Every finding on record at Complete Care at Fox Hill

Based on observations of dining and interviews, the facility failed to ensure that substitutions made during the noon meal were posted on the daily menu prior to mealtime. The findings include: An observation and interview with the Regional Dietary Manager on 2/24/2025 at 12:10 PM indicated the kitchen was out of peas and they were substituting cabbage and spinach because their delivery was not received the day prior due to the snowstorm. Outside the main dining room, the daily meal list was posted but the substitutions had not been added to the menu. The Regional Dietary Manager indicated when the residents were served in the dining room they would be notified of the change. Observation of the main dining room meal identified no staff communicating to the residents the substitutions made for the noon meal. During the observation of the breakfast steam table service on 2/25/2026 at 8:25 AM noted each resident's diet type was called out to the cook and plated, no gravy was served as indicated on the menu which included biscuits and gravy, also noted corn bread being served that was not on the menu. The Dietary Manager indicated there were not enough biscuits, so corn bread was made instead. An observation and interview with the cook on 2/25/2026 at 8:27 AM indicated corn bread was also made secondary to not enough biscuits and indicated the gravy would break down the corn bread if used and the residents do not like the gravy. Although, the [NAME] indicated having made gravy none was visible on the steam table and residents would have to ask for gravy if they wanted it. The cook also indicated she/he knew the residents' diets and what they wanted. On 2/25/2026 at 9:00 AM a copy of the Service Line check list for breakfast items made and temperatures taken, no gravy was found on the list. 0n 2/25/2026 10:50 AM a meeting with Residents #8, # 50, 51, 55, 83, 89, 91, 108 and #123 indicated they were not being notified of changes to the menu and not being served what was on the menu.An interview on 2/27/2026 at 10:55 AM with the Regional Dietary Manager indicated the Dietary Manager met with residents regarding their concerns and indicated she/he was working on improvements and will continue to discuss residents' concerns at the monthly food committee meetings.

Based on clinical record review, observation, facility policies and staff interviews for 1 of 4 sampled residents (Resident #53), the facility failed to ensure the resident was assessed for self-administration of medications prior to allowing the resident to self-administer medication independently. The findings include:Resident #53's diagnoses included schizoaffective disorder, bipolar type; chronic obstructive pulmonary disease; type II diabetes mellitus; lumbar intervertebral disc degeneration; anxiety disorder; major depressive disorder; lumbar intervertebral disc disorders with radiculopathy; syncope and collapse; low back pain; and incontinence.A quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #53 was cognitively intact, mobilized in a wheelchair, and independent with activities of daily living, including hygiene, eating, and transfers.During observation of medication administration on 2/24/26 at 9:22 A with Licensed Practical Nurse (LPN #3) identified LPN # 3 administered Resident #53's oral medications without incident. LPN #3 then left a medicated oral rinse solution and a medicated pain relief patch at the resident's bedside, stating that the resident preferred to self-administer these medications.During clinical record review and interview with LPN #3 on 2/24/26 at 9:34 AM, LPN #3 identified Resident #53 did not have a screening or assessment for self-administration of medications and did not have a physician's order for self-administration. LPN #3 stated the resident was alert and oriented and leaving the medications was based on the resident's preference. LPN #3 stated she would return to confirm application of the patch and use of the oral rinse.LPN #3 returned to the resident's room at 9:45 AM to verify medication use but found the resident in the restroom and refused entry at that time. LPN #3 returned a second time at 10:00 AM and confirmed the resident had applied the patch and used the oral rinse.Further review of the clinical record on 2/24/26 identified no physician's order authorizing self-administration of medications. Record review identified an existing physician's order dated 10/12/20 indicating the resident may not self-administer medications, which renewed every 60 days.During an interview and medical record review with the Director of Nursing Services (DNS) on 2/26/26 at 12:55 PM, the DNS indicated that medications are expected to be consumed or applied in the presence of the licensed nurse. The DNS stated that if medications are left at the bedside for self-administration, the resident must have an assessment for self-administration, a care plan reflecting the resident's ability and choice, and a physician's order authorizing self-administration.The DNS also stated she had not been made aware Resident #53 had requested to self-administer the medicated mouth rinse or pain patch. However, based on her knowledge of the resident, she believed the resident could potentially self-administer medications if the required assessments and documentation were completed. A review of the clinical record with the DNS identified no assessment or physician's order authorizing self-administration was present when the medications were left at the bedside.After inquiry, the facility updated the resident's physician's orders. Physician orders dated 2/26/26 at 9:00 PM directed the resident to self-administer the medicated mouth rinse and the pain-relief patch. An additional physician's order dated 2/27/26 at 12:03 PM authorized the resident to self-administer medications and discontinued the prior order dated 10/12/20 that indicated the resident may not self-administer medications.Review of the facility policy Medication Administration (NUR086), dated 7/1/24, directed that medications are to be administered by licensed nurses or other legally authorized staff in accordance with physician's orders and professional standards of practice, and directed staff to observe the resident consuming the medication.Review of the facility policy Resident Rights (SS022), dated 7/1/24, indicated that residents have the right to participate in their care and may self-administer medications when the interdisciplinary team has determined that the practice is clinically appropriate.

Based on clinical record review, facility documentation, review of facility policy and staff interviews for 1 of 4 sampled residents (Resident # 141) reviewed for abuse, the facility failed to report an allegation of verbal abuse yelling to the state agency within 2 hours. The findings include:Resident # 141's diagnoses included ovarian cancer, lymph edema, congestive heart failure (CHF), encephalopathy (altered mental state), cirrhosis of the liver, depression, anxiety disorder, cognitive communication deficit, anemia, diabetes mellitus type 2 and dysphagia.The admission Minimum Data Set (MDS) assessment dated [DATE] identified the resident was moderately cognitively impaired and identified the resident required assistance with Activities of Daily Living (ADL).The ADL care plan dated 12/23/25 identified an intervention to have two staff members assist with transfer from bed to chair.A review of the Grievance Form dated 12/29/25 identified Person #3 complained that during transferring Resident # 141 to bed on 12/29/25 the resident was short of breath. The form additionally noted Resident # 141 was interviewed on the day of incident and stated Nurse Aide # 4 was trying to help her/him get into bed. Person # 3 confirmed the aide was trying to assist the resident to return to bed. Education was provided and Resident # 141 was interviewed and no care concerns identified.A review of the local police report dated 12/30/25 at 1:57 PM identified Person # 3 calling the police to the facility and stating a staff member yell at Resident # 141 last night. Additionally, the report noted Person#3 shared complaints of staff rudeness during what sounded like lift assistance. Person #3 believed that during the assist Resident # 141 was struggling to breathe and staff was on top of the resident. The report further indicated that Person#3 believed that the facility looked up her/his credentials after she/he filed this complaint. Staff are conducting their own internal investigation and noted this is not a police matter at this time. Person #3 requested that the incident be documented for the record.A review of the Grievance Form file dated 12/29/25 and the facility investigation dated 12/29/25 identified the facility conducted an investigation with staff members and 5 residents between 12/29/25 through 1/2/26. The investigation further identified staff alleged that Person # 3 was speaking profanity to them and stated get the F---- out of Resident # 141's room and threaten facility staff. Additionally, noted Resident # 141 during an interview identified no care concerns or issues at this time. The investigation further identified during resident interviews no resident felt that NA # 4 was threatening or rude and that staff interviewed believed that Person #3 was threatening to staff. However, further review of facility documentation of the investigation of grievance filed on 12/29/25 and facility investigation on 3/2/2/26 and 3/3/26 failed to identify that the state agency had been notified of a potential allegation of verbal abuse within 2 hours.Interview with Nurse Aide (NA) # 4 on 3/2/26 at 11:15 AM identified she/he heard someone yelling for help at which time she/he started walking down the hallway and saw Resident # 141hanging and dangling off the bed. NA # 4immediately went to assist the resident and LPN # 6 came into the room with her/him. NA # 4 further indicated Person # 3 was screaming and yelling at them, so she got the resident back to bed safely and left the room. Nurse Aide #4 identified she/he was not on top of Resident # 141 during the transfer so the resident could not breathe.Interview with Person # 3 on 3/2/26 at 11:30 AM and again on 3/4/26 at 10:55 AM identified she/he told the facility on 12/29/25 that staff were speaking to Resident # 141 like a child and on 12/30/25 call the local police because staff were yelling at Resident # 141 and she/he wanted the incident documented because it was a form of abuse. Person#3 also indicated she/he told administration and facility staff that she/he believes Resident # 141 felt threatened and unsafe at the facility. Person#3 further indicated she/he believed that administration did not take her/his allegation of abuse seriously that is why she/he called the local police to come onsite to document the incident.Interview with the DNS on 3/2/26 at 12:15 PM identified the facility investigated the grievance on 12/29/25 as a grievance because the facility did not believe any abuse had occurred. She believes it was a miss understanding between the NA # 4 and Resident # 141.Interview with multiple facility staff from 3/2/26 to 3/3/26 identified Person #3 was speaking profanity to staff and made threatening comments to staff members in resident areas at which time supervisory staff had to intervene to de-escalate the situation. Additionally, interview with multiple staff members identified at no time did Person # 3 express any concerns of abuse.Interview with the Administrator on 3/2/26 at 4:30 PM and 3/3/26 at 3:15 identified at no time did the facility believe Resident 141 was abused and Person # 3 's comments about Resident # 141 being yelled at, threatened or feel unsafe based on interviews with staff and residents about abuse. Interview with the Administrator on 3/10/26 and 3/11/26 at 10:30 AM identified she still believes that based on the grievance filed 12/29/25, police report dated 12/30/25 and staff comments during the investigation that Person # 3 allegation that Resident # 141 was being threatened or felt unsafe at the facility was not an abuse issue. Interview with the Administrator on 3/11/26 at 10:38 AM identified although the facility conducted an investigation regarding the grievance file dated 12/29/25 by Person #3 and educated staff on Resident Rights, she could not provide evidence that staff reported the allegation of yelling at Resident # 141 and concerns of threatening behavior by staff was reported to the state agency within 2 hours.

Based on review of the clinical record, facility policy and interviews for 1 of 3 residents reviewed for reviewed for Preadmission Screening and Resident Review (PASARR) for (Resident # 85), facility failed to ensure a resident with a newly identified mental health diagnosis was refer to the appropriate state-designated authority for Level II PASARR evaluation and determination per facility policy. The findings include: Resident #85's diagnoses included psychotic disorder with delusions due to a known physiological condition, anxiety disorder, and chronic obstructive pulmonary disease.On 8/25/25, Resident #85's medical record indicated a new diagnosis of psychotic disorder with delusions due to a known physiological conditionThe care plan dated 12/1/25 identified Resident #85 uses antipsychotic medication related to diagnoses of anxiety and psychotic disorder. Interventions included, in part, administering psychotropic medications as ordered by the physician and monitoring for side effects and effectiveness every shift.The quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #85 was moderately cognitively impaired and was independent with eating, toileting hygiene, and bed mobility.A physician's order dated 12/6/25 directed staff to administer 5 mg Buspirone HCl tablets for anxiety. A second physician's order dated 2/9/26 directed administration of 0.25 mg Alprazolam (Xanax) oral tablets for anxiety.Review of the resident's clinical records indicated the resident was initially assessed on 4/19/21 for a Preadmission Screening and Resident Review (PASARR Level I) at which time it was determined, There is no evidence of a PASARR condition of an intellectual/developmental disability or a serious behavioral health condition. If changes occur or new information changes these findings, a new screen must be submitted.An interview on 2/26/2026 at 9:23 AM with the Director of Social Services indicated that if a resident has a change in diagnosis, a new assessment request should have been submitted to evaluate the resident. She was unsure why this was not done.The facility's Resident Assessment - Coordination with PASARR Program policy, revised 7/1/24, states in part: Any resident who exhibits a newly evident or possible serious mental disorder, intellectual disability, or related conditions will be referred promptly to the state mental health, intellectual disability authority for a Level II resident review.

Based on clinical record reviews, facility documentation, facility policy and interviews for 2 of 3 residents reviewed for PASARR for (Residents # 8 and # 79), the facility failed to ensure a referral for a level 1 and/ or 2 evaluations. The findings included: 1.Resident #8's diagnoses include bipolar disorder, unspecified; anxiety; and depression.The admission Minimum Data Set (MDS) assessment dated [DATE] identified Resident #8 as cognitively intact, requires setup assistance for eating, and is dependent for toilet hygiene and bed mobility. The MDS also noted in Section 1510 (Level II PASRR conditions) that a serious mental illness was identified; however, the section was not completed.The care plan dated [DATE] indicated Resident #8 has mood problems related to bipolar disorder, depression, and anxiety. Interventions include, in part, consulting with psychiatry for medication evaluation, non pharmacological interventions, and ongoing treatment as needed. Interventions also include monitoring, recording, and reporting to the physician as needed for any acute episodes of sadness; loss of pleasure or interest in activities; feelings of worthlessness or guilt; changes in appetite or eating habits; changes in sleep patterns; diminished ability to concentrate; and changes in psychomotor skills.The clinical record identified Resident #8 was admitted to the facility with diagnoses and a 30 day exemption, which expired on [DATE]. The facility was unable to provide documentation to support that a PASRR Level I or Level II assessment was completed.A physician's order dated [DATE] directed staff to administer 100 mg of Sertraline HCl (Zoloft) oral tablets for depression.During an interview on [DATE] at 9:15 AM the Director of Social Services identified no evaluation had been submitted since the 30 day exemption expired on [DATE]. She stated that an evaluation should have been submitted and was unsure why it had not been completed. She also identified she was responsible for overseeing submission requests for evaluations.After inquiry an assessment evaluation was submitted on [DATE] at 10:37 AM. 2.Resident #79's diagnoses include bipolar disorder, depression, and Type 2 diabetes mellitus.The admission MDS assessment dated [DATE] indicated the resident is cognitively intact, requires setup assistance for eating, requires substantial assistance for toileting hygiene, and is dependent with bed mobility.The care plan dated [DATE] identified Resident #79 is at risk for falls due to cognitive loss and lack of safety awareness.A physician's order dated [DATE] directed staff to administer 1 tablet of 10 Milligrams (MG) Aripiprazole (Abilify) by mouth once daily for bipolar disorder, 3 mg capsule of Vraylar for bipolar disorder, and a 10 mg Fluoxetine (Prozac) HCl tablet for depression.The facility was unable to provide documentation to support that a PASRR Level I or Level II assessment had been completed for Resident #79.During an interview with the Director of Social Services on [DATE] at 9:15 AM identified Resident #79 had a 7 day approval (expired on [DATE]). Based on their records, a referral request for evaluation was attempted on [DATE]; however, it was not accepted due to being submitted too soon after the initial approval (resident approved on [DATE], with a new request attempted on [DATE]). The Director of Social Services stated that although the request was rejected, another evaluation request should have been submitted on or before [DATE]. She was unsure why this was not completed and reported that she was responsible for ensuring all referrals are submitted timely. After inquiry, a PASRR assessment evaluation was submitted on [DATE] at 10:13 AM.The facility's Resident Assessment - Coordination with PASARR Program policy, revised [DATE], states in part: All applicants to this facility will be screened for serious mental health or intellectual disabilities and related conditions. A record of the pre-screening shall be maintained in the resident's medical record. The policy further states: If a resident who was not screened due to an exception remains in the facility longer than 30 days: (A) The facility must screen the individual using the state Level I screening process.

Based on clinical record review, review of facility policy for 1 of 1 resident (Resident # 119) reviewed for bowel and bladder, the facility failed to ensure a resident's bowel regimen was followed as ordered. The findings include: Resident #119 was admitted on [DATE] with diagnoses that included muscle weakness and cognitive communication deficit. A physician's orders dated 2/7/2026 directed the following: Administer 30 milliliters (mL) of milk of magnesia suspension (a medication for constipation) 400 milligrams (mg)/5mL every 24 hours as needed for constipation if the resident had no bowel movement in 3 days; administer 17 grams (g) of Miralax powder (a medication for constipation) every 24 hours as needed for constipation if the resident had no bowel movement in 72 hours; and administer a dulcolax suppository (a medication for constipation) 10mg every 24 hours as needed if no result was obtained from milk of magnesia or Miralax by the next shift. The admission MDS assessment dated [DATE] identified Resident #119 had severe cognitive impairment and required substantial/maximal assistance for toileting. On 2/24/2026 at 3:07 PM, during a screening interview, Resident #119 indicated she/he had not had a bowel movement in weeks. Person #2, who was accompanying Resident #119 in the room, identified Resident #119 had no bowel movement in a week and that Resident #119 had received an enema in the afternoon. A review of the bowel documentation in the electronic medical record and in the Bowel Movement book identified Resident #119's last bowel movement was on 2/17/2025. A review of the Medication Administration Record( MAR) identified Resident #119 had received 17 g of Miralax powder on 2/20/2026 at 9:45 AM (3 days after the last bowel movement). On 2/22/2026 at 8:42 AM, Resident #119 received 30 mL of magnesia milk (2 days after having received Miralax powder and 5 days after the last bowel movement). The MAR failed to identify that any bowel regimen medication was administered on 2/21/2026 or 2/23/2026. Additionally, the MAR failed to identify any administration of a Dulcolax suppository. On 3/2/2026 at 11:48 AM, an interview with LPN#5 indicated she administered Miralax powder on 2/20/2026 because Resident #119 was complaining of nausea and noted the resident had not had a bowel movement in 3 days. LPN#5 indicated Resident #119 did not have a bowel movement during the 7 :00 AM to 3:00 PM shift and she reported to the 3:00 PM to 11:00 PM shift Resident #119 was due to be reevaluated for a bowel movement after the administration of Miralax powder. LPN#5 indicated that, based on the bowel protocol, residents should be evaluated by the end of the next shift to determine if they needed additional medications such as milk of magnesia or a suppository. On 3/2/2026 at 12:18 PM, an interview with the nursing supervisor (RN #5) indicated the facility had a bowel protocol that indicated when residents should be evaluated after receiving an as-needed bowel medication. RN#5 indicated that re-evaluations were based on 8-hour shifts and that if a medication is not effective by the end of the next shift, it should have been readdressed. On 3/3/2026 at 10:39 AM, an interview with Advanced Practiced Registered Nurse (APRN #1) identified that she ordered an enema for Resident #119 on 2/24/2026 because when she assessed the resident on a routine visit, Resident #119 complained of constipation, and she/he noted Resident #119 had not had a bowel movement in the prior three days. APRN #1 further indicated that a 7-day period between bowel movements is considered too long and that residents should have a bowel movement at least every 3 days. A review of Resident #119's orders with APRN#1 identified that after administration of Miralax powder or milk of magnesia, the next shift would need to assess for effectiveness based on the orders and the facility's bowel protocol. APRN #1 further indicated that administration would be able to provide the specifics of the bowel protocol. Although requested, the facility was unable to provide a specific bowel regimen protocol and provided batch order sets for bowel regimen medications for providers' selection during order entry.

