Every finding on record at Dolphin Pointe Health Care Center

Based on observations of kitchen food preparation and storage areas and interviews with staff, the facility failed to adhere to acceptable food storage practices to prevent food contamination or foodborne illness by failing to ensure opened foods were sealed, labeled and dated, and food preparation and storage equipment was clean and sanitary. Food storage and kitchen sanitation is important in health care settings serving nursing home residents. Unsafe food handling practices present a potential source of pathogen exposure and has the potential to affect all residents who consumed foods from the facility, An initial tour of the kitchen was conducted with the Certified Dietary Manager (CDM) on 1/26/26 at 2:15 PM. Inspection of the commercial ice machine's ice chute cover revealed an a 2-inch square area covered with wet, dark matter resembling biological growth such as mildew. Condensation had formed on the surface of the cover, which could drip into the ice below. When the CDM wiped the matter with a paper towel-covered finger, the matter easily wiped off. Seemingly puzzled, he explained the machine was cleaned weekly. The heat-on-demand plate base (an insulated base designed to fit under plates and maintain food temperatures) warmer next to the tray line service area had a white powdery, tacky substance on the horizontal surfaces. When wiped with a finger, the powdery substance wiped away. The same powdery matter was observed on the bottom of the plate warmer bases. The CDM acknowledged the substance and suggested it could be cleaned. The deep fryer basket still held two fries from a prior meal and food crumbs and debris was observed where the oil line met the fryer walls. Reach-in freezer #2 held multiple boxes of frozen food. One box was unsealed and had an open plastic bag of frozen omelets inside. The bag was not dated, and the omelets were exposed to air. The CDM acknowledged the finding and suggested the contents could have been stored in zipper lock baggies. The walk-in refrigerator's floor had approximately 1/4 inch of pooled water on one side. The pipe coming out of the bottom of the fan's housing was covered in condensation and dripping onto two boxes of chocolate muffins. The CDM acknowledged the findings and removed the boxes from the shelf. When he did, water poured off of the boxes and spilled onto the floor. Inside, the boxed muffins were sitting in water. The CDM recognized the pipe coming out of the fan housing had been bent, assuming it may have been hit by a box as dietary staff stored the items. The fan blades and both protective fan grilles had a buildup of dark feathery matter resembling dust. In a subsequent visit to the kitchen on 1/29/26 at 11:51 AM, the CDM requested a second inspection of the ice machine, explaining he had removed the chute cover and cleaned it. Upon reinspection of the interior of the chute, a much larger amount of the dark buildup was noted on the vertical sides and corner of the ice chute, covering a surface area of approximately 8 to 10 square inches. The CDM suggested the area was stained, not soiled, and wiped it with a rag. The substance wiped off with a rag and scraped off with a fingernail. (Photographic evidence was obtained) The CDM acknowledged the condition of the ice machine despite efforts to clean it. When asked who was responsible for cleaning the machine, he said he was.

Based on observations, interviews, and record review, it was determined that the facility failed to ensure residents who were dependent on staff for grooming and personal care received necessary assistance with activities of daily living (ADLs), specifically related to fingernail and toenail trimming and cleaning, for four of six residents reviewed for ADLs (Residents #76, #116, #67, and #45).The findings include: 1. On 1/27/26 at 10:40am, Resident #76 was observed with elongated fingernails on her right hand with brown debris noted under each fingernail. The resident stated she likes her fingernails long and she likes to get them painted. They were not observed to be painted or polished. She was asked if staff clean under her fingernails. She stated no but they should. Her left hand was observed contracted and she stated she can't really open that hand. Unable to observe left hand fingernails. (Photographic evidence obtained.) On 1/28/26 at 10:05am, Resident #76 was observed awake in her bed. Her right-hand fingernails were observed elongated, as observed yesterday with brown debris observed under each fingernail. She stated no one has cleaned under her nails. Her left hand was observed contracted with fingers to palm. She was asked if she has any pain in her left hand and stated no. She was asked if she could open her fingers at all and stated no. Her left fingers were observed flat against her left palm, and the fingernails were observed elongated and dusky in color. On 1/29/26 at 12:00pm, Resident #76 was observed lying in her bed, awake. She was observed to have a hand splint on her left hand. The fingernails on her left hand were observed to be elongated with dark brown debris under the nails. (Photographic evidence obtained.) Her right hand was observed with each fingernail elongated with brown debris under each nail. She was asked if any staff had come in to clean or trim her fingernails and she stated no. A review of the medical record for Resident #76 revealed: A Minimum Data Set (MDS) quarterly evaluation dated 11/2/25 revealed Section C (Cognitive Patterns) Brief Interview for Mental Status (BIMS) was conducted, and the resulting score was 11. A score of 8-12 indicates the resident assessed is moderately cognitively impaired.Section of E (Behavior) of the same assessment on the same date revealed Resident #76 did not have any behavioral symptoms, which included no rejection of care, as documented specifically in Section E 0800.A review of the comprehensive person-centered care plan for Resident #76 revealed: Focus (1/27/24, revised 3/15/24) The resident has an ADL self-care performance deficit related to impaired mobility, impaired cognition.Interventions/Tasks (1/27/24) Provide the amount of assistance/supervision that is needed. 2. On 1/28/26 at 10:00am, Resident #116 was observed in her room, awake and sitting up in her bed, dressed for the day. Her fingernails were observed to be elongated on both hands, with some filed and jagged. She was asked if she prefers to keep her fingernails long. She stated no, not at all. When asked if staff trim her fingernails, she stated no one here has ever trimmed her fingernails and expressed her desire to have that done. She stated her daughter had to do it once when she was here. (Photographic evidence obtained.) On 1/29/26 at 12:15pm, Resident #116 was observed sitting up in her bed, awake and dressed for the day. Her fingernails were observed untrimmed, as observed yesterday. She stated no one has trimmed her fingernails since she has been here except for her daughter. A review of the medical record for Resident #116 revealed: A Minimum Data Set (MDS) quarterly evaluation dated 1/20/26 revealed Section C (Cognitive Patterns) Brief Interview for Mental Status (BIMS) was conducted, and the resulting score was 15. A score of 13-15 indicates the resident assessed is cognitively intact. Section of E (Behavior) of the same assessment on the same date revealed Resident #116 did not have any behavioral symptoms, which included no rejection of care, as documented specifically in Section E 0800.A review of the comprehensive person-centered care plan for Resident #116 revealed: Focus (1/14/26, revised 1/14/26) The resident has an ADL self-care performance deficit related to left side hemiparesis due to Cerebral Vascular Accident.Interventions/Tasks (1/14/26) Provide the amount of assistance/supervision that is needed.Focus: (1/14/26) The resident has Diabetes Mellitus.No Goals/Interventions related to fingernail care in person-centered care plan for focus of Diabetes Mellitus. 3. On 1/27/26 at 10:30am, Resident #67 was observed awake, dressed for day, and lying in her bed. She presented as non-verbal and did not answer any questions, including simple yes/no questions. She was observed with elongated fingernails on both hands with brown debris observed under each fingernail. (Photographic evidence obtained.) On 1/28/26 at 9:45am, Resident #67 was observed awake, dressed for the day, lying in her bed. Her fingernails were observed on both hands to be elongated with brown debris observed under each fingernail. A review of the medical record for Resident #67 revealed: A Minimum Data Set (MDS) annual evaluation dated 10/21/25 revealed Section C (Cognitive Patterns) Brief Interview for Mental Status (BIMS) was conducted, and the resulting score was 00. A score of 00 indicates the resident assessed is severely cognitively impaired.Section of E (Behavior) of the same assessment on the same date revealed Resident #67 did not have any behavioral symptoms, which included no rejection of care, as documented specifically in Section E 0800.A review of the comprehensive person-centered care plan for Resident #67 revealed: Focus (9/11/23, revised 1/25/26) The resident has an ADL self-care performance deficit related to muscle weakness and disease process.Interventions/Tasks (9/11/23) Provide the amount of assistance/supervision that is needed. Personal hygiene: the resident requires x1 staff assistance with personal hygiene. 4. On 1/26/26 at 2:50pm, Resident #45 was observed lying in bed, eyes closed. She did not open eyes to her name being called. Her feet were observed uncovered. Both first toenails on each foot were observed to be elongated, thick, and yellow in color. Each of the other toenails on both feet were observed to be longer than the toe. On 1/27/26 at 4:15pm, Resident #45 was observed up in her wheelchair, in her room. She was smiling and pleasant. She was able to state her name and was able to say she was in a nursing home. She was asked if her toenails were elongated and stated yes. She was asked if she could remove her slippers, which she did. The toenails were observed as they were yesterday, with her first (big) toenail on each foot observed to be elongated, thick, and yellow in color. Each of the other toenails on both feet were observed to be longer than the toe. (Photographic evidence obtained.)She was asked if she was a diabetic and stated yes. She was asked if she had been seen by a foot doctor over the past few months and stated she didn't think so. On 1/29/26 at 11:50am, Resident #45 was observed sitting up in her room, dressed for the day. She was asked if anyone had been in to trim her toenails. She stated no. She removed her slippers which revealed elongated toenails on each toe. She stated they really need to be trimmed. A review of the medical record for Resident #45 revealed: A Minimum Data Set (MDS) quarterly evaluation dated 10/17/25 revealed Section C (Cognitive Patterns) Brief Interview for Mental Status (BIMS) was conducted, and the resulting score was 03. A score of 00-07 indicates the resident assessed is severely cognitively impaired.Section of E (Behavior) of the same assessment on the same date revealed Resident #45 did not have any behavioral symptoms, which included no rejection of care, as documented specifically in Section E 0800.A review of the comprehensive person-centered care plan for Resident #45 revealed: Focus (8/5/24, revised 11/5/24) The resident has an ADL self-care performance deficit related to impaired mobility.Interventions/Tasks (8/5/24) Provide the amount of assistance/supervision that is needed.Focus: (8/5/24) The resident has Diabetes Mellitus.No Goals/Interventions related to foot/toenail care in person-centered care plan for focus of Diabetes Mellitus.Further review of the medical record for Resident #45 revealed one visit by a podiatrist (a foot doctor) which was dated 9/3/25. The report notes a history of diabetes. The assessment on this report revealed:Assessment: Nail dystrophy [abnormal, thickened, or damaged nails]Provider Plan: Trimming of dystrophic nails 2-4 bilaterallyAssessment: Tinea Unguium [a fungal infection of the toenails] Provider Plan: After consent, the patient was seen and examined for foot care and for elongated toenails that a non-professional could not treat as it would be considered hazardous to the patient. The therapeutic management is direct toward prevention of pain and the control of complications. Foot exam performed. The patient meets criteria for at-risk foot care with two Class B findings- absent posterior tibial pulses and three advanced trophic changes: thickened nails, shiny skin, and absent pedal hair growth and two Class C findings- edema [swelling] and neuropathy [loss of feeling]. After consent, fungal nails 1 bilateral were debrided extensively utilizing a nail [NAME] [a type of nail clipper used for hard or thick nails] and Dremel [a small electric tool used to file and smooth nails] with reduction in length and girth to the patient's tolerance. I discussed with patient proper foot care. Regular podiatric care is recommended for this patient. On 1/29/26 at 12:40pm, during an interview with Employee A, a certified nursing assistant (CNA), she was asked who cleans and trims residents' fingernails. She stated the CNAs do that if the residents are not diabetic. She was asked how often this type of care is provided and she stated it's done as needed. She was asked if there is any type of schedule for providing fingernail care and stated there's no specific schedule. She was asked what the process is if a resident refuses this type of care. She stated we notify the nurse and then document the refusal. She was asked where she would document the refusal of this type of care. She stated in the computer, the Point of Care system, and on the bath/shower sheet. She was asked if she was caring for Resident #67 today and stated yes. She was asked if she had provided care for this resident's fingernails today for either cleaning under the nails or trimming them. She stated she provided her care, but didn't notice her fingernails. She was asked to observe Resident #67's fingernails. Upon making her own observation of Resident #67's fingernails, she confirmed they were long and need to be cleaned. She stated sometimes when CNAs switch units, that can fall off and might not get done. On 1/29/26 at 12:50pm, during an interview with Employee B, a CNA, she was asked who cleans and trims residents' fingernails. She stated, Well, we can clean them, but we can't clip their nails. Only the nurses can clip the resident's fingernails. She was asked what the process is if a resident refuses to have their fingernails cleaned. She stated they let the nurse know. She was asked if she documents when a resident refuses to have care completed for cleaning their fingernails. She stated yes and they have a Point of Care in the computer for documentation. She was asked if she was caring for Resident #76 today and stated yes. She was asked to observe Resident #76's fingernails. Upon making her own observation of Resident #76's fingernails, she was asked if she saw the brown debris under the resident's fingernails and she said yes. She was asked if cleaning the debris under a resident's fingernails was an expectation while providing Activity of Daily Living (ADL) care and she stated yes. On 1/29/26 at 1:00pm, Employee C, a licensed practical nurse (LPN) stated, I just spoke to Employee B, (a CNA) and I wanted to clarify about the fingernail care for you and follow up on what she told you. CNAs can clean and trim the resident's fingernails, as long as they are not diabetic or it's not contradicted for another reason. Activities staff also provides manicures as an activity and they can clean under the nails and polish the nails. On 1/29/26 at 1:10pm, during an interview with Employee D, an LPN and Unit Manager, she was asked what the expectation was for residents' fingernail care for cleaning and trimming the fingernails. She stated the CNAs are supposed to do them every Sunday, because there are no showers scheduled on Sundays. She stated the podiatrist comes in every Friday for toenails. The CNAs do not trim the diabetic resident's fingernails. She was asked who trims the diabetic resident's fingernails. She stated the nurses should do that. She was asked how often that should be done and she stated as needed. She was asked who cleans under the diabetic residents' fingernails and stated the CNAs can clean under the fingernails. She stated the CNAs should clean under the residents' fingernails when they notice it needs to be done, and they should check and do that with the morning ADL care. Activity staff will also clean, file, and cut resident fingernails on spa days, when they do manicures, and they will polish the fingernails. On 1/30/26 at 12:35pm, during an interview with the Director of Nursing (DON), she confirmed the facility does not have a policy regarding ADLs, including fingernail or toenail care. She was asked how often diabetic residents should be seen by a podiatrist for toenail care and trimming. She stated she was not sure, and the facility did not have a policy. She was asked to confirm if the last time Resident #45, a diabetic resident, had her toenails trimmed by the podiatrist was on 9/3/25. She was not sure, and stated they were looking to see if she has any other documentation. That was the only podiatry report that was found.

