door that led to the outdoor smoking patio. The staff member asked the resident if she needed her oxygen. Resident #23 responded she did not wear her oxygen outside to smoke. Resident #23 exited the building. At 10:27 a.m. Resident #23 was outside, had a cigarette in her hand and self-propelled her wheelchair toward the sidewalk and away from the facility. III. Record review Resident #23's smoking care plan, initiated 6/7/25 and revised 9/12/25, documented she had the potential for injury related to smoking. Pertinent interventions, initiated 9/12/25, included to complete a smoking assessment as needed; educate the resident on safe smoking practices; education was to be provided to the resident regarding the health complications related to smoking; and explain the smoking policy. -However, Resident #23's smoking assessment was completed 5/10/25 and the facility failed to complete additional smoking assessments until 1/14/26 (during the survey). The 5/10/25 smoking evaluation documented the resident smoked five times a day, utilized oxygen, safely lit smoking materials, held smoking materials safely and disposed of smoking materials appropriately. The evaluation also documented that a plan of care was used to assure the resident was safe while smoking. -However, the care plan's intervention to complete a smoking assessment as needed was not implemented after 5/10/25. A review of Resident #23's electronic medical record (EMR) revealed the following: A 6/5/25 nursing note documented Resident #23 left the facility at 12:00 p.m. to a local hospital for a procedure. A 6/6/25 nursing note documented Resident #23 returned from the hospital. A 7/22/25 physician note documented the resident was counseled that smoking was not advised. An 8/14/25 activities note documented Resident #23 liked to go outside and smoke or just hang out with friends. An 8/21/25 nurse practitioner (NP) note documented the resident was seen at request of nursing for chest pain that was ongoing for four to five days. The resident was sitting in her wheelchair, having just returned from smoking. An 8/29/25 physician note documented the resident was seen later smoking and discussed with her it was a significant risk to her heart and overall health. The resident stated she was cutting back. A 10/24/25 physician note documented the resident continued heavy cigarette smoking and to continue on 4 L (liters) nasal cannula. An 11/10/25 social services note documented the social services director (SSD) met with the resident who wanted more information and resources on quitting smoking. The SSD went over support services with the resident that included options for a nicotine patch which the resident expressed interest in. The SSD reached out to the resident's attending physician as well as the nursing team to inform them of the resident's desire to quit smoking and utilize nicotine patches through this process. An 11/11/25 activities note documented the resident liked to go outside and smoke or just hang out with friends. IV. Staff interviews Certified nurse aide (CNA) #5 was interviewed on 1/15/26 at 1:00 p.m. CNA #5 said Resident #23 did smoke. CNA #5 said Resident #5 left her oxygen in her room when she went outside to smoke. CNA #5 said Resident #23 did attempt to stop smoking for about three days but continued to smoke after that. Licensed practical nurse (LPN) #5 said a smoking assessment was done upon admission to the facility and monthly. LPN #5 said if the resident was hospitalized , a smoking assessment would be completed again upon the resident's return to the facility. -However, Resident #23 did not have a smoking evaluation completed after her return from the hospital and re-admission to the facility on 6/6/25 (see EMR review above). Registered nurse (RN) #2 was interviewed on 1/15/26 at 4:30 p.m. RN #2 said they filled out a smoking assessment upon admission and then another one either a week later or three days in a row when they admit. She said she could not remember the exact protocol, but knew they did it multiple times when a resident first admitted because sometimes people change their mind about smoking. RN #2 said the smoking evaluation was triggered to be filled out quarterly and was completed by a nurse. RN #2 said if residents wanted to quit smoking, and used the patch or were still smoking, a smoking evaluation would be completed. The director of nursing (DON) and nursing home administrator (NHA) were interviewed together on 1/15/26 at 5:00 p.m. The DON said a smoking evaluation could be scheduled and assessment could then be triggered to be completed automatically. The DON said Resident #23's smoking evaluation was not triggered and he was unsure why. The NHA said smoking evaluations were completed for residents who expressed a desire to smoke, or could have been observed smoking. The NHA said facility nurses completed the smoking evaluations. The social services director (SSD) was interviewed on 1/15/26 at 5:30 p.m. The SSD said the importance of the smoking evaluation was to determine whether or not the resident needed assistance or supervision.

Based on observations and interviews, the facility failed to provide adequate outside ventilation by means of windows and/or mechanical ventilation for five of eight resident bathrooms. Specifically, the facility failed to ensure the exhaust fans in five resident bathrooms were functioning.Findings include: I. Facility policy and procedure The Safe and Homelike Environment policy, revised 10/25/25, was provided by the nursing home administrator (NHA) on 1/15/26 at 4:45 p.m. It read in pertinent part, In accordance with the resident's rights, the facility would provide a safe, clean, comfortable, and homelike environment. Environment refers to any environment in the facility that is frequented by residents, including but not limited to the residents, rooms, bathrooms, hallways, dining areas, lobbies, outdoors, patios, therapy areas, and activity areas. II. Observations An observation of the facility was completed with the maintenance director on 1/14/26 at 3:40 p.m. To check the function of each exhaust fan, a small square of single-ply toilet paper was placed against the vent in room [ROOM NUMBER], #318, #416, #510, and #511. The exhaust fans were unable to hold the toilet tissue in place, indicating they were not functioning at that moment. None of the bathrooms had windows and the vents were not functioning.III. Staff interviews The maintenance director was interviewed on 1/14/26 at 4:05 p.m. The maintenance director said he monitored the motor operation of the vents once a month and immediately fixed any concerns that arose from his review. The maintenance director said he was not aware of the broken vents in the resident bathrooms. He said it not only moves air but also removes moisture, odors, and pollutants from the building, allowing residents to breathe fresh air. The maintenance director said it was important to ensure that all vents are functioning properly. The maintenance director was interviewed again on 1/15/26 at 11:20 a.m. He said upon reviewing the facility's ventilation fan, he noticed one of the roof-mounted ventilation motors was broken. He said he had placed an order for the parts and would replace it as soon as they arrived at the facility.

Based on record review and interviews, the facility failed to ensure residents who required dialysis services received such services consistent with professional standards of practice for two (#2 and #1) of three residents reviewed for dialysis out of 46 sample residents. Specifically, the facility failed to:-Ensure Resident #2's blood pressure was taken post dialysis treatment according to the physician's order and resident's comprehensive care plan; and,-Ensure the facility followed up on Resident #1's dialysis facility's fluid restriction recommendation on the dialysis communication form.Findings include: I. Facility dialysis contract The Outpatient Dialysis Services Care Coordination Agreement, signed on 8/27/24, provided by the nursing home administrator (NHA) on 1/12/26 read in pertinent part, For the purposes of care coordination, in advance of each resident's dialysis treatment, the long term care facility shall furnish all information and documentation necessary for the dialysis facility to provide safe and appropriate care, including any and all information reasonably requested by the dialysis facility. The long term care facility shall ensure that all renal dialysis services to be furnished to residents, including drugs, biologicals and laboratory tests furnished in the long term care facility are furnished by, or in coordination with the dialysis facility. II. Resident #2 A. Resident status Resident #2, age greater than 65, was admitted on [DATE]. According to the January 2026 computerized physician orders (CPO), diagnoses included hemiplegia and hemiparesis (partial or total paralysis) affecting right dominant side, end stage renal disease (permanent kidney failure), dependence on renal dialysis (process to filter wastes from the body), and hypertension (high blood pressure). The 11/4/25 minimum data set (MDS) assessment revealed the resident had moderate cognitive impairment with a brief interview for mental status (BIMS) score of 11 out of 15. He required substantial to maximum assistance for activities of daily living (ADL). The MDS assessment documented the resident received dialysis treatment. B. Record review Resident #2's dialysis care plan, initiated 8/8/24, documented the resident required hemodialysis due to a diagnosis of renal failure. Pertinent interventions included to obtain vital signs and weight and report significant changes in pulse, respirations and blood pressure immediately (initiated 8/8/24) and to obtain blood pressure upon return from dialysis (initiated 10/22/24). A review of Resident #2's CPO revealed the following orders: -Resident attended dialysis; the chair time was at 6:20 a.m. on Monday, Wednesday, and Friday, ordered 8/25/25. -Obtain blood pressure upon return from dialysis every evening shift every Tuesday, Thursday and Saturday, ordered 8/2/24 and discontinued 1/3/26. -Obtain blood pressure upon return from dialysis every evening shift every Monday, Wednesday and Friday, ordered 1/3/26. -However, the resident's order to obtain blood pressure upon return from dialysis was not updated to Monday, Wednesday and Friday until 1/3/26, approximately four months after the resident's dialysis days changed. A review of Resident #1's dialysis communication record documented the resident received dialysis treatment on the following days 11/28/25, 12/1/25, 12/3/25, 12/10/25, 12/12/25, 12/15/25, 12/17/25 and 12/21/25. -However, a review of the resident electronic medical record (EMR) revealed the Resident #2's blood pressure had not been obtained or documented in the resident's medical record. C. Staff interviews Licensed practical nurse (LPN) #5 was interviewed on 1/15/26. LPN #5 said Resident #2 had a vital sign communication sheet the facility completed prior to the resident going to dialysis. LPN #5 said post dialysis blood pressure was documented in the resident's EMR. The director of nursing (DON) and the NHA were interviewed together on 1/15/26 at 5:00 p.m. The DON said obtaining a resident's blood pressure after dialysis was a standing order for the facility. The DON said Resident' #2's blood pressure should have been obtained after he returned from dialysis. The NHA said a resident's blood pressure was obtained after dialysis because the resident was at risk for having a lower blood pressure after a return from dialysis. III. Resident #1 A. Resident status Resident #1, age [AGE], was admitted on [DATE]. According to the January 2026 CPO, diagnoses included end stage renal disease, type two diabetes mellitus without complications, and chronic viral hepatitis C. The 12/25/25 MDS assessment revealed Resident #1 was cognitively intact with a BIMS score of 14 out of 15. He required set-up or clean-up assistance with eating and oral hygiene. He was dependent on staff for toileting, bathing and dressing. The MDS assessment indicated the resident received dialysis treatments. B. Resident interview Resident #1 was interviewed on 1/14/26 at 1:16 p.m. Resident #1 said that a few weeks ago the dialysis center had told him to limit his fluid intake because there was too much fluid in his body during dialysis. Resident #1 said the nursing staff talked to him about limiting how much he could drink. He said he should drink no more than two pitchers per day, which he understood to be approximately 1000 milliliters (ml) per day. Resident #1 said he believed he drank two pitchers per day. Resident #1 said he also drank a 10 ounce grape juice as desired. Resident #1 said he did not know if he was getting the right amount of fluids. C. Record review Resident #1's dialysis care plan, initiated 7/23/25, revealed the resident needed dialysis related to end stage renal disease. Interventions included encouraging the resident to go for the scheduled dialysis appointment and monitoring for any signs and symptoms of infection to the dialysis access site. -However, the care plan did not include monitoring the resident's fluid intake. Review of Resident #1's January 2026 CPO revealed the following physician's orders related to dialysis: Resident to have dialysis Monday, Wednesday and Friday, ordered 8/8/25. Monitor dialysis port for any signs and symptoms of infection and bleeding, ordered 8/6/25. Resident #1's 12/24/25 dialysis communication form was reviewed on 1/13/26 at 9:00 a.m which revealed the following: The first section of the communication form was to be filled in by the facility before dialysis with the resident's name, chair time, vital signs, which included blood pressure, temperature, pulse, respirations, oxygen saturation levels, weight, diet, and dialysis access site assessment. There was also a comments section. A facility nurse's signature and date. The second section of the communication form was to be filled in by the dialysis center staff. The documentation included vital signs, which included blood pressure, temperature, pulse, respirations, oxygen saturation levels, weight, diet, and dialysis access site assessment. There was also a recommendations and comments section. A facility nurse's signature and date. The dialysis recommendations and comments section of the form revealed to limit fluids to one liter per day. -Review of Resident #1's EMR revealed the facility failed to follow the dialysis center's recommendation to limit fluids to one liter per day (1000 ml), failed to get physician's orders and failed to update his care plan. -Review of Resident #1's EMR did not reveal the facility was monitoring the resident's fluid intake. D. Staff interviews CNA #1 was interviewed on 1/15/26 at 11:19 a.m. CNA #1 said she knew if a resident had a fluid restriction by reviewing the diet order and checking the binder in the kitchen. CNA #1 said the meal tickets also indicated the type of diet and any fluid restrictions. CNA #1 said there were currently no residents at the facility with fluid restrictions. CNA #1 said if a resident was on a fluid restriction, the charge nurse would inform the CNA to monitor and document intake. CNA #1 said she would document the fluid limit in the chart in the computer for reference. CNA #1 said Resident #1 did not like or want water and usually asked for ice. CNA #1 said on 1/15/26 in the morning, she filled Resident #1's water pitcher halfway with ice. CNA #1 said fluids were measured and recorded using a cup with a 240 ml capacity. CNA #1 said she provided Resident #1 with two of these cups per meal, three times per day (1440 ml total - 440 ml over the residents fluid restriction). CNA #1 said if a resident asked for more fluids than allowed, CNA #1 would ask the nurse for further information. Registered nurse (RN) #2 was interviewed on 1/15/26 at 11:32 a.m. RN #2 said a couple of months prior the dialysis center recommended to limit the Resident #1's fluid intake. RN #2 said the dialysis center did not specify the amount of fluid restriction, the reason for the restriction or the duration. -However, the dialysis communication form indicated the resident should be on a one liter fluid restriction (see dialysis communication form above). RN #2 said she informed the resident of the fluid limitation and said the resident was not happy about it. RN #2 said she placed the dialysis communication note with medical records for scanning into the resident's chart but did not contact the dialysis center to clarify why the fluid restriction was ordered or how long it should be followed. RN #2 said she was working on 12/24/25 and could not recall who reviewed the dialysis communication logs that day. RN #2 said she would verify the information with the dialysis center to determine the reason for the fluid restriction and the length of time the restriction should remain in place. RN #2 said failure to follow dialysis center recommendations regarding fluid restrictions could place the resident at risk for renal failure. The DON was interviewed on 1/15/25 at 12:27 p.m. The DON said the facility generally did not accept residents with fluid restrictions because they were difficult to manage and control. The DON said there were currently no residents with fluid restrictions at the facility. The DON said it was the nurses' responsibility to read and follow the dialysis communication notes and then inform the DON when there were special instructions or comments from the dialysis center. The DON said dialysis communication forms were important for continuity of care. The DON said when the facility received vague comments from the dialysis center, such as limiting fluids to one liter per day, the nurse should have called the dialysis center for verification and to obtain additional information. The DON said after confirmation with the dialysis center, the facility would inform the resident of the restriction, notify the physician and the family, obtain physician orders, and discuss the issue through the interdisciplinary team process. The DON said if the interdisciplinary team determined the restriction should be implemented, it would be placed in physician's orders and nursing staff would be informed to follow the orders. The DON said for Resident #1 it was important to follow fluid restrictions to prevent fluid overload, which could cause difficulty breathing. The DON said that after learning of this situation, he would contact the dialysis center to obtain additional information. The NHA was interviewed on 1/15/26 at 12:57 p.m. The NHA said the facility needed to follow dialysis instructions and recommendations and follow through as much as possible. The NHA said there was no way to enforce fluid restrictions in the same manner as a hospital because the facility was a homelike environment and enforcing fluid restrictions were difficult. The NHA said staff discussed the dialysis center's fluid restriction recommendation with the resident and said the resident was not compliant and had the right to refuse. The NHA said the facility would discuss the issue with the medical director and review it through the quality assurance process.

Based on record review and interviews, the facility failed to ensure one (#21) of one resident out of 46 sample residents were provided prompt efforts by the facility to resolve a grievance. Specifically, the facility failed to complete and provide prompt resolution to grievances for Resident #21.Findings include: I. Facility policy and procedure The Grievance policy and procedure, revised 10/15/25, was provided by the nursing home administrator (NHA) on 1/15/26 at 3:40 p.m. It read in pertinent part, It is the policy of the facility to establish a grievance process to address residents' concerns without fear of discrimination or reprisal, make prompt efforts to resolve grievances the resident may have. The grievance official completes the Grievance resolution forms and takes appropriate corrective action in accordance with State law if the alleged violation of the resident's rights is confirmed by the facility or an outside entity having jurisdiction. II. Resident #21 A. Resident status Resident #21, age greater than 65, was admitted on [DATE]. According to the January 2026 computerized physician order (CPO), diagnoses included chronic obstructive pulmonary disease (COPD), fibromyalgia, dependence on supplementary oxygen, depressive disorder, presence of a cardiac pacemaker, and personal history of transient ischemic attack (TIA). The 1/2/26 minimum data set (MDS) assessment revealed the resident was cognitively intact, with a brief interview for mental status score (BIMS) of 14 out of 15. She required partial/moderate assistance with toileting and personal hygiene. B. Resident interview Resident #21 was interviewed on 1/13/26 at 2:46 p.m. Resident #21 said she reported that she was missing her portable oxygen tank to the NHA over three months ago. She said she has not received any resolution to the issue. Resident #21 said the original tank had not been found and she personally informed the NHA. She said the NHA had done nothing about it, so she stopped talking about it. Resident #21 said the NHA did not discuss with her what action they would take to rectify the situation. C. Record Review A review of the facility's grievance forms for Resident #21 over the previous six months revealed no records of any grievances filed by the resident. D. Staff interviews Registered nurse (RN) #2 was interviewed on 1/14/26 at 2:03 p.m. RN #2 said all nursing staff were responsible for reporting grievances to their supervisor. RN #2 said she would assist the resident in resolving any grievance reported to her and, if unable to resolve the issue, would immediately inform her supervisor. RN #2 said she thought the grievance forms were only for reporting abuse incidents.The NHA was interviewed on 1/14/26 at 4:14 p.m. The NHA said that grievance forms were located on each nurse's station by the facility's elevators. He said the facility staff were trained to handle grievances by providing residents with the form and assisting them in completing it and by immediately reporting them to the grievance official. The NHA said Resident #21 had informed him about the missing portable oxygen tank several months ago. The NHA said he was unable to locate the tank since the facility was under new management. He said the resident was currently using a facility-acquired tank when needed. The NHA said he did not file out a grievance form when he became aware of the missing tank. He said he should have filed one out immediately when he became aware.