Based on clinical record review and staff interview for 1 of 3 residents reviewed for nutrition (Resident # 125) review for nutrition, the facility failed to ensure the resident was re-weighed when there was a change in the resident's weight per facility practice. The findings include: Resident # 125 diagnoses included hypertension, depression and dysphagia.A review of the resident's weight record identified a weight of 113 pounds on 12/21/25 and on 12/23/25 weigh 118 pounds (indicating a weight gain of 2 pounds in 2 days.The physician's orders dated 12/24/25 directed to weigh every shift weekly time 4 and then every day for one month.However, further review of Resident # 125 weight record on 3/2/26 identified on 1/8/26 a weight of 112 pounds (reweigh 15 days later).Record review and interview with RN #2 on 3/2/26 at 12:45 PM identified the facility practice is to conduct a reweigh for 3 pounds or more and indicated that the weight on 12/23/25 may be a mistake. RN #2 further indicated the dietician reviews residents' weights and will send a notice for a reweight. However, she could not explain why a reweight was not conducted before 1/8/26 but would follow up.

Based on observations, clinical record reviews facility policy the facility failed to ensure staff stored clean linen in a sanitary manner, maintained specimen refrigerators with thermometers and temperature monitoring and for 1of 1 resident on contact precautions (Resident # 25), the facility failed to ensure a room of a resident on contact precautions was set up with appropriate equipment. The findings included: 1. An observation on 2/25/2026 at 5:30 AM identified the front flap of the linen cart on the south wing to be open revealing clean linen and with the linen was a Monster beverage with a plastic cup covering the opening and a closed personal water bottle. An Interview with the charge nurse (LPN #2) indicated the Nurse Aide (NA #1) was not available due to taking care of a resident at that time and stated s/he was pretty sure the beverages should not have been inside the clean linen cart while removing both beverages. An attempt to interview NA #1was unsuccessful. 2. An observation on 2/25/2026 at 5:46 AM of the north wing soiled utility room identified 2 trash bins with no covers containing closed bags of trash. A specimen refrigerator located on high shelf on the left side of the room identified no lock, a thermometer, but no temperature log and 2 specimens awaiting pick up. Numerous pillows were kept on the shelf within the dirty utility room. 3. An observation on 2/25/2026 0 at 5:49 AM clean utility room with lift pads hanging vertically on the right side of the wall with the lower portion of each of the pads touching the floor. Also noted were 2 closed bags of pillows on the floor, a small linen cart uncovered and an open brief bag in the sink. 3. On 2/25/2026 5:53 AM an observation with the Regional Dietary Manager who took pictures of the concerns identified the south dirty utility room without covers for bagged garbage, the specimen with a thermometer but no logbook. Further observation of the clean utility room identified mechanical lift pads hanging vertically on the wall each touching the floor, 3 closed bags of pillows on the floor against the wall and the sink with the small linen cart cover on top of it along with a folded sheet and a bottle of shampoo/body wash on it. The Regional Dietary Manager observed the north wing clean and dirty utility rooms along with the surveyor to share the findings noted earlier and indicated s/he would obtain a thermometer to place in the south wing specimen refrigerator.An interview on 2/25/2026 at 6:05 AM with the nursing Supervisor RN #1 with the Regional Dietary Manager present identified she/he was not sure if the specimen refrigerators needed to be locked if specimens were inside. On 2/25/2026 6:15 AM observations and interview with the Director of Nursing Services (DNS) who was made aware of the infection control concerns in the clean and dirty utility rooms and observed the mechanical lift pads hanging on the walls and touching the floors on both units and the bags of pillows on the floor of the dirty utility rooms. The DNS indicated nothing should be touching the floors and the problem would be corrected. The DNS also observed the refrigerators in the dirty utility rooms without temperature logs and the north specimen refrigerator had 2 specimens and the south none. It was also noted that the entry doors to the soiled utility rooms had no locks. A policy and procedure for storage of staff beverages and belongings, specimen refrigerator maintenance, storage of staff beverages/belongings were not provided.The facility policy labeled Handling Clean Linen indicated facility linen is considered hygienically clean (handled to prevent re-contamination with dust and dirt). Linen shall be delivered to the units on covered linen carts with the cover down and only rolled bags used for linen transport are to be kept on the carts in its designated pockets. Clean linen will be stored in a separate designated room with a closed door to reduce the risk of accidental contamination which can occur with pathogens from contact with intact skin or body substances or from environmental contaminants. The policy further indicated clean linens are not to be placed on the floor or other contaminated surfaces.The facility policy labeled Specimen collection indicated to place the collected specimen into a biohazard transport bag and send to the laboratory with the request form. The policy failed to provide how staff was to safely and correctly store laboratory specimens collected until the laboratory arrived to pick them up.4. Resident #25 's diagnoses included Sepsis and C. Diff (Clostridioides difficile, a highly contagious bacterium that causes diarrhea and colitis).The admission Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #25 was cognitively intact and being treated with antibiotics. A laboratory specimen result dated 2/22/2026 at 8:55 AM indicated a specimen sent to the laboratory on 2/20/2026 was positive for C. Diff. Resident #25's care plan revised on 2/24/2026 indicated he had a C. Diff infection with interventions including providing Contact Precautions, administering medication as ordered, encouraging fluids and assist Resident #25 with hand hygiene as needed. An observation on 2/25/2026 at 06:45 6:55 AM identified RN #1 conducting a blood sugar reading using a glucometer for Resident #25 while doffing of Personal Protective Equipment (PPE) after hand hygiene, including gloves, and a gown as required per the posted signage for contact precautions. After entering the room, completing the procedure, and moving toward the door no trash receptacle was noted for doffing used PPE a small individual trash container was noted at the bedsides of Resident #25 and his/her roommate. The Dietary Regional Manager passing by in the hall was alerted to the situation and a nurse provided a trash receptacle for the present moment.On 2/25/2026 at 7:00 AM the Director of Nursing Services (DNS) was at reception desk and indicated s/he was in-servicing staff members at this time as they entered the building to start work to be aware of the need for receptable specifically for used PPE in the room of a resident with contact precautions. The DNS further indicated a trash receptacle should have been located just inside the room's doorway. The DNS also indicated she/he did not know why there was not one there and she/he would have someone complete rounds to ensure all other rooms involved had trash receptacles. The facility labeled Transmission Based Precautions indicated Contact precautions refers to measures intended to prevent transmission of infectious agents spread through direct or indirect contact with the resident and the environment. Although the facility policy indicated PPE (gloves and a gown) would be donned prior to entering the room, the policy made no mention of how to correctly dispose of used PPE after doffing(removing).

Based on clinical record review and staff interviews for 1 of 2 residents reviewed for environment (Resident #14), the facility failed to ensure a resident's bathroom call bell was functioning properly and failed to implement an appropriate alternative method of calling. The findings include: Resident #14 was admitted on [DATE] with diagnoses that included left knee replacement and muscle weakness. A nursing admission assessment dated [DATE] identified Resident #14 was oriented to person, place, and time and was totally dependent for transfers and toilet use. Additionally, the admission assessment indicated Resident #14 was continent of bowel and bladder. On 2/24/2026 at 10:55 AM, an interview with Resident #14 indicated the emergency call cord in the bathroom did not work. Resident #14 indicated staff was aware shortly after her/his admission and indicated when staff came to evaluate emergency call cord, they indicated the problem was with the wiring. Resident #14 indicated that sometimes staff have stayed outside the bathroom or outside the room to make sure they were okay, and other times they would have her/his roommate ring their call bell to alert staff that Resident #114 was finished using the bathroom. On 2/27/2026 at 2:18 PM, an interview with NA#3 indicated Resident #14 required assistance to ambulate with a walker to the bathroom. NA#3 indicated that since Resident #14 was oriented, staff did not need to stay in the room while Resident #14 used the bathroom. NA#3 indicated she was aware Resident #14's bathroom call bell did not work and that sometimes staff would stay outside the room in case Resident #14 needed assistance. In other instances, Resident #14 would tell Resident #119 to push their call bell to alert staff that she/he had fished using the bathroom. An observation with NA#3 identified Resident #14's bathroom call bell was not functioning. NA#3 indicated that maintenance and the nursing supervisor were aware of the malfunctioning call bell and were not aware of any alternative method for Resident #14 to call staff. On 2/27/2026 at 2:31 PM, an interview with the DNS identified she was not aware of Resident #14's malfunctioning bathroom call bell and if she had known, she would have ensured the resident's bathroom had a hand bell as a temporary communication method. On 2/27/2026 at 2:36 PM, an interview with the Director of Maintenance indicated he was informed of Resident #14's malfunctioning bathroom call bell on 2/14/2026, and after troubleshooting, he concluded that it was an issue with wiring inside the wall. The Director of Maintenance indicated he contacted an outside vendor on 2/14/2026 for repair of the call bell but had not yet received a date for repair of the call bell. A review of the facility policy for Call Lights identified that staff would report problems with the call lights and provide immediate or alternative solutions until the problem could be fixed.

Based on observations, review of the clinical record, facility documentation, facility policy and interviews for residents reviewed for food, the facility failed to provide a palatable lunch. The findings include: 1. During initial pool interviews on 2/24/26 Residents #8, # 50, # 51, 70, 75, 75, 83, 89, 91, 108 and # 123 identified concerns with the taste of the food and/ or temperature with a particular focus on the lunch.A food test tray was conducted on 2/26/26 at 12:43 PM of the noon meal. The meal consisted of 1 Italian sausage, sauteed spinach with garlic and parmesan noodles, dinner roll, peach and coffee/ or tea. The alternative was grilled cheese sandwich, sliced carrots and oven roasted potatoes.Observation of the pasta with identified the meal lacking flavor, pasta was bland and spinach was soggy and the potatoes were hard in the middle.Interview with Food Director on 3/2/26 at 1:58 PM indicated that the kitchen staff were unable to put seasoning on the meal because they need to accommodate all residents. She further indicated residents have made suggestions in the food committee which they are trying to implement. A request for the facility Food and Nutrition policy was not provided.

Based on clinical record review, policy review and staff interviews, for 3 of 5 residents reviewed for immunizations (Residents #12, # 17, and # 57), the facility failed to ensure the residents' clinical records included documentation that the resident or representative was provided education related to the influenza vaccine. The findings included:1.Resident #12's diagnosis includes Multiple Sclerosis. An influenza immunization informed consent form dated 10/11/2024 identified Resident #12 consented to receive the influenza vaccine annually. The quarterly MDS assessment dated [DATE] indicated Resident #12 was cognitively intact. An immunization record with a date range of 10/1/2025 through 3/31/2026 identified on 10/23/2025, Resident #12 received an influenza vaccine to the right deltoid. Neither the immunization record nor the electronic medical record identified what education was provided to Resident #12 prior to being given the influenza vaccine for the 2025-2026 season. 2. Resident #17's diagnoses included epilepsy and muscle weakness. An influenza immunization informed consent form dated 9/26/2024 identified Resident #17's healthcare decision maker consented to receive the influenza vaccine annually. The quarterly MDS assessment dated [DATE] indicated Resident #12 was cognitively intact. Facility documentation dated 10/13/2025 identified that Resident #17's responsible party was emailed a letter indicating that influenza vaccines would be administered, along with a copy of the vaccination information sheet (VIS). An immunization record with a date range of 10/1/2025 through 3/31/2026 identified on 10/23/2025, Resident #17 received an influenza vaccine to the right deltoid. Neither the immunization record nor the electronic medical record identified what education was provided to Resident #17 or responsible party prior to being given the influenza vaccine for the 2025-2026 season. 3. Resident #57's diagnoses included dementia and delusional disorders. An influenza immunization informed consent form dated 9/26/2024 identified Resident #57 had consented to receive the influenza vaccine annually. The quarterly MDS assessment dated [DATE] indicated Resident #57 was moderately cognitively impaired. An immunization record with a date range of 10/1/2025 to 3/31/2026 identified on 10/23/2025, Resident #57 received an influenza vaccine to the left deltoid. Neither the immunization record nor the electronic medical record identified what education was provided to Resident #57 or their conservator prior to Resident #57 being given the influenza vaccine for the 2025-2026 season. On 2/27/2026 at 10:49 AM, an interview and record review with the Infection Control Nurse (RN#3) and Regional Infection Control nurse (RN#4) identified the facility uses a blanket consent form for the influenza vaccine, where residents or their representatives consent to ongoing annual vaccinations for influenza. RN#3indicated that residents who have a healthcare decision maker (responsible party), the decision maker was either mailed or emailed a letter in August 2025 indicating that vaccines would be administered for the 2025-2026 season, along with a vaccine information sheet (VIS), and that they could contact the facility with questions or concerns. RN#3 indicated that when she was administering the vaccine to residents who were able to consent themselves, she explained to them the side effects of the vaccine and that residents had the option to refuse vaccination. RN#3 indicated that she did not document the education provided in the residents' medical records. A review of the facility policy for Influenza Vaccination identified that prior to administration of the influenza vaccine, the person receiving the immunization or their legal representative would be provided with a copy of the Centers for Disease Control (CDC)'s current vaccine information statement. The policy further indicated that the resident's medical record would include documentation that the resident and/or the resident's representative were provided education regarding the benefits and potential side effects of immunization.

Based on clinical record review, facility documentation review, facility policy review, and interviews for one of three residents (Resident #2) reviewed for grievances, the facility failed to initiate a grievance timely. The findings include:Resident #2's diagnoses included chronic obstructive pulmonary disease, heart failure, pneumonia, obstructive sleep apnea, irritable bowel syndrome with constipation, and diarrhea. The admission Minimum Data Set (MDS) assessment dated [DATE] identified that Resident #2 had a Brief Interview for Mental Status (BIMS) score of 15 out of fifteen, indicative of no cognitive impairment and was dependent with toileting, transfers and ambulation, and was occasionally incontinent of urine and frequently incontinent of bowel. The Resident Care Plan (RCP) dated 7/24/2025 identified a decreased ability to perform ADLs. transfers, locomotion, and toileting. Interventions directed to assist with ADLS and toileting, and to provide toileting and incontinent care as needed. The nursing note dated 8/3/2025 at 6:06 PM written by RN #2 identified Resident #2 reported he/she had frequent diarrhea since 7/31/2025. Resident #2 appeared tired and fatigued and was having some respiratory difficulty, oxygen level was increased to two liters/minute (order for 1 to 4 liters/min), and Resident #2 received a nebulizer (breathing) treatment. Further, Resident #2 reported he/she often waited for a long time to be helped to the bathroom, get water or to get medications, and family member visiting at the time confirmed the concern. The note indicated RN #2 would notify the DNS of the concern. Review of facility grievance logbook on 9/25/2025 failed to identify a grievance was filed on Resident #2's behalf for the concerns expressed on 8/3/2025. Interview with RN #2 was not obtained during the survey. Interview, clinical record review, and facility documentation review on 9/24/2025 at 2:00 PM with DNS identified to her knowledge Resident #2 had no grievances or concerns that were voiced, and she did not recall being notified by RN #2 that Resident #2 and her/his family had shared care concerns with RN #2. The DNS stated she would have expected RN #2 to notify her when a resident and/or the family reported care concerns and further indicated any staff member can complete a grievance form. Review of facility Resident and Family Grievances Policy directed in part; it is the policy of this facility to support each resident's and family member's right to voice grievances without discrimination, reprisal or fear of discrimination or reprisal. Prompt efforts to resolved include facility acknowledgment of a compliant/grievance and actively working toward resolution of that compliant/grievance. The Grievance Official will take steps to resolve the grievance, and record information about the grievance, and those actions, on the grievance forms and will keep the resident appropriately apprised of progress towards resolution of the grievances. The facility will make prompt efforts to resolve grievances. Review of facility documentation identified staff education was initiated on 9/19/2025 regarding grievances and referring complaints to the supervisor and to refer families to the Family Council meetings. Audits were initiated on 8/12/2025 and a QAPI meeting was held on 9/16/2025. Based on documentation review a finding of past-non-compliance with identified.