Based on observation, interviews and record reviews the facility failed to ensure staff followed policy and procedure for reporting and investigating allegations of abuse for one of one resident sampled for abuse (Resident #38) and failed to ensure staff participated in annual training on abuse, neglect and exploitation for two of 10 staff members reviewed (Staff members J, and the Assistant Director of Nursing).The findings include: 1. On 01/26/26 at approximately 2:25 PM, an observation was made of Resident #38 who was standing in the doorway of her room. The resident stated, Someone just tried to hurt me and They came into my room. At this time, staff member J, Dietary Aide, was observed in the hallway and was told by the surveyor what the resident had said. Staff member J entered the resident's room and assisted the resident back to her bed. On 1/26/26 at approximately 3:27 PM, an interview was conducted with Staff member I, Licensed Practical Nurse (LPN), who was assigned to care for Resident #38, during which she was asked if she had been informed of the resident's report of someone trying to hurt her to which she responded, No. At this time she walked down the hall toward the resident's room and stated she would report it to management. She was observed to enter the resident's room. A review of the medical record for Resident #38 revealed she had care plans for self-care deficient related to senile degeneration, weakness and impaired cognition. She also had concerns with anxiety, depression, and insomnia with a history of wandering around the unit and not recalling receiving meals/food and forgetting to use her walker. She had impaired cognitive function/dementia with a Brief Interview for Mental Status (BIMS) of 2 out of 15 indicating severely impaired cognition. The review failed to reveal nursing documentation of the incident with Resident #38 on 1/26/26 or on 1/27/26. On 1/27/26 at 3:11 PM, an interview was conducted in the facility's conference room with the Assistant Director of Nursing (ADON) and the Director of Nursing (DON). The ADON stated that staff member, I, LPN had reported to her the incident with Resident #38 on 1/26/26, but she did not follow up because staff member I stated the resident did not remember saying that someone had tried to hurt her. She confirmed that Resident #38 had issues with memory and had a BIMS indicating severe cognitive impairment. She was asked if a resident cannot remember an incident does it mean she does not have to investigate the concern to which she offered that she should have investigated further and should have reported it to the DON. At this time the DON stated she was unaware of the allegation until this interview and that she should have been told immediately so she could report it to the administrator and start the investigation. On 01/28/2026 at 11:28 AM, an interview was conducted with the DON in the facility's conference room regarding the investigation related to the allegation made by Resident #38. During the interview the DON stated she obtained statements from staff member J, staff member I, and the ADON. The DON read each of the three staff statements out loud. After reading from the documents, she confirmed that the statements did not include a date of the incident, dates in which staff were notified of the concern or the date the ADON was notified of the issue. She stated these dates could be added at a later time after the investigation was completed. A review of the Interview Record for an interview conducted by the DON with staff member J stated, Telephone Interview conducted with (staff member J), regarding (resident #38). (Staff member J) states she was walking on unit 6 hall. She saw surveyor in hallway. Saw (resident #38) but did not hear her make comment someone tried to hurt me (resident #38) need help back to room. Escorted resident who sat herself in bed. Could not assist because not a CNA. The statement did not include a date of the incident or if the staff member reported the concern to anyone. A review of the Interview Record for an interview conducted by the DON with staff member I, dated 1/27/26 states, Interview conducted with (Staff member I, LPN) in regards to (Resident #38). Nurse stated that surveyor informed her that (Resident #38) stated that someone tried to hurt her. Nurse immediately went to resident and interviewed resident, did not recall statement. Nurse reported to ADON. The statement did not include a date of the incident or the date the ADON was informed of the concern. A review of the Interview Record for an interview conducted by the DON with the ADON on 1/27/26 states, Interviewed (ADON), regarding (resident #38). (ADON) stated that she was at the desk on unit 5 when (staff member I, LPN) reported to her that (resident #38) stated that someone tried to hurt her. Nurse stated that she interview [sic] the resident and did not recall making statement The statement did not include a date of the incident or the date the ADON was informed of the concern. On 01/29/26 at approximately 12:34 PM, an interview conducted with the Unit Manger (UM) who stated that Resident #38 is confused, and sun-downs (a worsening of confusion, agitation, anxiety or other behaviors changes that often occurs in people with dementia in the late afternoon and evening as the sun sets) around 5 or 6 in the evening. The UM reported that the resident usually sits outside her room, is up pretty much all night and wanders around the unit. She verified that the resident has had outbursts in the past which are better now. The UM stated she was not aware of the resident making false accusations, stating that the resident was never alert and oriented, but can have a conversation with you but won't remember having it. If she was saying someone hurt her she would report it to the abuse coordinator who is the Administrator and would not ignore it, just because she is confused you would still need to report it for them to investigate. She would document this in a progress note as well. It is her expectation that the nurses would do the same. She would follow the same process if it was a family member or visitors reported this concern and would conduct an investigation. 2. Review of the employee file for the ADON with a date of hire of 2/9/23 revealed she had abuse and neglect training on 1/20/26. Review of the employee file for staff member J, dietary aide had a date of hire 6/13/23 with abuse and neglect training conducted on 1/29/26.On 1/30/26 at approximately 11:35 AM, an interview was conducted with the Certified Dietary Manager (CDM) who stated all employees go through new employee orientation and get abuse and neglect training at that time. He stated that dietary staff should report concerns to him - all concerns but if they have a concern involving a resident they can report it to the nurse but they should also tell him. He stated that he has not been informed of any concerns by staff member J in the last week or so. On 1/30/26 at approximately 11:46 AM, an interview was conducted with the Staff Development Coordinator during which she stated that all employees go to new employee orientation in which abuse and neglect is reviewed verbally and there is a video they watch. They take a test before and after reviewing a video regarding abuse. They also have discussions about what is abuse to include verbal, physical and sexual abuse. She brought the new employee orientation folder for staff member J from 2023 which included a training on abuse upon hire in 2023 and from 1/29/26. She stated they keep the most current training in the folder and said the older ones go into a box. She said she would try and find the others. No additional documents were provided by the time of survey exit. Review of the Position Description for the Assistant Director of Nursing (ADON) signed by the ADON on 11/22/24, revealed, Safety Awareness: Follows safety program guidelines; immediately reports accidents and incidents to supervisors; The essential job duties include, Assist with overall supervision of the Nursing Department and provides guidance to the Nursing staff. Assist the Director of Nursing in directing and developing the nursing department to ensure the delivery of high-quality care and services in accordance with all laws, regulations and Company guidelines and makes recommendations to the DON. Assesses resident care needs and makes recommendations to the DON regarding the nursing department's ability to meet those needs. Performs daily rounds within the nursing department to effectively monitor residents and ensure that nursing needs have been met as outlined in the care plans. Review of the facility policy titled Resident Mistreatment, Abuse and Neglect Prohibition revealed the purpose, and personal possessions of every resident. Each facility has systems, procedures and a program of employee training and supervision in place to foster dignified treatment, respect and compassion for residents. Any form of mistreatment of any resident including but not limited to abuse, neglect, injuries of unknown origin and misappropriation of resident property is strictly prohibited. All allegations of mistreatment, abuse, neglect, injuries of unknown origin and misappropriation of resident property are to be reported immediately and investigated by the Administrator, Risk Manager or designee. Under the section for Training the policy states, Upon hire, annually, and additionally if determined appropriate by the facility management, each employee will be trained on the following topics: included in the list was, Resident Mistreatment, Neglect and Abuse Prohibition Guidelines; Appropriate interventions to deal with aggressive and/or potentially dangerous behaviors; What constitutes mistreatment, abuse, neglect, unreasonable confinement, injuries of unknown origin and misappropriation of resident property; How to recognize signs of burnout, frustration and stress that may lead to abuse; Employee responsibilities as a mandated reported.; How staff should report their knowledge of allegations without fear of reprisal. Employees are expected to review the educational material carefully and attend all training sessions. The policy defines mental abuse, includes, but is not limited to, humiliation, harassment, and threats of punishment or deprivation. Verbal abuse is defined, the use or oral, written, or gestured language that willfully includes disparaging and derogatory terms to residents or their families or within their hearing distance regardless of their age, ability to comprehend, or disability. Mandatory reported includes any person who has assumed full or intermittent responsibility for care or custody of an elderly person, whether or not that person receives compensation, such as administrators, supervisors, and any licensed staff of a facility that provides care or services for elderly adults or any care custodian, health practitioner, clergy member or employee of a county adult protection services agency or local law enforcement agency. Mandatory reporting is a legal obligation for mandated reports to formally report suspected, believed, or witnessed abuse, neglect or mistreatment of residents in accordance with state and federal laws. Neglect is defined as failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness. Under the section titled Prevention states, Each facility is required to identify, correct, and intervene in situations where abuse, neglect and/or misappropriation of resident property are likely to occur, or are suspected to have occurred. Under the heading Investigation states, Each facility will thoroughly investigate injuries of unknown origin and any suspected or alleged abuse, neglect, misappropriation of resident property in accordance with federal and state regulations. The electronic incident report and investigation system forms should be completed for all incidents of suspected or alleged mistreatment, abuse, neglect, misappropriation of resident property and for injuries of unknown origin