Based on record review and interviews, the facility failed to provide services in accordance with accepted professional standards for one (#4) of four residents reviewed for ostomy care out of four sample residents.Specifically, the facility failed to ensure Resident #3 was provided appropriate ostomy care per physician's orders.Findings include:I. Resident #4A. Resident status Resident #4, age [AGE], was admitted on [DATE] and readmitted on [DATE]. According to the October, 2025 computerized physician orders (CPO), diagnoses included morbid obesity, peripheral vascular disease, ileostomy, dementia and cognitive deficit. The 8/13/ 25 minimum data set (MDS) assessment revealed the resident had mild cognitive impairment with a brief interview for a mental status (BIMS) score of 12 out of 15. She required supervision or touching assistance with toileting hygiene, including managing an ostomy (a surgically created opening (stoma) in the abdomen to allow stool or urine to exit the body, bypassing the normal pathway) and wiping the opening with managing equipment.B. Resident interviewResident #4 was interviewed on 10/21/25 at 10:20 a.m. Resident #4 said she would change her own ostomy appliance if the nurses were too busy to do so. Resident #4 said she learned how to change her own colostomy by watching the nurses. Resident #4 said she did not receive any formal training from the nursing staff regarding how to change her colostomy, but they always let her do it. Resident #4 said on several occasions in August 2025 and September 2025, the facility constantly ran out of her nystatin powder which was supposed to be applied to the reddened areas on her skin around the ostomy appliance. Resident #4 said the nursing staff did not change her colostomy appliance consistently every time. She said each nurse changed her ostomy a different way using different types of appliances because the staff told her they had to use whatever was available for her treatments. C. ObservationsOn 10/21/25 at 10:06 a.m. registered nurse (RN) #1 was observed performing colostomy care for Resident #4. RN #1 said she had worked at the facility for three years. RN #1 did not review Resident #4's treatment orders prior to completing ostomy care for the resident. The colostomy was leaking stool from below the ostomy appliance onto the resident's skin. The skin around and below the ostomy stoma was red, inflamed and according to the resident, was very painful to the touch. RN #1 did not change his gloves between touching the dirty and the clean ostomy appliances. RN #1 did not have dedicated clean ostomy care scissors in his possession. RN #1 used Resident #4's scissors, which were sitting on her bedside table to cut the ostomy supplies. RN #1 proceeded to apply a new ostomy appliance to Resident #4's ostomy site. When he had completed the procedure, RN#1 disposed of the used ostomy bag in the trash and removed it from the room.-RN #1 did not clean the resident's scissors before use. -RN #1 did not follow the physician's treatment orders to apply skin prep to the surrounding ostomy stoma area and use nystatin powder to the area. -RN #1 did not use a wound cleanser to clean the stoma area before applying the new ostomy appliance. -RN #1 did not wash his hands with soap and water after the ostomy treatment was completed. D. Record reviewReview of Resident #4's ostomy care plan, initiated 2/10/25, revealed the resident had an alteration in gastro-intestinal status related to an ileostomy. Interventions included ileostomy care every shift and as needed, checking the ostomy bag and assisting the resident in emptying if warranted, monitoring the ileostomy site for signs and symptoms of infection and notifying the physician of concerns every shift (initiated 2/10/25), monitoring vital signs as ordered and recording and notifying the physician of significant abnormalities such as rapid pulse, shallow, rapid or labored respirations, low blood pressure (initiated 2/10/25), obtaining and monitoring laboratory or diagnostic work as ordered and reporting results to the doctor and following up as indicated (initiated 2/10/25), ostomy wafer changes were to gently cleanse area around stoma, pat dry, apply skin prep to area, cut hole in wafer to fit the size of stoma, attach drainage bag, wafer/bag size 2 3/4 every day shift on scheduled days (initiated 2/10/25).Review of Resident #4's October 2025 CPO revealed the following physician's orders:Ostomy Care - Cleanse with wound cleanser, pat dry, apply nystatin powder to wound bed, leave open to air, every shift for skin integrity. Monitor for signs and symptoms of infection or worsening, if present notify provider, ordered 10/20/25.Ostomy Wafer Changes: gently cleanse area around stoma, pat dry, apply skin prep to area, cut hole in wafer to fit the size of stoma, attach drainage bag every day shift every Monday, Wednesday and Friday, ordered 10/3/25.II. Staff interviewsRN #1 was interviewed on 10/21/25 at 10:35 a.m. RN #1 said the nurses were supposed to assess Resident #4's skin every day the ostomy bag and appliance were changed. He said the ostomy appliance needed to be changed every day. RN #1 said it was the nurse's responsibility to check the treatment order before changing the ostomy bag to make sure it was done safely and correctly for the resident. RN #1 said he did not check Resident #4's physician's orders prior to initiating ostomy care because he was in a rush to get the treatment done quickly and assumed there were no changes. RN #1 said he would make sure to check treatment orders before initiating treatment for a resident moving forward. RN #1 said Resident #4 would cut the ostomy wafer herself and the staff would remove the old ostomy and apply the new one after the resident cut the wafer. He said the nurses were provided training on how to correctly apply an ostomy RN #2 was interviewed on 10/21/25 at 11:15 a.m. RN #2 said it was facility's policy for the nurses to check the physician's orders prior to administering medications or initiating treatments for resident safety.Licensed practical nurse (LPN) #2 was interviewed on 10/21/25 at 11:58 p.m. LPN #2 said if a resident wanted to administer their own medications or treatments they needed to be assessed for safety, but it was rare to have residents administer their own treatments. LPN #2 said the nursing staff usually needed to administer the residents' medications and treatments to ensure they were done properly. LPN #2 said the nursing staff always needed to do wound care treatments, including ostomy care, for the residents, as the residents would not know how and when to perform hand hygiene and change their gloves in a way to prevent infection. LPN #2 said she did not think any residents could do wound care treatments or ostomy care for themselves, as the nurses knew how to do it more comfortably and effectively. LPN #2 said the nursing staff needed to wash their hands before and after wound and ostomy care and complete glove changes whenever they moved from touching a dirty area to a clean area. LPN #2 said whenever the nursing staff noticed even the smallest changes in a resident's skin, they needed to do a skin assessment right away and document the changes in risk management. LPN #2 said the nursing staff then needed to inform the director of nursing (DON), resident's representative and the physician about the skin change and receive orders for how to treat it, even for the most minor cuts or open areas. The assistant director of nursing (ADON) was interviewed on 10/21/25 at 11:29 a.m. The ADON said nurses were supposed to use designated scissors which were specific for each resident when performing wound and ostomy care. She said the scissors were located in the treatment nursing cart. The ADON said the facility provided the wound supplies, including the scissors for the nurses and were kept in the treatment cart. The ADON said the nurses were supposed to check the physician's orders before the treatment was performed for resident safety and to make sure the physician's orders were followed appropriately. She said this was important because a resident's skin could get worse if the nurses applied the wrong treatment to the resident's skin. The ADON said Resident #4 insist on changing her own colostomy herself. She said the nurses were responsible for educating and assisting Resident #4 with her colostomy. Certified nurse aide (CNA) #3 was interviewed on 10/21/25 at 2:22 p.m. CNA # 3 said a resident's colostomy bag should be emptied in the toilet. She said Resident #4 would empty her own colostomy bag in the trash can, and also change her own colostomy bag. CNA # 3 said she thought the nurses were supposed to change the resident's colostomy bag and she was surprised to see Resident #4 doing it on her own.The DON, the ADON, and the clinical nurse resource were interviewed together on 10/21/25 at 3:49 p.m. The DON said Resident #4 could cut the ostomy wafer but it was difficult for the resident to see the area to apply it. The DON said he preferred if staff applied the device. The DON said the CNAs would let the nurses know about any new skin issues. The DON said the nurse would notify the DON and the ADON of new skin issues and would call the physician and follow up with any new treatment orders. The DON said CNAs were educated to let the charge nurse know about any skin changes. The DON said the nurses would set up a risk management task and it would automatically trigger them to do a skin assessment. The DON said Resident #4's skin issue around her ostomy site was a recurring issue. The DON said the nursing staff did not document the education provided to Resident #4 for her ostomy change because it was assumed she understood the nurses' directions. The DON said the expectation for the nurses was to check resident treatment orders prior to initiating the treatment for every resident in the facility. The DON said the Resident #4's skin was not infected, it was just red and irritated. The DON said the wound care physician would look at the reddened skin area on the resident the following day.The ADON said the facility followed any new skin changes for three days following the identification of a skin issue.

Based on record review and interviews, the facility failed to ensure one (#1) of four residents were free from abuse out of 18 sample residents.Specifically, the facility failed to ensure Resident #1 was free from abuse from Resident #2.Resident #1 was admitted on [DATE] with diagnoses of dementia and right-sided hemiplegia and hemiparesis following cerebral infarction. Resident #2 was admitted on [DATE] with diagnoses of diabetes mellitus type 2, dementia with behavioral disturbance, schizoaffective disorder, heart disease and chronic kidney disease. On 9/7/25 Resident #1 told Resident #2 to shut up. Resident #2 responded by pushing Resident #1. Resident #1 fell to the ground and sustained a left wrist fracture. Findings include: I. Physical abuse by Resident #2 towards Resident #1 on 9/7/25. A. Facility investigation The 9/7/25 facility investigation was provided by the nursing home administrator (NHA) on 10/29/25 at 9:30 a.m. The investigation documented that on 9/7/25 at approximately 1:40 p.m. Resident #2 was seated in the common area watching the television. Resident #1 was ambulating through the same area making noises and then told Resident #2 to shut up. Resident #2 stood up and pushed Resident #1, which caused her to fall. The investigation documented that staff interviews confirmed Resident #1 spoke first, followed by Resident #2's response and physical action. The facility also interviewed and documented the responses of all residents who resided on the floor of the facility where the incident occurred. The investigation revealed that on 9/7/25, the social services director (SSD) documented the following staff statements regarding the altercation: Registered nurse (RN) #1 said she saw Resident #1 walking around and talking aloud to herself. She said Resident #2 was sitting on the couch talking to himself. RN #1 said she saw Resident #1 walked over to Resident #2 and told him to shut up. RN #1 said Resident #2 then stood up and she saw Resident #1 fall. Cook (CK) #1 said he was bringing snacks upstairs and when he got off the elevator he witnessed Resident #1 tell Resident #2 to shut up. CK #1 said Resident #2 responded by pushing Resident #1, and she fell. Certified nurse aide (CNA) #1 said she saw Resident #1 walking around and talking out loud and Resident #2 was sitting on the couch, watching television and talking to himself as he normally did. CNA #1 said she saw Resident #1 walk over to Resident #2 and say shut up. CNA #1 said Resident #2 then stood up and pushed Resident #1. The investigation revealed that documentation review showed a history of behavioral expressions for Resident #2, while Resident #1 had no prior involvement in altercations. The investigation documented Resident #1 sustained a left wrist fracture. The investigation documented that the SSD spoke with adult protective services (APS), who said they would be substantiating the event and closing the case due to no evidence of abuse. -However, abuse occurred due to Resident #2 pushing Resident #1, which resulted in a wrist fracture. B. Resident #1 (victim) 1. Resident status Resident #1, age greater than 65, was admitted on [DATE]. According to the October 2025 computerized physician orders (CPO), diagnoses included dementia and right-sided hemiplegia and hemiparesis (weakness and paralysis) following cerebral infarction (stroke). The 10/9/25 minimum data set (MDS) assessment revealed a brief interview for mental status (BIMS) assessment was not conducted as the resident was rarely understood. The 10/9/25 MDS assessment revealed the resident was independent with activities of daily living (ADL), including eating and oral hygiene. She required set-up or clean-up assistance with toileting, mobility and upper body dressing, and supervision assistance with showering, lower body dressing and putting on/removing footwear. 2. Record review Resident #1's dementia care plan, initiated 11/20/24, documented she had impaired cognitive function and dementia or impaired thought processes. Pertinent interventions, initiated 5/27/25, included to report to the nurse any changes in cognitive function, specifically awareness of surroundings and others and difficulty expressing self or understanding others. Resident #1's psychosocial care plan, initiated 11/20/24, documented she was at risk for a psychosocial well-being problem related to her dementia. Pertinent interventions, revised 9/8/25, included to provide support to identify potential solutions to present problems and to provide support to identify problems that could not be controlled. A late entry social services progress note, documented on 9/7/25 at 11:29 a.m., but back dated to 1:40 p.m. (prior to the incident) revealed the SSD was informed by facility staff that Resident #1 was involved in a resident-to-resident incident that resulted in Resident #1 falling. According to the nurse on the floor, the resident had no visible injuries and the nurse's assessment was that Resident #1 presented at baseline, however, the resident reported pain to her left side. The SSD spoke to the staff on the floor who reported that Resident #1 told another resident (Resident #2) who was sitting across from her in the common area to shut up and the resident who was talking to himself got up and pushed Resident #1, resulting in her falling. Resident #1 was immediately assessed by nursing staff and taken to the emergency room (ER) by emergency medical services (EMS). Review of Resident #1's hospital Discharge summary, dated [DATE], revealed the resident sustained a closed left distal radius fracture. The discharge summary documented the following physician's order: Maintain splint for closed left distal radius fracture. Nonoperatively managed. Follow up with the doctor in the clinic in one to two weeks. No weightbearing to the left upper extremity (LUE). C. Resident #2 (assailant) 1. Resident status Resident #2, age greater than 65, was admitted on [DATE]. According to the October 2025 CPO, diagnoses included diabetes mellitus type 2, dementia with behavioral disturbance (agitation including verbal and physical aggression, wandering) schizoaffective disorder (bipolar type), heart disease, and chronic kidney disease. The 9/3/25 MDS assessment revealed the resident was rarely understood and had a memory problem impairment. He was independent with ADLs. The assessment documented the resident did not have physical or verbal behaviors toward others. 2. Record review Resident #2's psychotropic medication care plan, initiated and revised 1/16/25, documented the resident used psychotropic medication for a diagnosis of schizoaffective disorder. Pertinent interventions, initiated 1/16/25, included to monitor episodes of delusions, hallucinations, and paranoia; monitor side effects such drowsiness, dry mouth, blurred vision, constipation and less common side effects including edema, extra pyramidal symptoms, urinary retention, stiff or tight muscles, and restlessness. Non-pharmacological interventions included: back rubs, redirection, speak to and approach the resident in a calm manner, reposition, offer snacks, fluids, milk, assess for pain, provide a quiet environment, encourage to express feelings, take to activities and provide reassurance. Resident #2's antipsychotic medication care plan, initiated 1/3/25 and revised 9/8/25, documented the resident used an antipsychotic medication for a diagnosis of schizoaffective disorder. Pertinent interventions, revised 9/25/25, included to document episodes of behavior; monitor episodes of delusions/hallucinations, talking to the television, and paranoia (non-stop screaming). Non-pharmacological interventions included redirection, speak to and approach the resident in a calm manner, offer television and quiet shows, offer snacks and/or fluids, assess for pain, provide a quiet environment or music in the resident's room. Resident #2's psychosocial care plan, initiated 1/21/25, documented he had potential for well-being problems from a diagnosis of schizoaffective disorder and the resident had limited cognitive function. Pertinent interventions, initiated 1/21/25, included the resident needed assistance, encouragement, and support to identify problems that cannot be controlled; encouraging participation from the resident who depended on others to make decisions, the resident needed assistance/supervision/support to identify causative and contributing factors; the resident needed assistance, supervision, and support to identify precipitating factors and/or stressors, and the resident needed assistance, supervision and support with the identification of potential solutions to problems. Resident #2's mood care plan, initiated and revised 3/28/25, documented he had potential for a mood problem due to his disease process. The resident could get very angry and frustrated at times. Pertinent interventions, initiated 3/28/25, included administering medications as ordered, encouraging the resident to express his feelings and assist the resident to identify strengths, positive coping skills and reinforce these. Resident #2's behavior care plan, initiated 3/28/25 documented he had the potential for a behavior problem of touching himself in public places due to his disease process. Pertinent interventions, initiated 3/28/25, included to anticipate and meet needs, approaching the resident in a calm manner, documenting behaviors, and resident response to interventions, if reasonable, discuss the behavior and explain or reinforce why the behavior was inappropriate and or unacceptable. Resident #2's physical behaviors care plan, initiated 9/8/25, documented he had the potential to demonstrate physical behaviors and may resort to physical behaviors against others due to a dementia diagnosis and poor impulse control. Triggers included being told to shut up or approached in a confrontational manner. Pertinent interventions, initiated 9/8/25, included analyzing the key times, places, circumstances, triggers, and what de-escalated the resident's behavior and document the findings; documenting the resident's observed behavior and attempted interventions; ff the resident began talking out loud to himself in an argumentative manner, please redirect him to an activity of his choice such as listening to music in his room or watching television; when the resident became agitated, guiding the resident away from the source of distress, engaging calmly in conversation and if his response was aggressive, staff were to walk away and approach the resident later. -The care plan did not included in the interventions to guide other residents away from Resident #2 if he demonstrated physical behaviors. A review of Resident #2's progress notes revealed a history of documented behaviors: A 5/29/25 behavior note, documented by licensed practical nurse (LPN) #1, revealed Resident #2 was very agitated off and on all throughout the shift. He was yelling at the television and at the ceiling at times. A 6/5/25 behavior note, documented by LPN #1, revealed Resident #2 was becoming more and more vocal, yelling at the television and other residents; he would walk around and stare at the ceiling frequently. A 6/6/25 nursing note, documented by LPN #1, revealed Resident #2 continued to yell at other residents and the television and continued to walk around the unit staring at the ceiling. A 6/12/25 behavior note documented Resident #2 continued to yell at other residents, the television and the ceiling. A 6/12/25 physician's progress note documented a report of an acute episode. Nursing requested that Resident #2 be seen. The chief complaint was that the resident's behavior continued to escalate and the resident also was very threatening during his interview. A 6/17/25 physician's note documented Resident #2's assessment and plan included a diagnosis of unspecified dementia, unspecified severity with psychotic disturbance and to restart risperidone (antipsychotic medication used to treat schizophrenia) 1 milligram (mg) every evening. A 9/7/25 progress note documented Resident #2, who had a diagnosis of dementia with severe cognitive impairment, was seated in the common area watching television. Resident #1, who also had a diagnosis of dementia with a BIMS score of five indicating severe cognitive impairment, was ambulating through the same area making noises. Both residents were known to ambulate independently without the use of assistive devices. There was no indication of prior interaction or any identifiable trigger between the two residents before the incident occurred. Resident Resident #2 stood up, verbally stated shut up and pushed Resident #1, causing Resident #1 to fall. Resident #2 was unable to articulate what happened due to cognitive deficit but he said, It is her, it is her. Staff responded immediately and separated both residents. Resident #2 was placed on 15-minute checks. Resident #2 had no skin issues except a mark from the police handcuffs. The physician, medical director and the resident's representative were notified. -However staff interviews (see interviews below) and the facility investigation (see investigation above) revealed Resident #1 told Resident #2 to shut up, and Resident #2 pushed Resident #1 causing her to fall. A 9/7/25 social services note documented the social services director (SSD) came in to speak to Resident #2 regarding the resident-to-resident incident that occurred earlier in the day (see above note). The resident did not display any outward signs of distress or discomfort. The resident stated he was okay and did not seem to be able to recall the incident and the resident had severe cognitive impairments. III. Staff interviews CNA #2 was interviewed on 10/30/25 at 11:45 a.m. CNA #2 said she was not present for the resident altercation between Resident #1 and Resident #2. She said Resident #2 talked to himself and frequently refused care including oral care and dressing. RN #1 was interviewed on 10/30/25 at 2:59 p.m. RN #1 said she could not see the altercation between Resident #1 and Resident #2 because a pillar blocked her view. She said she could hear Resident #2 talking out loud and increasing his volume. RN #1 said Resident #2 frequently talked out loud, and talked louder and louder but she had never seen him hit or strike out. RN #1 said the day of the altercation, Resident #2 was particularly loud and she said she heard Resident #1 yell at Resident #2 to stop or shut up. She said she and CNA #1 went over to assess both residents immediately after Resident #1 fell. She said the NHA and the director of nursing (DON) and EMS were notified. IV. Additional staff interviews CNA #4 was interviewed on 10/30/25 at 11:40 a.m. CNA #4 said Resident #1 lived on the current unit for approximately a month. CNA #4 said Resident #1 kept to herself, and came out for coffee social, breakfast and lunch. CNA #4 said Resident #1 did not have many interactions with other residents and was the quiet type. CNA #4 said she received abuse training during her facility orientation and had received abuse training in person in which different types of abuse were reviewed. CNA #4 said she would report abuse immediately. CNA #4 said if a resident told another resident sitting at the same table to shut up she would intervene and ask the resident if they needed help. CK #1 was interviewed on 10/30/25 at 1:07 p.m. CK #1 said he was taking some snacks to the unit on 9/7/25. CK #1 said he was trying to check the status of a game on the television and was facing the television while standing at the nurses' station. CK #1 said Resident #2 was yelling while sitting down on the couch. CK #1 said Resident #1 stood up and she yelled shut up. CK #1 said Resident #1 was not standing over Resident #2 and Resident #2 walked over to her. CK #1 said he had no idea Resident #2 would push Resident #1. CK #1 said Resident #2 went right up to Resident #1 and faced her and he saw Resident #2 make contact with Resident #1. CK #1 said Resident #1 fell on the floor and she was moaning in pain. CK #1 said Resident #2 was yelling (on 9/7/25) like he always did. CK #1 said Resident #2 frequently yelled as his baseline. CK #1 said Resident #2 sat in a chair by himself and would yell and talk in his native language and not to anyone in particular. CNA #1 was interviewed on 10/30/25 at 1:28 p.m. CNA #1 said Resident #1 walked independently prior to the incident (on 9/7/25). CNA #1 said on 9/7/25 Resident #2 was talking a lot and it was getting on Resident #1's nerves, so Resident #1 told Resident #2 to shut up. CNA #1 said Resident #2 stood up and walked over and pushed Resident #1 down, and it happened so quickly. CNA #1 said Resident #2 did not like being told to shut up. CNA #1 said Resident #1 fell on the floor and hit the floor hard. CNA #1 said she ran to the Resident #1 and she and a nurse separated Resident #2 from Resident #1. CNA #1 said Resident #1's behaviors were primarily yelling and making a lot of noise but he had not physically harmed anyone. CNA #1 said when the resident would get louder, the staff would redirect him. CNA #1 said when other residents told Resident #2 to shut up the staff told the residents to not tell Resident #2 to shut up. CNA #1 said Resident #2 spoke a foreign language but he understood shut up and it triggered him, and he did not like it. The SSD was interviewed on 10/30/25 at 1:40 p.m. The SSD said she came to the building on 9/7/25 after the incident between Resident #1 and Resident #2 was reported. The SSD said she and the social services assistant (SSA) interviewed all residents on the unit to ensure the residents felt safe. The SSD said if the staff heard something out of the norm prior to the incident between Resident #1 and Resident #2, they would have turned and given the residents their attention. V. Facility follow up The in-service education record for interventions for Resident #2, dated 9/8/25, was provided as part of the facility investigation on 10/29/25 at 9:30 a.m. The education included the following: Resident #2 may exhibit behaviors such as talking to or yelling at the television. If he was becoming agitated at the television it may increase the chances of him becoming agitated with other residents and could place them at risk of an altercation. Please encourage other residents to avoid him if he appears to be agitated. Interventions that may reduce his agitation include: redirection, speak to/approach in a calm manner, offer tv-change to quiet shows, offer snacks and fluids, assess for pain and provide a quiet environment and music in his room These interventions may be found in the Kardex (staff directive tool) and in the monitoring order. The resident spoke English as a second language but may need a translation service at times (information is available at the nurses' station). The in-service education record for Abuse/Neglect Allegations, dated 9/8/25, was provided as part of the facility interventions on 10/29/25 at 9:30 a.m. The education included the following: The resident had the right to be free from abuse, neglect, misappropriation of resident property and exploitation, including freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident's medical symptoms. Physical abuse included hitting, slapping, throwing objects, pushing, spitting, grabbing and restraints. Verbal abuse included threats, yelling, profanity, and mocking. Sexual abuse included any non-consensual sexual contact. Neglect included failure to provide necessary care or supplies. If a resident exhibited increased signs of agitation/frustration, please attempt to intervene and calm the resident down. Early interventions may reduce the risk of any altercation.