Based on observation, review of the clinical record, facility documentation, facility policy, and interviews for three (3) of six (6) residents (Resident #2, #3 and #4) reviewed for oxygen, the facility failed to ensure the residents' care plan included oxygen use per facility policy. The findings include: 1. Resident #2 was admitted to the facility with diagnoses that included acute respiratory failure and diastolic heart failure. The nursing admissions assessment dated [DATE] identified Resident #2 had oxygen at 1 liter per minute via nasal cannula. A physician's order dated 4/29/23 directed oxygen via nasal cannula 1 to 4 liters to maintain an oxygen saturation greater than ninety (90) percent. The Resident Care Plan (RCP) dated 4/29/23 identified Resident #2 had an ADL self-care performance deficit related to activity intolerance, fatigue and limited mobility. Interventions included to provide Resident #2 with limited assist of one staff for bed mobility and staff assistance with personal hygiene and oral care. The RCP failed to identify a focus and interventions for oxygen therapy. A physician's note dated 5/1/23 directed to continue to wean Resident #2 off oxygen as tolerated and noted Resident #2 was currently on 1 liter. The admission MDS dated [DATE] identified Resident #2 had a Brief Mental Interview for Mental Status (BIMS) score of fifteen (15) indicative of intact cognition, required extensive assistance of one staff member for activities of daily living (ADL's) and received oxygen therapy. A physician's note dated 5/15/23 identified Resident #2 was being discharged on 1 liter of oxygen. 2. Resident #3 was admitted to the facility with diagnoses that included acute respiratory failure. A physician's order dated 9/4/24 directed oxygen at 0 to 4 liters/minute via nasal cannula continuously. The quarterly MDS dated [DATE] identified Resident #3 had a Brief Mental Interview for Mental Status (BIMS) score of thirteen (13) indicative of intact cognition, required extensive assistance of one staff member for activities of daily living (ADL's) and received oxygen therapy. The Resident Care Plan (RCP) dated 3/24/25 identified Resident #3 was at risk for decreased ability to perform ADL's related to recent illness resulting in fatigue, activity intolerance and confusion. Interventions included to monitor for decline in ADL function, provide Resident #2 with an assist of one for bed mobility and monitor medications. The RCP failed to identify a focus and interventions for oxygen therapy. The nursing quarterly assessment dated [DATE] identified Resident #3 had oxygen at 2 liters per minute via nasal cannula. Observation conducted on 4/29/25 at 11:50 AM identified Resident #3 was lying upright in his/her bed eating lunch with oxygen being administered at 2 liters/minute via nasal cannula. Subsequent to surveyor inquiry, the RCP was updated on 4/29/25 and identified Resident #3 exhibited or was at risk for respiratory complications related to asthma. Interventions included oxygen as ordered via nasal cannula. 3. Resident #4 was admitted to the facility with diagnoses that included chronic obstructive pulmonary disease. A physician's order dated 1/22/25 directed oxygen at 2 liters/minute via nasal cannula to maintain oxygen greater than ninety-two (92) percent. The quarterly MDS dated [DATE] identified Resident #4 had a Brief Mental Interview for Mental Status (BIMS) score of eleven (11) indicative of a moderate impairment in cognition, required extensive assistance of one staff member for activities of daily living (ADL's) and received oxygen therapy. The Resident Care Plan (RCP) dated 2/25/25 identified Resident #4 exhibited or was at risk for respiratory complications related to chronic cough and shortness of breath. Interventions included to obtain labs as ordered, monitor and report oxygen levels, nebulizer treatments and position upright to facilitate respirations. The RCP failed to identify a focus and interventions for oxygen therapy. The nursing quarterly assessment dated [DATE] identified Resident #4 had oxygen at 2 liters per minute via nasal cannula. Subsequent to surveyor inquiry, the RCP was updated on 4/29/25 to include interventions for oxygen as ordered via nasal cannula. Interview with the DNS on 4/29/25 at 12:46 PM identified oxygen use should be a part of the RCP. Review of the oxygen administration policy directed that the resident's care plan shall identify the interventions for oxygen therapy, based upon the resident's assessment and orders, such as, but not limited to the type of oxygen delivery system, when to administer, such as continuous or intermittent and/or when to discontinue, equipment setting for the prescribed flow rates, monitoring of SP02 (oxygen saturation) levels and/or vital signs as ordered and monitoring for potential complications associated with the use of oxygen. Review of the comprehensive care plans policy directed that the care planning process will include an assessment of the resident's strengths and needs, and will incorporate the resident's personal and cultural preferences in developing goals of care. The comprehensive care plan will describe, at a minimum, the services that are to furnished to attain or maintain the residents' highest practicable physical, mental, and psychosocial well-being.

Based on review of the clinical record, facility documentation, facility policy, and interviews for one (1) of two (2) residents (Resident #2) reviewed for facility discharge, the facility failed to provide a medically necessary walker for a resident upon discharge. The findings include: Resident #2 was admitted to the facility with diagnoses that included acute respiratory failure and congestive heart failure. The care plan dated 4/29/23 identified Resident #2 had the potential for discharge. Interventions included to evaluate discharge planning needs taking into consideration care plans, resident/patient goals, cognitive skills, functional mobility and need for assistive devices. The occupational therapy discharge summary for dates of service 5/1/23 - 5/12/23 identified Resident #2 demonstrated an increase in active tolerance and balance using the walker for mobility. The physical therapy discharge summary for dates of service 5/1/23 - 5/12/23 identified the discharge recommendations were for an assistive device for safe functional mobility, home health services, grab bars and a walker. A social services note dated 5/12/23 at 4:07 PM identified the plan was for Resident #2 to be discharged home safely on 5/15/23 with services. Resident #2's family would purchase a tub bench for Resident #2. The social worker would order oxygen for Resident #2 for him/her to return home with. The discharge MDS dated [DATE] identified Resident #1 had a Brief Mental Interview for Mental Status (BIMS) score of fourteen (14) indicative of intact cognition and required extensive assistance with transfers and walking in the room. A physician's note dated 5/15/23 identified Resident #2 was being discharged and that Resident #2's discharge condition was stable, Resident #2 did well in short term rehab, was walking with a walker and had home health services. The note identified the durable medical equipment needed was a walker, shower bench and oxygen. A social services note dated 5/15/23 at 3:55 PM identified Resident #2 would be discharged home safely with his/her family member, oxygen would be delivered to his/her home and an oxygen tank was delivered to his/her room for transport home. A home health care agency was set up for home care services. The social services note failed to include documentation that a walker was ordered for Resident #2's discharge. Review of the post-discharge assessment day 3 dated 5/18/23 identified there were problems with the oxygen and walker. The medical record failed to identify a follow up for Resident #2's post discharge problems and the outcome. Review of the post-discharge assessment day 30 dated 6/16/23 identified one call attempt was made to Resident #1's family member with no further details. Interview with the Director of Social Services on 4/29/25 at 12:46 PM identified the social worker prepared resident discharges to include arranging services and equipment. She identified if a resident needed oxygen for discharge, the social worker would set it up. She identified if the family or resident specified needing a commode, walker, or wheelchair, the facility would order the equipment. Although requested, documentation that Resident #2 was provided with a walker or that a walker was ordered for discharge, was not provided. Interview with Person #1 on 4/30/25 at 1:59 PM identified when his/her family member was discharged , they were not provided with a wheelchair or walker. She identified the day after Resident #2 came home, he/she fell two times. Person #1 identified she had to go out and buy a walker the following day. Review of the discharge planning process policy directed that an active individualized discharge care plan will address, at a minimum, the identified needs, such as medical, nursing, equipment, educational, or psychosocial needs. The facility will document any referrals to local contact agencies or other appropriate entities made for the purpose of the resident's interest in returning to the community.

Based on review of the clinical record, facility policy and interviews for one (1) of three (3) residents (Resident #1) reviewed for hospitalizations, the facility failed to ensure the resident, who was admitted with multiple cardiac diagnoses and an internal cardiac defibrillator (a battery powered device that corrects irregular heart rhythms), followed up with cardiology per hospital discharge paperwork and physician's order. The findings include: Resident #1's diagnoses included ventricular tachycardia (an abnormal heart rhythm that causes the heart to beat too fast in the lower chambers to pump well and the body doesn't receive enough oxygenated blood), congestive heart failure (heart doesn't pump blood adequately to the body), hypertensive heart disease with heart failure (high blood pressure that damages the heart muscle over time leading to the inability of the heart to pump blood to the body effectively) and presence of an automatic implantable cardiac defibrillator. The admission Minimum Data Set (MDS) assessment dated [DATE] identified Resident #1 had a Brief Mental Interview for Mental Status (BIMS) of fifteen (15) indicative of intact cognition and required substantial assistance with toileting and moderate assistance with transfers and ambulation. The Resident Care Plan (RCP) dated 1/30/25 identified that Resident #1 exhibits or is at risk for cardiovascular symptoms or complications related to the diagnosis of ventricular tachycardia with interventions that included administering medications as ordered and assess for the effectiveness and side effects and report any abnormalities, assess and monitor for chest pain including intensity, location and duration and report to the physician and assess and monitor vital signs as ordered and report abnormalities to the physician. Review of hospital after visit summary dated 1/30/25 identified that Resident #1 had been admitted for ventricular tachycardia and directed to schedule an appointment with cardiology as soon as possible for a visit in one (1) week. A physician's order dated 1/30/25 directed for Resident #1 to follow up with cardiology as soon as possible for a visit in one week. Review of nurse's note dated 1/30/25 through 2/14/25 failed to identify that Resident #1 had been transported to or followed up with cardiology per physician's order. Interview with Person #2 (cardiology office) on 3/4/25 at 1:41 PM identified that Resident #1 was last seen in their office on 11/4/24, and no appointments had been scheduled or canceled since. Interview with the DNS on 3/4/25 at 2:32 PM and accompanied by RN #2 (Regional Nurse) identified that when a resident is admitted to the facility, the admitting nurse will review the hospital discharge paperwork and input physician's orders for any follow-up appointments that are needed with outside providers. She reported that the Unit Manager Registered Nurse or the Assistant Director of Nursing (ADON) will then review the admission orders and are responsible for calling and making any follow-up appointments that are needed for residents, stating they will then give the appointment information to the Transport/Central Supply staff who will then schedule transportation. The DNS identified that she was unable to locate any documentation or consultative reports identifying that a cardiology appointment was either scheduled for Resident #1 or that he/she had been transported to a cardiology appointment. She reported that RN #4 (Unit Manager) was responsible for Resident #1's unit but identified that she was out sick at the time of the resident's admission, stating that RN #3 (Unit Manager) was covering for her and that RN #3 should have reviewed the resident's admission and scheduled the cardiology appointment. Interview with RN #3 on 3/4/25 at 2:42 PM identified that although she was covering for RN #4, she did not review Resident #1's admission paperwork and did not call to make the resident any follow-up appointments with outside providers, stating that she should have, and she was unsure why she did not. Although requested, a facility policy for scheduling and transporting residents to outside provider appointments was not provided.