Based on observations, interviews, and record review, it was determined that the facility failed to ensure residents' rights to self-administer medications was consistently assessed and safely implemented, as evidenced by the failure to complete required self-medication assessments and to ensure medications approved for self-administration were securely stored for three of three residents reviewed (Residents #116, #80, and #37). The findings include: 1. On 1/27/26 at 4:30pm, during an interview with Resident #116, she stated she has always had her eye drops and Flonase nasal spray left for her at the bedside per her request and stated yesterday afternoon staff took them away and said she couldn't have then in her room. She stated she wants her eye drops and nasal spray in her room, and that she has always administered them herself. On 1/28/26 at 10:00am, a Flonase nasal spray box and Artificial Tears box were observed on bedside table of Resident #116. She stated the staff gave them back to her. The boxes were observed to be empty, and she stated she put the medications into her small, zippered makeup bag, which was observed on her bedside table. On 1/29/26 at 12:15pm, during an interview with Resident #116, she was asked if she still had her Flonase nasal spray and Artificial Tears in her room. She stated yes, I have them in my pouch. She unzipped a cloth pouch that was on her bedside table and showed it contained a bottle of Flonase nasal spray and a bottle of Artificial Tears. She was asked if she has anywhere to lock them up to keep them secure. She stated no. She was asked if her nightstand has a locking drawer. She stated she didn't know, but couldn't reach it if it did. Her bedside nightstand was observed to have a key in the bottom drawer. She confirmed she does not use that drawer to store anything and wouldn't be able to reach it. A review of the medical record for Resident #116 revealed: A Minimum Data Set (MDS) quarterly evaluation dated 1/20/26 revealed Section C (Cognitive Patterns) Brief Interview for Mental Status (BIMS) was conducted, and the resulting score was 15. A score of 13-15 indicates the resident assessed is cognitively intact. Section of E (Behavior) of the same assessment on the same date revealed Resident #116 did not have any behavioral symptoms. A review of the Self-Administration of Medication Evaluation completed for Resident #116, dated 1/20/26, revealed the resident was assessed for self-administration of Fluticasone Propionate Suspension 50 micrograms per actuation 2 spray per nostril daily for allergic rhinitis (this medication is also known as Flonase Nasal Spray) and Artificial Tears 1 drop in both eyes two times a day for dry eyes. Part 7 of the evaluation stated: The resident can appropriately demonstrate secure storage of medications kept in room with completely capable checked off. A review of the comprehensive person-centered care plan for Resident #116 revealed: Focus (1/21/26, revised 1/22/26) The resident has a physician's order for unsupervised self-administration of the following medications: Fluticasone Propionate Suspension 50 micrograms per actuation; Artificial Tears Ophthalmic Solution 1%.Interventions/Tasks (1/21/26) May keep medication at bedside as ordered. 2. On 1/28/26 at 9:30am, a bottle of Refresh eye drops was observed on bedside table of Resident #80. She stated they are her eyes drops, and she that they aren't allowed to keep prescription medications in the room, but those are over the counter, so they allow her to keep those there. On 1/29/26 at 11:55am, a bottle of Refresh eye drops was observed on the bedside table of Resident #80. Resident #80 stated she uses them maybe once a week or so for dry eyes. She was asked if any staff had evaluated her use of the eye drops to ensure she could instill them properly. She stated no. She was asked where she stores the bottle of eye drops. She stated right there, where you see them, on her table. On 1/29/26 at 12:06pm, during a medication pass observation, Employee E, a licensed practical nurse (LPN) was observed to pass medications to Resident #80. Employee E was asked if he knew about the bottle of Refresh Eye Drops on the resident's bedside table. He stated those are used for dry eyes and irritation, and thought she used them every 12 hours as needed.Employee E was asked if the resident has an order to self-medicate these eye drops. He stated she should. He was asked if he could check and stated yes. Upon reviewing the resident's orders, he didn't see an order on the Medication admission Record (MAR), but thought she had an as needed order for the eye drops. He confirmed the resident did not have an order to self-medicate the eye drops because she didn't have an order for the eye drops. He was asked what the process is for a resident to self-medicate medications. He stated if a resident requests to self-medicate any of their medications we would assess them for safe administration and safe storage and let the doctor know the resident is requesting to self-administer. He was asked what safe storage means for self-administered medications. He stated the medications should be locked in the bedside table drawer. A review of the medical record for Resident #80 revealed: A Minimum Data Set (MDS) quarterly evaluation dated 11/25/25 revealed Section C (Cognitive Patterns) Brief Interview for Mental Status (BIMS) was conducted, and the resulting score was 15. A score of 13-15 indicates the resident assessed is cognitively intact. Section of E (Behavior) of the same assessment on the same date revealed Resident #80 did not have any behavioral symptoms. A review of the medical record for Resident #80 did not reveal a Self-Administration of Medication Evaluation was completed. A review of the comprehensive person-centered care plan for Resident #80 did not reveal a focus related to self-administration of medications. 3. On 1/29/26 at 9:20am, during medication pass, Employee F, a licensed practical nurse (LPN) was observed preparing medications for Resident #37. Upon completion of administering the medications to Resident #37, Employee F was asked about the order Resident #37 had listed which read: Breo Ellipta Inhalation Aerosol Powder Breath Activated 50-25 MCG/INH (Fluticasone Furoate-Vilanterol): 1 inhalation inhale orally one time a day for ANTIASTHMATIC AND BRONCHODILATOR AGENTS unsupervised self-administration. Rinse mouth with water and spit.(Breo Ellipta Inhalation Aerosol Powder Breath Activated 50-25 MCG/INH (Fluticasone Furoate-Vilanterol) is a prescription inhaled medication used to help control breathing problems such as asthma or chronic lung disease by keeping the airways open). Employee F stated yes, the resident took that medication earlier this morning. She was asked how she knew the resident had taken the medication and stated she watched her take it earlier. She was asked where the resident stores the medication and stated it's locked in her bedside drawer; she has the key. On 1/30/26 at 9:54am, during an interview with Employee N, a licensed practical nurse (LPN), she was asked if Resident #37 self-administers any of her medications. Upon checking the MAR, she stated yes, she self-medicates her Breo inhaler. She stated see the medication is in green, that indicates a resident self-administers the medication. She was asked how she ensures a resident self-administered a medication if the order indicates that and stated there's nothing to sign. They have to pass a test to ensure they can safely self-administer. She was asked how she knows the medication was taken and stated she asks the resident. If she says no, the nurse will remind her to take it. She was asked where the resident stores her inhaler and stated she was not sure. She was asked if Resident #37 had taken her morning medications today and stated not yet because she's in therapy right now. On 1/30/26 at 10:30am, during an interview with Resident #37, she was asked if she self-administers any of her medications. She stated, Yes, I have my Breo inhaler. They weren't bringing it on time, so I wanted to keep it in my room. I talked to the Administrator, and he said it was ok. She was asked where she stores it and she said in her locked bedside table drawer. A review of the medical record for Resident #37 revealed: A Minimum Data Set (MDS) annual evaluation dated 10/22/25 revealed Section C (Cognitive Patterns) Brief Interview for Mental Status (BIMS) was conducted, and the resulting score was 15. A score of 13-15 indicates the resident assessed is cognitively intact. Section of E (Behavior) of the same assessment on the same date revealed Resident #37 did not have any behavioral symptoms. A review of the Self-Administration of Medication Evaluation completed for Resident #37, dated 1/27/26, revealed the resident was assessed for self-administration of Nystatin Powder 100,000 unit/gram Apply to groin abdominal folds topically every shift for redness and Anti-Diarrheal Solution (Loperamide) with no instructions on the assessment. The assessment did not reveal Resident #37 was assessed for self-administration of Breo Ellipta Inhalation Aerosol Powder Breath Activated 50-25 micrograms/inhalation. A review of the comprehensive person-centered care plan for Resident #37 revealed: Focus: (1/20/25, revised 1/28/26) The resident has a physician's order for self-administration of the following medications: Refresh Plus Ophthalmic Solution, Anti-Diarrheal Oral Solution (Loperamide HCl), Nystatin Powder 100,000 UNIT/GRAMGoal: The resident will demonstrate the ability to take medications at the correct dose, route, time, frequency and for the right reason. Resident able to verbalize of side effects to report.Interventions: Assess resident's ability to safely self-administer medications specified on admission/re-admission, quarterly, with change in medication orders and with significant changes in condition. May keep medication at bedside as ordered. Review medication self-administration with the resident as needed to reassess abilities. A review of this care plan did not reveal any reference to self-administration of Breo Ellipta Inhalation Aerosol Powder Breath Activated 50-25 micrograms/inhalation. On 1/30/26 at 12:42pm, during an interview with the Director of Nursing (DON), she was asked if Resident #37 had been assessed for self-administration of her Breo inhaler. She stated no, she doesn't have an assessment for that medication. She was asked if Resident #80 had been assessed for self-administration of Artificial Tears. She stated she was assessed for that today. She was asked to confirm Resident #80 was only assessed for self-medication as of today, and not at any other previous date during her stay at the facility. She stated that was correct. She was asked if Resident #116 had been evaluated for self-administration of her Flonase and artificial tears and stated yes. She was asked where and/or how residents with self-administration medication orders store their medication in their rooms. She stated they would store them at bedside; they have a locked drawer to store them in after use. She was asked if the expectation was that the self-administered medications be stored in a locked drawer. She stated that's what we expect them to do. She was asked if she was aware Resident #116 was not securing her self-administered medications securely and stated no. A review of the facility policy titled Self-Administration of Medications (undated) revealed:Purpose: To respect the wishes of competent residents to self-administer prescribed medications.To provide evaluation process to determine if a resident is capable of self-administration. Procedure: 1. If a resident desires to participate in self-administration, the interdisciplinary team will assess the competence of the resident to participate by completing a Self-Administration of Medication Evaluation. 2. The nurse will interview the resident to determine their ability to identify, prepare, and administer medications. 3. The nurse will obtain a physician's order for each resident conduction self-administration of medications. 4. The nurse will educate the resident regarding reaction and side effects of the medication. 5. Nurses will evaluate compliance of self-administration and record self-administered medications as indicated. A review of the facility policy titled Medication Storage (undated) revealed: Best Practice Guidelines:Medication carts and storage rooms should be locked. This policy did not address the specifics of securing self-administered medications.