Based on interviews and record review, the facility failed to ensure one (#1) of three residents was free from abuse out of six sample residents. Specifically, the facility failed to prevent and protect Resident #1 from verbal abuse by a staff member who yelled and cursed at Resident #1. Findings include: I. Facility policy and procedure The Abuse and Neglect policy and procedure, revised 9/30/22 and 1/16/23 (after the incident with Resident #1), was provided by the nursing home administrator (NHA) on 3/13/24 at 2:44 p.m. by email. It revealed in pertinent part, Each resident has the right to be free from abuse, neglect, misappropriation of property, exploitation, involuntary seclusion, and physical or chemical restraints imposed for the purpose of discipline or convenience not required to treat the resident's medical symptoms. Residents will not be subjected to abuse by anyone, including staff (to include agency or contract vendors), residents, volunteers, consultants, family members or legal guardians, friends, or any other individuals. Verbal abuse The use of oral, written, or gestured language that willfully, consciously or with understanding is certain to cause harm and includes disparaging and derogatory terms to residents said within their hearing distance, regardless of their age, ability to comprehend, or their disability. Some examples of verbal abuse include threats of harm, saying things to frighten a resident such as telling a resident that he/she will never be able to see his/her family again, or using profanity to insult or scold a resident. II. Facility investigation On 12/10/23 at approximately 1:00 p.m., Resident #1 went to a door outside the facility's main kitchen and knocked. Resident #1 went to the kitchen to request bread which was not provided on his lunch tray. The dietary cook (DC) opened the door to the kitchen, yelled profanity at the resident and told him I'm going to shove a bread up your 'expletive.' The incident was witnessed by other staff members. Resident #1 was interviewed and said after the DC yelled at him he became afraid, he was afraid he would be beaten up by the DC. Resident #1 said he quickly went back to his room after the incident. The social service director (SSD) progress note on 12/13/23 at 8:24 a.m. (three days after the incident) revealed she visited the resident for a mood check and he said he was okay. -There was no documentation Resident #1's representative, who was the power of attorney (POA), was called after the incident. III. Resident status Resident #1, age under 65, was admitted on [DATE]. According to the March 2023 computerized physician orders (CPO), diagnoses included type 2 diabetes mellitus, major depressive disorder, post-traumatic stress disorder (PTSD), seizures and chronic pain syndrome. The 12/11/23 minimum data set (MDS) assessment revealed the resident had mild cognitive impairment with a brief interview for mental status (BIMS) of 11 out of 15. He required supervision or touch assistance with showers, toilet use and personal hygiene. He was independent with eating. He used a front wheel walker to ambulate. He did not reject care from staff. IV. Resident and representative interview On 3/18/24 at 9:45 a.m. the resident refused to be interviewed about the incident on 12/10/23. Resident #1's representative was interviewed on 3/18/24 at 3:10 p.m. He said he was the resident's legal POA. He said no staff from the facility called him to report the incident in December 2023. He said he wished the facility had called him because when he spoke to the resident over the phone it helped the resident be calm. He said Resident #1's son moved out of state. He said he was the only family member in the state. He said before the incident, the facility had called him to explain things to the resident and it always helped. V. Record review The 11/6/23 comprehensive care plan revealed Resident #1 had communication problems at times. His primary language was Ethiopian-Amharic. He was able to understand and speak English but struggled with some word finding in English. When he got frustrated when he tried to communicate, the facility was to call his representative to interpret or if the representative was not available, the facility was to call an interpreter line (see representative interview above). The Preadmission Screening and Resident Review (PASARR) Level II for post-traumatic stress disorder revealed the resident had a history of PTSD from being a police officer in Ethiopia during civil unrest and was ambushed and beaten by soldiers. He was in an African refugee camp. He perseverated on being attacked/beaten. To alleviate symptoms of trauma, the resident could talk to his representative over the phone for a coping strategy. Resident #1's identified trauma trigger was being spoken to in an accusatory manner. VI. Staff interviews The housekeeper (HSK) was interviewed on 3/18/24 at 1:45 p.m. The HSK said she and another housekeeper had stepped out of the elevator on 12/10/23 around lunchtime and heard the DC screaming at Resident #1. She said both housekeepers watched the DC yell at Resident #1. She said the DC was screaming profanity over and over at Resident #1. She said she heard the DC say that he was going to shove bread up Resident #1's (expletive). The DC was interviewed on 3/18/24 at 2:00 p.m. The DC said he only worked in the facility on Sundays and Mondays. He said he was helping cook in the kitchen on 12/10/23. He said Resident #1 banged on the door to the kitchen because he wanted bread. He said it was lunch time. He said Resident #1 was a special case, who needed extra attention and was the problem child. He said he opened the door and yelled at Resident #1 and he said he yelled profanity. The DC said he told Resident #1 he was going to shove a loaf of bread up his (expletive). He said another dietary staff member came out of the kitchen while he was yelling and brought Resident #1 bread. The DC said he knew he should not have screamed at Resident #1. He said the incident occurred around 1:00 p.m. on Sunday 12/10/23 and he said he continued to work until the end of his shift at 6:00 p.m. He said he was told by the assistant dietary manager (ADM) on 12/10/23 at about 6:00 p.m., that he was suspended the next day. He said the NHA at the time called him on Wednesday 12/13/23 to ask him about the incident. He said the NHA asked him about the facts only. The DC said he did not receive an education about abuse at that time or any time after the incident. He said the NHA left him a voicemail on Friday 12/15/23 to come into work on the upcoming Sunday, 12/17/23. He said he did not know that Friday 12/15/23 was the NHA's last day to work in the facility. He said he worked Sunday 12/17/23 for a full shift and returned to work on Monday 12/18/23. He said at about 1:00 p.m. on Monday 12/18/23 he was told to go to the human resource (HR) office where he was notified he was fired. The dietary manager (DM) was interviewed on 3/18/24 at 2:20 p.m. The DM said Resident #1 liked two pieces of white bread with breakfast, lunch and dinner. He said he was not at work the day the DC yelled at Resident #1. He said from what he learned when he spoke to his employees in the kitchen, there was bread in the freezer on 12/10/23 but it was not put on the resident's food tray. He said that was why the resident came to the kitchen to get two slices of bread. The DM showed Resident #1's daily meal cards for the dining room staff to follow. The daily meal cards revealed the resident was to have two slices of bread with every meal. The DM said everyone who worked in the kitchen knew to make sure Resident #1 had his two slices of white bread with every meal. He said he had never seen the DC get angry at any residents before the incident with Resident #1. The ADM was interviewed on 3/18/24 at 2:45 p.m. The ADM said she worked on 12/10/23 and heard the DC yell at Resident #1. She said Resident #1 knocked on the kitchen door over and over. She said she heard the DC cuss at Resident #1. She said he cursed at the resident a lot. She said Resident #1 said he just wanted bread. She said she was afraid to step in and stop the DC from yelling because of how angry she felt the DC was. The ADM said she called the DM to help her with what to do with the DC. She said when the DC's shift was over she told him he was not to return to work on Monday 12/11/23. Licensed practical nurse (LPN) #1 was interviewed on 3/18/24 at 3:00 p.m. LPN #1 said Resident #1 always had bread three times a day. She said he had two slices of bread with each of his three meals. Certified nurse aide (CNA) #1 was interviewed on 3/18/24 at 3:05 p.m. CNA #1 said Resident #1 had two slices of white bread every day, not toasted, for breakfast, lunch and dinner. She said the nursing staff all knew to never miss his bread with all three meals. The NHA was interviewed on 3/18/24 at 3:30 p.m. She said she had only worked in the facility for less than two weeks. She said Resident #1's representative was not called after the incident because the resident was his own POA. She said all the documentation the facility had about the incident in December 2023 was provided during the survey. The interim nursing home administrator (INHA) was interviewed on 3/18/24 at 2:35 p.m. The INHA said she was brought in by the facility's corporation to be the INHA on 12/18/23. She said after the incident with the DC and Resident #1 on 12/10/23 she was at work in the corporate office and was alerted to the incident. She said she told the former NHA to terminate the DC and not to let him return to the facility to work. She said when she arrived on 12/18/23 someone informed her that the DC was in the building. The INHA said she had the DC go to the HR office where he was immediately terminated. The INHA provided abuse in-service training which was provided to staff on 1/18/24 (over one month after the verbal abuse incident) and 2/16/24 -2/21/24. The INHA said the training did not happen for more than a month after the incident. She said there was no abuse education documented for the facility staff after the incident except to the two housekeepers who witnessed the 12/10/23 incident. She said there was no documentation that the dietary staff had abuse training after the incident until over a month later. The INHA said there was no documentation that the former NHA educated the DC before he returned to work.

Based on observations, interviews and record review, the facility failed to ensure residents and or their representatives were provided prompt efforts by the facility to resolve grievances for three (#1, #2 and #3) of three residents out of three sample residents. Specifically, the facility failed to address, resolve, document and follow up on grievances for: -Resident #1 regarding missing medications, call light wait times and schedule to ensure he arrived to dialysis timely; -Resident #2 regarding the staff getting him out of bed, call light wait times and providing showers; and, -Resident #3 regarding extended call light wait times. Findings include: I. Facility policy and procedure The Grievances policy, revised November 2016, was received on 1/11/24 at 3:00 p.m. from the nursing home administrator (NHA). The policy documented in pertinent part, Within three days of receipt of an verbal or written grievance, the Grievance Officer or designee, will give a written explanation of findings and proposed remedies, if any, to the complainant and to the aggrieved party, if other than the complainant. An oral explanation will be provided, along with the written statement whenever possible. II. Resident interviews Resident #1 was interviewed on 1/10/24 at 11:50 a.m. Resident #1 said he had reported concerns with extended call light times over one and a half hours long to the director of nursing (DON) and NHA multiple times. He said the concern had not been addressed and he had received no follow up from the DON or NHA. Resident #1 said he had been out of one of his kidney failure medications,Velphoro, for several weeks. He said the nurse on duty and the DON were aware but he had received no follow up about when the medication would be available (cross reference F760 significant medication errors). Resident #1 said he had dialysis three times per week. He said he was frequently late to dialysis. Resident #1 said the night shift was supposed to get him ready and dressed, and the day shift was supposed to put him in his chair at 6:30 a.m. He said the day shift did not get him in his chair by 6:30 a.m. The resident said the DON was aware of his concern, but there had been no resolution (cross reference F698 dialysis). Resident #1 was interviewed again on 1/11/24 at 3:27 p.m. He said the social worker had come to his room today (1/11/24) and told him he was not allowed to leave messages on the staff's voicemail with his concerns. She handed him several concern forms and told him he needed to fill out a form if he had a concern. Resident #2 was interviewed on 1/10/24 at 12:48 p.m. He said he had reported concerns about extended call light wait times for over an hour to the nurses on duty and the social worker. He said he had not heard any follow up on his concern. Resident #2 said the nursing staff would refuse to get him out of bed, put him back to bed timely, or give him a shower. He said he had reported his concerns to the nurse on duty and the DON. He said there had been no improvement to his concerns. Resident #3 was interviewed on 1/10/24 at 1:22 p.m. He said he had reported concerns with call light wait times up to one and a half hours long to the nurse on duty. He said he had not seen any improvement to the extended call light wait times. IV. Record review Grievance concern forms were requested from the NHA on 1/11/24 at 1:11 p.m. related to the concerns above for Residents #1, #2 and #3. -No grievances or concern forms were received by the end of the survey on 1/11/24. Grievance concern forms were requested from the DON on 1/11/24 at 1:51 p.m. related to the concerns above for Residents #1, #2 and #3. -No grievances or concern forms were received by the end of the survey on 1/11/24. On 10/15/23 at 10:56 p.m., a nursing progress note documented Resident #2 went to the second floor and told the nurse he had been waiting since 7:00 p.m. to be put to bed. The second floor nurse called the 3rd floor where the resident lived but there was no answer. The second floor nurse went to the 3rd floor and informed the 3rd floor nurse the resident had been waiting to go to bed. On 10/23/23 at 12:56 p.m. the social service note documented that Resident #2 had concerns with showers, receiving timely care and feeling his needs overall were being ignored. The SW informed the nurse manager. -However, there were no grievances or concern forms completed for Resident #2's concerns. IV. Staff interviews Licensed practical nurse (LPN) #1 was interviewed on 1/10/24 at 12:31 p.m. She said she was the nurse for Resident #1. LPN #1 said the resident had been out of his Velphoro medication for a few weeks. She said she did not know if his primary physician was aware. She said the DON was aware. LPN #1 said she had not followed up with the resident regarding the progress on obtaining his medication. LPN #1 said she had worked with Resident #1 during the night shift and day shift. She said she was aware of his concerns with extended call light wait times. She said sometimes he called frequently with his call light for assistance and sometimes he did not. She said he was very picky and liked things done a certain way. She said, as an example, Resident #1 liked the books in his room organized in a certain order. LPN #1 said the resident had expressed concerns with being late for dialysis. She said Resident #1t did not want to get up in his wheelchair before 6:30 a.m. and when the day shift arrived they would get caught up in rounds and not get him up on time. Certified nurse aide (CNA) #1 was interviewed on 1/10/24 at 1:40 p.m. CNA #1 said Resident #2 and Resident #3 had both expressed concerns to her about extended call light times, especially on the night shift. The DON was interviewed on 1/11/24 at 1:51 p.m. She said she was aware of Resident #1's missing medication, Velphoro. She said she was waiting on prior authorization from the insurance provider for the medication. The DON confirmed the resident had not had the medication in several weeks. She said we dropped the ball and too much time had gone by that the resident had not had the medication. She did not know if anyone had followed up with the resident regarding his concern of not having the medication. The DON said she had call light concerns reported to her from Resident #1 and Resident #2 in the past. She thought it was several months ago. She said she did not know if she had grievances reports with follow up regarding call lights. She said she would look. The DON said she was aware of Resident #1's concerns with having been late to dialysis. She said it was the resident that caused the problem. She said he always wanted one more thing done before he could get in his chair. She said 6:30 a.m. was at shift change for the nursing staff and they could not get him up at that time. The DON said she had no grievance report for Resident #1 indicating follow up or attempts to resolve the issue. The DON said she was aware of Resident #2's concerns with not getting out of bed, or being put back to bed timely, as well as his concern with call lights. She said it was a couple of months ago and did not realize it was still a concern. She said she did not have a grievance report on his concerns. The NHA was interviewed on 1/11/24 at 2:38 p.m. She said she started a few weeks ago and had identified grievance reports were not being completed.The NHA said she had not had a chance to put a corrective plan in place yet. She said if a resident had a concern the staff should complete a grievance form for them. She said a copy went to the NHA and to the department head responsible. She said the department responsible then had 72 hours to investigate the concern and respond back to the resident with possible solutions. She said she did not have grievances for Residents #1, #2 or #3, or call lights. The NHA said she had identified that the majority of concerns reported seemed to come from her night shift and she would plan to come in on that shift to observe what was happening.

Based on record review and interviews, the facility failed to ensure one (#1) of three residents out of 3 sample residents did not experience a significant medication error. Specifically, the facility failed to ensure that Resident #1 received all doses of his prescribed kidney failure medication, Velphoro, which resulted in a significant medication error of omission. Findings include: I. Facility policy The Medication Administration policy, dated 7/25/19, was received on 1/11/24 at 3:00 p.m. from the nursing home administrator (NHA). The policy documented in pertinent part, Medications will be administered in accordance with written orders authorized by the attending physician. II. Resident status Resident #1, age less than 65, was admitted on [DATE] and readmitted on [DATE]. According to the January 2024 computerized physician orders (CPO), diagnoses included end stage renal disease. The 11/24/23 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score of 15 out of 15. The resident required setup assistance with personal hygiene, parietal to moderate assistance with toileting and bed mobility. He required substantial maximum assistance with transfers. The assessment documented the resident was on dialysis. III. Record review The January 2024 CPO revealed the following: On 2/13/23 at 4:00 p.m. the resident had an order for Sucroferric Oxyhydroxide (Velphoro) tablet chewable 500 mg (milligram). Give two tablets by mouth three times daily. On 12/28/23 at 5:19 p.m. there was an order to hold the Velphoro because prior authorization was needed. The order listed the start date as 12/28/23 and the end date as 12/31/23. The January 2024 CPO no longer listed an order to hold the medication because the order to hold the medication had ended on 12/31/23. The December 2023 medication administration record (MAR) documented the last time the resident received the medication was 12/24/23, four days prior to the order to hold the medication. IV. Interviews Resident #1 was interviewed on 1/10/24 at 11:50 a.m. He said he had been out of one of his kidney failure medications,Velphoro, for several weeks. He said the nurse on duty and the DON were aware but he had received no follow up about when the medication would be available. Licensed practical nurse (LPN) #1 was interviewed on 1/10/24 at 12:31 p.m. LPN #1 said she was the nurse for Resident #1. LPN #1 said the resident had been out of his Velphoro medication for a few weeks. She said she did not know if his primary physician was aware. Looking at her laptop and the resident's orders, she said there was no order to hold the medication. She said the DON was aware. The DON was interviewed on 1/11/24 at 1:51 p.m. She said she was aware of Resident #1's missing medication Velphoro. She said she was waiting on prior authorization. The DON confirmed the resident had not had the medication in several weeks. She said we dropped the ball and too much time had gone by that the resident had not had the medication. The DON said she did not know if the medication was at the facility yet. She said the facility had obtained an order to hold the medication from the primary physician on 12/28/23 while prior authorization was obtained. However, she said that order was to have ended as of 12/31/23 (see record review above). The dialysis center clinical manager (DCM) was interviewed on 1/11/24 at 11:20 a.m. She said she was concerned the resident had not been getting the phosphorus binding medication, Velphoro. The medication removed excess phosphorus from the blood. The DCM said dialysis did not remove phosphorus from the blood like the kidneys. She said the phosphorus would build up in the blood and act as a toxin affecting all the other electrolytes. The DCM said the build up of phosphorus would lead to muscle cramps and pain, bone breaks, joint pain, itching of the skin and many other problems. She said the resident was supposed to take it three times per day. The DCM said the resident reported he had not received the medication for several weeks and the facility said they were waiting on a prior authorization. The DCM said she and several other staff members at the dialysis center had sent the facility the prior authorization multiple times. The DCM called regarding the phosphate level results after the survey exit on 1/18/24 at 9:08 a.m. She said the resident's phosphate level on 12/14/23 was 2.6 mg/dL (milligrams per deciliter). The DCM said on 1/11/24 the phosphate level was 6.0 mg/dL. She said the phosphate level should be less than 5 mg/dL which was the high end of an acceptable range. The DCM said the elevated phosphate level was a result of Resident #1 not receiving the Velphoro. V. Facility follow up On 1/10/23 at 12:02 p.m. a nursing progress note documented the medication would be sent to the facility as of that date, according to the pharmacy.

Based on observations, record review and interviews, the facility failed to ensure that residents who require dialysis receive such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences, for one (#1) of three residents reviewed for dialysis out of three sample residents. Specifically, the facility failed to ensure Resident #1 was ready to leave the facility timely in order to get to dialysis to receive all ordered dialysis treatment. Findings include: I. Facility policy The Dialysis Care policy, revised 7/12/23, was received on 1/11/24 at 3:00 p.m. from the nursing home administrator (NHA). The policy documented in pertinent part, Coordination of dialysis care will include communication about care concerns and appropriate interventions, if dialysis is postponed or canceled the provider will be notified. II. Resident status Resident #1, age less than 65, was admitted on [DATE] and readmitted on [DATE]. According to the January 2024 computerized physician orders (CPO), diagnoses included end stage renal disease. The 11/24/23 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score of 15 out of 15. The resident required setup assistance with personal hygiene, parietal to moderate assistance with toileting and bed mobility. He required substantial maximum assistance with transfers. The assessment documented the resident was on dialysis. III. Resident interview Resident #1 was interviewed on 1/10/24 at 11:50 a.m. Resident #1 said he had dialysis three times per week. He said he was frequently late to dialysis. Resident #1 said the night shift was supposed to get him ready and dressed, and the day shift was supposed to put him in his wheelchair at 6:30 a.m. He said the day shift did not get him in his chair at 6:30 a.m. IV. Record review The January 2024 CPO documented the resident had physician orders dated 5/25/2023 for dialysis on Tuesday, Thursday and Saturday at 12:10 p.m. The January 2024 CPO documented Resident #1 was to be gotten up by 6:00 a.m. by night shift staff for dialysis. -However, the resident's dialysis was scheduled to begin at 7:30 a.m. not 12:10 p.m. -The resident did not want to sit up in his chair earlier than 6:30 a.m. Dialysis communication records for Resident #1,dated 12/19/23 and 12/26/23, were reviewed on 1/11/24. Both records documented the resident was late for dialysis. The dialysis care plan, initiated 2/26/2020, documented the staff was to ensure the resident was ready for dialysis at 6:30 a.m. On 12/18/23 at 2:43 p.m., the social services progress note documented the resident was non- compliant with his dialysis pick up time. -However, according to a staff interview, the resident did not want to wait for extended periods of time sitting up in his wheelchair for transport to dialysis and the staff frequently got caught up in their rounds and did not have him ready at 6:30 a.m. V. Additional interviews Licensed practical nurse (LPN) #1 was interviewed on 1/10/24 at 12:31 p.m. lpn #1 said the resident had expressed concern with being late for dialysis. She said the resident did not want to get up in his wheelchair before 6:30 a.m. and when the day shift arrived they would get caught up in rounds and not get him up on time. The director of nursing (DON) was interviewed on 1/11/24 at 1:51 p.m. The DON said she was aware of Resident #1's concerns with having been late to dialysis. The DON said the nursing staff told her it was the resident that caused the problem. She said the nursing staff told her Resident #1 always wanted one more thing done before he could get in his chair. She said 6:30 a.m. was at shift change for the nursing staff and they could not get him up at that time. The DON said she had not spoken to the resident about the problem and did not know what his story version was regarding being late. The DON said she had not heard the nursing staff got caught up in their rounds and did not get Resident #1 up timely. The dialysis center clinical manager (DCM) was interviewed on 1/11/24 at 11:20 a.m. She said the resident had dialysis three times per week on Tuesday, Thursday and Saturday at 7:30 a.m. She said Resident #1 was late for almost every session. The DCM said this resulted in the resident having to be taken off dialysis before he had a full session because he started late. The DCM said this meant the resident missed about one and a half hours per week of dialysis. She said receiving the full dialysis time was critical to the resident's health. The DCM said with a shortened dialysis time Resident #1 was not getting enough fluid, chemicals and waste pulled off of his body. She said this could lead to significant issues with his heart and breathing and lead to increased hospitalization s.