Based on observations, review of the clinical record, review of facility documentation, and interviews for 2 of 5 residents (Resident #27 and 83) reviewed for dining, the facility failed to ensure a dignified dining experience when breakfast was served and utensils were not provided to residents for 35 minutes, and for 3 of 5 residents (Resident #54, 63, and 67) reviewed for dining, the facility failed to ensure a dignified dining as the necessary assistance for residents who were dependent for eating was not provided, and for 1 of 2 residents (Resident #22) reviewed for urinary devices, the facility failed to ensure the urinary device had a privacy cover for dignity. The findings include: 1. Resident #27 was admitted to the facility in November 2023, with diagnoses which included dementia with agitation, dysphagia, diabetes, dysarthria and anarthria, and traumatic brain injury. The care plan dated 2/15/24 identified Resident #27 has an ADL self-care performance deficit related to activity intolerance, dementia, stroke. Interventions included to provide the resident with a lip plate and built-up utensil for all meals. The quarterly MDS assessment dated [DATE] identified Resident #27 had severely impaired cognition and required set up with eating. The physician's order dated 5/1/24 directed to provide a regular texture, thin consistency, weighted utensils, and plate divider. Review of the resident rooster on 5/19/24 for the Red Oak Terrace South Right Wing identified the resident census was 20. Observation on 5/19/24 at 9:00 AM on the Red Oak Terrace South Right Wing identified the dietary aide delivered a cart with coffee, hot water, juices, milk, tea, sugar, condiments, empty coffee/tea cups, and eating utensils on the unit. Observation on 5/19/24 at 9:10 AM on the Red Oak Terrace South Right Wing identified DA #1 pushing a cart with multiple breakfast plates with a lid, multiple bowls of oatmeal, and multiple bowls with a variety of cold cereals. Interview with DA #1 indicated she only delivers the breakfast plates, bowl of hot oatmeal, and bowl of cold cereal to the resident in the rooms and places it on the overbed tables. DA #1 indicated she does not pass out the coffee, juice, or the eating utensils as it is the responsibility of the nurse aides on the unit. Observation on 5/19/24 at 9:11 AM on the Red Oak Terrace South Right Wing identified DA #1 delivered and placed a plate of scrambled eggs and toast with a lid over the plate (with a hole in the middle of lid for grasping), and a bowl of oatmeal with a plastic lid on Resident #27's overbed. Resident #27 was not provided with eating utensils, no coffee, no juice, no milk, no sugars, no condiments, no napkin at that time. Resident #27 was sitting in a regular standard wheelchair in his/her room fully dressed. No nurse aides were observed in the hallway on the unit at that time. Observation on 5/19/24 at 9:15 AM identified NA #16, and NA #2 in different resident rooms providing care with the doors closed. RN #6 was observed distributing morning medications. Observation on 5/19/24 at 9:30 AM (20 minutes after receiving breakfast) identified Resident #27 sitting in the wheelchair in his/her room in front of the overhead table eating the scrambled eggs with his/her fingers out of the plate. No nurse aides were observed in the hallway on the unit at that time. Observation on 5/19/24 at 9:45 AM (35 minutes after breakfast was distributed to the residents) observed NA #16 pushing the cart with coffee, hot water, juices, milk, tea, sugar, condiments, empty coffee/tea cups, and eating utensils on the unit going from room to room distributing the items. Interview with RN #6 on 5/19/24 at 10:00 AM identified she was aware that the unit was short of nurse aide staff on the 7:00 AM - 3:00 PM shift. RN #6 indicated there are 20 residents on the unit. RN #6 indicated she was aware that the residents on the unit did not receive coffee, and eating utensils when breakfast was served. RN #6 indicated there is 11/2 nurse aide for the unit. RN #6 indicated both nurse aides had answered call lights and had to provide care to soiled residents at the time breakfast was on the unit. Interview with Resident #27 on 5/19/24 at 10:05 AM identified his/her scrambled eggs cold were cold, and he/she had to eat the scrambled eggs with his/her fingers because there was no fork, or spoon to eat with. Resident #27 indicated his/her breakfast was cold by the time he/she received the eating utensils. Resident #27 indicated he/she took one spoonful of oatmeal and he/she did not want the rest because the oatmeal was cold as well as the coffee was cold, and the toast. Resident #27 indicated he/she did not enjoy his/her breakfast. The nurse aide care card dated 5/21/24 identified Resident #27 was able to eat independently after set-up, uses divided plate, and weighted utensils with meals. 2. Resident #83 was admitted to the facility in April 2024, with diagnoses which included acute respiratory failure, chronic kidney disease stage 4, and diabetes. The admission MDS assessment dated [DATE] identified Resident #83 had intact cognition and was independent with eating meals. The April 2024 care plan identified Resident #83 was at risk for decreased ability to perform ADL's in bathing, grooming, personal hygiene, dressing, eating, bed mobility, transfer, locomotion, toileting related to chronic obstructive pulmonary disease, coronary artery disease, congestive heart failure, chronic kidney disease, recent intensive care unit admission. Interventions included monitor for decline in ADL function. Refer to rehabilitation therapy if decline in ADL's is noted. The physician's order dated 5/1/24 directed to provide Resident #83 with a regular texture, thin consistency diet. Observation on 5/19/24 at 9:10 AM on the Red Oak Terrace South Right Wing identified DA #1 pushing a cart with multiple breakfast plates with a lid, multiple bowls of oatmeal, and multiple bowls with a variety of cold cereals. Interview with DA #1 indicated she only delivers the breakfast plates, bowl of hot oatmeal, and bowl of cold cereal to the resident in the rooms and place it on the overbed tables. DA #1 indicated she does not pass out the coffee, juice, or the eating utensils it is the responsibility of the nurse aides on the unit. Observation on 5/19/24 at 9:10 AM on the Red Oak Terrace South Right Wing identified DA #1 delivered and placed a plate of scrambled eggs and toast with a lid over the plate (with a hole in the middle of lid for grasping), a bowl and a small box of cold cereal on Resident #83 overbed table by the first bed. Resident #83 was not provided with eating utensils, no coffee, no juice, no milk, no sugars, no condiments, no napkin at that time. Resident #83 was sitting in a regular wheelchair in his/her room. No nurse aides were observed in the hallway on the unit at that time. Interview with Resident #83 on 5/19/24 at 10:03 AM identified he/she did not receive milk and eating utensils when he/she was served his/her breakfast. Resident #83 indicated the nurse aides took too long to bring the milk and eating utensils. Resident #83 indicated the scrambled eggs were cold, and he/she did not get the milk on time for the cold cereal. Resident #83 indicated she did not call for assistance because they are always short of staff on the weekends on the 7:00 AM - 3:00 PM shift. Interview with RN #3 on 5/19/24 at 10:15 AM identified she has been employed by the facility for approximately 5 1/2 months. RN #3 indicated she is the 7:00 AM - 3:00 PM supervisor every weekend. RN #3 indicated she was not aware the residents on the Red Oak Terrace South Right Wing did not receive coffee and eating utensils when breakfast was served. RN #3 indicated she was on the North side of the facility helping with breakfast, feeding, picking up the dirty dishes, and answering call lights. RN #3 indicated the facility is short of staff every weekend and she has to assist in the care of residents and also do her duties as a supervisor. RN #3 indicated the DNS is aware of the staffing challenges. Interview with RN #7 (unit manager) on 5/19/24 at 10:25 AM identified she has been employed by the facility for 2 years. RN #7 indicated she was aware that the staffing was short for the 7:00 AM - 3:00 PM shift. RN #7 indicated she was not aware that the residents on the Red Oak Terrace South Right Wing did not receive coffee and eating utensils when breakfast was served. RN #7 indicated she was on the South Center Wing helping with breakfast and feeding residents. RN #7 indicated the facility is short of staff a lot on the weekends. RN #7 indicated the facility does not use agency replacement staff. The nurse aide care card dated 5/20/24 identified Resident #83 was encouraged to consume all fluids during meals. Provide fluids of choice. Interview with the DNS on 5/21/24 at 1:25 PM identified the facility was not short of staff on 5/19/24 on the 7:00 AM - 3:00 PM shift. The DNS indicated RN #2, RN #3, and RN #7 were on the units working as nurse aides. The DNS was unable to verify that RN #2, RN #3, and RN #7 work every weekend when the facility is short of staff. The DNS indicated she was not aware that the residents on the Red Oak Terrace South Right Wing did not receive coffee and eating utensils when breakfast was served. The DNS indicated the facility has been reviewing applications and conducting interviews for nurse aides. The DNS indicated it is the responsibility of the nurse aides to pass out the coffee, juice, and eating utensils. 3. Resident #54 was admitted to the facility in December 2024, with diagnoses that included dementia with behavioral disturbance, pseudobulbar affect, anxiety disorder, and cerebrovascular disease. The care plan dated 3/20/24 identified Resident #54 had a nutrition/hospice care plan related to diagnoses of dementia and depression which sometimes affects weight/appetite. Intervention included to provide the resident with a lip plate. Further, review of the care plan failed to reflect the resident required level of assistance with meals. The quarterly MDS assesment dated 4/1/24 identified Resident #54 had severely impaired cognition and was dependent with eating. The physician's order dated 5/1/24 directed to provide a regular diet, chopped texture, and requires lip plate for all meals. Review of the resident roster on 5/19/24 for the Red Oak Terrace South Right Wing identified the resident census was 20. Observation on 5/19/24 at 9:00 AM on the Red Oak Terrace South Right Wing identified the dietary aide delivered a cart with coffee, hot water, juices, milk, tea, sugar, condiments, empty coffee/tea cups, and eating utensils on the unit. Observation and interview on 5/19/24 at 9:10 AM on the Red Oak Terrace South Right Wing identified DA #1 pushing a cart with multiple breakfast plates with a lid, multiple bowls of oatmeal, and multiple bowls with a variety of cold cereals. Interview with DA #1 indicated she only delivers the breakfast plates, bowl of hot oatmeal, and bowl of cold cereal to the resident in the rooms and place it on the overbed tables. DA #1 indicated she does not pass out the coffee, juice, or the eating utensils it is the responsibility of the nurse aides on the unit. Observation on 5/19/24 at 9:11 AM on the Red Oak Terrace South Right Wing identified DA #1 delivered a plate of scrambled eggs with a lid over the plate (with a hole in the middle of lid for grasping), and a bowl of oatmeal with a plastic lid on Resident #54's overbed table by the window bed. Resident #54 was not provided with eating utensils, no coffee, no juice, no milk, no sugars, no condiments, no napkin at that time. Resident #54 was lying in bed with eyes open, with head of the bed at 30 degrees in his/her room. Resident #54 is a feed (RN #6 indicated the resident was a feed). No nurse aides were observed in the hallway on the unit at that time. Observation on 5/19/24 at 9:15 AM identified NA #16, and NA #2 in different resident rooms providing care with the doors closed. RN #6 observed passing out morning medications. Observation on 5/19/24 at 9:45 AM (35 minutes after breakfast was served) observed NA #16 pushing the cart with coffee, hot water, juices, milk, tea, sugar, condiments, empty coffee/tea cups, and eating utensils on the unit going from room to room distributing the items. Observation on 5/19/24 at 9:50 AM identified (40 minutes after breakfast was served) RN #3 was feeding Resident #54 his/her breakfast in bed. The nurse aide care card dated 5/21/24 identified Resident #54 prefer some meals in bed. Encourage the resident to consume all fluids during meals and offer fluids of choice. The care card failed to reflect Resident #54 was a feed with meals. Interview and clinical record review with the DNS on 5/21/24 at 10:25 AM identified she was not aware of Resident #54 care card failed to reflect that Resident #54 was a feed with all meals. Subsequent to surveyor inquiry Resident #54 care card was updated to reflect the resident required feedings. 4. Resident #63 was admitted to the facility in August 2019, with diagnoses that included Parkinson's disease, Alzheimer's disease, dementia with severe agitation, dysphagia, and diabetes. The quarterly MDS assessment dated [DATE] identified Resident #63 had severely impaired cognition and was dependent with eating. The care plan dated 3/30/24 identified Resident #63 was at risk for malnutrition secondary to diagnoses of dementia and depression, on psychotropic medication which affects weight and appetite. Interventions included resident was a feed at mealtimes, provide diet as ordered. The physician's order dated 5/1/24 directed to provide a no added salt (NAS) diet with ground texture, and thin consistency. Review of the resident roster on 5/19/24 for the Red Oak Terrace South Right Wing identified the resident census was 20. Observation on 5/19/24 at 9:00 AM on the Red Oak Terrace South Right Wing identified the dietary aide delivered a cart with coffee, hot water, juices, milk, tea, sugar, condiments, empty coffee/tea cups, and eating utensils on the unit. Observation and interview on 5/19/24 at 9:10 AM on the Red Oak Terrace South Right Wing identified DA #1 pushing a cart with multiple breakfast plates with a lid, multiple bowls of oatmeal, and multiple bowls with a variety of cold cereals. Interview with DA #1 indicated she only delivers the breakfast plates, bowl of hot oatmeal, and bowl of cold cereal to the resident in the rooms and place it on the overbed tables. DA #1 indicated she does not pass out the coffee, juice, or the eating utensils it is the responsibility of the nurse aides on the unit. Observation on 5/19/24 at 9:11 AM on the Red Oak Terrace South Right Wing identified DA #1 delivered and placed a plate of scrambled eggs with a lid over the plate (with a hole in the middle of lid for grasping), and a bowl of oatmeal with a plastic lid on Resident #63 overbed table at the foot of the bed by the window. Resident #63 was not provided with eating utensils, no coffee, no juice, no milk, no sugars, no condiments, no napkin at that time. Resident #63 was lying in bed with eyes open with head of the bed at 60 degrees in his/her room. Resident #63 is a feed. No nurse aides were observed in the hallway on the unit or in resident's room at that time. Observation on 5/19/24 at 9:15 AM identified NA #16, and NA #2 in different resident rooms providing care with the doors closed. RN #6 observed passing out morning medications. Observation on 5/19/24 at 9:45 AM (35 minutes after breakfast was served) observed NA #16 pushing the cart with coffee, hot water, juices, milk, tea, sugar, condiments, empty coffee/tea cups, and eating utensils on the unit going from room to room distributing the items. Observation with RN #3 on 5/19/24 at 10:18 AM identified NA #2 entering Resident #63's room and exiting the room with the breakfast plate and bowl of oatmeal. NA #2 indicated she is going to warm up the breakfast before feeding Resident #63 the breakfast. Interview with NA #2 on 5/19/24 at 11:00 AM identified with NA #2 identified she has been employed by the facility for [AGE] years. NA #2 indicated the unit has 11/2 nurse aides. NA #2 indicated Resident #63 was on her assignment. NA #2 indicated she was the 1/2 for 3 different units. NA #2 indicated it is hard being the 1/2 nurse aide for 3 different units. NA #2 indicated she was providing care to a resident that was soiled that is why she was late feeding Resident #63, and did not pass out the breakfast coffee, juices, and eating utensils. The nurse aide care card dated 5/21/24 identified Resident #63 prefer to eat most of meals in bed. Assist times one for feeding-needs fork placed in hand. Encourage the resident to consume all fluids during meals and offer fluids of choice. Resident to be placed at a 90 degrees upright position or out of bed when swallowing food or drink. 5. Resident #67 was admitted to the facility in January 2020, with diagnoses that included dementia with agitation and behavioral disturbance, and dysphagia. The quarterly MDS assessment dated [DATE] identified Resident #67 had severely impaired cognition and was dependent with eating. The care plan dated 5/1/24 identified Resident #67 nutrition has been altered due to dysphagia. Resident #67 had a diagnoses of dementia, and is on psychotropic medications which affects weight and appetite. Interventions included feed at mealtimes and prefers to eat most of meals in bed. The physician's order dated 5/1/24 directed to provide a regular diet, dysphagia puree texture, nectar consistency, 1:1 assistance in feeding, ensure resident is positioned upright for eating and drinking. Review of the resident roster on 5/19/24 for the Red Oak Terrace South Right Wing identified the resident census was 20. Observation on 5/19/24 at 9:00 AM on the Red Oak Terrace South Right Wing identified the dietary aide delivered a cart with coffee, hot water, juices, milk, tea, sugar, condiments, empty coffee/tea cups, and eating utensils on the unit. Observation and interview on 5/19/24 at 9:10 AM on the Red Oak Terrace South Right Wing identified DA #1 pushing a cart with multiple breakfast plates with a lid, multiple bowls of oatmeal, and multiple bowls with a variety of cold cereals. Interview with DA #1 indicated she only delivers the breakfast plates, bowl of hot oatmeal, and bowl of cold cereal to the resident in the rooms and place it on the overbed tables. DA #1 indicated she does not pass out the coffee, juice, or the eating utensils it is the responsibility of the nurse aides on the unit. Observation on 5/19/24 at 9:11 AM on the Red Oak Terrace South Right Wing identified DA #1 delivered and placed a plate of puree eggs with a lid over the plate (with a hole in the middle of lid for grasping), and a bowl of puree oatmeal with a plastic lid on Resident #67 overbed table by the wall by the first bed. Resident #67 was not provided with eating utensils, no coffee, no juice, no milk, no sugars, no condiments, no napkin at that time. Resident #67 was lying in bed facing the door with eyes closed with head of the bed at 60 degrees in his/her room. Resident #67 was a feed. No nurse aides were observed in the hallway on the unit or in resident's room at that time. Observation on 5/19/24 at 9:15 AM identified NA #16, and NA #2 in different resident rooms providing care with the doors closed. RN #6 observed passing out morning medications. Observation on 5/19/24 at 9:45 AM (35 minutes after breakfast was served) observed NA #16 pushing the cart with coffee, hot water, juices, milk, tea, sugar, condiments, empty coffee/tea cups, and eating utensils on the unit going from room to room distributing the items. Interview with RN #6 (nurse on the unit on the 7:00 AM - 3:00 PM shift) on 5/19/24 at 10:00 AM identified she was aware that the unit was short of nurse aide staff on the 7:00 AM - 3:00 PM shift. RN #6 indicated there are 20 residents on the unit. RN #6 indicated she was aware that the residents on the unit did not receive coffee, and eating utensils when breakfast was served. RN #6 indicated there was 11/2 nurse aide schedule for the unit. RN #6 indicated both nurse aides had answered call lights and had to provide care to soiled residents at the time breakfast was on the unit. RN #6 indicated RN #3 was aware of the issue. Observation on 5/19/24 at 10:00 AM identified NA #16 had warmed up the breakfast and started feeding Resident #67 breakfast in bed. Interview with NA #16 on 5/19/24 at 10:05 AM identified she was providing care to a resident that was soiled that is why she was late feeding Resident #67, and late passing out the breakfast coffee, juices, and eating utensils. The nurse aide care card dated 5/21/24 identified Resident #67 prefer to eat most of meals in bed. Resident #67 requires staff to feed with meals. Interview with RN #3 on 5/19/24 at 10:15 AM identified she has been employed by the facility for approximately 5 1/2 months. RN #3 indicated she is the 7:00 AM - 3:00 PM supervisor every weekend. RN #3 indicated she was not aware the residents on the Red Oak Terrace South Right Wing did not receive coffee and eating utensils when breakfast was served. RN #3 indicated she was on the North side of the facility helping with breakfast, feeding, picking up the dirty dishes, answering call lights. RN #3 indicated she was aware that the staffing was short for the 7:00 AM - 3:00 PM shift. RN #3 indicated the facility is short of staff every weekend and she has to assist in the care of residents and also do her duties as a supervisor. RN #3 indicated the DNS was aware of the schedule. RN #3 indicated she had to feed Resident #54 his/her breakfast. RN #3 indicated she was not aware the residents that needed to be fed by the nursing staff were not fed in a timely manner. Interview with RN #7 (unit manager during the week days) on 5/19/24 at 10:25 AM identified she has been employed by the facility for 2 years. RN #7 indicated she was aware that the staffing was short for the 7:00 AM - 3:00 PM shift. RN #7 indicated she was not aware that the residents on the Red Oak Terrace South Right Wing did not receive coffee and eating utensils when breakfast was served. RN #7 indicated she was on the South Center Wing helping with breakfast and feeding residents. RN #7 indicated the facility is short of staff a lot on the weekends. RN #7 indicated the facility does not use agencies for replacing staff. RN #7 indicated she was not aware the residents that needed to be fed by the nursing staff were not fed in a timely manner. Interview with the DNS on 5/21/24 at 1:25 PM identified the facility was not short of staff on 5/19/24 on the 7:00 AM - 3:00 PM shift. The DNS indicated RN #2, RN #3, and RN #7 were on the units working as nurse aides. The DNS was unable to verify that RN #2, RN #3, and RN #7 work every weekend when the facility is short of nurse aides. The DNS indicated she was not aware that the residents on the Red Oak Terrace South Right Wing did not receive coffee and eating utensils when breakfast was served. The DNS indicated it is the responsibility of the nurse aides to pass out the coffee, juice, and eating utensils. Review of the facility resident rights policy identified: Respect and Dignity The resident has a right to be treated with respect and dignity, including: The right to resident and receive services in the facility with reasonable accommodation of resident needs and preferences, except when to do so would endanger the health or safety of the resident or other residents. 42117 6. Resident #22 was admitted to the facility on [DATE] with diagnoses that included urinary retention, obstructive uropathy, and benign prostatic hyperplasia. The admission MDS assessment dated [DATE] identified Resident #22 had moderately impaired cognition, requires maximum assistance with toileting, bathing, showering, dressing upper and lower body, and personal hygiene. Additionally, Resident #22 has a indwelling catheter. The care plan dated 3/27/24 does not reflect Resident #22 has a urinary catheter. A physician's order dated 4/15/24 directed to a Foley catheter to drainage, perform Foley catheter care on evening and night shift, and empty catheter drainage bag at least once every 8 hours to when it becomes 1/2 to 2/3's full as needed. Additionally, had Flomax 0.8 mg and bladder scan if post void residual is greater than 300 ml insert Foley catheter. Observation on 5/19/24 at 7:40 AM noted Resident #22 was lying in bed with urinary device hanging on left side of bed facing the hallway lying on floor with urine visible from hallway and without the benefit of a privacy bag. Interview with charge nurse LPN # 1 on 5/19/24 at 7:45 AM indicated Resident #22's urinary device should not be lying on the floor and should have a privacy bag covering it. Observation and interview with the DNS on 5/19/24 at 7:49 AM identified Resident #22's urinary device needs to be covered for dignity and that it should not be touching the floor for infection control/ sanitary reasons. The DNS indicated that it was lying on the floor because the bed was in the low position as Resident #22 was a fall risk. Review of the facility Catheter Care identified it is the policy of the facility to ensure that residents with indwelling catheters receive appropriate catheter care and maintain their dignity and privacy. Privacy bags will be available and catheter drainage bags will be always covered while in use. Empty drainage bags when bag is half full or every 3 to 6 hours.