Based on observations, interviews, and record review, the facility failed to ensure accurate medical records were reflective of residents' care for one of one resident (Resident #155) observed with edema and ordered to wear compression stockings (snug knee-high socks that provide pressure to the legs, ankles, and feet to improve circulation, reduce swelling, and prevent blood clots), out of a total of 45 residents in the sample. An observation conducted of Resident #155 on 1/27/26 at 10:29 AM found her barefoot and in bed. During an interview at this time, she was asked if she had any socks available to wear. Resident #155 answered, Yes, but they are over there. (pointing across the room to a pair of slippers) No socks or stockings were observed in the vicinity. Resident #155 was able to provide a detailed medical history leading up to her transfer to this facility. During an observation on 1/28/26 at 2:47 PM, Resident #155 was sitting on the side of her bed barefoot. Some mild edema (swelling caused by an accumulation of fluids) was noted to her ankles. When asked about being barefoot, she explained she did not like to wear shoes. When she was first admitted to the facility, they tried some vibrating things on her legs (described intermittent compression devices which are used to stimulate the legs by mimicking walking and prevent blood clots), but she hated them and told staff to get them off. She has not worn them since. When asked if she wore compression stockings, she said she had not. On 1/29/2026 at 11:33 AM, Resident #155 was observed in the beauty parlor getting a haircut. Mild edema was noted to her right ankle. She had on slippers, but no socks or stockings. During a second observation this day at 2:13 PM, Resident #155 was once again observed without socks or stockings. In a final interview at this time, she insisted she had no awareness of any compression stockings. A record review revealed Resident #155 was admitted on [DATE]. Per her comprehensive minimum data set (MDS) assessment dated [DATE], she had a brief interview for mental status (BIMS) score of 13, reflecting she was cognitively intact. Diagnoses included, but were not limited to, chronic obstructive pulmonary disease (COPD- a progressive lung disease), cancer, schizophrenia and medically complex conditions. A psychiatric progress note dated 1/22/26 reflects Resident #155 was pleasant and conversant. She described a detailed medical history to the practitioner, and although she had a diagnosis of schizophrenia, had no presenting symptoms and was not on psychotropic medication. Resident #155 presented with fair short-term memory, normal long-term memory, an appropriate fund of knowledge, logical thought processes, and intact associations. The practitioner noted Resident #155 was compliant with medical care and treatment. Photographic evidence was obtained. Resident #155 had a physician's order dated 1/23/26 for [Brand name] hose (compression stockings) knee high on in the AM (morning), remove in the PM (afternoon/evening), every day and evening shift for prevention. Review of the corresponding treatment administration record (TAR) revealed two different lines for nurses to document the use of the hose, specifically, ON for the Day shift, and OFF on the Evening shift. On 1/23/26 the hose were signed OFF on the evening shift. The hose had been signed off by nursing staff for both the day shift as ON and the evening shift as OFF on 1/24/26, 1/25/26, 1/26/26, 1/27/26, 1/28/26 and 1/29/26. (Photographic evidence obtained) Further review of the record revealed no corresponding nursing or exception notes indicating Resident #155 had refused or removed her physician's ordered stockings, and no record of reporting non-compliance with their use to the prescribing physician. An interview was conducted with Employee K, Registered Nurse, on 1/29/2026 at 2:13 PM. She explained Resident #155 did wear compression stockings but had asked her to remove them this morning. When asked what time Employee K removed the stockings, she said, About 2 (PM). When advised Resident #155 was in the beauty parlor without her hose at 11:33 am, Employee K hesitated, then said Resident #155 could remove them herself. Any refusals to wear the stockings would be noted on the TAR. An interview was conducted with Employee L, Certified Nursing Assistant (CNA), on 1/29/2026 at 2:21 PM. He confirmed he was assigned to Resident #155. When asked about the compression stockings, he stated he had seen her in those a while ago but couldn't recall when. He could not recall seeing them on recently. Employee L confirmed the CNAs can apply compression hose; nurses usually give them to the CNAs to put on the resident. An interview was conducted with the Director of Nursing on 1/30/26 at 10:51 AM. She said she heard Resident #155 was removing her physician's ordered hose. She was asked if resident refusals were expected to be noted on the TAR. The DON said she wasn't sure. When advised Resident #155 was observed for 3 days without the hose and denied their existence, the DON acknowledged nurses were signing the TAR that the stockings were applied as ordered, instead of noting refusals or removal. Review of the facility's clinical guidance manual's subject Elastic Stockings CCHC0608, no date) revealed the purpose of the stockings is to prevent formation of deep vein thrombosis (blood clots) and potential pulmonary embolism (sudden blockage in the lung artery that usually results from a blood clot travelling from the legs), provide support for, and aid return of circulation from lower extremities. Procedures directed to apply the stockings per the plan of care and ensure they were worn in bed and during ambulation to provide continuous therapy. The application of stockings should be documented in the resident electronic record. (Photographic evidence was obtained)

Based on the kitchen food service observations, staff interviews, facility record review, and facility policy and procedure review, the facility failed to document temperatures and sanitation, and clean and maintain kitchen foodservice equipment to prevent the outbreak of foodborne illness, with the potential to affect all residents who consumed foods from the facility. The facility failed to maintain temperature logs for the 3-compartment sink and maintain the kitchen oven in a clean and sanitized condition. Food safety and sanitation is important in health care settings serving nursing home residents. Kitchen equipment shall be maintained and kept free of food residue and other debris to avoid a potential source of pathogen exposure. The findings include: An initial tour of the kitchen was conducted on 2/12/24 at 10:55 AM. During the tour, there was no temperature log sheet maintained for the 3-compartment sink. During the initial tour on 2/12/24 at 11:05 AM, Cook G reported that he washed, rinsed, and sanitized dishes in the 3-compartment sink and there was no sheet to document temperatures. He confirmed that he had not documented temperatures and sanitation after washing dishes in the 3-compartment sink. During the initial tour of the kitchen on 2/12/24 at 11:10 AM, the Certified Dietary Manager (CDM) was asked to provide the temperature log for the 3-compartment sink. The CDM initially stated staff mostly used the dish machine and had not used the 3-compartment sink, but later provided a blank temperature log dated 9/2023. The CDM later confirmed there were no 3-compartment sink temperature logs for the past 6 months. (Photographic evidence obtained) A follow-up kitchen tour was conducted on 2/14/24 at 12:15 PM. Two ovens had food residue, a white powdery substance, and grease deposits on the floor below the rack and on and around the doors. The bottom convection was covered with food debris and grease build-up on and around the inside oven door. The mixer, located next to the prep table, with clear plastic covering, had food debris stuck on and around the safety guard. The same observations of the two ovens were made again on 2/15/24 at 1:40 PM. (Photographic evidence obtained) An interview was conducted on 2/15/24 at 1:45 PM with Cook H. She reported the cook was responsible for documenting temperatures and sanitation for the 3-compartment sink. The cook or any staff that use equipment outside of the cook area was responsible for cleaning after each use or as needed. When asked how often the ovens and mixer were cleaned, she replied, It varies depending on its use. The oven was cleaned yesterday. Before that day, it had been a while since it was last cleaned. An interview was conducted on 2/15/24 at 1:54 PM with Cook I, who reported the cook was responsible for documenting 3-compartment sink temperatures daily after breakfast, lunch, and dinner. He also stated the cook was responsible for cleaning the oven. Other kitchen equipment was cleaned after each use or weekly if not used and kept covered with plastic. A second interview was conducted on 2/15/24 at 1:57 PM with the CDM. She reported the cooks or any kitchen staff were responsible for cleaning the kitchen and food service equipment. Ovens were cleaned weekly by the cook and mixers were cleaned as needed. She stated, I just created job flows for all the positions. When asked who was responsible for documenting temperatures and sanitation for the 3-compartment sink, she confirmed it was the cook. When asked what the requirement for documenting temperatures for the 3-compartment sink was, the CDM stated staff had not used the 3-compartment sink due to the CDM cleaning and organizing the dish area. They had not really started using the sink because there were no stoppers. The stoppers were received about one month ago, but the staff used the 3-compartment sink mainly to soak pans. An interview was conducted on 2/15/24 at 2:05 PM with Dietary Aide K. She reported the cook cleaned the oven. The mixer was cleaned by whoever used it last or weekly if not used. When asked how often the oven was cleaned, she replied, weekly. When asked what the requirement for documenting the 3-compartment sink temperatures was, Dietary Aide K was not sure of the requirement for documenting the 3-compartment sink. She stated it was the cook's responsibility. When asked how often the 3-compartment sink was utilized, she confirmed it was used daily, three times a day and as needed. Whoever washed dishes was responsible for documenting the temperature and sanitation. A review of the facility's policy and procedure titled HACCP Tips for Food Safety (dated 2015) revealed: Staff to be educated and supervised on HACCP information and procedures. Procedure #8. Dishwashing: Be sure the wash and rinse temperatures are appropriate for your dish machine. Document temperatures regularly on a temperature log. Policy and Procedure entitled Sanitation - Overview dated 2015 revealed: Standards established by the U.S. Public Health Service FDA Food Code are followed regarding safe food handling techniques and food temperatures. Procedure #18. Clean and sanitize food-contact surfaces and equipment: before and after every use, at least every 4 hours during continual use. 19. Maintain clean and sanitary kitchen facilities and equipment by following cleaning instructions procedures. (Copy Obtained) Reference: 2022 Food Code, United States Food and Drug Administration. Chapter 4, Page 127 and 165. https://www.fda.gov (Accessed on 2/20/24). Equipment, Utensils, and Linens. 4-601.11 Equipment, Food-Contact Surfaces, Nonfood-Contact Surfaces, and Utensils. (A) Equipment Food-Contact Surfaces and Utensils shall be clean to sight and touch. (B) The food-contact surfaces of cooking equipment and pans shall be kept free of encrusted grease deposits and other soil accumulations. (C) NonFood-Contact Surfaces of Equipment shall be kept free of an accumulation of dust, dirt, food residue, and other debris.

Based on interview and record review, the facility failed to make prompt efforts to resolve a grievance for one (Resident #77) of one resident reviewed for personal property (missing clothing) from a total sample of 53 residents. The findings include: On 02/13/24 at 12:54 pm, Resident #77 stated he lost his pants on two different occasions. He could not remember the exact dates, but stated it was around August 2023 and December 2023. He added that he notified the certified nursing assistant (CNA), but he could not recall the employee's name. He also notified the housekeeping director. Per the resident, the facility had not done anything about it. He stated at one time he even provided the receipt when he bought replacement pants, but the facility never reimbursed him. He stated he had already lost the new pants that he bought despite putting his name on them. He was frustrated because he liked a particular brand of pants. The quarterly minimum data set (MDS) assessment, with an assessment reference date (ARD) of 12/11/23, revealed that the resident had a Brief Interview for Mental Status (BIMS) score of 15 out of 15 possible points, indicating that he was cognitively intact. A review of the facility's Grievance Log from August 2023 through February 2024 revealed that there were no grievances documented for Resident #77. In an interview on 02/14/24 at 10:59 am, the Housekeeping Supervisor stated when residents were admitted to the facility she introduced herself within 24 hours. If the resident chose to have their laundry done by the facility, she took the clothing to the laundry for labeling. She added that she also encouraged residents who wanted family to do their laundry to have their clothing labeled in case the clothing was inadvertently sent to the laundry. When asked how residents' clothing was sent to the laundry, she said, Residents' clothes are sent to the laundry with the linen. When it gets to the laundry, it is sorted and washed separately. Normally residents have their clothes back within 24 hours. She was asked to explain the process if she was notified that a resident had missing clothing items. She stated she checked the lost and found, and if the items could not be located, the resident was asked for the clothing receipt and social services took over from there for reimbursement of the lost items. She was asked if she was aware that Resident #77 had missing pants. She confirmed that the facility did this resident's laundry. She stated the resident reported his missing pants but she could not find them. She added that she reported this to the Social Services Director and the resident provided the receipt, but she was not sure if the resident was reimbursed. On 02/14/24 at 11:32 am, an interview was conducted with the Assistant Administrator. She stated she was stepping in for the Social Sservices Director who was on leave. She was asked to explain the facility's process for residents' personal items that went missing. She stated if the laundry department could not locate the missing items, the resident was asked to provide the receipts for reimbursement. She was asked if Resident #77 had a grievance related to missing clothing items, and she replied, I am not sure but I will check. For the grievance I am aware of, I think the daughter was reimbursed. On 02/14/24 at 3:06 pm, the Assistant Administrator stated she checked the facility's records and she could not find a formal grievance filed for Resident #77. She stated she contacted the daughter, who mentioned that she had replaced the pants and she provided the receipts. When asked to describe the grievance process, the Assistant Administrator stated the person who received the grievance should write it down, then pass the grievance to the Social Services. Social Services then assigned someone to investigate, and once resolved, got back with the resident about the resolution. She added that she had re-initiated the grievance. (Copies obtained) A review of the facility's policy and procedure titled Grievances/Complaint reports (effective 2008), revealed: The policy purpose read, To document receipt of a grievance or complaint, facility action and resolution. A grievance is defined as a concern or complaint that is unable to be immediately resolved and requires further investigation and action by facility leadership to achieve a resolution. The procedure guideline included: Responsible person: -May be initiated by any staff member upon identification of grievance or complaint. -Follow up conducted by Grievance Official, Administrator or the Director of Social Services or Designee. When: - Upon identification of a grievance /complaint. - Follow up done as soon as possible after identification. Instructions: Receipt and documentation of the grievance /Complaint. 1. Enter the date notified of the grievances/ complaint. 2. Print the name of the staff member receiving the grievance /complaint. 3. Enter a check to indicate the person (s) initiating the grievance/ compliant. 4. Print the individual's name initiating the grievance/complaint.5. Print the phone number of the individual initiating the grievance/ complaint. 6. Document the factual description of the concern. 7. Sign as the staff member documenting the concern. Assignment of Actions 8. Identify and document the individual (s) designated to take action on the concern. 9. Enter the date assigned and the date to be resoled by 10. Note: Initial investigation and report will occur within three (3) working days , of the receipt of the grievance.