Based on observations, interviews and record review the facility failed to store, prepare, distribute and serve food in a sanitary manner in the kitchen. Specifically, the facility failed to: -Ensure proper hand hygiene and maintain a sanitary environment where food was being served; and, -Ensure the refrigerators on the units were cleaned properly. Findings include: I. Hand washing and use of hair nets A. Professional reference The Colorado Department of Public Health and Environment (2019) The Colorado Retail Food Establishment Rules and Regulations, https://www.colorado.gov/pacific/sites/default/files/DEHS_RetailFd_6CCR10102_RFFC_EffJan2019.pdf. It read in pertinent part; Food employees shall clean their hands and exposed portions of their arms including surrogate prosthetic devices for hands or arms with soap and water for at least 20 seconds and shall use the following cleaning procedure: Vigorous friction on the surfaces of the lathered fingers, finger tips, areas between the fingers, hands and arms for at least 15 seconds, followed by;Thorough rinsing under clean, running warm water; and Immediately follow the cleaning procedure with thorough drying of cleaned hands and arms with disposable or single use towels or a mechanical hand drying device. Food employees shall clean their hands and exposed portions of their arms immediately before engaging in food preparation including working with exposed food, clean equipment and utensils, and unwrapped single-service and single-use articles.After handling soiled equipment or utensils; After engaging in any activities that contaminate the hands.Hand antiseptics may be used in addition to but not in place of proper handwashing. Food employees engaged in food preparation shall wear hair restraints, such as hats, hair coverings, hair or beard nets, or other effective means, to effectively keep hair from contacting exposed food, clean equipment, utensils, and linens, and unwrapped single-service or single-use articles. B. Facility policies and procedures The Handwashing Dietary policy and procedure, revised 9/1/22, was provided by the nursing home administrator (NHA) on 10/12/23 at 4:45 p.m. It revealed in pertinent part, Staff will wash hands frequently as needed throughout the day following proper handwashing procedures. Handwashing facilities should be readily accessible and equipped with paper towels and soap. Encourage handwashing instead of the use of chemical, sanitizing gel's or lotions. If chemical, sanitizing gel or use, staff must first wash hands as stated below. Clean hands and exposed portions of the arms immediately before engaging in food preparation, including working with exposed foods. When to wash hands, after touching bare human body parts, other than clean hands and clean, expose portions of arms after using the toilet room. During food preparation, as often as necessary to remove soil contamination prevent cross-contamination when changing tasks. Before donning gloves for working with food. After removing gloves. Before distributing meals to residents. After collecting soil, plates and food waste. C. Observations Observation on 10/10/23 at 12:00 p.m. on floor number four. Kitchen staff brought up lunch to serve, an unknown kitchen staff had a cart of plates that were not covered. The cart was not in the kitchen area and was in the nurses station area. An unknown RN was passing medications and had her backside leaning up against the cart touching the uncovered plates. Several staff walked by and they did not move the cart into the kitchen area. The kitchen staff used the plates to serve lunch. At 12:45 p.m. the kitchen staff ran out of plates the activities director went to a different floor and came back with a plate without it being covered and gave it to the kitchen staff to plate the food. Observations on 10/11/23 at 11:15 a.m. in the main kitchen area where the staff was preparing for lunch service. Dietary assistant (DA) #1 was preparing hotdogs and hamburgers for lunch service. DA #1 had gloves on and touched the handle to get the hotdogs and hamburgers out of the steam oven. DA #1 grabbed the hotdogs and hamburgers with gloved hands and touched the lettuce tomato and onion with the same gloves. -At 11:25 a.m. cook (CK) #1 was pureeing dessert and grits. CK #1 put gloves on before starting this task. CK #1 put the dessert in the blender and needed to add more dessert and went to the steam oven and kept the same gloves on. CK #1 dished the dessert into a cup and touched the lip of the cup and the lid with the same gloves. CK #1 changed gloves and did not preform hand hygiene. CK #1 was pureeing grits and had to add more grits to it. CK #1 touched the handle of the steam oven. CK #1 touched the top of the cup and lid while putting the grits into the cup. -At 12:11 p.m. on the third floor kitchen. CK #2 had started serving the residents. CK #2 had the cart with uncovered clean plates and plates with food on them. CK #2 had the dishes of food uncovered on the steam table and on the steam table without coverings and staff were coming into the kitchen with hair coverings (see below). Certified nurse aide (CNA) #3 entered the kitchen without a hair net and performed hand hygiene. CNA #3 opened the refrigerator to get drinks. CNA #3 went to the dining area and touched a resident's shoulder then came back into the kitchen performing hand hygiene. CNA #3 rubbed up against the counter where the dessert was being served. CNA #3 went into the refrigerator and got drinks, went into the dining room and came back into the kitchen. CNA #4 came into the kitchen. CNA #4 did not have a hairnet on. CNA #4 did not perform hand hygiene and came into the kitchen. CNA #4 had delivered food to the dining area and came into the kitchen to get drinks. She opened the refrigerator. CNA #3 went into the kitchen without performing hand hygiene. CNA #3 went to the dining area to deliver a drink. CNA #3 came back into the kitchen without performing had hygiene. CNA #3 used the microwave that was above the counter. The cart with the uncovered dishes and plates of food that had plastic on them was under the microwave. CNA #3 reached to put the food in the microwave. CNA #3 touched the front of her body onto the cart. D. Staff interview CK #2 was interviewed on 10/11/23 at 12:53 p.m. CK #2 said before entering the kitchen area staff should wash their hands and have hair nets on. CK #2 said nursing staff would come into the kitchen whenever they want. The infection preventionist (IP) was interviewed on 10/11/23 at 3:08 p.m. The IP said nursing staff should not be in areas that have food products in it. The IP said nursing staff should wash their hands and wear an apron if they went into the kitchens when food was present. The IP said nursing staff work directly with residents. The IP said there was a risk of contaminating food and spreading infections when nursing staff was in the kitchens while serving food. CNA #5 was interviewed on 10/12/23 at 9:53 a.m. CNA #5 said CNAs should not go into the kitchen area during food service. CNA #5 said staff that go into the kitchen area needed a hair net and should perform hand hygiene before entering the kitchen if they need to. The nutrition service director (NSD) was interviewed on 10/12/23 at 9:22 a.m. The NSD said she saw her kitchen staff using gloves and touching multiple things before touching the food and bowls that food went into. The NSD said she had already started to inservice her staff on proper hand hygiene. The NSD said kitchen staff should make sure the cart with the plates on it were in the kitchen area. The NSD said nursing staff should not lean against the counters or carts that have plates or food on them because their clothing was not sanitary. The NSD said nursing staff should not enter the kitchens while kitchen staff was serving. The NSD said hair nets and hand washing were required to enter kitchens that have food being served. The NSD said nursing staff should be patient and wait for the server to assist them. The NSD said she had educated CNAs in the past and will re-educate them about going into the kitchen areas. The director of nursing (DON) was interviewed on 10/12/23 at 2:43 p.m. The DON said nursing staff should not enter the kitchens. The DON said the way the refrigerators were set up made it hard for the CNAs to help with food service. The DON said staff should wash their hands before entering the kitchen areas. The DON said the staff entering the kitchen should wear hair nets. The DON said the nursing staff should be careful and not let their bodies touch the counters or plates in the kitchens. The DON said there was an infection control risk if nursing staff went into the kitchens without proper hand hygiene. II. Refrigerator cleanliness A. Observations Observations on 10/11/23 at 12:00 p.m. on the third floor kitchen the refrigerator had crumbs on the bottom of it. The door handle had a film of a dark brown tacky substance that had built up it was a dark color and appeared to not have been cleaned for a long time. Observations on 10/12/23 at 11:17 a.m. the refrigerator on the fourth floor had dark streaks on the inside of the refrigerator and crumbs throughout the refrigerator. The handle had a buildup film that was dark and tacky. -At 11:20 p.m. the refrigerator on the fifth floor had crumbs throughout and the handle had a thick buildup of dark tacky substance. B. Staff interviews CK #2 was interviewed on 10/11/23 at 12:53 p.m. CK #2 said nursing staff cleaned the kitchens when they were done with food service. CK #2 said nursing and housekeeping staff made sure the refrigerators were cleaned. CNA #5 was interviewed on 10/12/23 at 9:53 a.m. CNA #5 said kitchen staff were required to clean the kitchens in between services. CNA #5 said the kitchen staff were required to keep the refrigerators clean. The NSD was interviewed on 10/12/23 at 9:22 a.m. The NSD said that housekeeping, kitchen and nursing staff made sure the kitchens were clean. The NSD said it was a group effort to ensure the refrigerator were clean. The NSD said they did not have a schedule of when they cleaned refrigerators. The director of nursing (DON) was interviewed on 10/12/23 at 2:43 p.m. The DON said cleaning the kitchens including the refrigerators was a group effort with the kitchen staff, housekeeping and nursing staff. The DON said they did not have a schedule for cleaning the refrigerators. The DON said the refrigerators including the handle should be cleaned. The DON said keeping the kitchens areas clean was to ensure infection control.

Based on observations and interviews, the facility failed to safely store and properly dispose of medications in a manner consistent with standards of practice for two of four medication storage rooms. Specifically, the facility failed to ensure: -Expired medications were discarded and removed from the medication storage room refrigerators in a timely manner; -All drugs and biologicals were kept safe and secure in locked compartments when not in direct line of sight of nurse; and, -All refrigerated drugs and biologicals were monitored daily for proper temperature controls in accordance with manufacturers specifications Findings include: I. Facility policy and procedure The Medication Storage policy, revised October 2023, was provided by the nursing home administrator (NHA) provided on 10/12/23 at 4:33 p.m. it read in pertinent part: The director of nursing (DON)/designee is responsible for drug storage per regulatory requirements to promote safety and security of medications and biologicals. Expired or discontinued non-narcotic medication will be stored in a locked area. Non-narcotic medication will be stored in a locked secure area. Medications requiring refrigeration or temperatures between 36-46 degrees Fahrenheit will be kept in a refrigerator with a thermometer to allow daily monitoring. II. Expired medication stored in refrigerator The second floor medication room was observed on 10/11/23 at 10:04 a.m. The refrigerator to contain the following expired medications: -Tuberculin purified protein derivative solution with an expiration date of 9/8/23; -Dulcolax laxative suppositories with an expiration date of 9/1/23; and, -Anasept topical gel (antimicrobial skin and wound cleanser) with an expiration date of 8/30/23. Registered nurse (RN) #2 was interviewed on 10/11/23 at 10:13 a.m. RN #2 said the nurse on the evening shift was responsible for checking the refrigerator for expired medication on a monthly basis. If a nurse forgot to check medication expiration dates it was up to the day nurse to complete the task. The fifth floor medication storage room was observed on 10/11/23 at 1:28 p.m., with licensed practical nurse (LPN) #1 The storage room ' s refrigerator contained a narcotic locked box and expired medication: -Diazepam suppositories with an expiration date of 7/12/23. LPN #1 was interviewed on 10/11/23 at 1:36 p.m. LPN #1 said nurses on the evening and night shifts were responsible for monitoring medication expiration dates and knew to remove the expired medication for disposal. LPN #1 said monitoring for expired medication was completed twice per month. III. Unsecured medication storage room On 10/11/23 at 1:48 p.m. the door to the fifth floor medication storage room was observed. The door to the medication storage room was slightly ajar and accessible to anyone walking by and without a nurse in direct line of sight. LPN #1 was observed removing personal belongings from the medication storage room leaving a book on the floor to hold the door open. LPN #1 had his back to the door for approximately three minutes. LPN #1 was interviewed on 10/11/23 at 1:52 p.m. LPN #1 said the lockers on the unit were too small for his backpack and did not have another space to put the backpack. LPN #1 said personal items were not supposed to be stored in the medication storage room nor should the door to the medication storage room remain open or ajar at any time. Registered nurse (RN) #2 was interviewed on 10/11/23 at 2:18 p.m. RN #2 said staff's personal items, non-medication items and food products should not be stored in the medication storage room. IV. Medication refrigerator temperature monitoring On 10/11/23 at 10:40 a.m. the medication refrigerator on the fifth floor was observed with LPN #1. LPN #1 provided temperature logs that were in a binder. The temperature log was not consistently completed and there were days when the refrigerator ' s temperature was not monitored. The temperature logs for August, September, and October 2023 were reviewed. The temperature logs revealed inconsistent monitoring for daily temperature checks. The August 2023 refrigerator temperature log did not contain temperature checks for 8/3/23 through 8/8/23. The September 2023 refrigerator temperature log did not contain temperature checks for 9/12/23 through 9/15/23. The October 2023 refrigerator temperature log did not contain temperature checks for 10/3/23 through 10/6/23. -There was no way to know if the medications needing refrigeration were stored at the proper temperatures to maintain the stability and effectiveness of that medication on the dates when the staff failed to check the refrigerator temperatures. LPN #1 was interviewed on 10/11/23 at 1:41 p.m. LPN #1 said on the dates when the temperature checks were not conducted there were agency staff working the shift. LPN #1 said agency staff were provided an orientation to the unit and believed they received a packet of information that included monitoring temperatures of the refrigerators in the medication storage room. LPN#1 said permanent staff always check the refrigerator temperature. RN #2 was interviewed on 10/11/23 at 2:05 p.m. RN #2 said the temperature logs should be monitored on a daily basis by the nurse on the evening or night shift. RN #2 said the temperature logs were picked up by the assistant director of nursing (ADON) and/or the weekend nurse for compliance purposes. RN #2 said he worked on the fifth floor every Thursday from 7:00 a.m. to 11:00 a.m. and relied on the evening shift nurse to check the fifth floor refrigerator temperature in the medication storage room. V. Administrative interview The director of nursing (DON) was interviewed on 10/12/23 at 2:56 p.m The DON said all agency staff who worked at the facility received a binder that covered their responsibility. The binder included instructions to monitor for expired medication in the medication storage refrigerators and monitoring refrigerator temperatures for proper medication storage on a daily basis while on shift. The DON said permanent facility staff know to monitor and remove expired medications and to check the refrigerator temperatures daily on the evening or night shift. VI. Unattended medication The fourth floor refrigerator medication cart was observed on 10/11/23 at 8:30 a.m. The fourth floor medication cart was left unattended with two medication cards continuing medications in the bubble pack cards. LPN #2 was interviewed on 10/11/23 at 8:55 a.m. She identified the two medications on her cart as fluoxetine (antidepressant) with two pills left in the card and myrbetriq (a medication that relaxes the bladder muscles to prevent urgency and frequency in overactive bladder) with four pills in the card. LPN #2 said medications should not be left on the cart unattended because a resident could take them and could lead to adverse reactions if the medication was not ordered for them or if they received too much of a prescribed medication. 47064

Based on observations, interviews and record review, the facility failed to maintain an infection control program designed to provide a safe, sanitary and comfortable environment to prevent the development and transmission of disease and infection. Specifically, the facility failed to: -Ensure continuous positive airway pressure (CPAP) masks were stored off the floor, in a clean bag and replaced when contaminated; -Ensure staff performed hand hygiene during medication administration; and, -Ensure staff disposed of needles appropriately. Findings include: I. Facility policy and procedure The Infection Control policy and procedure, revised 5/7/23, was provided by the nursing home administrator (NHA) on 10/9/23 at 10:15 a.m. It read in pertinent part, Standard precautions include: A group of infection prevention practices that apply to all resident's environments, regardless of suspected or confirmed infection status, in any setting where healthcare is delivered. Includes: resident care equipment likely to have been contaminated by bodily fluids must be handled in a manner to prevent the transmission of infectious disease. II. Continuous positive airway pressure (CPAP) mask A. Observation On 10/9/23 at 10:15 a.m. Resident #97 CPAP mask was observed hanging in an unsanitary manner on the floor next to the resident's foley bag with urine. On 10/10/23 at 11:30 a.m. Resident #97 CPAP mask was observed under his upper body while he was lying in bed. B. Resident interview Resident #97 was interviewed on 10/9/23 at 10:15 a.m. He stated the staff care for his CPAP mask and clean it for him. He was not able to get out of his bed independently and clean his CPAP. He also had contractures in his hands and this prevented him from being able to clean his CPAP mask or take care of it without the staff's assistance. C. Staff interviews Registered nurse (RN) #1 was interviewed on 10/10/23 at 10:35 a.m. Resident #97 had a CPAP and when he was not using it, the staff had to clean it and keep it in a bag on his dresser. RN #1 did not know how many times a week it needed to be cleaned. He said the nurse is responsible for the cleaning and maintenance of Resident #97's CPAP mask. RN #1 said the CPAP mask should never be on the resident's floor next to his foley bag. This could cause the spread of bacteria. The CPAP mask should not be kept in the resident's bed under his body because it could damage the mask. The infection preventionist (IP) was interviewed on 10/11/23 at 2:58 p.m. She was not sure of Resident 97's CPAP mask cleaning schedule but stated the mask should not be on his floor next to a foley bag. The mask should be on his dresser or in a drawer. The risk of having his CPAP mask on the floor, especially next a foley bag with urine, was contamination and the spread of bacteria. 47064 III. Hand hygiene with medication administration A. Facility policy and procedures The Medication Administration General Guidelines policy and procedure, dated 10/15/10, was received from the NHA on 10/12/23 at 4:45 p.m. revealed in pertinent part Procedure: wash or sanitize hands before and after administration of medications. B. Observation On 10/11/23 at 7:54 a.m. licensed practical nurse (LPN) #1 was observed preparing medications to Resident #39, he did not perform hand hygiene prior to preparing the medication. LPN #1 then knocked on her door when entering the room, passed the medication cup to the resident and grabbed the resident's personal water cup and handed it to her. LPN #1 then exited the room, returned to the medication cart and began charting the medications administration. LPN #1 failed to perform hand hygiene on exit of Resident #39's room. At 8:04 a.m. LPN #1 began preparing medications for Resident #25. LPN #1 knocked on Resident #25 door, assisted the resident to sit up in bed using the bed control and took the resident's blood pressure. LPN #1 then handed the medications to Resident #25, then washed his hands with soap and water. LPN #1 then applied gloves to administer eye drops to the resident. LPN #1 then washed his hands upon removal of gloves. LPN #1 took the empty bottle of Boost (supplement drink) tossed it into the trash, touching the trash bag as it fell into the trash bin, he then adjusted the bedside table and the bed position for Resident #25. LPN #1 then exited the residents room returning to the medication cart, placed eye drops back in the cart and charted the administration of medications. LPN #1 failed to perform hand hygiene after leaving Resident #25's room. At 8:23 a.m. LPN #1 began preparing medications for Resident #64. Resident #64 was in the dining room when he administered the medications to her. LPN #1 returned to his medication cart and charted the administration. LPN #1 failed to perform hand hygiene after medication administration to Resident #64. C. Staff interviews LPN #1 was interviewed on 10/11/23 at 3:39 p.m. He said nurses were to wash with soap and water or use sanitizer on their hands if they administer eye drops, insulin (medication for abnormal glucose) or if they touch any of the resident's personal items. LPN #1 said if residents were only receiving medication in pill forms he did not have to wash his hands. The director of nursing (DON) was interviewed on 10/12/23 at 2:41 p.m. She said the nursing staff were to sanitize their hands before dispensing medications and again after the resident took the medication. The DON said nurses should perform hand hygiene to prevent infections. IV. Proper disposal of needles A. Facility policy and procedure The Sharps Storage and Disposal policy and procedure, dated 10/15/10, was received from the NHA on 10/12/23 at 4:45 p.m. revealed in pertinent part, Sharps such as syringe, needles, lancets, razors will be secured out of residents reach. After use, sharps will be placed into an approved designated sharps container and disposed of in accordance with applicable laws and safety regulations. Immediately after use syringe, needles, or lancets will be placed in a puncture resistant, one way container with a lid that prohibits reaching into the container. B. Observations On 10/11/23 at 8:31 a.m. LPN #2 was observed passing medications to Resident #57. LPN #2 administered Insulin (glucose control) via injection into the Resident #57's right arm. LPN #2 then placed the safety sleeve over the needle and placed the syringe and needle into an empty water cup along with trash from two alcohol swabs and her used gloves. She returned to the medication cart. LPN #2 placed the cup and its contents into a trash bag hanging over the sharps container on the medication cart and then sanitized her hands and charted the medication administration. LPN#2 failed to properly dispose of a sharps. C. Staff interviews LPN #2 was interviewed on 10/11/23 at 8:37 a.m. She said the needle and syringe were to be disposed of into the sharps container not the trash when asked about where the needle was disposed of. LPN #2 then proceeded to dig through the trash bag with no gloves on to retrieve the syringe and needle. LPN #2 found the syringe and needle and moved the trash bag to access the sharps container on her medication cart where she then properly disposed of the syringe and needle. She then re-hung the trash bag over the sharps container. The director of nursing (DON) was interviewed on 10/12/23 at 2:41 p.m. She said needles were to be disposed of in the sharps container to reduce the risk of contamination or a needle stick which could lead to blood borne disease transmission. The DON said the nurse should not have dug through the trash to retieve the syringe and needle because it increased the risk of being struck by the needle.