Based on review of the clinical record, facility documentation, facility policy, and interviews, the facility failed to ensure sufficient nurse staffing levels to care for residents' needs. The findings include: Interview with Resident #14 on 5/19/24 at 9:00 AM indicated that his/her shower day was scheduled for Tuesdays. On Tuesday 5/14/24 he/she was out of the facility for an appointment and upon return the staff informed him/her that a shower would have to be given on Wednesday, instead. Resident #14 identified that on Wednesday the nurse indicated that his/her shower was scheduled for Tuesday, and a shower would not be given on Wednesday. Interview with NA # 3 on 5/21/24 at 8:40 AM indicated that on 5/14/24 she was assigned to Resident #14 but did not give Resident #14 a shower due to short staffing. NA #3 further indicated that she was the only nursing assistant on that unit, so she did not have time to give showers. Interview with NA #7 on 5/21/24 at 11:57 AM identified that staffing at the facility has been terrible, especially on the weekends. NA #7 further identified that sometimes she is on the master schedule to be on the floor by herself, particularly on weekends. NA #7 indicated that when the facility is short staffed, she prioritizes incontinent care but there have been times that she has been unable to get residents out of bed, perform mouth care, or provide showers due to lack of staff. NA #7 further indicated she had brought her staffing concerns to the attention of the facility's management, but they have indicated that they don't have the help available. Interview with the staff scheduler on 5/22/24 at 11:55 AM identified that on 5/14/24 the facility had one extra nurse aide scheduled for the 7AM-3PM shift, but then 2 nurse aides called out and they were unable to replace them; on the 3-11 PM shift 1 nursing staff member called out, but they were able to replace her. The staff scheduler further indicated that there are challenges with scheduling: call outs and sufficient staffing, especially on the weekend shifts. Interview with the DNS on 5/22/24 at 12:04 PM identified that the facility is experiencing challenges with having enough available staff, as well as challenges with nursing staff call-outs, particularly on the weekend shifts. Review of the Facility Assessment described resident's acuity level over the past year or during a typical month as follows: A. Number of residents requiring an assist of 1-2 staff for the following activities: Dressing-47 Bathing-57 Transfer-48 Eating-39 Toileting-51 B. Number of dependent residents for the following activities: Dressing-44 Bathing-21 Transfer-23 Eating-9 Toileting-37

Based on observation, facility policy, and interviews, the facility failed to ensure dietary staff were wearing beard restraints, opened food and beverage items in the refrigerator were dated, the kitchen refrigerators were free of employee's personal beverages, and frozen food items were properly sealed. The findings include: 1.During an initial tour of the facility kitchen on 5/19/24 from 6:58 AM through 7:40 AM with cook #1, the following were identified: a. Observation of dietary aide #2 and cook #1 identified that they were without the benefit of a beard restraint while prepping for breakfast service. Interview with dietary aide #2 identified that he usually wears a beard restraint; today he was unable to obtain a beard restraint because they were stored in the food service manager's office and the office door was locked. Dietary Aide #2 indicated that he would not have access to a beard restraint until the manager arrived. Interview with cook #1 identified that this was his first day at the facility, as he was covering for the facility's full-time morning cook. [NAME] #1 further identified that he was unable to obtain a beard restraint because they were stored in the manager's office, the door had been locked, and he was unable to locate the key. [NAME] #1 indicated that the manager was on her way into the facility, and he would be able to put on a beard guard before breakfast was served. b. Observation of the reach-in refrigerator identified a metal pan containing chocolate pudding and a metal pan containing Jello uncovered and not labeled or dated. Additional observations identified the following containers were opened and not dated: 1-5lb container of sour cream 1-5lb container of cottage cheese 2-half gallons of whole milk 7-half gallons of orange juice 3-half gallons of chocolate milk 7-pitchers of iced tea Further observation of the reach-in refrigerator identified an opened 16 oz personal bottle of water and a blue personal coffee cup with a lid. Interview with cook #1 identified that the Jello and pudding were not covered because they were made the night before and could not be covered immediately after cooking due to the heat of the items. c. Observation of the reach-in freezer identified the following items were not covered and were open to air: 1-bag of breaded chicken patties 1-bag of pull and rise dinner rolls 1-bag of fish fillets Interview with the food services district manager on 5/21/24 at 9:53 AM identified that she was covering for the facility's food service manager. The food service district manager further identified that it is her expectation that beard restraints are worn by dietary staff to prevent hair from contacting the food; beard restraints were stored in her office, but the door had been accidentally locked the night before and prevented the dietary staff from having access to them, on the morning of 5/19/24. The food service district manager identified that it is her expectation that all opened containers are labeled and dated, employee's personal food and beverage items are not stored in the kitchen refrigerators, and frozen items are covered and sealed; a labeling and dating in-service was provided to the dietary staff on 5/20/24. The Food Safety Requirements policy directs the storage of food is done in a manner that helps prevent deterioration or contamination of the food, keeping foods covered or in tight containers, and labeling, dating, and monitoring refrigerator food, so it is used by its use by date, frozen, or discarded. The policy further directs dietary staff to wear hair restraints to prevent hair from contacting food. The Staff Attire policy directs all staff members to have their hair off the shoulders, confined in a hair net or cap, and facial hair properly restrained. The Food Storage: Cold Foods policy directs all foods will be stored wrapped or in covered containers, labeled and dated, and arranged in a manner to prevent cross contamination. Although requested a policy for the storage of staff personal beverage and food items was not provided.

Based on observation, facility documentation, facility policy, and interviews, the facility failed to ensure ongoing surveillance of staff/resident COVID-19 testing was maintained, failed to ensure a nurse aide performed hand hygiene after exiting the room of a resident on contact precautions, and failed to ensure the resident-care equipment was sanitized upon leaving the room of a resident on contact precautions. The findings include: 1.A request was made on 5/20/24 to the facility to provide documentation identifying surveillance of staff and resident COVID-19 testing. Interview with the Infection Control Nurse (RN) #2 on 5/20/24 at 10:00 AM identified that the COVID-19 staff and resident testing logs were last updated in September 2023, but she would update the logs with information from the current outbreak, which began on 5/12/24. RN #2 indicated that prior to this outbreak, there had been no recent reports of staff having Covid-like symptoms and therefore no staff testing had been completed, except for one nursing staff member who reported a positive COVID test, earlier in the day. RN #2 further indicated that when a resident experiences COVID-like symptoms the nursing staff will complete an as needed (PRN) COVID-19 test and document the results in the electronic health record. RN #2 identified that maintaining an accurate facility log of COVID-19 resident tests would be challenging because nursing staff did not always report to her when a resident had been tested . Interview with the Regional Clinical Manager (RN #9) on 5/21/24 at 11:07 AM indicated that the facility should have documentation of routine COVID-19 testing for staff and residents. RN #9 further indicated that the expectation of the facility is that a file is maintained within the facility, including surveillance, contact tracing, and all the steps that the facility has taken. Interview and facility documentation review with the DNS on 5/22/24 at 7:35 AM failed to identify that COVID-19 resident and staff testing logs were maintained prior to surveyor inquiry. The DNS identified that it would be her expectation that a log of COVID-19 testing was maintained within the facility. The facility's Infection Preventionist policy directs the infection preventionist will collect, analyze, and provide infection and antibiotic usage data and trends to nursing staff and health care practitioners; consult on infection risk assessment and prevention control strategies; provide education and training; and implement evidence-based infection prevention and control practices. The facility's COVID-19 Prevention, Response, and Reporting policy directs the infection preventionist, or designee, will monitor and track COVID-19 related information to include, but not limited to the number of residents and staff who have suspected or confirmed COVID-19 and date of confirmation. 2. Observation with RN #2 on 5/21/24 at 8:00 AM identified NA #11 exiting the room of a resident on transmission-based precautions, secondary to a COVID-19 infection, without the benefit of hand hygiene or sanitizing the vital sign machine upon exit. Subsequent to surveyor inquiry, NA #11 performed hand hygiene and was then observed walking to the north wing nurse's station with the vital sign machine. Immediately following the observation, an interview with NA #11 identified that she should have washed her hands after removing her personal protective equipment (PPE) and should not have wheeled the vital sign machine to the nurse's station prior to cleaning it. NA #11 indicated that she had wheeled the vital sign machine to the nurse's station so she could clean it, as the appropriate sanitizing wipes were not available on the isolation cart. Interview with RN #2 on 5/21/24 at 8:05 AM identified that it is the expectation of the staff that they wash their hands or hand sanitize after coming out of an isolation room. RN #2 further identified that the vital sign machine should not have been brought to the nurse's station without first being sanitized; the vital sign machine should be sanitized after each use upon exiting a resident's room. RN #2 indicated that she would immediately begin staff education on hand hygiene and sanitizing the vital sign machine. Interview with the DNS on 5/22/24 at 12:04 PM identified that it is her expectation that staff perform hand hygiene after exiting a resident's room that is on transmission-based precautions and that any equipment brought into the room be sanitized. The facility's Hand Hygiene policy directs all staff to perform proper hand hygiene procedures to prevent the spread of infection to other personnel, residents, and visitors. Hand hygiene is indicated and will be performed under the conditions listed in, but not limited to: between resident contacts, before and after removing PPE (including gloves), and before and after providing care to residents on isolation. The facility's Standard Precautions Infection Control policy directs resident-care equipment and instrument/devices have established policies and procedures for containing, transporting, and handling resident-care equipment. The policy further directs employees are provided job and/or task-specific training and education on preventing the transmission of infectious agents associated with healthcare during their orientation program, annually, during regularly scheduled infection control training programs, and when new or modified procedures are implemented in the facility. Although requested, NA #11's clinical competency for sanitizing resident-care equipment was not provided.

Based on review of the clinical record, facility documentation, facility policy, and interviews the facility failed to ensure 3 of 5 residents (#75, 79, and #88) were provided with education and consented to receive the COVID-19 vaccine and failed to ensure 2 of 5 residents (Resident # 62 and 80) were provided education about the COVID-19 vaccination and consented or refused to receive the COVID-19 vaccine. The findings include: 1.Resident #75's immunization record identified the COVID-19 vaccine additional dose/booster was last administered on 1/5/24. Resident #75's clinical record failed to show that he/she was provided with education on the COVID-19 vaccine or provided consent. 2.Resident #79's immunization record identified the COVID-19 vaccine additional dose/booster was last administered on 1/5/24. Review of Resident #79's clinical record failed to show that he/she was provided with education on the COVID-19 vaccine or provided consent. 3. Resident #88's immunization record identified the COVID-19 vaccine additional dose/booster was last administered on 1/5/24. Resident #88's clinical record failed to show that he/she was provided with education on the COVID-19 vaccine or provided consent. 4. Resident #62's immunization record identified the COVID-19 vaccine additional dose/booster was last administered on 1/4/23. Resident #62's clinical record failed to identify documentation that identified that he/she had been provided education on the COVID-19 vaccine and consented or refused the COVID-19 vaccine during the 2023/2024 season. 5.Resident #80's immunization record identified the COVID-19 vaccine additional dose/booster was last administered on 10/15/22. Resident #80's clinical record failed to identify documentation that identified that he/she had been provided education on the COVID-19 vaccination and consented or refused the COVID-19 vaccine during the 2023/2024 season. Interview and review of facility documentation with RN #2 and the regional clinical manager (RN) #9 on 5/21/24 at 10:52 AM identified that the facility was unable to locate and provide documentation of written or verbal consent for the 3 sampled residents (#75, 79, and 88) that received the COVID-19 vaccine on 1/5/24, nor could the facility provide documentation that the remaining 2 sampled residents (#62 and 80) were educated and offered the COVID-19 vaccine during the 2023/24 season. RN #2 indicated that there were no progress notes documented in the resident's clinical record nor could she find the paper consents. RN #9 indicated that she would expect to see documentation in the clinical record that the 3 sampled residents who received the COVID-19 vaccine had provided consent, and she would expect to see documentation in the clinical record supporting that the 2 sampled residents that did not receive the COVID-19 vaccine during the 2023/2024 season were educated and refused or consented. The facility's COVID-19 Prevention, Response, and Reporting policy directs the facility to educate and offer resources and counseling to healthcare personnel, residents, and visitors on the importance of receiving the COVID-19 vaccine and staying up to date with all recommended COVID-19 vaccine doses. The facility's Vaccination of Residents policy directs that all residents will be offered vaccines that aid in preventing infectious disease unless the vaccine is medically contraindicated, or the resident has already been vaccinated. Prior to receiving the vaccinations, the resident or legal representative will be provided information and education regarding the benefits and potential side effects of the vaccinations. Provision of such education shall be documented in the clinical record. The resident and legal representative may refuse vaccines, for any reason, if vaccines are refused, the refusal shall be documented in the resident's clinical record.

Based on review of the clinical record, facility documentation, facility policy, and interviews for one (1) of one (1)residents reviewed for Cardiopulmonary Resuscitation (CPR), (Resident #1), the facility failed to provide continuous (CPR) once initiated for a resident who was found pulseless and not breathing, and had a full code status (a full code identifies that all resuscitative efforts will be provided) resulting in a finding of Immediate Jeopardy. The findings include: Resident #1 was admitted to the facility on [DATE] with diagnoses that included chronic obstructive pulmonary disease (COPD) with acute exacerbation, acute respiratory failure and was dependent on supplemental oxygen. The nursing admission assessment dated [DATE] at 6:44 PM identified Resident #1 was alert and oriented to person, place, and time, had a regular respiratory rate, had clear lung sounds, with an oxygen saturation of 93% on two (2) liters of oxygen via nasal cannula (normal range 95% - 100%), and had stable vital signs. A nursing progress note dated [DATE] identified that Resident #1 was a full code. A nurse's note dated [DATE] at 5:20 AM written by RN #1 identified at 12:00 AM during rounds, Resident #1 was redirected to go back to bed, however, no distress was noted. At 12:10 AM the Nurse Aide (NA) reported that she was unable to obtain vital signs and that Resident #1 was not responding. Resident #1 was assessed to be unresponsive, breathing, with a weak radial pulse. The nurse was unable to obtain an apical pulse, oxygen saturation, or blood pressure, 911 was called and CPR was initiated. The Emergency Medical Services (EMS) arrived in the building at approximately 12:30 AM and Resident #1 was transported to the hospital. A change in condition note dated [DATE] at 12:45 AM written by Registered Nurse (RN) #1 identified Resident #1 was a full code, was unresponsive, had labored/ rapid breathing, an altered level of consciousness, the physician was notified and 911 was called. Review of the pre-hospital care report (ambulance run sheet) dated [DATE] identified at 12:16 AM the ambulance was dispatched for a patient experiencing shortness of breath. Upon arrival to Resident #1's bedside at 12:22 AM it was noted that the resident was found unattended in his/her room, on a back board (used to provide a firm surface during CPR) in a supine position (lying down), apneic (lack of breathing), pulseless, and unresponsive. CPR was initiated by EMS at 12:22 AM. At that point, facility staff entered the room. Interview with Emergency Medical Technician #1 on [DATE] at 10:40 AM identified she was called to the facility for a patient in respiratory distress. She identified when her and her partner got to the facility, a staff member opened the door but did not follow them to the patient's room. She identified there were no staff in the hallways or in Resident #1's room upon arrival. She identified Resident #1 was found alone in the room, supine in his/her bed, a CPR board under him/her, not breathing, pulseless, and appeared to be deceased . She identified she started CPR. Interview with Paramedic #1 on [DATE] at 10:41 AM identified she was the primary paramedic of the region where the facility is located. She identified that upon arrival at Resident #1's bedside Resident #1 was observed with a CPR board under him/her, pulseless, apneic, and alone in the room. She identified that CPR was started at that time. Interview with RN #1 on [DATE] at 10:20 AM identified she was the nursing supervisor during the 11:00 PM - 7:00 AM shift on [DATE] through [DATE] and identified Resident #1 was a new admission, and it was documented in the hospital Discharge summary dated [DATE] that Resident #1 was a full code. NA #1 went to Resident #1's room to take vitals at approximately 12:10 AM and identified that Resident #1 did not look well and that she could not obtain a blood pressure on the resident. RN #1 went to assess Resident #1 and identified Resident #1 was breathing with a weak radial pulse, however she could not obtain a blood pressure or oxygen saturation, RN #1 called 911 and went to get the crash cart, NA #1 left the room to answer the front door of the facility for EMS arrival. When RN #1 came back to Resident #1's room, after obtaining the crash cart, Resident #1 no longer had a pulse, she placed the back board under Resident #1 and initiated CPR. RN #1 identified that she then started to panic and stopped CPR to go to the doorway of Resident #1's room to await EMS arrival (although 2 EMS workers identified that the resident was alone in the room upon arrival) RN #1 identified she made a mistake and should have continued CPR until EMS came and took over CPR for Resident #1. Interview with the Director of Nursing Services (DNS) on [DATE] at 12:28 PM identified that both RN #1 and NA #1 had current CPR certifications. Resident #1's hospital Discharge summary dated [DATE] identified that the resident was a full code. The DNS was not aware of the details and concerns that CPR was not continued once initiated on [DATE] for Resident #1, and that the resident was left unattended while experiencing a medical emergency. The DNS further identified if she were aware of the issues, she would have investigated the event and educated the staff involved. She further identified her expectation that a resident will not be left alone while experiencing a medical emergency and as once CPR is initiated, it is not stopped until emergency personnel arrive, or a pulse returns. She identified Resident #1 was intubated in the intensive care unit of the hospital and subsequently expired. Interview with the Medical Director on [DATE] at 1:40 PM identified if a resident is identified pulseless and CPR is initiated, CPR should be continued until emergency personnel arrive and assume care of the resident. Multiple attempts to contact NA#1 were unsuccessful. Review of the facility's policy for emergency procedure, cardiopulmonary resuscitation directed if an individual is found unresponsive, briefly assess for abnormal or absence of breathing. If sudden cardiac arrest occurs begin CPR and continue with CPR until emergency medical personnel arrive.