Based on observation, medical record review, and staff interviews, the facility failed to ensure a new Pre-admission Screening and Resident Review (PASARR) was conducted for one (Resident #38) of two residents reviewed for PASARR completion from 53 residents in the sample. Resident #38 had psychiatric diagnoses that were not documented on the original PASARR and should have been screened for a Level II after admission to the facility. The fndings include: A review of the medical record for Resident #38 revealed an admitted [DATE] and included the following diagnoses: schizophrenia and dementia with mood disorder. The current PASARR received by the facility on 12/12/23 noted no diagnoses checked under Section I, and under Section II, a diagnosis of dementia was checked no. An interview was conducted with the Assistant Administrator on 02/15/24 at 11:38 a.m. She stated she was filling in for the Social Services Director while she was on leave. She stated a PASARR was needed for admission to the facility and was reviewed and discussed in morning meetings. The PASARR was reviewed for accuracy, and if there was a diagnosis of schizophrenia, bipolar disorder and other psychiatric diagnoses, [Beneficiary and Family Centered Care Quality Improvement Organization] would be contacted online and a new PASARR would be generated. Notification would be sent if a Level II was needed. The Assistant Administrator reviewed the PASARR for Resident #38 with the resident's admission diagnoses on electronic medical record. She stated nothing was checked. The resident was diagnosed with schizophrenia and dementia, and a new PASARR should have been generated. She did not know if this happened and stated she would check the [Beneficiary and Family Centered Care Quality Improvement Organization] website. An interview was conducted with the Assistant Administrator on 02/15/24 at 1:42 p.m. She confirmed that there was no new PASARR generated for Resident #38 and she would notify the nurse to initiate a new one.

Based on observations, interviews, and medical record reviews, the facility failed to ensure that one (Resident #6) of four residents reviewed for wound care, from a total sample of 53 residents, received wound care according to professional standards of practice to promote healing. The findings include: A review of the medical record revealed that Resident #6 was admitted to the facility on [DATE] with diagnoses including acute obstructive pulmonary disease with acute exacerbation, hypertension, sleep apnea, chronic pain, unspecified dementia - unspecified severity with psychotic disturbance, and depression - unspecified. On 02/13/24 at 9:50 AM, Resident #6 was observed with an undated adhesive wound care wrapping on her right forearm. On 02/14/24 at 10:05 AM, a second observation was made of Resident #6. She had the same undated adhesive wound care wrapping on her right forearm. On 02/15/24 at 10:47 AM, a third observation was made of Resident #6 with the same undated adhesive wound care wrapping on her right forearm. The resident reported she was scheduled to have wound care performed yesterday (02/14/24) and didn't receive the scheduled wound care. A review of the 01/25/24 physician's order for wound care revealed: Clean right forearm biopsy site with soap and water, apply ointment, cover bandage daily until site heals. The start date was noted as 01/25/24. A review of the resident's care plan, dated 10/19/23, revealed the following focus area: The resident has a potential for impaired skin integrity r/t impaired mobility. Date initiated 10/19/23. Revision on 10/19/23. Goal: The resident will be free from skin breakdown through the review date. Interventions: Administer/monitor effectiveness of medications as ordered. Administer treatments as ordered and monitor for effectiveness. Encourage good nutrition and hydration in order to promote healthier skin. Encourage patient to float heals whenever in bed. Identify potential causative factors and eliminate/resolve when possible. If skin breakdown occurs, treat per facility protocol and notify MD (physician), family. Keep skin clean and dry. Use lotion on dry scaly skin. Turn and reposition as needed. Weekly skin checks per facility protocol. On 02/15/24 at 11:48 AM, Registered Nurse (RN) N was interviewed. She reviewed Resident #6's electronic medical record and reported that the order for wound care documented: Clean right forearm biopsy site with soap and water, apply ointment, cover with bandage daily until site heals with at start date of 01/25/24. She reported that the standard practice for wound care should include initialing wound care dressings by the nurse who provided wound care and then documenting the date wound care was administered. She explained that according to the resident's electronic medical record, the last time the resident received wound care was on 02/14/23 at 18:43 (6:43 PM). On 02/15/24 at 11:54 AM, RN N verified that Resident #6 had no date or initials on her wound care dressing. On 02/15/24 at 11:58 AM, the Assistant Director of Nursing (ADON) was interviewed. She explained that when wound care was provided by nursing staff, the date should be entered on the wound care dressing so staff were aware that wound care was provided. She further explained that she preferred to put her initials on the wound dressing so staff were aware of who provided the wound care. On 02/15/24 at 12:01 PM, Resident #6 showed her wound care dressing to the ADON, who verified that the wound care dressing had no date indicating the last date of wound care. The ADON removed the bandage and reported that she observed a wound approximately four to five centimeters in length and two and a half centimeters in width. On 02/15/24 at 2:22 PM, an interview with the Wound Care Nurse was conducted. She reported she had been employed at the facility for two years. Wound care rounds and rounds with the facility assigned wound care physician occurred once a week on Thursdays. During each shift, the expectation was for her to learn about new admissions who required wound care. She was not familiar with Resident #6's wound care order and reviewed the electronic medical record. She explained that according to Resident #6's electronic medical record, the order instructed nursing staff to clean the right forearm, cover with a band aid daily until site heals with a start date of 01/25/24. She further explained that the standard of practice for wound care was to date wound care dressings with the date of wound care and to initial them identifying who provided the wound care. The resident's Medication Administration Record/Treatment Administration Record (MAR/TAR) was reviewed and revealed that Resident #6 did not receive wound care treatment on 01/29/24, 02/06/24, 02/07/24, or 02/11/24. On 02/15/24 at 5:02 PM, the Wound Care Nurse was again interviewed. She reported she did not know how to review blank spaces on the MAR/TAR to research why Resident #6 did not receive wound care treatment on 01/29/24, 02/06/24, 02/07/24, or 02/11/24. She verified that wound care treatment for Resident #6 was not documented as having been provided on 01/29/24, 02/06/24, 02/07/24, or 02/11/24. She confirmed that care not documented in the electronic medical record reflected that the care was not provided. A review of the facility's Skin Integrity policy (Copyright 2008), revealed: Clinical Guideline Manual and Subject: Skin integrity documentation should address . A description of dressings and treatments. A review of Nursing.Com Wound Care - Dressing Change (1) (s) (Accessed on 02/15/24) revealed: Best standard of practice for wound care process is to time, date and initial wound care dressings.

Based on observations, interviews, and medical record reviews, the facility failed to ensure that one (Resident #22) of two residents reviewed for pressure ulcers, from a total sample of 53 residents, received pressure ulcer care according to professional standards of practice to promote healing, prevent infection, and prevent new ulcers from developing. The findings include: On 02/13/24 at 11:16 AM, Resident #22, was observed lying in an upright position in bed, covered by a blanket with a nasal cannula in place. When greeted, she moaned and pointed to the corner where a family member was seated. The family member introduced herself as Resident #22's daughter, and stated her mother recently returned from the hospital and should be receiving treatment for the two sores on her bottom. She said the hospital ordered wound care treatment along with frequent re-positioning, but she felt the facility was not addressing the wounds, and she feared the wounds would worsen. A review of Resident #22's record revealed her initial admitted was 2/9/2022 with a readmission on 2/10/24. Her diagnoses included COVID-19, acute and chronic respiratory failure with hypoxia, and dementia. The facility's admission notice, dated 2/10/24 at 18:51 (6:51 PM), and signed by the authorized RN, revealed that the resident was alert and oriented x2 (She knew who she was and where she was, but not what time it was or what was happening to her). She was incontinent of bowel and bladder, and had two sacral pressure ulcers that were open to air with wound care orders to apply ointment and leave open to air. (Photographic evidence obtained) A review of the Admission/Readmission Minimum Data Set (MDS) assessment, dated 2/11/24, revealed that Resident #22 had a left thigh (front) skin tear, a left buttock stage 2 pressure ulcer, and a right buttock stage 2 pressure ulcer. A review of the active physician's orders revealed there were no active orders for wound care treatment in place addressing Resident #22's left buttock stage 2 pressure ulcer, or right buttock stage 2 pressure ulcer. (Photographic evidence obtained) A review of the care plan addressing skin integrity and wound care, provided by RN, Regional Director of Clinical Services/Interim DON, revealed no updates or revisions had been made since 01/18/24, no mention of the left or right buttock stage 2 pressure ulcers was noted, and no baseline care plan was provided. (Photographic evidence obtained) On 2/14/24 at 10:23 AM, a second observation was made of Resident #22, who was joined by her daughter. Her daughter stated, You just missed her Certified Nursing Assistant (CNA) changing her and providing wound care. She put that cream over her sores and left them uncovered. The daughter pointed to a yellow tube of cream that was uncapped. [NAME] residue was observed on the outside of the tube located on top of Resident #22's dresser that read, Triad Hydrophilic Wound Dressing Pansement hydrophile, Coloplast 2.5 oz. (An over-the-counter zinc oxide-based wound treatment for difficult to dress sacral wounds. It can be used on wet, eroded skin, including macerated skin.) (Photographic evidence obtained) On 2/14/24 at 12:54 PM, an interview was conducted with Licensed Practical Nurse (LPN) C, who had been assigned to Resident #22, and who confirmed that upon admission and readmission, all discharge orders should be verified, skin issues documented, and a head-to-toe assessment completed within the first 24 hours. She reported not being aware of any skin conditions for Resident #22, but after reviewing the electronic medical record, she stated the resident had two pressure wounds to the sacrum, and the physician's orders for wound treatment could be found in the MAR/TAR. She was asked to review the MAR/TAR showing the wound care orders. After her review, she confirmed there were no current active physician's orders for wound care treatment located on the MAR/TAR or in the electronic medical record. On 2/14/24 at 1:35 PM, Resident #22's wounds were observed by a registered nurse surveyor (RNS) along with LPN C. Per the RNS, the wound was approximately 5 cm x 7 cm (centimeters), with a pink-red wound base and no slough (dead tissue). (Photographic evidence obtained) On 2/15/24 at 2:20 PM, the Wound Care Nurse reported all new admissions and readmissions were discussed in the facility's morning meetings. She was then provided with a list of all the residents who triggered with new skin/wound orders that she made rounds on for treatment that day. When asked if she was familiar with Resident #22, she stated she was. She visited with her yesterday evening and confirmed that the resident did come in with a stage 2 pressure ulcer, and the admitting nurse should have obtained the order. She added that she reached out to the physician to evaluate the wound and mentioned that the measurements were approx. 11 cm x 7 cm because the physician clustered all three open areas into one. She added that treatment orders were put in place as of 2/15/24 and barrier cream was being applied for treatment. When asked if barrier cream would require a doctor's order she stated, Yes, there should be an order to apply the barrier cream. She further confirmed there were no active physician's orders in place for Resident #22 for barrier cream and stated, If the order wasn't there, that means the admitting nurse missed it. The Wound Care Nurse was asked to look at the photo of Triad Hydrophilic Wound Dressing Pansement hydrophile, Coloplast 2.5 oz. that was observed in Resident #22's room. She was then asked to identify the item. She stated the item was not barrier cream, but what appeared to be wound cream. She further confirmed that the wound cream observed in the photo would be applied by a licensed nurse, not a CNA. A review of the facility's policy on Pressure Ulcers (CCHC 0312, with a copyright year of 2016), noted on page 1, item #8: Perform wound care as per the physician's orders. A review of the facility's policy on Admission Completion Check-Off List Mandatory Forms (copyright year of 2016), noted on page 1, Item #10: Skin and Wound Evaluation Completed. Page 1, Item #13: Admit/Re-Admit orders verified with MD (physician). Two nurses sign off for accuracy. On page 2, Item line #11: Treatment orders for all skin areas/wounds noted upon admission. On page 3, Item line #7: 2nd Skin Sweep Completed by Unit Manager. On page 3, Item #9: Unit Manager to review Admission Orders for Accuracy.