Based on interviews and record review, the facility failed to notify the state mental health agency promptly after a significant change in the mental condition of three (#33, #36 and #97) of seven residents reviewed for preadmission screening and resident review (PASRR) out of 46 sample residents. Specifically, the facility failed to: -Notify the state mental health agency of Resident #33, and Resident #97 necessity for inpatient psychiatric hospitalization s, and, -Notify the state mental health agency of worsening symptoms for Resident #36. Findings include: I. Resident #33 A. Resident status Resident #33, age under [AGE] years, was admitted on [DATE]. According to the October 2023 computerized physician orders (CPO), the diagnoses included bipolar disorder. The 9/29/23 minimum data set (MDS) assessment revealed the resident had moderate cognitive impairment with a brief interview for mental status (BIMS) of 10 out of 15. It did not identify level II PASRR. B. Record review The comprehensive care plan, initiated on 7/10/23, revealed the resident exhibited behaviors of yelling obscenities towards staff and other residents. Interventions included allowing the resident to calm down, educating the resident on appropriate communication with others, frequent checks to ensure her needs were met, and offering mental and emotional support services as needed. The resident took medications to manage symptoms of bipolar disorder and had a level II PASRR for major mental illness. Interventions included frequent mood checks and behavior monitoring. According to the October 2023 CPO, the resident had orders dated 7/19/23 to be sent out for a psychological and psychiatric evaluation and treatment. Progress notes dated 7/5/23 through 10/10/23 revealed in pertinent part: Social services progress note date 7/18/23 revealed a referral was sent per the resident's request for psychological services Social services progress note dated 7/19/23 revealed the resident was scheduled to see the psychology provider on 7/25/23 and the resident had been notified. PASRR progress note dated 7/21/23 revealed the resident was reviewed in the psychotropic medication committee. The resident had recently returned from a psychiatric hospitalization . -No progress notes were located documenting the behaviors leading up to the resident's need for an inpatient psychiatric hospitalization or an update being sent to the state mental health agency. The resident's pre-admission level II PASRR was reviewed on 10/12/23. The level II notice of determination dated 2/8/23 identified the resident as meeting criteria for PASRR mental illness. The level II evaluation dated 2/16/23 identified a history of psychiatric hospitalization s over her lifetime related to bipolar instability. II. Resident #36 A. Resident status Resident #36, aged [AGE] years, was admitted on [DATE]. According to the October 2023 CPO, the diagnoses included post traumatic stress disorder and major depressive disorder. The 8/30/23 MDS assessment revealed the resident had moderate cognitive impairment with a BIMS score of 11 out of 15. It indicated the resident did not meet criteria for a level II PASRR diagnosis. B. Record review The comprehensive care plan, initiated on 9/21/18, revealed the resident exhibited behaviors of getting easily annoyed with others and changes in appetite. He had periodic episodes of suicidal ideations but not currently. Interventions included follow up from the social services director (SSD) and for staff to notify the SSD or the physician of suicidal ideations. The resident took medications to manage symptoms of post traumatic stress disorder (PTSD), major depression, and anxiety. He had a level II PASRR for major mental illness. Interventions included behavior monitoring for depressive symptoms and frequent check ins to meet his needs. Progress notes dated 6/1/23 through 10/10/23 revealed in pertinent part: Social services progress note date 7/26/23 revealed the resident expressed suicidal ideations and desiring to end his life. He was assessed and determined to be at low risk for attempting suicide. Social services progress note date 8/1/23 revealed the resident expressed suicidal ideations and desiring to end his life. He was assessed and determined to be at low risk for attempting suicide. Social services progress note date 8/21/23 revealed the resident expressed suicidal ideations and desiring to end his life. He was assessed and determined to be at low risk for attempting suicide. -No progress notes were located documenting an update was sent to the state mental health agency for worsening symptoms. The resident's resident review level II PASRR was reviewed on 10/12/23. A status change had been submitted 3/25/19 due to a time limit expiration. The level II notice of determination dated 5/28/19 identified the resident as meeting criteria for PASRR mental illness. The level II evaluation dated 6/4/19 identified the resident without a history of suicidal ideations. Suicidal ideations were first care planned 9/21/18. -However, this was not included in his status change PASRR 3/25/19 or subsequent PASRRs to the state mental health agency and behaviors continued. III. Resident #97 A. Resident status Resident #97, age under [AGE] years, was admitted on [DATE]. According to the October 2023 CPO, the diagnoses included post traumatic stress disorder, suicidal ideations and major depressive disorder. The 8/30/23 MDS assessment revealed the resident was cognitively intact with a BIMS score of 15 out of 15. It did not identify level II PASRR. B. Record review The comprehensive care plan, revised on 2/15/23, revealed the resident exhibited behaviors of suicidal ideations and suicidal attempts. The resident had a history of being hospitalized for a suicide attempt via medication overdose related to frustration over medical condition. Interventions included mood check ins and behavior tracking. His last suicide attempt was 7/19/23 via wrapping a call light cord around his neck (this was added to the care plan 10/12/23, during the survey). Interventions included following a safety plan which outlined activities he enjoyed. It included frequent checks from the SSD and encouragement to socialize. According to the October 2023 CPO, the resident had orders dated 4/24/23 to receive psychological and psychiatric evaluation and treatment. Progress notes dated 7/1/23 through 10/10/23 revealed in pertinent part: Order administration note dated 7/17/23 revealed the resident had a behavior related to suicidal ideations and verbal aggression. The resident had been throwing water. Social services note dated 7/18/23 at 7:14 a.m. revealed the SSD completed a suicide lethality assessment with the resident due to statements he wanted to die due to increased pain. The resident was determined to be low risk and without a plan. Nursing progress note dated 7/18/23 at 9:05 p.m. revealed the nurse entered the resident room after his call light had been pulled to find the resident had wrapped the call light around his neck. 911 was contacted. Nursing progress note dated 7/19/23 reveled the resident had been admitted to the hospital on a mental health hold due to suicide attempt. Admission summary note dated 7/20/23 revealed the resident returned to the facility. -No progress notes were located documenting an update being sent to the state mental health agency. The resident's pre-admission level II PASRR was reviewed on 10/12/23. The level II notice of determination dated 9/29/22 identified the resident as meeting criteria for PASRR mental illness. The level II evaluation dated 10/6/22 identified the resident had a history of suicidal ideations and a suicide attempt in 2022 via medication overdose. IV. Staff interviews The social services director (SSD) was interviewed on 10/11/23 at 1:28 p.m. She stated residents with a mental health diagnosis have a level II PASRR. An update was sent to the state mental health agency when a resident's mental health condition worsened, the resident had a new diagnosis or a new medication. An update was needed if a resident had an inpatient psychiatric hospitalization . Resident #36 had expressed to her suicidal ideations on three occasions. Resident #33 and #97 had been sent out to inpatient psychiatric units for worsening mental health symptoms requiring evaluation. She had not sent in updates for Resident #33, #36, and #97.

Based on record review and interviews, the facility failed to prevent misappropriation of property for four (#19, #44, #48 and #49) of five residents reviewed for misappropriation out of 46 sample residents. Specifically, the facility failed to prevent staff members from exploiting money from Residents #19, #44, #48 and #49. Findings include: I. Facility policy The Abuse and Neglect policy and procedure, revised 1/16/23, was provided by the nursing home administrator (NHA) on 10/10/23 at 10:12 a.m. It read in pertinent part, Each resident has the right to be free from abuse, neglect, misappropriation of property, exploitation, involuntary seclusion, and physical or chemical restraints imposed for the purpose of discipline or convenience not required to treat the resident's medical symptoms. Residents will not be subjected to abuse by anyone, including staff (to include agency or contract vendors), residents, volunteers, consultants, family members /legal guardians, friends, or any other individuals. II. Resident #48 A. Resident status Resident #48, age 78, was admitted on [DATE]. B. Resident interview Resident #48 was interviewed on 10/9/23 at 1:19 p.m. Resident #48 said he loaned a certified nurse aide (CNA) money with the understanding that she would pay him back, but when he found out she quit he realized he was not going to get his money back. Resident #48 said he no longer gives staff money and was working with the police to see if he could get his money back. C. Facility investigation Incident investigation dated 6/6/23 read in pertinent part: On 5/25/23 it was reported by Resident #48 that CNA #11 borrowed around $8,000.00 from him and he was worried he would not get paid back. CNA #11 was suspended immediately. Resident #48 told the investigator he gave CNA #11 $8,600.00 plus in loans which he expected to be paid back but the CNA had not paid anything back. Resident #48 said he started giving CNA #11 money back in August 2022 she asked to borrow $5000.00 because she had wrecked her car, needed dental work and new glasses. Then she said she needed to move and needed a deposit so he loaned CNA #11 an additional $2,800.00 in January 2023. There was an additional check that he endorsed over to CNA #11 totaling $845.00. Resident #11 said CNA #11 had not seen any repayment and he stated to question if he would ever see his money again. CNA #11 was interviewed on 5/26/23, at first CNA #11 said Resident #48 gave her the checks to cash for him and bring back to him. The facility asked for proof that she did not deposit the money into her account and that the money had been provided to the resident. CNA #11 said she would provide proof but instead, she resigned from her position. CNA #11 was reported to the police and to the State Nursing Board. CNA #11's licensure as a nurse aide was revoked. Resident #48 was educated to not give money to staff he agreed. On 6/5/23, an email education notification was sent to all staff. The email read: Subject: Accepting gifts, gratuities, and payments from residents: Please be advised and reminded of page 16 in the Employee Handbook. Gifts, Gratuities, and Payments: It is the policy of (facility name) to prohibit any employee from receiving or giving any gifts, gratuity, or payment for services rendered, the making of any promise (s) on behalf of (facility name), or engaging in any activity, practice, or act which conflicts with the interest of (facility name) or its customers. For further clarification, speak to your supervisor or reference (facility name) Compliance Program. III. Resident #19 A. Resident status Resident #19, age 87, was admitted on [DATE]. B. Resident interview Resident #19 was interviewed on 10/9/23 at 9:02 a.m. Resident #19 pointed to her dresser drawer and said, someone took my purse to take money from her, who would do something like that, who would do something like that? Resident #19 said she did not have a way to lock up her purse prior to it going missing. Resident #19 said she did not know the name of the person who took her banking information and bank cards. Resident #19 was upset that someone would try to steal from her. C. Facility investigation Incident investigation dated 9/13/23 read in pertinent part: Resident #19 reported that her purse went missing on 8/16/23, but no report was made at that time. On Friday 9/8/23 at approximately 4:00 p.m. when she still could not find her purse and the contents of her purse, the resident reported that her purse was still missing. The unit nurse reported to the social worker and an investigation was initiated. The resident said she kept her purse in the bottom drawer of her dresser. A search was conducted and the purse was not found. A review of bank documents revealed evidence of fraudulent activity and attempts to divert the resident's money. The facility identified a suspect and suspended the staff pending an investigation. The resident bank account was frozen and the police were notified. The investigator found that the assailant cashed a check for $700.00 on 8/9/23 and attempted to cash a second check for $2,650.00 on 8/16/23. Additionally, there was an attempted charge to the local energy company for $1,195.51 and a cellphone company for $369.44. The $2,650.00 check was written out to CNA #10 and the $700.00 check was written out to a known associate with the same last name as CNA #10. CNA #10 was interviewed by facility staff and confessed to forging the $2,650.00 but did not believe it was a crime because he did not get any money. CNA #10 denied knowing anything about other fraudulent activity. The staff was no longer working in the facility. The State Nursing Board was notified during the survey (on 10/12/23). The outcome of the police investigation was ongoing. IV. Resident #44 A. Resident status Resident #44, under the age of 65, was admitted on [DATE]. B. Resident interview Resident #44 was interviewed on 10/9/23 at 1:22 p.m. Resident #44 said a staff stole his credit card and charged approximately $400.00 to his card at a local big box store. Resident #44 said the same staff stole another resident's check and tried to get money for that resident. Resident #44 said the staff was no longer working at the facility and he now kept his card safe in a locked box provided by the facility. C. Facility investigation Incident investigation dated 9/13/23 read in pertinent part: Resident #44's son called the NHA on 8/28/23 to inform the facility that the credit card that he left with his dad had been used for a purchase at a local box store (store name) on Saturday night 8/26/23. The son said he immediately called Resident #44 to see if the credit card was still in his possession and it was not. The resident was not able to identify when it had gone missing, he was just able to say that he used it to buy Chinese food the night before which was Friday 8/25/23. The resident's son was able to work with the credit card company to report the charge as fraudulent and stop the payment to the box store. The police in the county where the crime occurred had video evidence but because the resident resided in a different county, the facility was not able to view the video evidence to verify if the assailant was a staff member. The investigation was ongoing. The facility suspected the assailant was the same staff (CNA #9) who committed a crime against Resident #19. On 8/28/23, the facility provided Resident #44 with a locked box, provided education on using the locked box to secure valuables and ensured the resident could use the locked box effectively. V. Resident #49 A. Resident status Resident #49, age 67, was admitted on [DATE]. B. Resident interview Resident #49 was interviewed on 10/9/23 at 9:55 a.m. Resident #49 said she withdrew $50.00 from her personal account to purchase a couple of things and shortly after $25.00 turned up missing. Resident #49 said she reported it to the leadership and they were investigating. She did not know any more about who might have taken her money. Resident #49 said she now kept her money in a locked box. C. Facility investigation Incident investigation dated 9/13/23 read in pertinent part: Resident #49 stated that on 9/14/23, she took $50.00 out of her account to buy soda and a candy bar; on 10/2/23 she noticed that $25.00 was missing. The resident's room was searched with the resident's permission. The social services provided emotional support and the resident was given a locked box on 10/2/23, to protect other valuables and encouraged to use the lockbox. The facility had no leads and was unable to determine who might have taken the resident money. VI. Staff interview The activities director (AD) and the NHA were interviewed on 10/12/23 at 9:13 a.m. The AD said the police department community representative came to the facility last April 2023 to provide in-services for residents on protecting themselves from scammers who may target them through phone calls, emails and text messages. The AD said the training did not include information for residents to know how to protect themselves from being taken advantage of financially. The residents had not been provided education regarding asset misappropriation and theft of intellectual property. The residents were not educated on how another person could take advantage of them financially if they had access to their credit cards, checkbooks, banking statements, social security cards and other government identification. The NHA said the facility provided education for staff to refresh orientation that was provided to them at orientation. This training was provided to staff on a couple of occasions. In that training, facility staff were reminded that taking money or property from a resident was not permitted by facility policy. Additionally, the facility would look into providing residents with additional education to protect themselves financially. The NHA said they had locked boxes available for any resident who wanted a way to protect their personal belongings only upon request.

Based on observation, record review and interviews the facility failed to ensure self-administration of medications was clinically appropriate for one (#39) resident out of 46 sample residents. Specifically the facility failed to: -Ensure Resident #39 was assessed for the appropriateness and safety of self-administration of oral medications; and, -Ensure there was a physician order for self-administration of oral medications. Findings include: I. Facility policy and procedure The Medication- Self Administration policy and procedure, dated 2/24/14, received from the nursing home administrator (NHA) on 10/12/23 at 4:45 p.m. revealed in pertinent part an assessment will be completed prior to self administering medications to ensure residents safety. If the nurse and/or interdisciplinary team (IDT) deems the resident safety and competent, a physician order will be obtained containing specifics about the medications itself and an order for the medication to be self-administered by the resident. The Medication Administration General Guidelines policy and procedure, dated 10/15/10, received from the NHA on 10/12/23 at 4:45 p.m. revealed in pertinent part, Residents will be observed after medication administration to ensure the dose was completely swallowed. II. Resident #39 A. Resident status Resident #39, age 79, admitted on [DATE]. According to the October 2023 computerized physician orders (CPO), diagnosis included pneumonia (infection in the lungs), chronic obstructive pulmonary disease (air flow blockage), heart failure (decrease in the pumping mechanism of heart), myocardial infarction (heart attack), hypertension (high blood pressure), and gout (urea crystallization in the joints). The 7/20/23 minimum data set (MDS) revealed the resident was cognitively intact with a brief interview of mental status (BIMS) score of 15 out of 15. She required one person's assistance with dressing. Set up assistance with bed mobility and eating. She was independent with transfers, toileting and personal hygiene. B. Record review The October 2023 CPO revealed Resident #39 had an order to self administer inhalers, eye drops, ear drops, topicals, nasal sprays/creams and could be stored at bedside ordered on 7/3/23. The medication self-administration safety screen dated 7/3/23 documented the following medications safe for resident to administer independently and be kept at bedside: Ventolin inhaler; Trellegy inhaler; Debrox ear solution; Biofreeze topical; Latanoprost eye drop. The 7/20/23 comprehensive care plan identified that the resident was safe to keep medication at bedside and be re-evaluated for self administration quarterly. C. Observations Licensed practical nurse (LPN) #1 was passing medication on 10/11/23 at 7:54 a.m. LPN #1 dispensed the following medications for Resident #39; Omeprazole (used for acid reflux); tylenol (pain medication); acidophilus (good gastrointestinal bacteria); Amoxicillin-Pot Clavulanate (antibiotic); aspirin (clot prevention); azithromycin (antibiotic); Furosemide (decrease fluid retention); losartan (decreases blood pressure); metoprolol (blood pressure reducer); senna (stool softener); and spironolactone (decrease fluid retention). LPN #1 entered Resident #39's room and handed the medication to the resident and left the room prior to the resident taking the medications. LPN #1 returned to medication cart and charted the Resident #39 took her medications. -None of the medications LPN #1 dispensed were approved in the physician order for self administration or to be kept at bedside (see order above). LPN #1 failed to observe Resident #39 take her oral medications. III. Staff interviews LPN #1 was interviewed on 10/11/23 at 3:39 p.m. He said only residents who have been assessed to self administer medications could have medications left in their rooms. LPN #1 said medications could not be left with a resident as medications could be not taken, lost or another resident may get a hold of them and lead to complications. The director of nursing (DON) was interviewed on 10/12 23 at 2:41 p.m. She said residents were assessed with a self administration tool to prove they could safely self-administer medications. Medications should not be left in the resident room during medication pass as it places the risk of the resident not taking them or someone else taking them.

Based on record review and interviews, the facility failed to ensure one (#48) of two residents reviewed for abuse out of 46 sample residents were free from abuse. Specially, the facility failed to prevent a resident to resident altercation between Resident #48 and Resident #66. Findings include: I. Facility policy The Abuse and Neglect policy, dated 7/11/21, was received from the nursing home administrator (NHA) on 10/12/23. It read in pertinent part: Physical abuse is defined as including hitting, slapping, pinching, and kicking of residents. The two elements needed are: -Intent or knowingly or recklessly -Bodily injury and/or serious bodily injury, and/or -Unreasonable confinement or restraint. II. Resident to resident physical altercation between Residents #48 and #66. A. Facility investigation Incident 9/2/23 The incident between Resident #48 and Resident #66 occurred in the room where both residents reside. Resident #48 alerted the nurse Resident #66 had punched him in the nose after Resident #48 accidentally ran over his foot with the electric wheelchair. The residents were separated by staff and assessed for injuries, Resident #48 had a bloody nose. Resident #66 was moved to a different room the same day. Resident #48 was interviewed by manager on duty, where he stated Resident #66 was sitting in a chair in the room when Resident #48 bumped into him with his electric wheelchair. Resident #66 became upset and punched him in the nose. Resident #66 was interviewed by the manager on duty, where he stated Resident #48 ran over his foot with the wheelchair and this aggravated him so he turned and punched Resident #48 in the nose. The facility failed to substantiate the abuse citing Resident #66 did not intend harm to Resident #48 when he punched him. -However, the abuse should have been substantiated due to Resident #66 punching Resident #48 in the face and causing a bloody nose. During the facility investigation, Resident #66 admitted to punching Resident #48 because he was aggravated with Resident #48. B. Resident #48 (victim) 1. Resident status Resident #48, aged 78, was admitted on [DATE]. According to the October 2023 computerized physician orders (CPO), diagnoses included anxiety, post traumatic stress disorder, Parkinson's disease and congestive heart failure. The 8/23/23 minimum data set (MDS) assessment documented the resident was cognitively intact with a brief interview of mental status (BIMS) score of 15 out of 15. He had no behaviors indicated. 2. Resident interview Resident #48 was interviewed on 10/10/23 at 12:45 p.m. He stated his former roommate, Resident #66, thought he had deliberately ran over his foot with his electric wheelchair and punched Resident #48 in the front of his face. The staff moved his roommate the same day and he did not feel fearful. 3. Record review The comprehensive care plan, revised 5/23/23, revealed the resident had impaired cognitive functioning related to impaired thought processes due to Parkinson's disease. And was to be monitored for elopements. He required a wheelchair for mobility. He received one person assist with bed mobility, transfer, dressing, toileting, hygiene. No behaviors were indicated. C. Resident #66 (assailant) 1. Resident status Resident #66, age 88, was admitted on [DATE] According to the October 2023 CPO, diagnoses included unspecified dementia and depression. The 9/25/23 MDS assessment documented the resident had severe cognitive impairment with a BIMS score of seven out of 15. He only required staff set up for bed mobility, transfers, walking, dressing, eating, toileting, and personal hygiene. He had no behaviors indicated. 2. Resident interview Resident #66 was approached on 10/10/23 at 2:15 p.m. and refused to be interviewed. 3. Record review The comprehensive care plan, revised 9/12/23, identified the resident had behavior of perseverating on the location of his money and needing staff reminders to look in his lock box. The resident had behaviors of urinating on washcloths and hanging the cloths in his room to dry instead of using the bathroom. Staff were to encourage and remind the resident to use the restroom. III. Staff interview The nursing home administrator was interviewed on 10/12/23 at 4:15 p.m. This was the first incident of this nature between Resident #48 and #66. Nether resident had a history and Resident #66 was moved to another floor of the building the same day of the incident. The facility did not substantiate the incident as physical abuse due to determining Resident #66 reacted to Resident #48 running over his foot and would not have hit him otherwise. The NHA did not believe Resident #66 intended to be physically abusive.