Based on clinical record review, facility documentation, and interviews, for one (1) of three (3) residents reviewed for accidents, (Resident #1), the facility failed to ensure that the resident was transferred in accordance with the plan of care resulting in an injury. The findings include: Resident #1 had a diagnosis of Alzheimer's disease, diffuse osteopenia, and osteoarthritis. A Minimum Data Set, dated dated dated [DATE] identified that Resident #1 had severe cognitive impairment, required total care for Activities of Daily Living (ADL's), including assistance of two (2) with transfers. A care plan dated 6/5/23 identified that the resident had an ADL deficit related to Alzheimer's disease with interventions that included to transfer the resident with assist of two (2) into the tilt in space wheelchair. An Advanced Practice Registered Nurse (APRN) note dated 6/13/23 (not timed) identified that she was asked to see the resident because the resident had cried out in pain during care when h/her right arm was lifted to wash. No swelling or bruising was evident, the resident had a history of osteoarthritis in the shoulder, a complete blood count, sed rate, and C-reactive protein (blood work used to determine inflammation) were ordered for the next laboratory draw day. A nurse's note dated 6/14/23 at 11:27 AM written by RN #3 identified that the resident was noted with increased swelling of the Right upper extremity, there was pain with movement, a new order for a Xray of the right arm was ordered. A nurse's note dated 6/15/23 at 6:41 AM identified that the resident was observed with wheezing, and had pain in Right arm and bilateral hips. The Right arm was swollen but had good color and positive pulses, however the range of motion was limited. The Right arm X-ray results had been called into the facility by the vendor and identified subacute to chronic fracture of the distal humerus. The physician was updated and the resident was sent to the emergency department. An Xray report dated 6/15/23 identified that Resident #1 had a sub-acute to chronic fracture of the distal humerus. An APRN note dated 6/15/23 (not timed) identified that the facility had contacted her the day before (6/14/23) to notify her of that the right arm had become edematous, a STAT Xray of the arm and shoulder, a complete blood count, a C-reactive protein and a sed rate (blood work that is used to determine inflammation) were ordered. The facility reported to her that the blood work had come back and was indicative of a huge inflammatory process, and Levaquin (and antibiotic) was ordered. On the morning of 6/15/23 the resident complained of hip pain and shortness of breath and was sent to the hospital. Review of a reportable event dated 6/15/23 at 9:00 AM identified that the resident had complained of Right arm pain and was noted to have a Right humeral fracture. The reportable event summary dated 6/20/23 identified that the resident was admitted to the hospital with a right humeral fracture and during the hospitalization Resident #1 was also noted to have a Right and Left femur fracture. Review of hospital paperwork dated 6/19/23 identified that the resident was admitted with a Right humeral fracture and bilateral non-displaced femoral neck fractures. Interview with NA #1 on 7/12/23 at 2:00 PM identified that on 6/13/23 the resident called out when he lifted h/her arm to be washed, and he notified that charge nurse. On 6/14/23 while caring for the resident he noted swelling in the right arm which was a change from the day before, and notified the charge nurse again. Interview with LPN #1 on 7/12/23 at 11:22 AM identified that on 6/13/23 NA #1 had come to her to report that Resident #1 had called out in pain when h/her arm was moved. LPN#1 went to evaluate the resident and noted although there was pain when moved, there was no bruising or swelling present, she then notified the nursing supervisor and the APRN ordered blood work. Interview with RN # 1 on 7/12/23 at 2:20 PM identified that she was the charge nurse on the unit on 6/14/23 when NA #1 notified her that Resident #1's arm had become edematous. Upon assessment the right arm was significantly edematous, so she called the APRN and obtained an X-ray. RN#1 identified that the resident was uncomfortable when the right arm was moved, but the resident seemed comfortable at rest. Interview with APRN #1 on 7/12/23 at 1:36 PM identified that she had been notified on 6/13/23 that the resident had complaints of pain when h/her Right arm was moved, she assessed the resident and there was no swelling or bruising, so she had ruled out any type of trauma, so she ordered bloodwork thinking that it may be a flare up of osteoarthritis. On 6/14/23 she was notified that the Right arm was swollen so she ordered an X-ray. When the lab work came back on 6/15/23 it was determined that there was a huge inflammatory process, so she ordered Levaquin. Interview with RN #3 on 7/12/23 at 1:11 PM identified that she received the results of the Xray around 1:30 AM on 6/15/23 and contacted the physician who gave orders for the resident to have a orthopedic consult. When the NA went to give her care to Resident #1 the resident was guarding h/her hips and flinched when they were touched, she called back the physician and a new order was received to send the resident to the hospital. Interview with the Director of Nurses on 7/12/23 at 10:00 AM identified that the facility had done an investigation and determined that the resident's injuries were caused by a transfer on the 3:00 PM to 11:00 PM shift on 6/12/23 when NA#3 had transferred the resident by himself from the wheelchair into the bed, instead of with an assist of 2. NA #3 was terminated. Interview with NA #3 on 7/12/23 at 3:00 PM identified that he worked the 3:00 PM to 11:00 PM shift on 6/12/23 and did not check Resident #1's care card that identified that Resident #1 was a transfer with assist of 2. He identified that he transferred the resident by himself by placing both of his arms under the resident's arms and pivoting h/her into bed. NA #3 identified that the resident tolerated the transfer without any complaints of pain. NA#3 also worked the 11:00 PM to 7:00 AM shift on 6/12 into 6/13/23 and the resident did not show any signs and symptoms of pain when repositioned or changed. Interview with Resident #1's orthopedic physician on 7/31/23 at 5:01 PM identified that the resident had osteopenia had not been ambulatory or weight bearing for quite some time and any weight bearing could cause the hip fracture, and the way NA#3 placed his arms under Resident #1's arms could have caused the fracture in a resident with osteopenia. The orthopedic physician further stated that there was an acute Right arm fracture and a Right hip fracture, the Left hip fracture was not acute and had most likely happened in the last year or so because it was completely healed. Review of the safe resident handling and transfer policy identified that the residents in the facility will be transferred safely to prevent or minimize risks for injury. Subsequent to the incident the facility in-serviced all staff on checking resident care cards, did competencies on transfers, conducted audits of transfers and discussed the incident in the QAPI meeting.

Based on a review of clinical records, review of manufacturer's directions for use, review of facility documentation, interviews, and policy review, for two of five residents reviewed for non-pressure related impaired skin integrity (Resident #301 and #304), the facility failed to notify the physician when the wound vacuum was not operational and failed to perform wound assessments in accordance with facility policy and failed to ensure wound monitoring was completed. The findings include: 1. Resident #301's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The admission MDS assessment dated [DATE] identified intact cognition, requiring extensive assistance of one staff for ADLs, and an unstageable pressure ulcer. The resident care plan includes at risk for skin breakdown or actual skin breakdown related to chronic [MEDICATION(S)] use with intervention to observe skin condition daily with ADL care and report abnormalities. Physician readmission orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The readmission nursing assessment dated [DATE] identified skin tears to the bilateral legs and pressure ulcers to the outer aspect of the left knee, right ankle. Physical Therapy Evaluation dated 2/25/21 identified ecchymosis/discoloration/darkening all limbs with wounds on right shin and left knee. Nursing note also dated 2/25/21 after an emergency room visit noted skin tears on both arms. There were no skin integrity reports completed until a report dated 3/3/21 identifying left upper arm and left leg skin tears. Interview and review of the clinical record with the DNS on 11/16/21 at 12:30 PM failed to identify that assessment and monitoring of the skin tears and pressure areas documented on 2/24/21 and 2/25/21 were completed. In addition, review of the physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The DNS indicated the unlikeliness of the pressure ulcers. The facility skin integrity management policy includes to perform wound observations and measurements and complete the skin integrity report upon initial identification of altered skin integrity, weekly and with anticipated decline of wound. The policy also includes to notify physician/APP to obtain orders. 2. Resident #304 had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] The Resident Care Plan dated 10/5/21 identified that the resident had a surgical wound status post [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The order further identified to cut the small black sponge to the size of the wound, use barrier spray to surrounding skin, and to call the surgeon with any concerns. a) A skin integrity report dated 10/5/21 identified that the wound measured 1.5 centimeters (cm) in length by 8.2 cm in width with a depth of 0.7 cm and had 75% granulation and 25% slough. An Admission Minimum Data Set (MDS) assessment dated [DATE] identified that the resident was cognitively intact, required extensive assistance with activities of daily living, and had a surgical wound. An APRN progress note dated 10/11/21 identified that the wound had a large amount of slough and measured the same as on 10/5/21, 1.5 cm in length, 8.0 cm in width and 0.4 cm in depth. The APRN failed to document the amount of slough in the wound. A nurse's note dated 10/12/21 written by RN #1 at 6:39 PM identified that at 3 PM the wound vacuum clog alarm sounded and the wound vacuum was flushed with 60 milliliters (ml) of normal saline. At 6 PM the clog alarm sounded again, and the line was flushed again. The wound vacuum canister was noted to be full and the facility was awaiting delivery of new canisters. A subsequent nurse's note dated 10/12/21 written by RN #1 at 11:07 PM identified that the wound vacuum was attached to the wound, but the canister was full. On 10/13/21 at approximately 9 AM, a new canister, and wound dressing were applied to the wound. During the period of 10/12/21 at approximately 6 PM through 10/13/21 at approximately 9 AM the facility failed to notify the physician that the wound vacuum treatment could not be administered as prescribed. A skin integrity report dated 10/18/21 identified that the wound had 75% slough and 25% granulation and measured 3.75 cm in length, 9.5 cm in width and 2.5 cm in depth (the wound measurements increased as well as the amount of slough increase from 25% to 75%). A nurse's note dated 10/18/21 at 10:20 PM identified that the wound was very odorous and had a lot of slough noted inside the wound, and the skin surrounding the wound was inflamed (previous wound documentation did not identify an odor). A consult dated 10/19/21 from Surgeon #1 identified that the resident should be started on [MEDICATION(S)] (antibiotic) twice a day for seven days for the surgical wound. Interview with RN #1 on 11/19/21 at 3:30 PM identified that the canister was full on 10/12/21 and there were no available canisters for replacement. He stated that he shut the wound vacuum off around 6 PM, left the dressing in place, and informed the nursing supervisor. RN #1 stated that he notified the person in charge of the central supply that there were no more cannisters for the wound vacuum and was informed they would be overnighted to the facility. RN #1 further stated that the sponge was still in place in the wound when he went off duty at 7 AM (on 10/13/21). Interview with LPN #4 on 11/19/21 at 12:30 PM identified that the wound vacuum canisters were delivered to the facility around 9 AM on 10/13/21 and at that time she changed the dressing and replaced the canister. The wound vacuum remained off from approximately 6 PM on 10/12/21 until 9 AM on 10/13/21 (approximately 15 hours). Interview with the RN #7 on 11/19/21 at 3:40 PM identified that she was the nursing supervisor on 10/12/21 when RN #1 informed her that the wound vacuum canister was full. She stated RN #1 informed her that he shut the wound vacuum off and that more canisters had been ordered, however, she did not inform the physician for further instruction for wound care. Interview with the Medical Director on 11/19/21 at 12:30 PM identified that the nurse should have contacted the physician if the wound vacuum was not able to be administered on 10/12/21, and an alternative treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . Interview with Surgeon #1 on 11/19/21 at 6 PM identified that he had treated Resident #304 when his/her mastectomy surgical incision dehisced and had ordered the wound vacuum treatments to be administered at the facility. Surgeon #1 identified that when he evaluated the wound on an outpatient basis on 10/19/21 the wound had a moderate infection, a large amount of slough, and the wound edges had significant [CONDITION(S)]. He stated that the wound vacuum dressing being left in place without the wound vacuum for fifteen (15) hours posed a significant portal for infection and was the most likely cause of the large amount of slough and the infection in the wound. The surgeon further stated that he placed the resident on an oral antibiotic and continued the wound vacuum treatment to be completed at the facility. Interview with the Director of Nurses on 11/19/21 at 4 PM identified that the resident was requiring a replacement canister almost every shift so the facility may not have ordered enough canisters initially. The DON stated whomever took the last canister should have notified the central supply clerk so more could be ordered. The DON further identified that it would have been her expectation for the RN supervisor to call the physician if the wound vacuum was shut off and possibly obtain alternate wound care orders. The central supply clerk was unavailable for an interview. Review of the V.A.C. therapy clinical guidelines (manufacturer' s directions for use) identified to keep V.A.C. therapy on, and to never leave a dressing in place for more than 2 hours, if therapy is off for more than 2 hours, remove the old dressing and irrigate the wound, and either apply a new dressing or apply an alternative dressing at the direction of the physician. Review of an in-service given on 12/20/20 on wound vacuums identified that if supplies are needed to notify the nursing supervisor. b. A skin integrity report dated 10/5/21 identified that the surgical wound on the right breast measured 1.5 centimeters (cm) in length by 8.2 cm in width with a depth of 0.7 cm and had 75% granulation and 25% slough, had moderate serosanguinous drainage, the surrounding tissue was inflamed, the wound edges were rolled, and there was no odor. An APRN progress note dated 10/11/21 identified that the wound had a large amount of slough and the wound measured 1.5 cm in length, 8.0 cm in width and 0.4 cm in depth. (the assessment failed to include the amount of slough seen and any other wound observations). A nurse's note dated 10/25/21 identified that the wound was measured to be 8.0 cm in width, 2.5 cm in length and 1 cm in depth (the note lacked any type of assessment of the amount of slough, and any other wound observations). The clinical record failed to identify any assessments regarding the appearance of the wound other than measurements of the wound on 10/11/21 and 10/25/21. Interview with the Director of Nurses on 11/19/21 at 4 PM identified that the skin integrity report should be used when assessing a wound and should include a full assessment of the wound including percentage of granulation and slough. Review of the skin integrity management policy directed to perform wound observations and measurements and to complete the skin integrity report weekly. The skin integrity report included to monitor the appearance, measurement, odor, surrounding tissue, drainage, undermining and tunneling of the wound.

Based on clinical record review, facility documentation review and interview for one of five residents (Resident #305), reviewed for impaired skin integrity, the facility failed to ensure that pressure ulcers were treated and measured in accordance with facility policy and physician orders. The findings include: 1. Resident #305 diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] A quarterly Minimum Data Set, dated dated dated [DATE] identified that the resident was cognitively intact, required extensive assistance with activities of daily living, was at risk for skin breakdown, and had intact skin integrity. A Resident care plan dated 12/13/21 identified that the resident had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a skin integrity report dated 2/8/21 identified that an unstageable pressure ulcer was noted to the coccyx that measured 2 centimeters (cm) in length and 1.1 cm in width and had intact eschar. A physician's order dated 2/8/21 directed to apply Calazyme cream to the coccyx area once a shift and after every incontinent episode. An Advanced Practice Registered Nursing (APRN) note dated 2/18/21 identified that the coccyx was 100 % granulation and measured 2 cm in length and 1 cm in width, a new order was written on 2/18/21 to change the treatment to cleanse the coccyx with normal saline followed by calcium alginate and a foam dressing. Although an order was written to change the treatment to the coccyx to calcium alginate on 2/18/21, the physician's order was not transcribed onto the Treatment Administration Record (TAR), and the resident continued to receive the calazyme treatment to the coccyx from 2/18/21 until 2/25/21 instead of the physician ordered calcium alginate (7 days without the physician ordered treatment). An APRN note dated 2/25/21 identified that the resident's coccyx wound had a measurement of 1.7 cm in length and 1.8 cm in width and now had 50% eschar in the wound (a deterioration from 2/18/21 when the wound had 100% granulation). A physician's order dated 2/25/21 directed to cleanse the coccyx with normal saline followed by calcium alginate and a foam dressing daily. Review of the TAR and clinical record failed to reflect a treatment to the coccyx from 2/25/21 until 3/1/21 (6 days without a treatment). An APRN note dated 3/1/21 identified that the coccyx measured 1 cm in length and 1.7 cm in width with 100% slough, and sero- sanguineous drainage (a deterioration from 2/25/21 when the wound had no drainage and was 50 % eschar). No physician's order was written for the treatment and the resident remained without a treatment to the coccyx from 3/1/21 until 3/13/21 (12 days without a treatment). A physician's order dated 3/13/21 directed to cleanse the coccyx with normal saline followed by calcium alginate and a foam dressing daily, the resident was treated with the calcium alginate daily as ordered. An APRN note dated 3/24/21 identified that the coccyx wound measured 1 cm in length and 1cm in width and 0.1 cm in depth with sero-sanguineous drainage with 100 % slough with recommendations to change the treatment to a rinse with normal saline followed by nickel thick Santyl followed by calcium alginate and a foam dressing daily. Although the APRN recommended this treatment on 3/24/21 the order was not written until 3/29/21 (from 3/24/21 until 3/29/21 the resident continued to receive the calcium alginate treatment until the Santyl was ordered on 3/29/21). Interview with the APRN #1 on 11/19/21 at 3:49PM, identified that the wound had deteriorated from a wound with granulation on 2/8/21 to a wound with slough on 3/1/21 and deterioration was due to combination of receiving the wrong treatment from 2/18/21 to 2/25/21 and receiving no treatment to the wound from 2/25/21 until 3/13/21. Interview with the Director of Nurses (DON) on 11/19/21 at 5:15 PM identified that the coccyx wound that was identified on 2/8/21, although measured weekly, the treatments were not changed in accordance to physicians orders, resulting in the resident receiving the wrong treatment from 2/25/21 until 3/1/21 (6 days). Further review of the clinical record identified that the coccyx did not have a treatment from 2/25/21 until 3/13/21 (17 days without a treatment), in which time the wound deteriorated from a wound with granulation to a wound with slough. 2) An admission assessment dated [DATE] identified that resident #305 was cognitively intact, required extensive assistance with activities of daily living. The Resident Care Plan dated 10/15/20 identified that the resident was at risk for pressure ulcers related to decreased mobility and incontinence with interventions that included to observe skin condition daily and to report abnormalities. A Braden scale dated 10/14/20 identified that the resident was at high risk for pressure ulcers. a) A skin integrity report dated 10/14/20 identified that the resident had a deep tissue injury to the left hip that measured 2.0 centimeters in length and 2.0 centimeters in width and was covered in eschar, and an unstageable pressure ulcer to the coccyx that measured 2.0 cm in length and 1.0 cm in width, additionally the wounds were present upon admission. A skin integrity report dated 10/26/20 identified that the left hip was 1.6 cm in length and 0.8 cm in width. Additional skin integrity report dated 11/25/20 identified that the area to the left hip and coccyx had healed. The clinical record lacked documentation that the wounds to the coccyx and left hip had been measured and assessed between 10/14 and 10/26/20 (one week without measurements or assessments), and further identified that there were no measurements or assessments from 10/26/20 until 11/25/20 when the wound was identified as healed (4 weeks without measurements or assessments). b) Review of the clinical record from 10/14/20 until 10/27/20 failed to identify that the unstageable area to the coccyx had received any type of treatment. A physician's order dated 10/27/20 (13 days after the wound was identified) directed to cleanse the coccyx with wound cleanser and calcium alginate and to apply a foam dressing (there was no treatment from 10/14 until 10/26/21, 12 days without a treatment). Review of the clinical record failed to identify any type of treatment was provided to the left hip unstageable area between 10/14/20 when the wound was identified until the wound healed on 11/25/20 (41 days without a treatment). Interview with the Director of Nurses on 11/19/21 at 5:15 PM identified that the coccyx wound lacked treatments 10/26/21 (13 days without a treatment), and the left hip had not received any treatment according to the clinical record (no treatment from 10/14/21 until the area healed on 11/25/21, a total of 41 days). Review of the skin integrity policy identified that the wounds will be assessed and measured weekly, and the center will provide safe and effective care to prevent the occurrence of pressure ulcer, manage treatment and promote the healing of all wounds.