Based on observations, record review, staff interviews, and a review of the policy and procedure for Oxygen Therapy, the facility failed to ensure oxygen was administered at the physician-ordered flow rate for two (Residents #29 and #129) of six residents reviewed for oxygen use, from a total sample of 53 residents. The findings include: 1. An observation was made of Resident #29 in her room on 2/12/14 at 11:00 a.m. She was observed with oxygen infusing via a concentrator through a nasal cannula. She reported her oxygen flow rate should have been set at 3 liters per minute (LPM). Her oxygen concentrator was observed with a flow rate set at 2.5 LPM. A medical record review for Resident #29 revealed an admitted [DATE] with the following diagnoses: chronic obstructive pulmonary disease (COPD), obstructive sleep apnea, and atrial fibrillation. A 1/23/24 physician's order noted oxygen at 2 LPM as needed (PRN) for oxygen saturations of less than 92% for COPD. The care plan, updated on 1/23/24, noted: Resident has altered respiratory status/difficulty breathing related to COPD and sleep apnea. Interventions included to elevate the head of the bed, and administer oxygen as ordered. On 2/12/24 at 2:00 p.m., an observation was made of the resident in her room using oxygen and the concentrator was set at 3 LPM. On 2/13/24 at 9:30 a.m., an observation was made of the resident in her room using oxygen and the oxygen flow rate was set at 2.5 LPM. On 2/14/24 at 9:20 a.m., an observation was made of the resident in her room using oxygen in bed, which was set at a flow rate of 3 LPM. A review of the February 2024 Medication Administration Record (MAR), noted oxygen at 2 LPM via nasal cannula PRN for oxygen saturations of less than 92%. Vital signs were documented with oxygen saturations at 94% or above on all days except 2/1/24, when her saturation was documented at 84%. An interview was conducted with Licensed Practical Nurse (LPN) A on 2/14/24 at 1:38 p.m. She reviewed the oxygen order for Resident #29 and reported the oxygen was to be set at 2 LPM PRN. She was not aware that the resident is wearing the oxygen constantly. She confirmed the order was as needed (PRN) with parameters for oxygen saturations. LPN A walked into the resident's room and confirmed that the oxygen was set at 3 LPM. She changed the oxygen to 2 LPM and confirmed the resident was using the oxygen. 2. An observation and interview was conducted with Resident #129 on 2/12/24 at 12:52 p.m., which noted the resident sitting up in bed with the head of the bed elevated and oxygen infusing at 2.5 LPM via nasal cannula. The resident reported being on 2 LPM of oxygen. A medical record review was conducted which noted an admitted [DATE] with a diagnosis of COPD. The physician's orders were reviewed, which noted continuous oxygen at 3 LPM via nasal cannula on 11/22/23. The MAR was reviewed, which noted continuous oxygen at 3 LPM, dated 11/22/23. The current care plan, updated on 11/22/23, noted: Resident has altered respiratory status related to COPD. Interventions included to administer medications and respiratory therapy as ordered. An observation was made of the resident in her room on 2/13/24 at 9:25 a.m. Her oxygen flow rate was set at 2.5 LPM. An observation was made on 2/14/24 at 9:39 a.m. The resident was sitting up in bed with oxygen infusing at 2.5 LPM. An observation was made on 2/14/24 at 1:15 p.m. The resident was sitting up in a wheelchair with an oxygen canister attached to the back of it. The oxygen canister was set at 2 LPM. An interview was conducted with LPN B on 2/14/24 at 1:26 p.m. She reviewed the resident's physician's order for oxygen and reported it was ordered for 3 LPM. LPN B walked into the resident's room and confirmed the resident had an oxygen canister on the back of her wheelchair with a flow rate set at 2 LPM. The resident wanted her oxygen saturation taken and asked when the oxygen order was changed to 3 LPM. The resident removed her oxygen while the LPN was retrieving the pulse oximeter. The LPN took the resident's oxygen saturation which was 87%. The resident applied the oxygen cannula and the LPN changed the oxygen to 3 LPM. The oxygen saturation went to 95%. A review of the facility's policy for Oxygen Therapy (2019) revealed under Purpose, a statement that oxygen must be prescribed by an appropriate clinician and administered by appropriate clinical staff. Under procedure .5, a statement to check the oxygen prescription, administer according to prescription, and use the appropriate delivery device was in place.

Based on observations, record reviews, and staff interviews, the facility failed to ensure a medication error rate of 5% or less. There were six errors out of 26 opportunities for error, resulting in an error rate of 23% and involving two (Residents #123 and #166) of three residents observed for medication administration. Failure to administer medications appropriately as ordered could result in side effects leading to harm to the residents. The findings include: During a medication administration observation on 2/14/24 at 8:52 a.m., Licensed Practical Nurse (LPN) A was observed preparing medication for Resident #123. She obtained Potassium Chloride (KCL), 20 miliequivalent (meq) tablet and Rytary extended release (ER) 48.75 -195 milligrams (mg) capsule (A combination of carbidopa and levodopa used to treat symptoms of Parkinson's disease). She crushed each medication separately and mixed with applesauce. She did not crush the KCL she mixed in apple sauce. She opened the Rytary capsule and poured the powder in applesauce. She then proceeded to the resident's room and administered the medication to the resident . In an interview on 2/14/24 at 9:10 a.m., LPN A was asked why she did not crush the KCL. She stated Resident #123 took the medication crushed but the the label for KCL indicated do not crush. She was then asked about the Rytary capsule. She said, That's the medication label noted do not crush, but the capsule cannot be crushed, it can be opened and that's why I opened it. She was asked why she did not administer the Lidoderm patch, Omega 3 or Vitamin D. She stated the medications were not in the cart and she would have to get them from central supply. She added that she also had to wait for the resident to finish breakfast so she could apply the Lidoderm patch. On 2/14/24 at 9:35 a.m., Registered Nurse (RN) L was observed preparing medication for Resident #166. She obtained a blister pack of Gabapentin 100 mg (milligrams) and popped one tablet into the medication cup. She then obtained Breo Elipta Inhalation aerosol powder breath activated 100-25 mcg (micrograms). RN L confirmed that there was only one 100 mg gabapentin pill. (Photographic copy of the blister pack obtained) She then proceeded to the resident's room and administered the medication. The resident was not offered water to rinse her mouth after the inhaler treatment. A review of the Breo Ellipta medication package insert revealed instructions to use water to rinse/gargle and spit after dose to prevent yeast infection (candidiasis/thrush). (Copy obtained) A review of the medication label revealed Gabapentin 100 mg, give 2 tablets once a day. A review of the physician's order, dated 1/17/24, revealed Gabapentin 400 mg, give one tablet three times a day. (Copy obtained) In an interview on 2/14/24 at 9:45 a.m., RN L stated Resident #166 had two blister packs of Gabapentin (400 mg and 100 mg). She stated she was confused and chose the wrong dosage. A follow-up interview was conducted with LPN A on 2/14/24 at 10:17 a.m. She confirmed that she had still not given the medication (Lidocaine patch, Omega 3 and Vitamin D) to Resident #123. She added that she was to obtain medications from central supply. During an interview on 2/14/24 at 10:20 a.m., LPN N/Unit Manager said, If the medications are not available in the cart, the nurse should stop and check to see if the medication is in the Pyxis. If it is not available, she should notify the physician and also contact the pharmacy to check when the medication was ordered. For the over-the-counter (OTC) medication, the facility has stock in the medication room and central supply. LPN N was made aware that Resident #123 had not received all of his medication (Lidoderm patch, Omega 3, and Vitamin D). She stated they should be on the cart because she had just restocked all of the medication carts. She proceeded to the medication cart that LPN A was assigned to. She opened the top drawer, obtained the medication fish oil, vitamin D and a Lidocaine patch, and placed the medication on top of the cart. She educated LPN A about medications' generic names. Upon review of Resident #123, LPN A confirmed that she had already checked the medications as having been administered before administering them. A review of the active physician's orders for Resident #123, revealed Cholecalciferol, 1000 units, give one tablet by mouth one time a day. Omega 3 capsule, 1000 mg one time a day for nutritional support. Lidoderm Patch 5 %, apply to lower back topically one time a day. Another follow-up interview was conducted on 2/14/24 at 10:20 a.m. with RN L, who was asked if she had completed medication administration. She replied, I still have around ten residents to give medications to. She was asked when medications were due and she replied, They were due at 9:00 a.m. She added that medications could be administered up to an hour before or an hour after they were scheduled. She confirmed that she was running behind schedule because it was her first time working on the unit. She was then asked what she would do now that she was behind schedule. She said, I will continue to pass them. I was assigned 28 residents and I have to pass to all of them. The nurse was not familiar with the facility's process for late medication administration. A review of the computer screen revealed that 16 residents had not yet received their medication. During an interview with the RN Regional Director of Clinical Services (RDCS)/Interim Director of Nursing (DON) on 2/14/24 at 1:38 p.m., she was informed of the concerns identified during medication administration. She stated additional education would be initiated. A review of the facility's policy and procedure titled Medication Pass Guideline (2008), revealed the Purpose read, To safely and accurately administer medications according to physicians' orders and patient needs. The procedure was outlined as follows: 2 .Read transcribed physicians' orders on MAR, patient name, medication name, dosage, route and interval ordered. - remove medication from the cart - compare MAR with medication label for accuracy 3. If medication is new for the resident, or the medication is unfamiliar or physician order is questioned -read original physician order -compare original physician order with MAR for accuracy -verify allergy status -contact physician for clarification as needed 4. Read special medication instructions Tablet and Capsule - Do not crush medication when contraindicated in a cautionary statement on MAR, if appears on pharmacy list of non-crushable or without a physician's order. 7 . Administration of medications; -Administer medication in accordance with the frequency prescribed by the physician.