Based on observations, interviews, and record review, the facility failed to provide a clean, comfortable, homelike environment. Specifically, the facility failed to ensure resident rooms were clean to minimize odors and in good repair. Findings include: I. Facility policy On 10/12/23 at 3:33 p.m. A request was made for the facility's home like environment policy, the nursing home administrator (NHA) said the facility did not have a homelike environment policy. II. Resident #100 A. Observation and interviews On 10/9/23 at 3:01 p.m. Resident #100 was observed laying in bed with a bedpan containing feces. A trash can beside the bed contained multiple wipes stained brown matter. There were two urinals that were half full with urine hanging on the side of the waste basket. The room had the odor of urine and stool. On 10/10/23 at 10:53 a.m. to 4:10 p.m. Resident #100 was observed laying in bed. The bed pan was covered with brown paper towels and was on the resident's bed leaning against a pillow pushed against the wall. The resident has two urinals with one urinal completely full and the other half full. The room had the odor of feces and urine. Resident #100 was interviewed on 10/10/23 at 3:01 p.m. The resident said he kept the bed pan on his bed against the wall for easy access. The resident said he preferred the bedpan to be close to him in the event he needs to go now. The resident said he used his call light to call for help with toileting but they take too long and he can not always wait for staff to arrive. The resident said he was not bothered by the smell and did not think his roommate was bothered by the smell either. Resident #100's roommate was interviewed on 10/10/23 at 3:15 p.m. The resident's roommate said he kept the curtain closed 100 percent of the time and he was not bothered by the odor because he had Lysol spray which he used to keep the odor down. On 10/11/23 at 7:47 a.m. Resident #100 was observed in bed with a soiled bed pan on the bed next to him; the waste basket was full of stool soiled wipes.The room had the odor of stool. -At 8:36 a.m. The resident's breakfast arrived. The certified nurse aide (CNA) delivering the resident's food emptied the resident's urinals but left the trash can full of the stool soiled wipes at the resident's bedside next to where he ate. The resident's room smelled of stool. -At 10:15 a.m., a housekeeper entered the resident's room to empty the waste basket after the resident had finished his meal. On 10/12/23 at 10:43 a.m. a housekeeper entered the resident's room to empty the trash can containing the soiled wipes but the urinals were not emptied. The urinals were left hanging on the side of the resident's waste basket. A staff member near the resident's room was notified by the housekeeper about the urinals. The staff member did not enter the resident's room. B. Staff interviews CNA #7 was interviewed on 10/12 23 at 11:42 a.m. CNA #7 said Resident #100 was very independent and used the urinal and bedpan on his own. CNA #7 said the resident could lift himself up to put the bedpan underneath him. CNA #7 said the resident would sometimes call staff to assist him with wiping. CNA #7 said she always cleaned the bedpan after use and flushed the wipes but returned the bed pan to the resident per his request. CNA #8 was interviewed on 10/12/23 at 12:15 p.m. CNA #8 said most CNAs respected the resident's independence and tried to keep up with cleaning the bedpan, urinals and emptying the waste baskets after he used them. However, some of the other CNAs did not touch the waste basket unless they were told to. The infection preventionist (IP) was interviewed on 10/11/23 at 3:40 p.m. The IP said staff should be emptying urinals routinely and empty the bed pan immediately after use. The IP said the bedpan should be removed from the resident's bed. The IP said if waste baskets were full of dirty wipes they should be emptied immediately and on a consistent basis. The director of nursing (DON) was interviewed on 10/12/23 at 3:25 p.m. The DON said it was the responsibility of all staff to create a homelike environment and immediately address cleaning needs. 46849 III. Resident #36 A. Observations and interview Resident #36 was interviewed on 10/9/23 at 9:45 a.m. He stated he had rheumatoid arthritis and had difficulty holding things with his hands resulting in the condition of his room. The facility did not want to help him clean his room and he did not believe the staff wanted to come into his room. The holes in his walls were a result of hitting the wall with his electric wheelchair. During the interview on 10/9/23, food and debris were observed on the floor. A brown banana, a sandwich in a bag, garbage and clothes were on his floor by his bed and heater. [NAME] matter was observed on the toilet seat and floor of his bathroom. There was a urinal full of urine with a drinking cup full of urine on his bedside table. Several baseball size holes were observed in the walls when first entering the room. Staff came into the resident's room to clean it on 10/9/23 at 10:15 a.m. The resident's room was observed on 10/10/23 at 10:30 a.m. Garbage and food was observed on the resident's floor. What appeared to be brown matter was observed on the floor next to the resident's bed. A cup of urine and a urinal with urine were sitting on his bedside table. [NAME] matter was observed covering the toilet seat. The holes in the walls remained the same as from 10/9/23. Staff came into the resident's room to clean it on 10/10/23 at 10:45 a.m. and removed all the debris and brown matter. The cup of urine remained on his bedside table. B. Staff interview Registered nurse (RN) #1 was interviewed on 10/10/23 at 10:45 a.m. He stated the resident had no behaviors he was aware of. CNA #1 was interviewed on 10/10/23 at 11:20 p.m. She stated the resident could be verbally aggressive and agitated with the staff. He would allow staff to clean his room, but he would yell at the staff while it was being cleaned. The resident was not incontinent of bowel or bladder, smearing stools was a behavior of the residents. He required staff assistance to go to the toilet and transfer but he would try to do it on his own. He used to have a bedside commode but he did not want to use it. The DON was interviewed on 10/12/23 at 3:40 p.m. The DON stated the resident often would throw his urinal on the floor with urine inside of it. He would throw food and garbage onto his floor. He would allow one particular housekeeper to clean his room but would tell the other staff to leave. She said his room had to be cleaned daily and after the room was cleaned, the resident would start throwing things on his floor again. She did not have daily cleaning documentation for the resident and had not documented this behavior on a daily basis. The resident's wall had been repaired several times, but he continued to run into the wall creating holes. She did not have documentation of the room repairs. C. Facility follow-up The housekeeping's daily cleaning schedule was provided on 10/12/23 at 1:15 p.m. from the NHA. It revealed the resident's room had been last cleaned 9/22/23. The scheduled documented resident rooms were to be cleaned daily between 6:00 a.m. to 2:00 p.m. Monday through Sunday. The floor of each room was to be cleaned daily. Any concerns were to be brought to management's attention and documented by the nurses.

Based on observations, interviews and record review, the facility failed to ensure the residents' environment remained free from accident hazards as possible, affecting eight out of 15 sample residents (#65, #73, #67, #79, #46, #42, #22 and #10). Specifically: SMOKING FAILURES The facility failed to develop and implement an effective system of oversight and safety interventions to prevent smoking accidents involving Residents #65, #73, #67, #79, #46, #42. Failures included a lack of identification and communication of residents' smoking risks and safe smoking needs, a failure to develop effective smoking interventions, and a failure to take steps to ensure the facility's smoking policy and procedures were implemented. The facility's failures created a situation with the likelihood of serious harm for Residents #65, #73, #67, #79, #46, #42, all of whom smoked, if immediate action was not taken. Resident #65, who was moderately cognitively impaired and diagnosed with left [CONDITION(S)] (weakness), sustained multiple cigarette [CONDITION(S)] in various stages of healing to the left thigh and left upper extremity, as well as cigarette [CONDITION(S)] to his clothing and his wheelchair. EQUIPMENT FAILURES The facility failed to investigate the root cause and assess Resident #22 for injury when the Hoyer mechanical lift broke and tilted during a transfer, and failed to properly position the Sabina lift for Resident #10 to prevent an accident. Findings include: SMOKING FAILURES I. Immediate Jeopardy A. Findings of Immediate Jeopardy Observation, record review, and interviews with staff and Resident #65 demonstrated the facility did not have an effective system in place to implement safe smoking practices for residents who smoked. Interventions were not implemented to prevent cigarette [CONDITION(S)] to Resident #65. Resident #65, according to the electronic medical record, had a known history of [CONDITION(S)] to his wheelchair and upper extremities from cigarette smoking. On 6/3/20, the resident experienced [CONDITION(S)] to his left upper extremity. There were no new interventions put in place. On 1/7/21 the resident's wheelchair was documented in the electronic medical record to have [CONDITION(S)] in the seat. No new interventions were implemented. Resident #65 was observed smoking on 4/7/21 at 4:33 p.m. without being encouraged to wear a smoking apron as his care plan indicated. On 4/8/21 at 11:00 a.m., Resident #65 was observed with three cigarette [CONDITION(S)] to his left upper extremity and [CONDITION(S)] to his wheelchair seat. Interviews revealed staff were not knowledgeable about the safe smoking interventions needed for Resident #65. Record review indicated smoking assessments were not accurate or complete for Resident #65, failing to include his need for an apron or supervision while smoking. Review of the facility policy revealed all residents who smoked were to be supervised; yet, staff interviews revealed not all were aware of this expectation in the policy. Further, contrary to facility policy, Residents #73, #67 #42 and #79 reported they kept their cigarettes, Residents #73, #67 and #42 kept both their cigarettes and lighter, and Residents #79 and #42 said they smoked when they chose to. Observations revealed Residents #73, #46, and #79 smoking on facility grounds in non designated areas; Residents #73 and #46 were not being supervised Finally, staff was not aware which residents had safe smoking interventions, such as smoking aprons, and unaware which residents currently smoked. B. Imposition of Immediate Jeopardy On 4/8/21 at 12:51 p.m., the nursing home administrator (NHA) was informed by the Colorado Department of Public Health and Environment (CDPHE) that the facility's failure to take steps to implement the facility's smoking policy, implement safe smoking interventions for residents who smoke and implement interventions to prevent multiple cigarette [CONDITION(S)] to Resident #65, created a situation of immediate jeopardy with the potential for serious resident harm. C. Facility response On 4/9/21 at 2:59 p.m., the facility submitted the following plan (draft #4) to remove the immediate jeopardy. The plan read: Corrective Action: On 4/8/2021 at 2:51 p.m., the community implemented one to one (1:1) with resident #65, 24 hours per day, seven days per week when the resident is on the facility's premises. Around the clock 1:1 will be reevaluated following discussion with MHCD (local mental health center). The nurse practitioner (NP) assessed the resident on 4/8/2021. An NP Acute Progress note stated, Resident #65 has several superficial scattered wounds L (left) lower forearm and L (left) thigh. Patient denies pain or concern about them. Patient declines to have leg examined. Diagnostic Statement: Abrasion of left little finger, Blister (nonthermal) of left forearm, initial encounter, and scar condition and fibrosis of skin. Wound team to assess and follow until resolved. Abrasion to the left little finger is being treated with skin prep. Assistant director of nursing (ADON) completed head to toe assessment of Resident #65 on 4/8/2021. The ADON observed: Left Medial wrist Wound # 1, l x 0.8 scab, Wound # 2, 1x 0.8 scab, Wound # 3, 0.7 x 0.7, Left thumb cluster Wound #4, 2.0 x 2.0, Left Pinky Wound #5, l.3 x 0.7, Left thigh Wound #6, left thigh 2 x l.7, Wound #7, left thigh l.8 x 0.7. All measurements listed in centimeters (cm). All wounds closed and not needing treatment. Social Service Coordinator reviewed the smoking agreement with Resident #65 and provided a copy on 4/8/2021. The community initiated smoking apron and cigarette extender for safety for Resident #65 by 4/8/2021. If resident #65 refused to wear a smoking apron and use cigarette extender resident will be observed 1:1 by Smoking Supervisor. Refusal to wear apron and use extender will be reported to Administrator or designee. Refusals may result in resident losing smoking privileges as designated by the care plan and per community smoking policy up to and including 30 day discharge from community. Director of Rehab ordered Resident #65 a bag for his wheelchair to hold smoking adaptive equipment for when he leaves Saint [NAME]'s premises. Resident #65's 1:1 will ensure resident has his smoking adaptive equipment in the bag prior to resident leaving St. [NAME]'s premises. The community ordered flame-resistant clothing for Resident #65 on 4/8/2021. The flame resistant clothing will arrive by Tuesday, April 13, 2021. Director of Nursing educated resident on how to safely use cigarette extender and smoking apron on 4/8/2021. Smoking supervisor/designee will load and unload Resident #65's cigarette extender during designated smoking times. On 4/8/2021 Resident #65 agreed for Saint [NAME] Health Center to search his room if Saint [NAME] has probable cause. Community will request permission with resident each time a search may be indicated. On 4/9/2021 the community will begin to collaborate with Resident #65's mental health provider to develop a behavior management program to keep Resident #65 safe. On 4/9/2021, the Director of Nursing (DON) offered Resident #65 an e (electronic) cigarette. Resident refused intervention. Social Service Coordinator/designee conducted a full house audit to identify residents that are smoking on 4/9/2021. 11 residents were identified as actively smoking. On 4/5/2021 it was initially reported that 15 residents were smoking however the audit conducted on 4/9/2021 indicated 4 residents have quit smoking. Social Service Director/designee will audit all residents who are identified as a resident who smokes to confirm accurate and current smoking safety screens, smoking agreements, and care plans to be completed by 4/9/2021. On 4/9/2021 Director of Nursing reviewed smoking safety screens, smoking agreement and care plans for accuracy. By 4/9/2021, Nurse/designee completed a skin observation tool for all residents who smoke. Nurse/designee documented results on Skin Observation tool. Results were communicated to IDT (Social Services, Nursing Administration, Administrator and Assistant Administrator) if burn marks were observed on resident's clothing, wheelchair, and cushion a high risk progress note would be completed. IDT will review the dash board during morning meeting for high risk progress notes. Systemic Measures: Director of Nursing/designee will provide education to all staff regarding smoking policy by 4/8/2021. Education includes the facility will provide a safe smoking environment that ensures the health and well-being of all members of the SPHC community. Smoking on campus is only allowed during the scheduled smoking times of: 7:00 a.m. to 7:30 a.m., 9:30 a.m. to 10:00 a.m., 11:30 a.m. to 12:00 p.m.,1:30 p.m. to 2:00 p.m., 4:30 p.m. to 5:00 p.m., 7:30 p.m. to 8:00 p.m., and 9:00 p.m. to 9:30 p.m. A staff member must be present during smoking times for residents. All residents are considered supervised for smoking. If a staff member identifies [CONDITION(S)], ashes, or holes in clothing on a resident, they will immediately report to the SS (social services), Nurse, and/or NHA. A skin assessment, a risk report, smoking safety screen and notifications to family will be completed. Tobacco products, e-cigarettes and smoking materials must be stored in smoking cart. If smoking materials are visualized in room, the staff will request to move the materials to the smoking cart. If any resistance from resident a call must be placed to facility management to report concerns. Residents are not to buy, borrow, trade, or give cigarettes/smoking materials to any other resident or visitors. Smoking supervision will be provided by an assigned member of the interdisciplinary or direct care staff as follows: Obtaining smoking materials and smoking products from the smoking cart. -Escort the residents to the designated smoking area. -Assistance with removal of oxygen apparatus, if applicable. -Assistance with application of smoking apron, if applicable. -Providing/lighting the tobacco product for the resident once they have arrived in the designated smoking area and/or loading their e-cigarette. -Monitor the smoking process until the tobacco product is extinguished. -Monitor the use of ashtrays and disposal of used tobacco products and e-cartridges. If a resident does not follow the smoking safety rules, the resident will be reassessed by direct care staff with the interdisciplinary team. If unsafe, residents may lose smoking privileges as designated by the care plan. If a resident is unable or unwilling to follow their safe smoking care plan, social services will coordinate additional education, assessment, and notifications to address smoking safety and residents' rights. This may include verbal or written warnings indicating the consequences of continued unsafe smoking, and family/responsible party, physician, and ombudsmen notification. Smoking Interventions for resident #65: -Must wear a smoking apron. -Must use extender on cigarettes. -Will have a one on one monitoring him. Starting 4/9/2021 Director of Nursing/designee will train all staff on how to properly use smoking adaptive equipment. Starting 4/9/2021 education is to be provided to resident by Social Services/designee about interventions identified on smoking safety screen. Quality Improvement Specialist will complete education with social services on Smoking Safety Screen by 4/8/2021. Director of Nursing/designee will educate all new employees on Saint [NAME]'s Smoking Policy prior to working the floor. Starting on 4/9/2021, Social Service Coordinator/designee will develop and implement a tool, Smoking Cliff Note to have in the smoking cart for staff to reference on residents who have smoking adaptive equipment. Social Service Coordinator/designee will update as needed. Social Service Director/designee will train all staff on Smoking Observation Form. Designated Smoking Supervisor will complete a Smoking Observation Form at every designated smoke time starting 4/9/2021. Starting 4/9/2021, prior to locking the Smoking Safety Screen, Social Services/designee will review quarterly per MDS schedule the screen with IDT for accuracy and interventions, if indicated. Starting 4/9/2021 SSC/designee will review Saint [NAME]'s Smoking Policy and Smoking Agreement with all residents who smoke as well as provide them a copy by 4/9/2021. Starting 4/9/2021 the nurse is to notify nursing management if a resident refuses a weekly skin observation or bath. All refusals will be reassessed by nursing management. Monitoring: Social Services Director/designee will complete audits of all smoking safety screens, smoking agreements, and care plans weekly based off the (minimum data set (MDS) schedule, policy violations, and change of conditions starting 4/8/2021. NHA/designee will review Smoking Observation Form in morning clinical meetings Monday Friday. On Saturday and Sunday the manager on duty will review Smoking Observation Form. Screener/designee will monitor 24 hours/day via camera or in person the smoking area during unsupervised times for four weeks, and if no issue is identified, the IDT can determine how often going forward. D. Removal of immediate jeopardy On 4/9/21 at 3:54 p.m., the NHA was notified the immediate jeopardy had been removed based on observations that the facility was taking steps to begin implementation of the above correction action plan. However, based on observations, interviews, and record review, deficient practice remained at a G (actual harm that is isolated). II. Facility policy and procedure A. The Smoking Policy, reviewed 8/20/15, was received from the director of nursing (DON) on 4/8/21 at 12:49 p.m. The policy documented in pertinent part: This policy includes the use of tobacco in cigarettes, pipes, cigars and vapors from electronic cigarettes (e-cigarettes). An illicit drug free environment will be maintained, including but not limited to medical marijuana. Colavria maintains smoke free facilities, with designated outdoor smoking areas. To sustain a safe environment, a smoking safety screen should be performed on admission, quarterly with a potential change of condition or behavior and as needed. The facility may impose smoking restrictions on residents at any time if the resident cannot smoke safely with the available levels of support and supervision. The facility may also conduct room and body searches in situations of a resident not complying with smoking privileges and creating a safety risk to others. If resident behavior or choices place them or others at risk, it may be necessary to consider a 30-day or emergency discharge notice. However, every effort will be made to partner with residents to safely accommodate their preference to smoke. Smoking times may be scheduled by the Community for all residents, or individualized as designated in a residents' care plan. Smoking paraphernalia will be kept at the nursing station for all residents. Residents may not manage or store their own cigarettes and lighters, and must follow the safety rules, including oxygen management. Safety Rules: All residents that smoke must follow safety rules which include: Tobacco products, e-cigarettes and smoking materials must be stored at the nursing station. Family members and visitors will be educated to leave tobacco products and smoking materials for these residents at the nursing station. Additional resident smoking interventions will be addressed on individual resident care plans. Residents are not to buy, borrow, trade, or give cigarettes/smoking materials to any other resident or visitors. Residents and resident rooms may be searched at any time by facility staff for unauthorized storage or possession of smoking materials. Prerequisites: Smoking Safety Screen Smoking Contract or Agreement Individualized Care Plan Procedure: Residents and /or their responsible party will receive smoking policy education prior to or upon admission. Education will be provided by the admissions coordinator, nurse liaison. or designee. Every effort will be made to assist residents and/or their responsible party to understand the extent to which their smoking or non-smoking preferences can be accommodated. Based on the smoking policy frequency, social services and/or nursing will evaluate residents for smoking safety using the smoking safety screen or assessment to determine any special needs for the resident during smoking (ie: Apron, cigarette holders, etc. for their safety) All residents will require Supervision regardless of risk. Therefore, staff is required to be present at all times when residents are smoking. (Limited accommodations may be made when family or visitors accept the responsibility of supervising the smoker including returning all smoking supplies to the nursing stall). All smoking supplies are kept in locked storage by the nursing staff. Smoking-related privileges. restrictions, and concerns will be care planned by social services or designee. Staff caring for the resident will be educated on the care plan, including safe smoking interventions. Social Services will inform the ombudsmen and physician if a resident's smoking choices put either them or other's safety at risk and it is unable to be resolved. Social Services and/or the Admissions Coordinator will provide resident smoking education prior to or upon admission, at resident council meetings, or individually as needed. Environmental service will monitor the smoking area to verify that appropriate ashtrays and metal containers are present per policy. Based on oxygen storage and resident use, nursing will post no smoking, oxygen in use signs in each neighborhood. Smoking supervision will be provided by an assigned member of the interdisciplinary or direct care staff as follows: -Obtaining smoking materials and smoking products from the nursing station. -Escorting the residents to the designated smoking area -Assistance with removal of oxygen apparatus, if applicable -Assistance with application of smoking apron, if applicable - Providing/lighting the tobacco product for the resident once they have arrived in the designated smoking area and/or loading their e-cigarette. -Monitoring the smoking process until the tobacco product is extinguished. -Monitoring the use of ashtrays and disposal of used tobacco products and e-cartridges. If a resident does not follow the smoking safety rules, the resident will be reassessed by direct care staff with the interdisciplinary team. If unsafe, residents may lose smoking privileges as designated by the care plan. If a resident is unable or unwilling to follow their safe smoking care plan, social services will coordinate additional education, assessment, and notifications to address smoking safety and residents· rights. This may include verbal or written warnings indicating the consequences of continued unsafe smoking. and family/responsible party, physician, and ombudsmen notification. Depending on the severity of smoking safety violations, an immediate emergency discharge or 30-day discharge notice may be necessary. The ombudsmen and the health department will be kept informed as needed, should this become necessary. If a safe discharge plan is not obtained by the end of the 30-day notice of discharge, the discharge notice may be extended until a safe discharge location is obtained or as soon as arrangements can be made for the resident to be discharged to their own custody. Smoking policy education will be provided to all staff upon hire, annually, and as needed. This education. coordinated by human resources, will include completion of smoking assessments. smoking risk education, oxygen use, and the resident's plan of care related to smoking. Education will also include the use of a smoking blanket, and/or rolling a person on the ground in the event of a smoking related fire. B. Interviews regarding the facility's smoking policy and procedures The director of admissions and marketing (DAM) was interviewed on 4/8/21 at 12:30 p.m. The DAM said the residents' cigarettes and lighters were kept in a locked smoking cart. She said residents were only allowed to smoke during designated smoking times, and they were to smoke in the designated smoking area. She said the residents were always supervised by a staff member during the designated smoking times. The DAM said if a resident was observed smoking when it was not a designated smoking time, the incident was documented and the resident was reminded of the facility smoking policy. She said the residents were not supposed to have their own lighters or cigarettes. She said if staff observed a resident with cigarettes and a lighter, staff were supposed to ask the resident to turn the items in to be kept in the smoking cart. She said if residents refused to turn the items in, the incident was documented. The DAM said if residents continued to be noncompliant, the facility could issue a 30-day notice for failure to comply with the facility smoking policy. The director of nurses (DON) was interviewed on 4/8/21 at 12:35 p.m. The DON said residents had the right to smoke, but they were not allowed to smoke unsupervised unless they went off campus which she explained was the sidewalk in front of the facility. She said they needed to sign out and then they could leave campus. She said the SW did the assessments for smoking. She said based on the findings on the quarterly assessments, interventions such as a smoking apron would be implemented. The nursing home administrator (NHA) and the DON were interviewed on 4/8/21 at 2:17 p.m. The NHA said all residents were to be supervised while smoking. She said the facility had recently made the decision to become a non-smoking facility, and the current residents who smoked were grandfathered in. She confirmed residents could smoke independently if they went off campus. She said that was their right. III. Resident failures A. Resident #65 1. Resident status Resident #65, age 47, was admitted on [DATE]. According to the April 2021 computerized physician's orders (CPO), diagnoses included cerebral infarction (stroke) due to embolism (clot), [CONDITION(S)], flaccid [CONDITION(S)] and [CONDITION(S)] of the left side, [MEDICATION(S)] dependence, traumatic brain injury, and tremors. According to the 3/12/21 minimum data set (MDS) assessment, the resident was moderately cognitively impaired with a brief interview for mental status (BIMS) score of nine out of 15. Resident #65 required supervision with bed mobility, transfers, dressing, toileting and hygiene. He had a wheelchair for mobility. He had no skin conditions, including [CONDITION(S)]. The assessment did not indicate tobacco use. However, the resident's care plan, initiated on 6/10/16, documented the resident was an unsafe smoker, as evidenced by not disposing of ashes in receptacles, smoking at undesignated times and searching through smoking receptacles or the ground for cigarette butts and smoking them. Interventions included: Provide with resources for smoking cessation; monitor for safe smoking practices and support safe smoking behaviors; encourage the resident to wear a smoking apron to prevent [CONDITION(S)] to clothes and skin; quarterly assessment for safe smoking practices; remind the resident of the safety of disposing ashes in receptacles, smoking unsupervised, and picking up cigarette butts from the floor; and remind him of consequences of not following the smoking agreement. 2. Observations and interviews On 4/5/21 at 3:12 p.m., Resident #65 was observed resting in bed. His wheelchair was next to his bed. There were approximately 20 round burn holes clustered in the front-center of the wheelchair seat. On 4/7/21 at 4:33 p.m., Resident #65 was observed smoking in the designated smoking area. One staff person was present. The resident did not have a smoking apron on and the staff person was not observed to encourage its use or offer him a smoking apron. On 4/8/21 at 11:00 a.m., Resident #65 was observed in the hallway. His left wrist and hand rested between his legs on the wheelchair seat. His hand was curled up, and he did not appear to be able to move his left arm or hand. He had three visible circular wounds on the left wrist and hand. The two wounds on the wrist appeared to be scabbed and approximately 1 cm, and the one toward his thumb was a round dark purple scarred area approximately 1.5 cm. The wounds were round and appeared to be cigarette [CONDITION(S)]. On 4/8/21 at 11:51 a.m., assistant director of nursing (ADON) #1 observed the resident's wounds. She said those are cigarette [CONDITION(S)]. She said there were at least three visible [CONDITION(S)]. ADON #1 said the wound near the thumb looked healed and the other two near his wrist were scabbed. The ADON said the first wrist wound on the outer wrist was 1.1x1.5 cm and the one below it was 1.7 x 1.3 cm. She said he refused skin assessments, but these wounds were visible without removing his clothes for a skin assessment. She said she was concerned he may have [CONDITION(S)] to his groin area, too, after she looked at the multiple holes in his wheelchair. The wheelchair still had ashes from the cigarette on top of the burned areas in the chair. (The resident refused to allow her to inspect his groin area at that time.) ADON #1 said she would notify the wound physician to come look at the wounds. She said Resident #65 is a supervised smoker and should have worn an apron to smoke on 4/7/21 (see observations above). On 4/8/21 at 12:00 p.m., Resident #65 said he thought the wounds on his left arm and hand were [CONDITION(S)] from his cigarette ashes. On 4/8/21 at 2:17 p.m., the nursing home administrator (NHA) and the director of nursing (DON) were interviewed. The NHA said, upon reviewing Resident #65's care plan, it documented the smoking apron was to be encouraged, not that he had to wear it. On 4/12/21 at 10:45 a.m., Resident #65 was observed in bed. He had the same wheelchair in his room with the cluster of [CONDITION(S)] at the center-front of the wheelchair seat. His closet door was open. A red sweatshirt in his closet had at least three burn holes, approximately 2 cm round, with brown edges. Certified nurse aide (CNA) #1 was present in the room. He said those are definitely [CONDITION(S)]. He said he could not determine if the [CONDITION(S)] were new or old but said the sweatshirt looked clean so it must have come up from laundry. On 4/12/21 at 11:33 a.m., Resident #65 was observed smoking in the smoking area. The concierge receptionist (CR) was present and the resident had an apron on and was using a cigarette extender. The resident had a long red glowing ash hanging from the cigarette and the staff person took the cigarette extender and ashed the cigarette for the resident. The CR said the resident does not always ash his cigarette and sometimes it just keeps burning and the staff have to ash it for him. He said other times, the resident will ash it himself. 3. Known history of unsafe smoking behavior resulting in [CONDITION(S)] to self, clothing and equipment In addition to the resident's care plan above identifying the resident as an unsafe smoker, record review revealed facility knowledge of the resident's potential and actual [CONDITION(S)] to self, clothing and equipment. On 12/3/19 at 7:35 a.m., social services offered the resident a cigarette extender to help prevent [CONDITION(S)] to his fingers. The resident accepted. On 6/3/20 at 3:36 p.m., nurses' notes documented the resident had scabs to his left arm, and darkened areas to his second and third fingers of his right hand. Resident encouraged to utilize supervised smoking times and allow for regular skin assessments to ensure his safety. NP (nurse practitioner) was notified. On 1/7/21, a Concern or Comment referral form documented, Resident observed on wheelchair with cigarette [CONDITION(S)] in wheelchair, wheelchair exchanged by rehab. Offered services to resident to help quit smoking. He refused, Wheelchair exchanged for clean and proper working new wheelchair. Staff to continue to monitor resident and safety during smoke breaks. The root cause section of the form was blank. 3. Facility failure to develop and implement an effective system of oversight and safety interventions to prevent smoking accidents involving Resident #65. a. Inaccurate smoking assessment The most recent smoking assessment prior to survey was dated 1/9/21. It documented the resident had no cognitive loss. The assessment documented the resident had no concerns with dexterity. Under the safety section, interventions for smoking apron, cigarette holder and one to one assistance were not checked as needed. Additionally, under resident safety awareness, the resident was not documented to smoke in non designated areas, throw cigarette butts in improper places, burn holes in clothing, or beg, borrow, buy or sell materials. The assessment inaccurately documented that none of the safety interventions applied to Resident #65. But see above: The resident's diagnoses (left [CONDITION(S)] and [CONDITION(S)], tremors), 6/3/20 nurses' notes (scabs to left arm, darkened areas to fingers of right hand) and the 1/7/21 Concern or Comment referral (cigarette [CONDITION(S)] in the resident's wheelchair), all indicated the need for implementation of safety interventions to prevent serious harm. b. Insufficient facility response to evidence of unsafe smoking. (1) Care plan - failure to develop and incorporate interventions to minimize harm See above; the care plan failed to address the resident's potential and actual [CONDITION(S)] identified on 12/3/19, 6/3/20 and 1/7/21 and incorporate interventions to minimize harm, such as the use of a cigarette extender, offered and accepted by the resident on 12/3/19. Likewise, the facility failed to review and consider revision of existing interventions, such as the degree of monitoring the resident required for safe smoking and the directive to encourage the use of a smoking apron. (2) Skin inspection - failure to accurately observe, document and assess skin A provider note dated 3/11/21, documented the resident was a smoker and the skin was intact to the bilateral lower extremities. The plan was to monitor skin per facility protocol. Review of weekly skin assessments and DON interview on 4/8/21 at 2:17 p.m. revealed the resident frequently refused skin assessments and bathing, which provided another opportunity to inspect the resident's skin. -The resident's skin assessments for February, March were reviewed. The resident refused skin assessments in February, 2/3/21, 2/10/21, 2/17/21, 2/24/2. The resident refused skin assessments in March, 3/3/21, 3/10/21, 3/17/21, 3/24/21, 3/31/21. -The CNA bath sheets were received from the DON on 4/8/21. The DON said the CNA documented any skin problem on the bath sheet and the nurse signed off on the sheet. The bath sheets for February to April were reviewed. The bath sheets documented the resident refused a bath on 2/5/21 and 2/17/21. Two bath sheets provided had no date and were blank, except for a nurse signature. On 3/17/21, the bath sheet documents the resident refused. On 3/31/21, the bath sheet documented the skin was ok and was signed by a nurse. There was no evidence the resident's refusals were addressed to ensure the resident's skin was inspected, even when documentation on 6/3/20 and 1/7/21 (see above) indicated he had sustained [CONDITION(S)] to his arm, fingers, and wheelchair. Record review revealed no nursing note documenting an assessment or attempted assessment of the resident's skin for [CONDITION(S)] on either date. Further, ADON #1, interviewed on 4/8/21 while observing Resident #65's wounds (see above), said the wounds were visible without removing his clothes for a skin assessment. She also said the resident had a shower last night (4/7/21) and the wounds should have been reported at that time. c. Lack of understanding[TRUNCATED]