Based on observation, clinical record review, facility documentation and interviews for one of three (Resident #201) sampled residents reviewed for pressure ulcers, the facility failed to provide treatment and services to promote healing and/or avoid deterioration of a pressure ulcer resulting in neglect. The findings include: Resident #201 ' s [DIAGNOSES REDACTED]. The acute care facility wound #1 assessment dated [DATE] identified Resident #201 with a stage 3 pressure ulcer measuring 3.50 cm (L) x 2.00 cm (W) x 0.20 cm (D) with some slough noted to the wound bed, free from drainage and the surrounding tissue was intact. The acute care facility wound assessment #2 dated 7/17/16 identified an unstageable area to the left coccyx measuring 1.00 cm (L) x .50 cm (W) x 0 cm (D) with eschar visible in the wound bed, free from drainage and the surrounding tissue was intact. The admission nursing assessment dated [DATE] identified the resident with a stage ll pressure ulcer to the sacrum and an unstageable pressure ulcer to the coccyx. The skin integrity report dated 7/19/16 identified the resident with an unstageable pressure ulcer to the left coccyx measuring 1.4 cm (L) x 0.6 cm (W) with 0 cm depth, surrounding tissue macerated and the wound was free from drainage. An additional skin integrity report dated 7/19/16 identified a stage ll pressure ulcer to the sacrum measuring 1.8 cm (L) x 0.6 cm (W) x 0.4 cm (D) with healthy wound edges and free from drainage. A third skin integrity report dated 7/19/16 identified the resident with a deep tissue injury to the right heel measuring 0.5 cm (L) x 1.5 cm (W) x 0 cm (D.) Review of the physician admission orders [REDACTED]. The physician orders [REDACTED]. A review of the 24 hour summary report dated 7/20/16 identified the resident had multiple skin issues on admission, including a stage ll pressure ulcer to the sacral area and a deep tissue injury to the right heel. The nurse ' s note dated 7/20/16 and 7/21/16 identified RN #2 changed the dressing to the coccyx pressure ulcer. A review of the TAR however failed to have a treatment indicated and/or initials by RN #2 indicating what treatment/dressing was performed to the coccyx wound on 7/20/16 and 7/21/16. Review of the nurse ' s notes from 7/21/16 through 7/26/16 failed to identify documentation to reflect care was provided to the pressure ulcer(s.) The resident care plan dated 7/22/16 identified the resident with actual skin breakdown related to a skin tear during transfer, however the care plan did not address the resident ' s pressure ulcer(s.) The Wound Care Specialist Initial Evaluation dated 7/25/16 identified an unstageable, deep tissue injury to the right heel measuring 0.5 cm (L) x 0.5 cm (W) x 0 cm (D.) Recommendations included to apply [MEDICATION NAME] twice daily and as needed and to float the heels in bed. Evaluation further identified as stage lll pressure ulcer to the medial sacrum measuring 2 cm (L) x 2 cm (W) x .2 cm (D) with a surface area of 4 cm with light serous exudate noted. Recommendations included dressing the wound with silver hydrogel once daily and as needed, applying a protective dressing and off-loading the wound. The physician's order [REDACTED]. The admission MDS dated [DATE] identified the resident with intact cognition, required extensive assistance with bed mobility, transfer and toilet use and had one stage ll ulcer, one stage lll ulcer and one deep tissue injury. A review of the TAR for the month of July 2016 identified that the physician's order [REDACTED]. The facility ' s skin inspection report dated 7/31/16 identified there was no change to the deep tissue injury to the right heel, however the left coccyx wound went from 0 cm depth to 0.2 cm depth and the surrounding tissue was now inflamed. The wound to the sacrum although measurements remained the same was now documented to have serous drainage from the wound as well as the wound edges which were documented as healthy on 7/19/16 were now documented as macerated. Interview and clinical record review with RN #2 on 8/3/16 at 1:07 PM identified that he/she was the admitting Nurse that performed the initial body audit and wound assessment of Resident #201 ' s pressure ulcers and deep tissue injury on admission. RN #2 indicated that he/she changed the dressing to the coccyx area on 7/21/16 and 7/22/16 as his/her nursing notes reflect using the facility ' s wound care guidelines/protocol as well as the information provided by the facility ' s clinical evaluator on admission. RN #2 identified that he/she cleansed the wound with wound cleanser, dried it and covered it with [MEDICATION NAME]. RN #2 further indicated he/she referred to the facility ' s wound care guidelines prior to performing the treatment. Review of the Wound Care Guidelines identified that for a stage ll or stage lll pressure ulcer the wound was to cleansed with wound cleanser, apply Sureprep to the peri wound, apply [MEDICATION NAME] Hydrogel and cover with a bordered gauze. Upon clinical record review with RN #2, he/she did indicate that upon admission wound care orders were not in place and/or he/she did not have a physician's order [REDACTED]. indicated on 7/21/16 and 7/22/16. RN #2 indicated that RN#4 was the nurse that confirmed admission orders [REDACTED]. Multiple attempts were made to contact RN #4 for interview without success. Interview with the DNS on 8/3/16 at 11:33 AM identified that the Supervisor receiving report from the hospital should be aware if a resident was being admitted with a wound and it would be his/her responsibility to get wound care orders when the physician was called to verify admission orders [REDACTED]. The DNS also identified that the expectation was that the facility ' s wound nurse should have looked at the wound and checked the orders for appropriateness on admission and/or the following day if an evening admission and/or weekend admission. (Resident #201 resident was admitted on a Tuesday) Interview with RN #1 on 8/3/16 at 1:40 PM identified that he/she was informed that Resident #201 had a pressure ulcer on 7/25/16 when wound rounds were conducted with the wound care specialist and was not aware that a wound order was not in place from admission date of [DATE] through 7/26/16 until record was reviewed with the Surveyor. When asked how he/she is informed by the staff if a resident is admitted with a wound, he/she indicated that staff will notify him/her when he/she is rounding on Mondays with the wound specialist. Subsequent interview with the DNS on 8/4/16 at 9:55 AM identified that those residents being admitted with a pressure ulcer are communicated via the 24 hour report and are discussed in morning report. When asked when the wound nurse should have become involved, the DNS identified it should have been immediately. The DNS was not able to identify a reason as to why this resident ' s pressure ulcer(s) which were identified on the 24 hour report were not discussed and why the facility did not ensure a treatment was in place until 7 days after admission. Subsequent interview with RN #1 on 8/4/16 at 9:55 AM identified that the charge nurses and/or nurse managers routinely assess wounds on admission and he/she is not routinely made aware of a new admission with a wound and/or new onset of a wound until he/she goes to the units on Mondays with the wound specialists and asks if there are any new residents that need to be seen. RN #1 indicated he/she does attend morning report, but is unable to identify how this resident and his/her pressure ulcer(s) were not discussed and/or addressed for up to 7 days following admission. Interview with RN #3 on 8/4/16 at 10:50 AM identified that he/she was aware that Resident #201 had a pressure area to his/her sacral area and recalled the area being scabbed over therefore the staff was leaving the area open to air and was applying a barrier cream on the shifts that he/she was scheduled. Interview with MD #1 on 8/4/16 at 12:30 PM identified that applying barrier cream to a stage lll pressure ulcer was not a treatment of [REDACTED]. MD #1 indicated that the measurement he/she documented to the sacrum on 7/25/16 included both of the areas (left coccyx and sacrum) which the facility had been measuring as two separate areas. Review of the facility ' s Skin Integrity Management Policy and Procedure identified the facility is to review pre-admission information to plan for the resident ' s needs prior to admission, identify the resident ' s skin integrity status and need for prevention intervention or treatment modalities, perform daily monitoring of wounds or dressings for presence of complications or declines and document and to notify physician/mid-level provider to obtain orders. A review of the facility ' s Abuse Prohibition policy and procedure identified the definition of neglect as the failure to provide goods and services necessary to necessary to avoid physical harm, mental anguish, or mental illness. The facility failed to provide care and services to Resident #201 ' s pressure ulcer(s) for a total of seven days resulting in a deterioration of the wound (s) constituting neglect.

Based on observation, clinical record review, facility documentation and interviews for one of three (Resident #201) sampled residents reviewed for pressure ulcers, the facility failed to provide treatment and services to promote healing and/or avoid deterioration of a pressure ulcer. The findings include: Resident #201's [DIAGNOSES REDACTED]. The acute care facility wound #1 assessment dated [DATE] identified Resident #201 with a stage 3 pressure ulcer measuring 3.50 cm (L) x 2.00 cm (W) x 0.20 cm (D) with some slough noted to the wound bed, free from drainage and the surrounding tissue was intact. The acute care facility wound assessment #2 dated 7/17/16 identified an unstageable area to the left coccyx measuring 1.00 cm (L) x .50 cm (W) x 0 cm (D) with eschar visible in the wound bed, free from drainage and the surrounding tissue was intact. The admission nursing assessment dated [DATE] identified the resident with a stage ll pressure ulcer to the sacrum and an unstageable pressure ulcer to the coccyx. The skin integrity report dated 7/19/16 identified the resident with an unstageable pressure ulcer to the left coccyx measuring 1.4 cm (L) x 0.6 cm (W) with 0 cm depth, surrounding tissue macerated and the wound was free from drainage. An additional skin integrity report dated 7/19/16 identified a stage ll pressure ulcer to the sacrum measuring 1.8 cm (L) x 0.6 cm (W) x 0.4 cm (D) with healthy wound edges and free from drainage. A third skin integrity report dated 7/19/16 identified the resident with a deep tissue injury to the right heel measuring 0.5 cm (L) x 1.5 cm (W) x 0 cm (D.) Review of the physician admission orders [REDACTED]. The physician orders [REDACTED]. A review of the 24 hour summary report dated 7/20/16 identified the resident had multiple skin issues on admission, including a stage ll pressure ulcer to the sacral area and a deep tissue injury to the right heel. The nurse' s note dated 7/20/16 and 7/21/16 identified RN #2 changed the dressing to the coccyx pressure ulcer. A review of the TAR however failed to have a treatment indicated and/or initials by RN #2 indicating what treatment/dressing was performed to the coccyx wound on 7/20/16 and 7/21/16. Review of the nurse ' s notes from 7/21/16 through 7/26/16 failed to identify documentation to reflect care was provided to the pressure ulcer(s.) The resident care plan dated 7/22/16 identified the resident with actual skin breakdown related to a skin tear during transfer, however the care plan did not address the resident ' s pressure ulcer(s.) The Wound Care Specialist Initial Evaluation dated 7/25/16 identified an unstageable, deep tissue injury to the right heel measuring 0.5 cm (L) x 0.5 cm (W) x 0 cm (D.) Recommendations included to apply [MEDICATION NAME] twice daily and as needed and to float the heels in bed. Evaluation further identified as stage lll pressure ulcer to the medial sacrum measuring 2 cm (L) x 2 cm (W) x .2 cm (D) with a surface area of 4 cm with light serous exudate noted. Recommendations included dressing the wound with silver hydrogel once daily and as needed, applying a protective dressing and off-loading the wound. The physician's order [REDACTED]. The admission MDS dated [DATE] identified the resident with intact cognition, required extensive assistance with bed mobility, transfer and toilet use and had one stage ll ulcer, one stage lll ulcer and one deep tissue injury. A review of the TAR for the month of July 2016 identified that the physician's order [REDACTED]. The facility ' s skin inspection report dated 7/31/16 identified there was no change to the deep tissue injury to the right heel, however the left coccyx wound went from 0 cm depth to 0.2 cm depth and the surrounding tissue was now inflamed. The wound to the sacrum although measurements remained the same was now documented to have serous drainage from the wound as well as the wound edges which were documented as healthy on 7/19/16 were now documented as macerated. Interview and clinical record review with RN #2 on 8/3/16 at 1:07 PM identified that he/she was the admitting Nurse that performed the initial body audit and wound assessment of Resident #201 ' s pressure ulcers and deep tissue injury on admission. RN #2 indicated that he/she changed the dressing to the coccyx area on 7/21/16 and 7/22/16 as his/her nursing notes reflect using the facility ' s wound care guidelines/protocol as well as the information provided by the facility ' s clinical evaluator on admission. RN #2 identified that he/she cleansed the wound with wound cleanser, dried it and covered it with [MEDICATION NAME]. RN #2 further indicated he/she referred to the facility ' s wound care guidelines prior to performing the treatment. Review of the Wound Care Guidelines identified that for a stage ll or stage lll pressure ulcer the wound was to cleansed with wound cleanser, apply Sureprep to the peri wound, apply [MEDICATION NAME] Hydrogel and cover with a bordered gauze. Upon clinical record review with RN #2, he/she did indicate that upon admission wound care orders were not in place and/or he/she did not have a physician's order [REDACTED]. indicated on 7/21/16 and 7/22/16. RN #2 indicated that RN#4 was the nurse that confirmed admission orders [REDACTED]. Multiple attempts were made to contact RN #4 for interview without success. Interview with the DNS on 8/3/16 at 11:33 AM identified that the Supervisor receiving report from the hospital should be aware if a resident was being admitted with a wound and it would be his/her responsibility to get wound care orders when the physician was called to verify admission orders [REDACTED]. DNS also identified that the expectation was that the facility ' s wound nurse should have looked at the wound and checked the orders for appropriateness on admission and/or the following day if an evening admission and/or weekend admission. (Resident #201 resident was admitted on a Tuesday) Interview with RN #1 on 8/3/16 at 1:40 PM identified that he/she was informed that Resident #201 had a pressure ulcer on 7/25/16 when wound rounds were conducted with the wound care specialist and was not aware that a wound order was not in place from admission date of [DATE] through 7/26/16 until record was reviewed with the Surveyor. When asked how he/she is informed by the staff if a resident is admitted with a wound, he/she indicated that staff will notify him/her when he/she is rounding on Mondays with the wound specialist. Subsequent interview with the DNS on 8/4/16 at 9:55 AM identified that those residents being admitted with a pressure ulcer are communicated via the 24 hour report and are discussed in morning report. When asked when the wound nurse should have become involved, the DNS identified it should have been immediately. The DNS was not able to identify a reason as to why this resident ' s pressure ulcer(s) which were identified on the 24 hour report were not discussed and why the facility did not ensure a treatment was in place until 7 days after admission. Subsequent interview with RN #1 on 8/4/16 at 9:55 AM identified that the charge nurses and/or nurse managers routinely assess wounds on admission and he/she is not routinely made aware of a new admission with a wound and/or new onset of a wound until he/she goes to the units on Mondays with the wound specialists and asks if there are any new residents that need to be seen. RN #1 indicated he/she does attend morning report, but is unable to identify how this resident and his/her pressure ulcer(s) were not discussed and/or addressed for up to 7 days following admission. Interview with RN #3 on 8/4/16 at 10:50 AM identified that he/she was aware that Resident #201 had a pressure area to his/her sacral area and recalled the area being scabbed over therefore the staff was leaving the area open to air and was applying a barrier cream on the shifts that he/she was scheduled. Interview with MD #1 on 8/4/16 at 12:30 PM identified that applying barrier cream to a stage lll pressure ulcer was not a treatment of [REDACTED]. MD #1 indicated that the measurement he/she documented to the sacrum on 7/25/16 included both of the areas (left coccyx and sacrum) which the facility had been measuring as two separate areas. Review of the facility ' s Skin Integrity Management Policy and Procedure identified the facility is to review pre-admission information to plan for the resident ' s needs prior to admission, identify the resident ' s skin integrity status and need for prevention intervention or treatment modalities, perform daily monitoring of wounds or dressings for presence of complications or declines and document and to notify physician/mid-level provider to obtain orders.