Based on observations and staff interviews, the facility failed to ensure medications were stored in locked medication carts for three (Residents #16, #22, and #77) of 53 residents in the total sample. Pain creams and other creams were found in residents' rooms, which could lead to overdosing or harm to other residents. The findings include: 1. An observation was made of Resident #16 in her room on 2/12/24 at 11:57 a.m. She was sitting up in bed with a neck brace on and Voltaren, Triamincolone, and Bacitracin were sitting on her dresser at bedside. The resident reported using her Voltaren for arthritis pain. She was asked about the other creams but did not respond. An observation was made of Resident #16's room on 2/13/24 at 9:30 a.m. The resident was not in the room. Voltaren and Triamincolone were observed at bedside. An observation was made of Resident #16 on 2/14/24 at 9:20 a.m. in her room. She reported not using Triamincoline. She said it came from the hospital. She used Voltaren before therapy and at bedtime. Voltaren and Triamicolone were observed at bedside in a drawer. A review of Resident #16's medical record noted an admitted [DATE] with a re-entry date of 1/18/24 and a diagnosis of Osteoarthritis of first carpometacarpal joint (thumb). The active physician's orders were reviewed, which noted to apply Voltaren gel 1% one application transdermally three times a day for pain, apply 2 grams (gm) to thumb for pain. A review of the current Medication Administration Record (MAR) noted nurses signing out the application of the Voltaren. There was no order for the Triamincolone. An interview was conducted with Licensed Practical Nurse (LPN) B on 2/14/24 at 1:26 p.m. She reported the resident had Voltaren ordered for her thumb pain. She reviewed the order which indicated the medication was to be used three times a day and apply 2 gms to the resident's thumb. She stated the resident wanted it applied to her hip and leg, but there was no physician's order, and the physician would have to be notified to obtain an order for the hip and leg applications. The LPN entered the resident's room and explained to the resident the medication (Voltaren) was on the medication cart, and the medications needed to be locked in the cart. The Voltaren was being applied by the nurses. She asked the resident if she could remove the medications, and the resident became upset, stating, You are going to do what you want, just take it. LPN B took the creams and locked them in the medication cart. An interview was conducted with the Administrator on 2/15/24 at 10:43 a.m. He stated upon admission medications were reviewed with the residents/families and they were made aware that mwdications could not be brought in or left in the resident room. The Welcome Committee also addressed this when meeting with the resident. Residents liked to order things online and receive medications that way. The facility was trying to have residents open packages in front of them to prevent this, but some would not agree to do that. Angel rounds were utilized for opportunities and not meeting the practice. Angel rounds were conducted daily during the week and turned in on Fridays. If there was an issue, it was brought to the Director of Nursing immediately. He was apprised of the creams left in Resident #16's room and he acknowledged receiving the information. He also stated a new improvement plan was started on 2/12/24 recognizing no medications or prescription creams should be left at the bedside of residents. 2. On 02/13/24 at 11:16 AM, Resident #22 was observed lying in an upright position in bed, covered in a blanket, with a nasal cannula in place. When greeted, she moaned and pointed to the corner where a family member was seated. The family member introduced herself as Resident #22's daughter, and reported her mother recently returned from the hospital, and should be receiving treatment for the two sores on her bottom. She said the hospital ordered wound care treatment, along with frequent re-positioning, but felt the facility wasn't addressing the wounds, and feared the wounds would get worse. A review of Resident #22's record revealed her initial admitted was 2/9/2022 and she was readmitted on [DATE]. The facility's admission notice dated 2/10/2024 at 18:51 signed by the authorized Registered Nurse (RN), revealed she was alert and oriented x2, incontinent of bowel and bladder, and had two sacral pressure ulcers that were open to air with wound care orders to apply ointment and leave open to air. (photo evidence obtained) On 2/14/2024 at 10:23 AM, a second observation was made of Resident #22, who was joined by her daughter. Her daughter stated you just missed her Certified Nursing Assistant (C.N.A.) changing her and providing wound care. She put that cream over her sores and left them uncovered. The daughter pointed to a yellow tube of cream that was uncapped, white residue observed on the outside of the tube located on top of Resident #22's personal dresser that read Triad Hydrophilic Wound Dressing Pansement hydrophile, Coloplast 2.5 oz. (Photographic evidence obtained) 42442 3. On 2/13/24 at 1:57 p.m,, Diclofenac cream for Resident #77 was observed on his activity table in his room. In an interview on 2/13/24 at 2:00 p.m., Resident #77 stated he was supposed to apply the cream on his wrist four times a day, but he did not remember to apply it. He said he used it when he remembered. (Photographic evidence obtained) A record review indicated that Resident #77 was admitted to the facility on [DATE] with a diagnosis of acute on chronic systolic congestive heart failure. The quarterly minimum data set (MDS) assessment with an assessment reference date (ARD) of 12/11/23, indicated that the resident had a Brief Interview for Mental Status (BIMS) score of 15 out of 15 possible points, indicating that he was cognitively intact. A review of Resident #77's physician's order dated 10/16/23, revealed Diclofenac Sodium gel 1%, apply to both wrists topically two times a day for arthritis pain. Another observation was made of the resident's room on 2/14/24 at 9:00 a.m. and the medication was still at bedside. During an interview with LPN A on 2/14/24 at 10:17 a.m., she confirmed that the medication was at bedside and stated that it should be in the medication cart.

Based on record reviews, interviews, and a review of the Medication Pass Guideline Policy and Procedure, the facility failed to ensure to maintain complete, accurately documented medical records for one (Resident #50) of 53 sampled residents for blood pressure medication with parameters. Documenting the blood pressures before administration ensures nurses are following the physician's orders and not administering medication if the resident's blood pressure is too low. The findings include: On 2/14/24 at 9:45 a.m., Resident #50 was observed in her room sitting up in bed. She reported she had a sore throat this morning. She reported receiving her medications this morning. A medical record review was conducted for the resident which noted an admitted [DATE] with diagnoses including dementia and hypertension. The active physician's orders were reviewed, which noted Lisinopril 2.5 milligrams (mg) every day for blood pressure and Metoprolol extended release 25 mg daily, hold if systolic blood pressure is below 110. The February 2024 Medication Administration Record (MAR) was reviewed, which noted Lisinopril and Metoprolol were being administered daily with no blood pressures documented. A physician's order dated 6/18/23, noted blood pressures to be taken weekly which was also noted on the February 2024 MAR. An interview was conducted with Licensed Practical Nurse (LPN) C at 3:55 p.m. on 2/14/24. The LPN reviewed the MAR and reported the resident had two blood pressure medications with parameters (Lisinopril and Metoprolol) and whoever put them in did not add space to write in blood pressures. She reported taking residents' blood pressures before administering the medications. When she was asked where she documented those blood pressures, she replied that she documented that information under Vital Signs in the electronic record. An interview was conducted with the Registered Nurse (RN)/Assistant Director of Nursing (ADON) at 1:33 p.m. on 2/15/24. The ADON was asked about inputting orders for medications such as Digoxin (apical pulse needed), and blood pressure medications with parameters. He stated a batch order could be pulled up in the electronic medical record. The nurse would click on the medication and it would give the dosage, parameters, etc. Blood pressures were attached to blood pressure medications with parameters and should be documented on the MAR. The RN reviewed the MAR for Resident #50. The ADON reported the orders were not input correctly, and blood pressures would be taken before administering the medications. He confirmed the blood pressures were not being documented on the MAR or under Vital Signs consistently. He stated, It is not clear whether the blood pressures were taken since it is not documented. A review of the facility's policy and procedure for Medication Pass Guideline, noted to safely and accurately prepare and administer medication according to the physician's order and patient needs. Under procedure 5. it was noted to obtain vital signs if applicable and record results on the MAR.

Based on a review of the Facility Assessment, CMS (Centers for Medicare and Medicaid Services) form 672 (Census and Condition of Residents), and interviews with staff, the facility failed to update the Facility Assessment on an annual basis in order to assess the population's acuity level and determine what resources were needed to provide care for its residents during not only day-to-day operations, but during an emergency. The facility also failed to employ the input of facility staff members including the Medical Director, Director of Nursing, any member of the governing body, residents or their representatives. This had the potential to affect all 124 residents in the facility. Without a comprehensive assessment of the residents' diagnoses, conditions and needs, the facility was not able to determine staff competencies required to provide appropriate care, nor the environment or equipment needed to perform such care. The findings include: A review of CMS form 672, Census and Condition of Residents, found there were 124 residents in the building at the time of the survey. Some of the current population's special care needs included, but were not limited to: 7 indwelling catheters, 3 bedfast residents, 10 residents with contractures, 14 residents with pressure ulcers, 6 residents with depression, 7 residents with dementia, 9 residents receiving hospice services, 4 residents on [CONDITION(S)], 3 residents requiring ostomy care, 55 residents receiving [CONDITION(S)] medications, 34 residents requiring injections, 6 residents receiving tube feedings, 65 residents requiring rehabilitative services, and 4 residents with significant weight loss. The Director of Nursing (DON) signed the CMS 672 on 3/21/22. (Copy obtained) A review of the Facility Assessment (FA), dated 2022, found there were two people involved in completing the assessment; the Administrator and the Compliance Officer. The FA was updated in 3/2020, 10/2020, 1/15/2021 and 1/2022, and the Quality Assurance and Performance Improvement (QAPI) committee reviewed the FA on those same dates. The Resident Profile section reported there were 146 licensed beds. It also asked for the following information: -Average daily census. -Average weekday admissions in 2021. -Average weekend admissions in 2021. -Average weekday discharges in 2021. -Average weekend discharges in 2021. Each section's response noted, Fluctuations due to Covid-19. The section titled Common Diagnoses/Conditions, provided general examples falling under each condition, however, the Acuity section of the FA asked for the following data based on resident needs: -Rehabilitation Plus Extensive Services. -Rehabilitation. -Extensive Services. -Special Care High. -Special Care Low -Clinically Complex. -Behavioral Symptoms and Cognitive Performance. -Reduced Physical Function. All fields asking for the number/average range of residents was left blank. The Special Treatments and Conditions section asked for data on the following resident needs: -Cancer treatments ([CONDITION(S)] and [CONDITION(S)]), respiratory treatments (oxygen therapy, suctioning, trachesostomy care, ventilator/respirator or [CONDITION(S)]/[CONDITION(S)] machines). -Mental health services (behavioral health needs, substance abuse disorders). -Other services (Intravenous medications, injections, [CONDITION(S)], ostomy care, hospice, respite care, isolation or quarantine for active infection diseases and advanced wound care needs). All of the corresponding fields asking for the typical number of residents with these needs were blank. The Assistance with Activities of Daily Living - Currently In-house section asked how many in-house residents required assistance with dressing, bathing, transfers, eating, toileting, mobility or other care needs. All fields were left blank. Section 3, Facility Resources Needed, revealed the facility staffing patterns were based on an average of 125 residents, however, this pattern was considered without first identifying the above resident-specific information. The final Risk Assessment section of the FA, the SWOT (Strengths, Weaknesses, Opportunities and Threats) Analysis was left blank for all 4 sections. (Copy obtained) An interview was conducted with the Administrator on 03/24/22 at 5:43 PM. He was asked where the updates to the 2022 FA were, since there was no assessment of the acuity levels of his resident population. He stated the facility's needs changed last year. After serving all COVID-19-positive residents, the census went to zero then built back up. He had no other explanation as to why residents' needs had not been assessed since initial licensure. He was asked if he had considered that initially, because there were primarily COVID-19-positive residents in the building, and each of those residents had conditions and special treatment needs other than COVID-19. He admitted he had not included that information in the assessment. The Administrator acknowledged after the facility zeroed out on the census, then rebuilt, the new residents' needs were also never assessed in order to determine proper staffing and other resources required to meet those needs. The Administrator was reminded that the FA was driven by census and acuity levels of the residents and without that information, it was not possible to accurately assess facility resources required. He acknowledged the requirement. The Administrator also confirmed that only he and the Compliance Officer were involved in the FA completion. He was not aware additional team members should be involved in its development in order to comprehensively assess needs and plan for meeting those needs. The Administrator stated he would review the FA requirements again.