Based on observations, interviews and record review, the facility failed to ensure the resident ' s environment remained free from accident hazards as possible, affecting one (#11) of 14 sample residents. Specifically the facility failed to ensure: -Resident #11 did not smoke with oxygen; and -Interventions were implemented after Resident #11 suffered [MEDICAL CONDITION] smoking without supervision while using oxygen. The facility ' s failure to ensure residents did not smoke while using oxygen caused Resident #11, on 12/12/19 to have oxygen induced [MEDICAL CONDITION] the face and nares (nostrils). On 12/12/19 Resident #11, who was unsupervised in the smoking area, took a cigarette from another resident, and began to smoke while wearing oxygen which caused [MEDICAL CONDITION] the resident ' s face. I. Facility policy The Smoking policy and procedure, revised 8/20/15, was provided by the director of nursing on 12/17/19 at 4:01 p.m. It read in pertinent part: Policy: To sustain a safe environment, a smoking safety screen should be performed on admission, quarterly, with a potential change of condition or behavior and as needed. -Smoking paraphernalia will be kept at the nursing station for all residents. Residents must follow the safety rules, including oxygen. -Environmental issues: Residents may not smoke anything while using portable oxygen, or when the portable oxygen tank is attached to the wheelchair. The portable oxygen tank must be removed and stored inside the facility prior to entering the smoking area. -Safety rules: all residents that smoke must follow safety rules -Procedure: Residents and/or their responsibility party will receive the smoking policy education prior to, or upon admission. Based on the smoking policy frequency, social services and/or nursing will evaluate for smoking safety using the smoking safety screen or assessment to determine any special needs for the resident during smoking. -All residents will require supervision regardless of risk. -Smoking-related privileges, restrictions, and concerns will be care planned by social services or designee. [NAME] Resident #11 status Resident #11, age 71, admitted on [DATE]. According to the (MONTH) 2019 computerized physician orders [REDACTED]. The 11/7/19 minimum data set (MDS) assessment revealed the resident had minimal cognitive impairment with a brief interview for mental status (BIMS) score of 13 out of 15. The MDS documented the resident was on oxygen therapy. B. Resident interview Resident #11 was interviewed on 12/17/19 at 12:50 p.m. The resident stated he recently had been smoking in the outside smoking area of the facility, and had forgotten to take off his portable oxygen and [MEDICAL CONDITION] the side of his face. The resident said he had a pack of cigarettes and lighter that he kept in his room, and would go to the facility smoking area various times throughout the day. He said he liked to go outside and smoke in the morning, and that was what he was doing the morning he suffered the burns. He said he usually would remove his portable oxygen inside the facility and leave it by the facility management offices, but he had forgotten to remove his portable oxygen and had worn it outside to the smoking area. The resident stated he was offered a cigarette from another resident who was in the facility smoking area. The resident stated as soon as he began smoking the cigarette he heard a sizzle and knew he was in trouble. The resident stated the next thing he remembered was facility staff standing around him and feeling pain all over his face. He said he was taken to the emergency room , and [MEDICAL CONDITION] treated and he was able to come back to the facility that evening. The resident stated it scared him so much that he has quit smoking. The resident stated there was never staff in the facility smoking area when he was smoking. He said staff went over the smoking policy and completed a smoking assessment after he returned from the hospital for treatment of [REDACTED]. II. Failure to implement interventions after the resident had been identified as an unsafe smoker [NAME] Social social progress notes regarding resident habitually smoking with oxygen The 10/10/19 social service progress note documented the following: SS (social service) spoke with resident regarding the smoking policy. SS reminded the resident that (name of facility) is a non smoking facility. The resident reports that he did not remember. SS was informed that the resident was smoking cigarettes with his oxygen on. SS briefed the resident on the dangers of smoking with his oxygen. He stated I know that it is dangerous I thought I took my oxygen off. I want to quit smoking and would like help. SS offered nicotine patches as a tool to assist the resident with quitting smoking.The resident agreed to try the patches. SS will continue to follow and assist as needed. The 10/17/19 social service progress note documented the following: SS reminded resident about his unsafe smoking habits. SS reiterated to the resident that (facility name) is a non smoking smoking facility and that it is not safe to smoke with the oxygen tank. The 11/14/19 social service progress note documented the following: On 11/13/19, SS issued a formal written warning to resident regarding his unsafe smoking habits. Resident verbalizes understanding and signed the warning. SS will continue to follow and assist as needed. B. Record review The 12/12/19 acute encounter progress, written by the resident ' s physician assistant, note documented the following: Facial burns- I was asked to evaluate patient this morning urgently. PAtient was smoking outside while wearing his oxygen. Unfortunately a flash flame ignited. He burned his face, nares, lips and mouth along with his hand. He was able to smother the fire out with his left hand. He has signed eyebrows and obvious soot across his face with reddened skin along his cheeks and forehead nares and mouth. He denies increased shortness of breath or respiratory distress. However he does report pain and soreness in his nares and mouth. Discussed with patient that it would be best for him to be evaluated in the emergency room and monitor closely as there is often delayed response. Will arrange patient to be transported emergently to the hospital for monitoring. Staff has notified wife. Patient understands and is in agreement with treatment plan. The 12/12/19 nursing progress note documented the following: Patient returned from ED (emergency department) with small superficial open area noted to left face under eye next to left nare, related to reportedly smoking outside with oxygen via NC (nasal cannula) still in place this am. No signs or symptoms of infection, increased redness, or drainage. Declined offer for dressing to site. Denies and no signs or symptoms of discomfort, SOB (shortness of breath), distress. Communicating needs effectively. Call light, fluids within reach. Notified medical doctor. The 12/12/19 admission smoking safety screen, completed after the resident returned from the hospital on [DATE], documented the following: Resident was issued warning on 11/11/19 for smoking with oxygen in place. Resident verbalized after incident he understood he was not to smoke with oxygen in place. A review of the resident's record revealed no additional smoking safety screens. The initial smoking care plan, initiated on 12/12/19 after the resident returned from the hospital, documented the resident had a history of [REDACTED]. The goal was for the resident to follow facility smoking protocol. The pertinent approaches included, the resident smoking during supervised smoking times, and providing education to the resident about the risks of smoking. C. Staff interviews The social service director (SSD) was interviewed on 12/17/19 at 1:23 p.m. She said the facility was a non-smoking facility, and the resident ' s who continued to smoke were grandfathered in and were allowed to continue to smoke. She said none of the resident ' s in the facility were allowed to smoke independently in the facility, and if a resident was a smoker they had to smoke during the scheduled smoking times that were supervised by a facility staff member, even if the resident was deemed a safe smoker. The SSD said smoking safety screens were to be completed when residents were admitted to the facility, and they also needed to be completed quarterly, annually and anytime an issue surrounding safe smoking had been identified. The SSD said the smoking safety screen for Resident #11 had not been completed when the resident was admitted to the facility, nor had any been completed when the resident had been observed smoking with oxygen. The SSD said a care plan regarding Resident #11 desire to smoke should have been a care planned, and updated when the resident had been observed smoking while wearing oxygen. The SSD said Resident #11 safe smoking screen and smoking care plan had been completed on 12/12/19 after the resident returned from the hospital for treatment to [MEDICAL CONDITION] suffered while smoking while wearing oxygen. The director of nursing (DON) was interviewed on 12/17/19 at 3:17 p.m. She said she was in the facility when Resident #11 [MEDICAL CONDITION] his face. She said the resident who was in the smoking area with Resident #11 had come into the building for help and several staff members went to the smoking area to assist Resident #11. The DON said the resident had soot around his nose and on his face. She said the residents physician assistant (PA) happened to be in the facility and had assessed the resident and determined he needed to be sent to the emergency department for further evaluation. The DON said Resident #11 had been observed smoking with oxygen prior to 12/12/19, and at that point a new safe smoking assessment should have been completed, as well as having the resident review and sign the facility smoking agreement. Facility follow-up and system changes On 12/17/19 at 3:30 p.m. the DON said the facility took the following steps after 12/12/19: -The social service department completed a building wide audit of the safe smoking screens to ensure every resident who smoked had a current and accurate assessment. -Smoking care plans were completed and updated for all residents who smoke. -The smoking area was being audited every half hour to make sure residents were not unsupervised. -The had all of the residents who smoke sign a new smoking agreement. -The facility searched the rooms of smokers, who allowed them, for smoking paraphernalia and removed all items and placed them into a locked cart.