Based on clinical record review and interview for one (R#1) of six residents reviewed for the provision of care and services, the facility neglected to provide a safe environment for a resident who expressed a wish to die, neglected to implement precautions for a resident who made a suicidal attempt, and neglected to develop strategies and implement interventions regarding intractable pain management which resulted in a finding of immediate jeopardy. The findings include: R#1 ' s [DIAGNOSES REDACTED]. The nursing admission assessment dated [DATE] identified R#1 as alert, oriented to person place and time, and was experiencing acute pain in the back described as sharp and aching with moderate pain as an acceptable level. The resident care plan dated 7/15/13 identified R#1 at risk for alterations in comfort related to low back pain, recent back surgery, compression fracture and limited mobility. Interventions included to evaluate pain characteristics of quality, severity, location and precipitating factors, utilize pain scale, and advise resident to request pain medication before pain becomes severe. Physician orders [REDACTED]. Physician notes dated 7/17/13 identified R#1 complained of back pain and an inability to move his/her legs and was transferred to an acute care hospital for evaluation and treatment. The hospital discharge summary dated 7/17/13 identified new [MEDICAL CONDITION] and enhancement in the compressed lumbar 1 vertebra suggesting a more recent fracture since 6/10/13. R#1 was transferred back to the facility with physician orders [REDACTED]. physician progress notes [REDACTED]. The orthopedic surgeon evaluated R#1 and recommended changes in pain medications that included [MEDICATION NAME] nasal 200 units per spray (used as an adjunct to pain management) and a [MEDICATION NAME] 5% patch. The [MEDICATION NAME] 5% patch was ordered and initiated by an APRN on 7/22/13. However, the [MEDICATION NAME] nasal spray was not ordered by the primary physician until 7/23/13, and R#1 did not receive the [MEDICATION NAME] between 7/23/13 and 7/30/13. The Medication Administration Record (MAR) dated 7/22/13 and interview with LPN#1 on 8/6/13 at 12:10PM identified that on 7/22/13 LPN#1 medicated R#1 every four hours between 7:00AM and 3:00PM for complaints of severe pain with [MEDICATION NAME] 5/325 two tabs and [MEDICATION NAME] 2 mg at 11:30 AM for anxiety and muscle spasm. Review of the MAR dated 7/22/13 identified that R#1 did not receive any further pain medication between 3:00 PM and 11:00PM. An interview with and review of the MAR and progress notes from 7/15/13 through 7/23/13 was conducted with the Corporate Nurse and the Assistant Director of Nursing (ADON) on 8/6/13 at 11:00AM. The MAR and nurses notes failed to identify documentation of R#1 ' s pain characteristics of quality, severity, location and precipitating factors and the utilization of a consistent pain scale. RN #1 ' s nurses note dated 7/23/13 for the 7/22/13 3:00 PM to 11 :00 PM shift identified that R#1 had anxiety issues through the shift and experienced episodes of groaning. Sutures from the prior lumbar disc decompression and discectomy revision on 6/13/13 were removed at 4:30 PM and the resident was described as calm with no identified pain at that time. Subsequently, (time unknown) R#1 was observed to be moaning, " calling out for attention " and making references to wanting to die and the clinical record lacked documentation of any intervention regarding the suicidal statement. The nurse ' s note identified that at 10:00 PM, R#1 was observed with a plastic bag over his/her head, " apparently sealed against the mouth, " and the bag was removed. The clinical record lacked documentation of any intervention regarding the suicidal gesture. Interview and review of the accident and facility investigation documentation on 8/5/13 at 12:30 PM with the Director of Nursing (DNS) and the Assistant Director of Nursing (ADON) identified that RN#1 failed to report R#1 ' s suicidal statement on 7/22/13 to the 3-11 nursing supervisor and failed to notify the supervisor that R#1 had then placed a bag over his/her head. The ADON first learned about R#1 ' s suicidal statement and gesture the following day when reviewing the 24 hour summary at morning report. At that time R#1 was place on one to one observation, the physician was notified and the resident was transferred to an acute care hospital for evaluation. R#1 ' s hospital emergency department assessment documentation dated 7/23/13 identified that R#1 reported having chronic back pain and pain medications that had been " abruptly cut down. " While hospitalized , R#1 received [MEDICATION NAME] (5) 2 tablets and [MEDICATION NAME] 2 milligrams by mouth for pain and anxiety before being transferred back to the facility. The hospital psychiatric evaluation dated 7/23/13 identified that R#1 stated being frustrated and overwhelmed with the pain and spasms in his/her back. R#1 reported that facility staff were not providing pain medications when R#1 requested the medications. Interview with RN#1 on 8/5/13 at 1:15PM identified that R#1 started to escalate and was screaming out in pain early in the shift on 7/22/13. RN#1 stated that R#1 ' s behavior was attention seeking and R#1 " got extreme with his/her expressions " stating " let me die " (time unknown). RN#1 stated that he/she " attempted to assure R#1 that he/she was safe and his/her needs would be met, " and R#1 appeared to quiet down. RN#1 stated that he/she " never asked if R#1 thought about suicide and if he/she had a plan. " On 7/22/13 at approximately 10:00 PM, RN#1 returned to R#1 ' s room and observed R#1 laying on his/her side with a plastic bag over his/her face. RN#1 stated that he/she " did not have to do a sternal rub but R#1 appeared to be alert and moving and wasn ' t making any statements of being upset. " RN#1 stated that he/she " could handle the situation and felt that R#1 was looking for a reaction " from RN#1. RN#1 could not recall if he/she reported the plastic bag incident to the 3-11 RN Supervisor but did recall reporting R#1 ' s statements to the 3:00 PM to 11:00 PM RN supervisor. RN#1 stated that he/she did tell the 11-7 nurse that R#1 needed to be watched. RN#1 further stated that he/she has not received any education regarding what he/she failed to do regarding that incident. Interview with RN #5 (11:00 PM to 7:00 AM staff nurse) on 8/6/13 at 1:30 PM identified that RN#1 did not report that R#1 had made a suicidal statement or gesture. Interview with RN #2 (11:00 PM to 7:00 AM supervisor) on 8/5/13 at 12:30 PM identified that it was reported that R#1 was medication seeking but had not been told that R#1 had made a suicidal statement or gesture. RN#3 (3:00 PM to 11:00 PM supervisor) was not available for interview. The facility abuse policy identified that the facility would prohibit abuse and neglect. Neglect was defined as failure to provide goods and services to avoid physical harm, mental anguish or mental illness. Review of facility policy identifies that suicide precautions are implemented for any patient displaying actual/potential suicidal behavior and a safe environment is to be provided for patients who display actual or potential suicidal behavior. Review of facility policy directs that patients receiving interventions for pain will be monitored for the effectiveness in providing pain relief and the care plan will be evaluated for effectiveness until satisfactory pain management is achieved.

Based on clinical record review and interview for one(R#1) of three residents reviewed for pain management, the facility failed to provide the necessary care and services to manage the resident ' s pain which resulted in a finding of immediate jeopardy. The findings include: R#1 ' s [DIAGNOSES REDACTED]. The nursing admission assessment dated [DATE] identified R#1 as alert, oriented to person place and time, a history of anxiety and was experiencing acute pain in the back described as sharp and aching with moderate pain as an acceptable level. The resident care plan dated 7/15/13 identified R#1 at risk for alterations in comfort related to low back pain, recent back surgery, compression fracture and limited mobility. Interventions included evaluate pain characteristics of quality, severity, location and precipitating factors, utilize pain scale, and advise resident to request pain medication before pain becomes severe. Review of the physician notes dated 7/17/13 identified R#1 complained of severe back pain and an inability to move his/her legs and was transferred to an acute care hospital for evaluation and treatment and returned to the facility on [DATE]. Review of the physician progress notes [REDACTED]. The orthopedic surgeon evaluated R#1 and recommended changes in pain medications that included [MEDICATION NAME] nasal 200 units per spray (used as an adjunct to pain management) and a [MEDICATION NAME] 5% patch. The [MEDICATION NAME] 5% patch was ordered and initiated by an APRN on 7/22/13. However, the [MEDICATION NAME] nasal spray was not ordered by the primary physician until 7/23/13, however R#1 did not receive the [MEDICATION NAME] between 7/23/13 and 7/30/13. RN #1 ' s nurses note dated 7/23/13 for the 7/22/13 3:00 PM to 11 :00 PM shift identified that R#1 had anxiety issues through the shift and experienced episodes of groaning. Sutures from the prior lumbar disc decompression and discectomy revision on 6/13/13 were removed at 4:30 PM and the resident was described as calm with no identified pain at that time. Subsequently, R#1 was observed to be moaning, " calling out for attention " and making references to wanting to die in relation to unrelieved pain. RN#1 ' s nurse ' s note identified that at approximately 10:00 PM, RN#1 observed R#1 laying on his/her side with a plastic bag over his/her face " apparently sealed against the mouth, " and the bag was removed. Interview and review of the accident and facility investigation documentation on 8/5/13 at 12:30 PM with the Director of Nursing (DNS) and the Assistant Director of Nursing (ADON) identified that RN#1 failed to report R#1 ' s suicidal statement to the supervisor and failed to notify the supervisor that R#1 had then placed a bag over his/her head. The ADON first learned about R#1 ' s suicidal statement and gesture the following day, 7/23/13 approximately nine hours later, when reviewing the 24 hour summary at morning report. At that time R#1 was place on one to one observation, the physician was notified and the resident was transferred to an acute care hospital for evaluation. The Hospital psychiatric evaluation dated 7/23/13 identified that R#1 stated being frustrated and overwhelmed with the pain and spasms in his/her back. R#1 reported that facility staff were not providing pain medications when R#1 requested the medications. Review of R#1 ' s MAR indicated [REDACTED]. Of the 16 doses, 11 did not include a pain reassessment or documentation according to the MAR indicated [REDACTED] Review of facility policy directs that patients receiving interventions for pain will be monitored for the effectiveness in providing pain relief and the care plan will be evaluated for effectiveness until satisfactory pain management is achieved.

Based on clinical record review and interview for one(R#1) of three residents reviewed for the provision of psychiatric services, the facility failed to provide psychiatric and/or psychosocial assessment and appropriate mental health treatment for [REDACTED]. The findings include: R#1 ' s [DIAGNOSES REDACTED]. The nursing admission assessment dated [DATE] identified R#1 as alert, oriented to person place and time, a history of anxiety and was experiencing acute pain in the back described as sharp and aching with moderate pain as an acceptable level. Review of the interim resident care plan dated 7/15/13 failed to identify R#1 with anxiety issues and recommendations for treatment. Review of the physician notes dated 7/17/13 identified R#1 complained of severe back pain and an inability to move his/her legs and was transferred to an acute care hospital for evaluation and treatment and returned to the facility on [DATE]. RN #1 ' s nurses note dated 7/23/13 for the 7/22/13 3:00 PM to 11 :00 PM shift identified that R#1 had anxiety issues through the shift and experienced episodes of groaning. Sutures from the prior lumbar disc decompression and discectomy revision on 6/13/13 were removed at 4:30 PM and the resident was described as calm with no identified pain at that time. Subsequently, R#1 was observed to be moaning, " calling out for attention " and making references to wanting to die. RN#1 ' s nurses note then identified that R#1 was observed with plastic bag over his/her head, " apparently sealed against the mouth. " Interview with RN#1 on 8/5/13 at 1:15PM identified that R#1 started to escalate and was screaming out in pain early in the shift on 7/22/13. RN#1 stated that R#1 ' s behavior was attention seeking and R#1 " got extreme with his/her expressions " stating " let me die " (time unknown). RN#1 stated that he/she " attempted to assure R#1 that he/she was safe and his/her needs would be met, " and R#1 appeared to quiet down. RN#1 stated that he/she " never asked if R#1 thought about suicide and if he/she had a plan. " At approximately 10:00 PM, RN#1 returned to R#1 ' s room and observed R#1 laying on his/her side with a plastic bag over his/her face. RN#1 stated that he/she " did not have to do a sternal rub but R#1 appeared to be alert and moving and wasn ' t making any statements of being upset. " RN#1 stated that he/she " could handle the situation and felt that R#1 was looking for a reaction " from RN#1. RN#1 could not recall if he/she reported the plastic bag incident to the Supervisor but did recall reporting R#1 ' s statements to the 3:00 PM to 11:00 PM supervisor. Interview and review of the accident and facility investigation documentation on 8/5/13 at 12:30 PM with the Director of Nursing (DNS) and the Assistant Director of Nursing (ADON) identified that RN#1 failed to report R#1 ' s suicidal statement to the supervisor and failed to notify the supervisor that R#1 had then placed a bag over his/her head. The ADON first learned about R#1 ' s suicidal statement and gesture the following day, 7/23/13 approximately nine hours later, when reviewing the 24 hour summary at morning report. At that time R#1 was place on one to one observation, the physician was notified and the resident was transferred to an acute care hospital for evaluation. Interview and review of the clinical record with Social Worker#1 (SW) on 8/6/13 at 1:00PM failed to identify that a social service assessment had been completed during R#1 ' s admission and failed to provide psychosocial services when R#1 presented with unsafe statements and behaviors. SW#1 stated that he/she cannot recall discussing in morning report R#1 ' s hospital admission for severe pain and problems with anxiety and pain management. Review of facility policy identifies that suicide precautions are implemented for any patient displaying actual/potential suicidal behavior and a safe environment is to be provided for patients who display actual or potential suicidal behavior.

Based on clinical record review and interview for one (R#1) of three residents reviewed for psychiatric services, the facility failed to provide a safe environment for a resident with a suicide ideation and/or suicide attempt which resulted in a finding of immediate jeopardy. The findings include: R#1 ' s [DIAGNOSES REDACTED]. The nursing admission assessment dated [DATE] identified R#1 as alert, oriented to person place and time, a history of anxiety and was experiencing acute pain in the back described as sharp and aching with moderate pain as an acceptable level. The resident care plan dated 7/15/13 identified R#1 at risk for alterations in comfort related to low back pain with interventions identified to complete pain assessment per protocol and evaluate resident ' s past coping mechanisms. RN #1 ' s nurses note dated 7/23/13 for the 7/22/13 3:00 PM to 11 :00 PM shift identified that R#1 had anxiety issues through the shift and experienced episodes of groaning. Sutures from the prior lumbar disc decompression and discectomy revision on 6/13/13 were removed at 4:30 PM and the resident was described as calm with no identified pain at that time. Subsequently, R#1 was observed to be moaning, " calling out for attention " and making references to wanting to die and the clinical record lacked documentation of any intervention regarding the suicidal statement. RN#1 ' s nurses note then identified that at 10:00 PM, R#1 was observed with plastic bag over his/her head, " apparently sealed against the mouth. " The clinical record lacked documentation of any intervention regarding the suicidal gesture. Interview and review of the accident and facility investigation documentation on 8/5/13 at 12:30 PM with the Director of Nursing (DNS) and the Assistant Director of Nursing (ADON) identified that RN#1 failed to report R#1 ' s suicidal statement to the supervisor and failed to notify the supervisor that R#1 had then placed a bag over his/her head. The ADON first learned about R#1 ' s suicidal statement and gesture the following day, 7/23/13 approximately nine hours later, when reviewing the 24 hour summary at morning report. At that time R#1 was place on one to one observation, the physician was notified and the resident was transferred to an acute care hospital for evaluation. Review of facility policy identifies that suicide precautions are implemented for any patient displaying actual/potential suicidal behavior and a safe environment is to be provided for patients who display actual or potential suicidal behavior.

Based on record review and staff interview for one of four sampled residents reviewed for accidents (R#184), the facility failed to provide adequate supervision to prevent a fall with injury. The findings include; Resident #184's [DIAGNOSES REDACTED]. A quarterly MDS dated [DATE] identified the resident as severely, cognitively impaired and requiring extensive assistance of one staff member with activities of daily living. The MDS further noted R#184 was not steady, and only able to stabilize with human assistance for moving from a seated to standing position, on and off toilet and surface to surface transfers. A care plan dated 4/3/12 identified a problem with requiring assistance with activities of daily living due to dementia, glaucoma and atrial fibrillation. Interventions included to provide assistance with dressing, grooming, bathing, bed mobility and eating. Requires assistance of 1 with rolling walker with w/c following for ambulation, and assist of 1 with transfers. The care plan also identified a problem with poor body alignment, requiring the use of an adapted wheelchair with interventions to assist resident in and out of adaptive w/c with contact guard, assist with and placement during stand/pivot. The interventions further noted to position her/him in the adaptive wheelchair with a foam cushion, headrest, lateral hip supports, pelvic positioning belt is available if needed. Physical therapy notes dated 1/22/12 identified the resident with functional limitations that impair safety related to decrease in vision/hearing, risk of falling and forward flexed posture positioning. Nurse's note dated 4/28/12 at 8:30 AM identified R#184 was lying down on the bathroom floor. Nurse's notes further identify the nurse aide assisted the resident to the bathroom, stepped to the door to get a brief to change the resident, and the resident stood up and fell . R#184 complained of severe left wrist pain and the wrist was noted to be swollen and displaced. A mobile x-ray revealed a left wrist fracture and the resident was transferred to the hospital for evaluation. The resident returned to the facility on [DATE] at 7:30 PM with a left wrist splint in place. Interview with NA#1 on 11/28/12 at 2:25 PM identified the resident was attempting to get up and go to the bathroom from the wheelchair when he heard the chair alarm go off. He then toileted the resident but needed an incontinent brief, left the bathroom to get an incontinent brief and when he re-entered the bathroom, R#184 was on the floor. NA#1 further indicated that he was aware he was not to leave the resident unattended in the bathroom and was to have rung the call light for staff assistance. Interview with the DNS on 11/28/12 at 11:11 AM identified that although staff is not inserviced on providing supervision to residents in the bathroom, the expectation is to not leave residents unattended on the toilet, because the toilet is not a stable device.

Based on clinical record review, observation, and staff interview for one of four sampled residents (Resident #107), reviewed for accidents, the facility failed to ensure appropriate supervision to prevent an accident. The findings include: Resident #107's [DIAGNOSES REDACTED]. The care plan dated 3/21/11 identified that the resident was at risk to fall with interventions that included to ensure call light in reach at all times, remind to use call light, toilet after supper, place necessary items in reach, and monitor for and assist with toilet needs. An accident/incident report dated 6/2/11 at 12:45PM identified the resident was found on the bathroom floor on her right side with her right arm under her body and after physician notification was sent to the hospital for evaluation. The hospital discharge summary dated 6/3/11 identified the resident was diagnosed with [REDACTED]. Interview with Licensed Practical Nurse (LPN) #1 on 10/4/11 at 2:00PM identified that as far as she knows, the staff would leave the resident alone in the bathroom if her husband was in the room. Additionally, if her husband was not in the room, staff would stay because they were afraid the resident would attempt to stand without assistance. Interview with Nurse Aide (NA) #1 on 10/5/11 at 10:45AM identified that it was the usual practice to leave the resident in the bathroom alone, with the door cracked, and her husband and/or staff member in the room. Additionally, NA#1 stated that the resident's husband would usually sit on the bed and peek through the crack of the door to monitor the resident, however, on 6/2/11 he didn't watch. Interview with Occupational Therapist (OT) #1 on 10/4/11 at 2:25 PM identified the resident should not have been left alone on the toilet due to her cognitive status. She remained an assist of one due to her cognitive level which meant staff were to stay right with her. The facility failed to implement measures to ensure the resident's safety.