Based on record review, staff and resident review, the facility failed to ensure that one of three sample residents (#1) received the necessary care and services to attain or maintain the highest practicable physical, mental and psychosocial well-being. Specifically, the facility was unable to manage pain for resident #1 because they did not obtain the appropriate medication for him. He suffered pain at a 5/10 that increased to a 9/10 level for six hours. Findings include: Resident #1, was a [AGE] year-old male, admitted to the facility on [DATE] with diagnoses, according to his face sheet, that included status [REDACTED]. He also had a history of [REDACTED]. Due to his short stay he did not have a Minimum Data Set (MDS) assessment completed. His temporary care plan revealed he required the assistance of one to two staff members for all ADLs (Activities of Daily Living), which included transfers, dressing, personal hygiene and bathing. Nurse's Notes Resident #1 was admitted at approximately 2:00 p.m. on 4/9/12. He stated his pain was a 5/10. His right leg was elevated on a pillow. The nurse documented, "Awaiting call back from Dr. _____(name of physician) to verify orders." The following notes were from 4/9/12: It was then noted the same physician was called at 3:30 p.m. to verify medication. The doctor returned the call at 4:15 p.m. The doctor arrived in the facility and stated he wanted to review the medication list from the hospital. The resident complained of pain again, this time a 6/10. The note read, in pertinent part, "Resident requested pain medication. Attempted to for (SIC) medication from Narc E-kit (Narcotic emergency kit). Unable to receive from pharm (pharmacy) since original medication orders not received. Offered resident Tylenol 650 mg PRN (as needed), pt. accepted, but stated he would need something stronger. MD completed med list at approximately 1830 (6:30 p.m.), stated that med list sent from hospital wasn't correct." The nurse then called the pharmacy to ensure they had received the orders (via fax). They stated they would get medications out "ASAP". It was also noted the resident became quite anxious in relation to [MEDICAL CONDITION] (that he usually took at 6:00 p.m.). At 5:00 p.m. the nurse offered the resident Tylenol 650 mg. One hour later (at 6:00 p.m.) the resident stated pain was still a 6/10. The nurse spoke with the resident's mother and stated she had medicated him (she did not say it was Tylenol that she had given). The NN (nurses notes) continued, "At 8:05 p.m., the resident sent a CNA to find the medication nurse, to tell her he needed his bedtime medication and his pain medication. Went to resident #1's room the resident was on the phone with his mother. Agitated & upset. Kept saying this is not right. RN explained to resident the process of receiving meds from pharmacy. Med dispense not working at this time (see below)." The NN went on to read, "RN called the pharmacy again and requested the meds be sent STAT (immediately). Nurse called the DON (Director of Nursing) at 8:25 p.m. to inform her of the situation". She documented in the NN, "Was able to medicate patient with 10 mg [MEDICATION NAME] at 8:15 p.m." She noted the resident was still unhappy, "stating he takes [MEDICAL CONDITION] at 1800 (6 p.m..") The nurse documented resident #1's pain to be a 9/10 at 8:15 p.m., and that it decreased to a 3/10 at 9:30 p.m. The pain medication orders read as follows: -[MEDICATION NAME] (mild narcotic [MEDICATION NAME]) 10/325 mg 1 by mouth every 4 hours as needed for pain between a 1 and a 3 out of 10. -[MEDICATION NAME] (mild narcotic [MEDICATION NAME]) 10/325 mg 2 by mouth every 4 hours as needed for pain between a 4 and a 6 out of 10. -[MEDICATION NAME] 5 mg by mouth every 4 hours as needed for pain between a 7 and an 8 out of 10. -[MEDICATION NAME] 10 mg by mouth every 4 hours as needed for pain between a 9 and a 10 out of 10. Staff Interviews The nursing home administrator (NHA) and DON were interviewed on 6/11/12 at approximately 2:00 p.m. When asked why the nurse on duty on 4/9/12, was unable to retrieve the [MEDICATION NAME] from the facility emergency kit, the DON explained. She stated the "Emergency Dispense Kit" was locked and was to be accessed using a code. The nurse on duty was not able to get the code to work. The DON stated the facility had a "back-up key" for emergencies, but that it was unavailable. The NHA stated she thought the previous DON may have taken it. They acknowledged that they should have been better prepared. They were aware the resident had pain at 5/10, which increased to 6/10 and was given Tylenol at 5:00 p.m., then at 8:15 p.m., when the pain was a 9/10, the nurse "borrowed" the [MEDICATION NAME] from another resident. When the NHA and DON were asked how the resident was given pain medication at 8:15 p.m., since they could not access the medication dispense system, the NHA stated the nurse had "borrowed" the medication from another resident. They both acknowledged that was not acceptable. They stated that nurse no longer worked there. Cross reference F281. The medications were finally delivered from the pharmacy at 10:35 p.m. The nurse on duty medicated the resident at 10:45 p.m. with another 10 mg of [MEDICATION NAME], even though his pain level was documented to be a 3/10 at 9:30 p.m. The nurse documented a conversation with the physician wherein the resident complained of severe pain. The doctor gave a one time order for another 10 mg of [MEDICATION NAME]. The nurse did not write a Telephone Order, nor did she transcribe the order on the MAR (Medication Administration Record). The nurse then had given the second dose of [MEDICATION NAME] without an order, as the directions on the MAR indicated and yet the resident received it at 8:15 p.m. and again at 10:45 p.m. Both the NHA and the DON acknowledged the medication error (borrowing from another resident) and giving the second dose without an order. From the time the resident was admitted at 2:15 p.m., he continued to complain of pain. While he was given Tylenol at 5:00 p.m., it was another three hours before he received the [MEDICATION NAME] (which was borrowed and should not have been administered). The resident suffered pain (in increasingly intensity) for six hours.

Based on record review, staff and resident interview and observations, the facility failed to provide appropriate care and services for a peripherally inserted central catheter line (PICC) for one (#1) of four sample residents. Specifically, the facility failed to follow physician orders [REDACTED]. These failures resulted in [MEDICAL CONDITION] requiring hospitalization for the resident. The findings include: 1. Definition: According to PICClinenursing.com -A PICC line is, by definition and per its acronym, a peripherally inserted central catheter. It is long, slender, small, flexible tube that is inserted into a peripheral vein, typically in the upper arm, and advanced until the catheter tip terminates in a large vein in the chest near the heart to obtain intravenous access. It is similar to other central lines as it terminates into a large vessel near the heart. Risk of Infection: It is possible for an infection to develop either inside the vessel or surrounding the insertion site where the catheter enters the vein. The symptoms include fever; chills; [MEDICAL CONDITION] fatigue; muscle aches; weakness; decreased blood pressure; redness, swelling or purulent drainage at site; or elevated white blood cell count. 2. Resident #1 Resident #1 was admitted to the facility on [DATE] and re-admitted on [DATE]. The current physician orders, dated 10/13/11, listed [DIAGNOSES REDACTED]. The facility failed to ensure the resident received the appropriate treatment and services for a central line IV, resulting in severe infection and hospitalization . More specifically: a. Resident Data The minimum data set (MDS) assessment, dated 9/6/11, coded the resident to have no short-term and long-term memory impairments and no impairment for decision making abilities. The resident was independent in transfers mobility, and needed set up for dressing, toileting and personal hygiene and needed one person assistance for bathing. The MDS also coded the resident to have exhibited verbal behaviors during the assessment period, but noted the verbal behaviors did not affect the resident's ADL assistance or the taking of her medications. There was no change of condition MDS assessment completed when the resident was diagnosed with [REDACTED]. The discharge MDS completed when the resident left the facility for admission to the hospital, dated 10/9/11, did not include the use of a PICC line under the special treatment and program section. The re-admission (when the resident returned to the facility) MDS completed on 10/13/11 did not include the use of a PICC line under the special treatment and program section. b. Nurses' Notes: -Nurses' notes, dated 9/25/11, read in pertinent part, "Received results (x-ray) negative for [MEDICAL CONDITION] ([MEDICAL CONDITION]...MRI to LLE (left lower extremity) (ankle) in process." -Nurses' notes, dated 9/29/11, read in pertinent part, "PICC line was ordered for left arm after MRI results. X-ray called in for stat order and to check placement. Resident denies pain and refused pain meds, after PICC line placement." -Nurses' notes, dated 9/29/11, read, "PICC line [MEDICATION NAME] (an antibiotic) IV 1.5 gm Q (every day) X (times) 10 days. X-ray to verify PICC line placement." -Nurses' notes, dated 9/29/11 at 2330 (11:30 p.m.), read, "ABX (antibiotic) started this p.m., no adverse Reax (reaction) noted. VS (vitals) 96 (temperature), 70/20 (respirations and pulse) blood pressure 108/63 and SPO2 (O2 saturation) 93% on room air. Denies pain, A&O (alert & oriented) and stays in bed per choice." -Nurses' notes, dated 9/30/11 at 0315 (3:15 a.m.), "VS SPO2 92% on room air, 112/80 BP, 96 temperature, pulse 76 and respiration 20. Remains on ABX/osteo[DIAGNOSES REDACTED], No adverse RXN noted. Denies pain or discomfort this shift. PICC line to LUE (left upper extremity) patent no s/sx (signs/symptoms) infiltrate." -Nurses' notes, dated 9/30/11 at 2200 (10:00 p.m.), in pertinent part read, "ABX for cellulites. No adverse reactions noted. RN supervisor for Parkside comes up to 5th at 2000 (8:00 p.m.) to start PICC line IV ABX. When writer and RN approach Resident to start therapy, she starts yelling, "No. No, go away. No more, I'm not doing it again." Writer explains to resident consequences of missing Tx (treatment) and importance of complying with TX. Resident still refuses, yelling at writer and RN supervisor. Slight bleeding noted under dressing. RN supervisor notified to come assess area. No more bleeding noted. Dressing clean/dry/intact. No s/sx of infx (infection) noted." -Nurses' notes, dated 9/30/11 2200 (10:00 p.m.), "Dressing reinforced with coban until RN can come assess." -Nurses' notes, dated 9/30/11 11-7 (shift), "Resident refused her IV fluids." -Nurses' notes, dated 10/1/11 2200 (10:00 p.m.), "Resident continues to refuse IV ABX. States will refuse tonight, tomorrow to next week. RN assesses Lt A (left arm) central line dressing torn with blood fluid drainage no s/s of infection or clots. Central line dressing changed per RN .....New orders noted TO (telephone order) Resident to start PO (oral) ABX for DX:(diagnoses) cellulites, to hold PICC line pharm." -Nurses' notes, dated 10/2/11 11-7, read in pertinent part, "Resident up all night long. Offered no complaints, skin warm and dry she is now on oral ABX. Her IV ABX is on hold." -Nurses' notes, dated 10/2/11 at 2200, read in pertinent part, "Resident continues to refuse IV ABX. does allow TX. to access. Lab here to draw blood work for BMP." -Nurses' notes, dated 10/4/11 at 0330 read, "VS 91% room air, 124/66, 96 degrees, 76,18. Remains on ABX due to cellulites, no adverse Rxn noted. Denies pain or discomfort at this time. PICC line to UE patent no s/sx infiltration noted, continue to monitor." -Nurses' notes, dated 10/4/11 at 1600 (4:00 p.m.), read in pertinent part, "Late entry for 10/3/11 3-11 shift. ABX for cellulites, no adverse reactions noted. Refusal of IV ABX, denies pain no s/s of infection." -Nurses' notes, dated 10/5/11 at 0400, read in pertinent part, "Remains on ABX cellulites, no adverse RXN noted. Denies pain or discomfort at this time. Continue to encourage PO fluids while awake." -Nurses' notes, dated 10/5/11 at 1600, read in pertinent part, "Late entry for 10/4/11 3-11 shift. ABX for cellulites, no adverse reactions noted. Refuses IV ABX so PO ABX given per MD orders. VS refused stays in bed per choice." -Nurses' notes, dated 10/6/11 at 0330, read in pertinent part, "Remains on ABX/cellulites. No adverse RXN noted. Denies pain this shift. No s/sx complications of infection. PICC line to LUE remains patent, no s/sx infiltration noted. Continue to encourage PO fluids while awake." -Nurses' notes, dated 10/6/11 at 1245, read in pertinent part, "Late entry for 10/5/11 3-11 shift. ABX for cellulites, no adverse reaction noted. VS 98.5 degrees, 20 respirations, 66 pulse and BP 126/82 and SPO2 90%. Refuses ABX, PO ABX per MD order." -Nurses' notes, dated 10/6/11 at 2300, read in pertinent part, "ABX for cellulites, no adverse reaction noted. VS 97.3 temperature, pulse 74, respiration 18 BP 132/80, SPO2 93%. Denies pain, refuses IV ABX, PO ABX given per MD orders, refuses skin assessment. Waiting for RN supervisor to flush PICC line, notified 2 X to flush." -Nurses' notes, dated 10/7/11 at 0230, read in pertinent part, "Remains on ABX/cellulites, no adverse RXN noted." -Nurses' notes, dated 10/7/11 at 1530 (3:30 p.m.), read in pertinent part, "VS 97.6 temperature, pulse 81, respirations 18, BP 102/66 SPO2 91%. Resident remains on ABX for cellulites. No adverse reaction notified from ABX. IC access site shows no signs of infection." -Nurses' notes, dated 10/8/11 11-7 (shift), read in pertinent part, "Resident remains on ABX, color is good and skin warm and dry. IV site clean and dressing applied. Vitals temperature 97, pulse 64 and respiration 20 and BP 118/76." The hospital admission records (see below) show the dressing the resident had in place was dated as applied on 10/1/11. -Nurses' notes, dated 10/9/11 11-7 (shift), read in pertinent part, "Resident remains on ABX. Up much of the night. Vitals Temperature 98, pulse 76, respiration 20, BP 120/70 and SPO2 96%." -Nurses' notes, dated 10/9/11, read in pertinent part, "At approx (approximately) 0830 a.m. CNA requested nurse to come to shower room. Res. up in shower chair is non-responsive. Res. per 2 assist manually assisted Res. to chair, has shallow breathing. With no response with verbal or tactile stimuli. Sternum rub done without response, 911 called and resident transported to the emergency room ." c. Medication and Treatment Records Review of the September 2011 medication administration record (MAR) and the treatment administration record (TAR) revealed there was no transcription of orders for the use of IV antibiotics for cellulites or for the use of an IV for the administration of medication, or directions for flushing the IV PICC line per physician orders. The nurses' notes stated the PICC line was inserted and verified on 9/29/11 with the first dose of IV antibiotic given on that date. However, there was no documentation on the MAR or TAR to evidence this had been completed per physician order. Review of the October 2011 MAR's IV flow sheet revealed the following order: Medication/[MEDICATION NAME]/Frequency [MEDICATION NAME] 1.5 gm q (every) 6 hours X 10 days DX: cellulites. Scheduled at 2000 (8:00 p.m.), 0200 (2:00 a.m.), 0800 (8:00 a.m.) and 1400 (2:00 p.m.). On 10/1/11, each time box had an initial of "H" located in it. On 10/2/11, the time boxes for 2000 and 0200 were blank and the time boxes for 0800 and 1400 contained an "H". On 10/3, 10/4 and 10/5, the letter "S" with a circle around it was located in the 2000 box. Nurses' comments for these dates and the time documented the resident refused ABX therapy. The boxes next to 0200, 0800 and 1400 were left blank. On 10/6/11, the letter "S" with a circle around it was located in the 2000 box. Nurses' comments for this date and time documented the resident refused ABX therapy. The boxes for 0200, 0800 and 1400 contained either an "X" or "H". On 10/7/11, the boxes by all scheduled times contained an "H". On 10/8/11, all boxes beside the scheduled times were left blank. The IV Flow sheet also contained the following instructions, "Saline Flush 5-10 cc in a 10 cc syringe before and after each med dose or Q 12 hrs if no med use." All dates from 10/1/11 through 10/9/11 were left blank. The IV Flow Sheet also contained the following instructions, "Central line dressing change per facility protocol every week and PRN." The following dates were designated for dressing changes; 10/6, 10/13, 10/20 and 10/27. The date of 10/6/11 was left blank. The Infusion Medication Administration Record contained the following information: -"Flush 5 ml NS (normal saline) before and after med. Follow with [MEDICATION NAME]. Flush 5 ml [MEDICATION NAME] 10 units/ml." The flushes were scheduled during the 11-7, 7-2 and 3-11 shifts. During the 11-7 shift there were no flushes documented on 10/1, 10/2, 10/3, 10/5, 10/7, 10/8 and 10/9. During the 7-2 shift there were no flushes documented on 10/1, 10/2, and 10/8. It was marked the resident refused on 10/3, 10/4, 10/5, 10/6 and 10/7. During the 3-11 shift, there were no flushes documented for 10/1, 10/2, 10/3, 10/6, 10/7 and 10/8. There was documentation the resident received a flush on this shift on 10/4 and refused a flush on 10/5 during this shift. There was also documentation on 10/5/11 during the 3-11 shift, the LPN requested (two times) the RN supervisor to come to the resident's floor to complete the flush. The documentation read, "They said they're busy and would come when they could. Writer LPN out of scope of practice. Report to 11-7 shift to have done." d. Hospital Records Review of the 10/9/11 emergency room record revealed the following: "Fever. This started today and is still present. The patient has had moderate measured fever of 101 F. (Patient was getting bath at nursing facility and became unresponsive for a few minutes, found to be febrile and [MEDICAL CONDITION] to the 140's. Was AT&O (alert and oriented) x 3 on arrival to ED. Has L (left) arm invasive line for med admin. She has had fatigue and altered mental status. Additional history - She has had a recent absolute [DIAGNOSES REDACTED] count. The patient has a PICC line (was placed 10/1/11, line was not sterile on arrival, open to air)." Hospital Progress and Procedures report, read in pertinent part, "Due to concerning appearance of L arm line (not sterilely dressed), and pt (patient) with septi[DIAGNOSES REDACTED], we sterilely removed the line (PICC) and sent for cx (culture). Course of Care: pt with septi[DIAGNOSES REDACTED], SBP (systolic blood pressure) down to low 80s, normal mentation, aggressive hydration; patient is stable. Physical exam findings are improved. The patient's symptoms are unchanged. Central line considered, but clinical condition improved in ED. SBP improved after 4+(plus) liters NS in ED. ICU attending, who came to eval. pt in ED; we all suspect line source. Clinical Impression:[MEDICAL CONDITION] (likely secondary to infected PICC line). (Murmur noted - not previously documented)." Further ED notes read, in pertinent part, "A PICC line was apparently placed on October 1, 2011. The patient received treatment with [MEDICATION NAME] initially, and then when she was willing to take oral medicines, [MEDICATION NAME] was begun. Today in the nursing home, she was noted to have decreased responsiveness as well as a fever to 101 and a heart rate up to 140. In the emergency room , the PICC line was noted to be soiled without a sterile dressing and it was missing the cap by report of emergency room physician. This line was removed by the ER staff, and subsequently, the patient developed significant [MEDICAL CONDITION] with systolic blood pressure in the 60's. This responded to IV fluids. She received a total of 3 L of IV saline in the emergency room with improvement in her blood pressure." ED nurses' notes, in pertinent part read, "This RN helped to settle pt in at bedside upon arrival of ems. This RN assessed PICC line in LUE to have an old dressing dated 10/1/2011. The PICC line appears to have been cut and the clamp was open with no closure at the end of it. Resident MD witnessed the appearance of PICC line. Resident MD with RN pulled PICC line. Line intact with tip cut off and placed in sterile container. Sent to lab for culture." Review of the admitting physician reports revealed the following: -"Temperature 101, blood pressure 80/40, heart rate 140, respiratory rate 16 and SPO2 98% on 2 liters nasal canula. -[MEDICAL CONDITION] with a regular rate and rhythm. She has 3/6 systolic murmur, best appreciated at the left upper sterna border- Extremities 2+ lower extremity [MEDICAL CONDITION]. Right leg is [DIAGNOSES REDACTED]tous and has a chronic venous stasis changes. Has [DIAGNOSES REDACTED] and warmth consistent with mild cellulites. -Impressions, read in pertinent part, 1. [MEDICAL CONDITION] with marginal blood pressure despite more than 3 liters of intravenous fluids. 2. Presumed central line infection due to indwelling peripherally inserted central catheter line. 3. Question of endocarditis with significant murmur 4. Cellulites." -The plan read, in pertinent part, "1. Admit to the IMC for close monitoring 2. Continue fluid resuscitation. If she deteriorates, she will require central line placement and vasopressor use. 3. Antibiotics to cover both the line infection and cellulites." Hospitalist progress notes read, in pertinent part, "Primary Diagnosis: [REDACTED]. Impression and Plan: 1. [MEDICAL CONDITION]: Prelim tip culture + (positive) for staph. Cont. vanc with [MEDICATION NAME] until micro back. Pt seems much improved compared to admit." Further record review revealed the resident was hospitalized for [REDACTED]. e. Interviews An interview was conducted on 10/18/11 at 1:00 p.m. with the facility RN on duty. She stated when a resident was on IV antibiotics she would do flushes per the physician order. She stated she only worked on Mondays and Tuesdays, so she would have only charted on those days to indicate whether the resident had received her IV medication or not. She stated the resident allowed her to do the flushes on 10/4/11. She stated she would have charted that administration on the MAR. (As noted above, documentation on the MAR showed the resident refused the IV antibiotics and the saline flushes). The RN further stated that if a resident refused medication, the facility policy was to chart the refusal on the back of the MAR and in the nurses' notes and then notify the physician and family as needed. During an interview on 10/19/11 at 1:30 p.m., the RN on duty stated the only way for the nurses to assess for IV line patency was through flushing. If the flushes were not completed they would be not able to correctly identify if the PICC line remained patent (open). The RN stated the PICC line should have been clamped and capped, in accordance with the PICC line protocol. However, she stated she did not know if it was clamped and capped when the resident left the facility. An interview was conducted with the director of nursing (DON) on 10/18/11 at 1:45 p.m. She stated she would expect the nurses to chart on the 24 hour report and create an acute (temporary) care plan for the resident's refusals of the medication and the flushes. She also stated the nurses should have been charting the resident's refusals in the nurses' notes, and brought that information to the "daily huddle" and morning meetings, so all pertinent staff would have been informed of this issue. The DON stated the facility policy was to change the dressing at the PICC line site weekly and to write the date it was changed on the dressing. She stated she had talked with the RN, who would have completed the dressing change on 10/6/11, and the RN reported she had changed it. There was no explanation as to why the dressing still read, 10/1/11. Furthermore, the DON stated the RN did not document in nurses' notes or on the MAR that the dressing had been changed.During another interview on 10/19/11 at 2:30 p.m. with the RN on duty, she stated the resident had refused her IV antibiotics and flushes that day, and the RN stated she would have completed her charting before the end of her shift. However, there was no documentation on the IV flow sheet or on the MAR to show the refusal. She further stated she would not contact the physician, as he had been contacted the day before when the resident also refused her IV antibiotics and flushes. The RN stated she would wait for the physician to contact her with instructions for the next course of action. She stated she documented the refusals on the 24 hour report and informed the next shift of the refusals.