Based on observation, dietary staff interview, facility document review, and facility policy and procedure review, the facility failed to store, prepare, and serve food under sanitary conditions when the dietary staff failed to wash hands between glove changes and change gloves when contaminated, as required. Food was stored in the walk-in cooler and walk-in freezer uncovered and not date marked. Food was kept beyond the allowed use by date. Baking sheets were wet nesting. Cutting boards were deeply grooved and in need of replacement. Handwashing sinks had no signage posted to indicate the sink was for handwashing only. The handwashing sink in the dish room was blocked by a mop bucket, broom, and dustpan. Food was observed on the floor of the freezer. Paper products to be used by residents were stored on the floor in the nutrition room. Hand hygiene and sanitation is important in health care settings serving nursing home residents due to the risk of serious complications from foodborne illness as a result of their compromised health status. Unsafe food handling practices represent a food safety hazard and a potential source of pathogen exposure for residents. The findings include: On 03/21/22 at 9:54 AM, Dish Room Aide D was observed putting insulated domes that had been washed and were still wet on a rack to air dry. He then went back to the dirty side of the dish room and started rinsing the dirty dishes and loading them into the dish machine. He then went to the clean side of the dish room and stacked the clean glasses on a pan. He did not change his gloves or wash his hands. He continued to go back and forth between the dirty and clean side without changing his gloves or washing his hands. At 10:14 AM, he changed his gloves but did not wash his hands. On 03/21/22 during the 9:54 AM kitchen observation, large stainless steel baking pans were observed to be wet and stacked on top of each other, not able to air dry on a rack near the dish room. Four large cutting boards were worn and deeply grooved. The handwashing sinks had no signage posted to indicate the sink was for handwashing only, and that staff must wash their hands. The milk cooler had no internal thermometer. Inside one milk crate was observed one quart-size carton of whipping cream that had not been opened and was dated 03/19/22. (Photographic evidence obtained) The Certified Dietary Manager (CDM) stated, I don't know why he left that in here. He was just here. Speaking in reference to the milk delivery man. On 03/21/22 at 10:20 AM, the walk-in cooler was observed with a large ham that was on a tray with plastic wrap covering it. There was no date mark. The CDM stated she thought a dietary aide had opened the package and sliced off a piece last Friday (03/18/2022). (Photographic evidence obtained) Cheese sandwiches were observed prepared and stacked in a large stainless steel pan with plastic wrap covering part of the pan. The sandwiches were not date marked. (Photographic evidence obtained) Eleven quarts of scrambled egg mix were on a tray on a bottom shelf. The date mark on the cartons was 03/07/22. (Photographic evidence obtained) The CDM confirmed they were out of date and needed to be discarded. Sliced cheese wrapped in plastic wrap was observed stacked on a large pan. The opened packages were not date marked. (Photographic evidence obtained) A cardboard box with cucumbers had one cucumber wrapped in plastic wrap with no date mark. (Photographic evidence obtained) A plastic re-sealable bag with sliced corned beef was dated 03/11/22. (Photographic evidence obtained) A pan of baked fish sitting on a shelf was observed to be uncovered. (Photographic evidence obtained) Two pans were observed covered with aluminum foil with no date marks. (Photographic evidence obtained) A plastic container was observed with lettuce in it. It was not covered or date marked. (Photographic evidence obtained) The CDM stated the expectation was that the dietary staff would cover the food and date mark it in the cooling units. On 03/21/22 at 10:42 AM, the walk-in freezer was observed with frozen beef patties uncovered in a box. (Photographic evidence obtained) Frozen plant-based chicken strips were observed uncovered in the freezer.(Photographic evidence obtained) There were two packages of unidentified frozen food observed on the floor of the freezer. (Photographic evidence obtained) During a second tour of the kitchen on 03/23/22 at 11:16 AM, observed in the walk-in cooler was the same plastic re-sealable bag with sliced corned beef that was dated 03/11/22. (Photographic evidence obtained) Observed in the walk-in freezer was the box of frozen beef patties still open and uncovered. An open box of frozen zucchini sticks was observed. (Photographic evidence obtained) The handwashing sink was still blocked by the mop bucket, broom and dust pan. There was still no signage at the sink. (Photographic evidence obtained) Observed wet nesting of baking sheets and pans. (Photographic evidence obtained) Dietary Staff C was observed preparing the lunch meal in the main kitchen on 03/23/22 from 11:50 AM until 12:25 PM. At 12:04 PM, he was observed wearing a pair of disposable gloves and was cooking the vegetables and meat patties. He touched the handle on the walk-in cooler, returned to the preparation area and continued to prepare the meal. He did not change his gloves. At 12:15 PM he changed gloves but did not wash his hands in between. He touched the handles of the oven and utensils used for the preparation of the meal. He moved food pans from the preparation area to the steam table, using a pair of oven mitts, touching the surfaces of the steam table. He doffed the oven mitts and donned new disposable gloves without washing his hands. On 03/23/22 at 12:35 PM, the Bistro kitchen and nutrition room on the second floor of the facility were toured. Paper products were stored on the floor in the nutrition room. (Photographic evidence obtained) On 03/23/22 from 12:35 PM until 12:50 PM, Housekeeping Staff Q and Social Services Staff R were working in the Bistro kitchen during the lunch food service and were observed donning and doffing disposable gloves without washing their hands in between. Social Services Staff R was preparing sandwiches on a panini press. She touched the utensils to make the sandwiches and kitchen equipment with her gloved hands and then touched the ready to eat sandwiches with her contaminated gloves. The hand sink for employees to wash their hands was located in the nutrition room next to the Bistro kitchen. During an interview with Dietary Staff C on 03/24/22 at 8:25 AM, he was asked if he was supposed to change his gloves when they became contaminated and wash his hands prior to donning new gloves. He replied Yes. Did I not do that? When he was informed that he was observed on 03/23/22 during the lunch meal service not changing gloves as needed and not washing his hands prior to donning new gloves, he stated, Oh, I'm sorry. I was a little nervous. During a 03/24/22 interview with the CDM at 8:35 AM, she stated she was not aware that her staff were changing gloves without washing their hands. She agreed that the food in the cooler and freezer was not covered. She stated the staff were running in there in a hurry, grabbing what they needed and then not covering it again. She confirmed that she did not have enough room in the kitchen to air dry the dishes. A review of the Food Storage Chart For Safety and Quality, used by the facility for date marking and shelf time, revealed prepared meat products should be kept only three days wrapped in the refrigerator. (Copy obtained) A review of the staff training dated 03/09/22, entitled Food Handling and Food Safety, Glove Usage, revealed Dietary Staff Q and Social Services Staff R received the training. A review of the staff training dated 02/17/22, entitled Storage of Foods Food Safety and Leftovers, revealed Dietary Staff C received the training. A review of the facility policy and procedure for Food Storage Overview revealed: Purpose: Food is stored by methods designed to prevent contamination. 3. Food items should be stored on shelves. 4. Containers are to be labeled. 11. Food is stored a minimum of 6 inches above the floor. 12. Leftover food is stored in covered containers or wrapped securely. Each item is securely labeled and dated before being refrigerated. Leftover food is used within 2 days or discarded. 14. e. Foods are to be covered, labeled, and dated including month, day, and year. A review of the facility policy and procedure for Glove Use revealed: Wash hands thoroughly before and after wearing or changing gloves.

Based on observations, resident and staff interviews, and a review of resident records and facility policies, the facility failed to accurately document resident medication and treatment records for one (Resident #121) of one resident who reported problems with receiving treatment and medication, out of six residents whose medication regimens were reviewed, from a total of 42 residents in the sample. The findings include: An observation of and an interview with Resident #121 was conducted on 03/22/22 at 10:24 AM. During the interview, she commented that by this time of day, her legs should already be wrapped. They were still not wrapped. She explained that staff were supposed to wrap her legs daily with ace bandages, however, some days it was after 4:00 PM or 5:00 PM by the time they finally applied the wraps. Some days, the staff did not apply them at all. Resident #121 added that her doctor recently prescribed her some nasal spray, but she still had not received it. It was intended for her wheezing and coughing. An observation at this time found no ace bandage wraps on either of Resident #121's lower legs, which were both edematous (swollen due to a buildup of fluid). Resident #121 was observed on 03/22/22 at 1:43 PM and again at 4:21 PM, and the ace wraps had still not been applied. During an observation and interview with Resident #121 on 03/23/22 at 10:08 AM, she had ace bandage wraps to both of her legs below the knees. She reported that Agency Certified Nursing Assistant (CNA) N wrapped her legs this morning before she got out of bed. She had gone to therapy this morning and the bandages were now loose. When asked if the wraps had been applied yesterday (3/23/22) after the 4:21 PM observation, she said, No. A record review for Resident #121 found she was readmitted to the facility on [DATE]. The 5-day minimum data set (MDS) assessment, dated 02/27/22, indicated Resident #121 had a brief interview for mental status (BIMS) score of 14 out of a possible 15 points, indicating she was cognitively intact. Resident #121 had a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . She also had a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The order was written on 3/14/22 (8 days ago), but said it was still Pending Confirmation instead of Active. (Copies obtained) A review of the electronic medication administration record (eMAR) found the [MEDICATION(S)] nasal spray was scheduled to be administered daily at 9:00 AM and 6:00 PM, however, between 03/14/22 (the day the order was written) and 03/21/22, the signature boxes used to indicate the medication was administered were all marked with Xs. There was no explanation of what X meant. On 03/22/22, both signature boxes had nurses' initials in them, indicating the spray was administered at 9:00 AM and 6:00 PM. A review of the electronic treatment administration record (eTAR) found Resident #121's ace wraps had been signed off as applied on 3/22/22, despite multiple observations and an interview with the resident verifying that they had not been put on. (Copies obtained) An interview was conducted with Licensed Practical Nurse (LPN) O on 03/23/22 at 3:09 PM. She confirmed that Resident #121 had [CONDITION(S)] and received ace wraps to her legs each morning. The wraps were removed at night, and this was to be done every day. LPN O was asked why Resident #121's nasal spray was still pending confirmation a week after it was ordered. She explained that Sometimes the physicians write an order, but the electronic medication ordering system does not allow the facility nurses to confirm the order. She speculated that perhaps that was why the order was pending for that long. LPN N said Resident #121's nasal spray just came in, but she had not received it yet. Photographic evidence of the [MEDICATION(S)] spray was obtained on 03/23/22. The medication label said it was filled by the pharmacy on 03/22/22, eight days after it was ordered. A handwritten note indicated the spray was not opened until 03/23/22. LPN P was interviewed on 03/24/22 at 9:29 AM. She stated if a medication was not available at the time of administration, she would go to the electronic medication dispenser to see whether the medication was available. If not, she would call the physician and mark the eMAR (electronic medication administration record) Other and note the medication was not available. The Director of Nursing (DON) was interviewed on 03/24/22 at 2:41 PM and was advised that Resident #121's ace wraps were being signed off by nursing as having been applied when they had not been applied. She was also told of the two doses of nasal spray that were signed as having been administered before the medication had been delivered to the facility. The DON explained there was a code on the eMAR and eTAR (electronic treatment administration record) for nurses to document Other if a medication was not available for administration. The nurses just received training on that. She had no explanation for why nurses were documenting that medication and treatments were being provided when they were not. She said she would speak with the nurses. A review of the Clinical Guidelines Manual Medication Pass Guidelines, CCHC 0115 Copyright 2008, revealed: Purpose: To safely and accurately prepare and administer medication according to physicians' orders and patient needs. Document: -Medication administered -Resident refusal of medication and reason, contact physician for guidance. (Copy obtained) .

Based on observations, interviews, and record reviews, the facility failed to ensure that [CONDITION(S)] medications were used to treat a specific, diagnosed condition and failed to ensure as-needed (PRN) anti-anxiety medications were limited to a use of 14 days for one (Resident #57) of five residents reviewed for unnecessary medications. The findings include: A review of Resident #57's medical record revealed an admitted [DATE]. She received hospice services for end-of-life care related to her primary medical diagnosis of Alzheimer's disease. Secondary diagnoses included dementia, major depressive disorder, and anxiety. A review of the resident's physician's orders revealed the following medication orders: An order dated 2/18/22 for [MEDICATION(S)] (antipsychotic medication) 25 milligrams(mg) to be given twice daily for behavior management. An order dated 2/18/22 for [MEDICATION(S)] 50 mg to be given by mouth at bedtime for behavior management. An order dated 1/25/22 for [MEDICATION(S)] (anticonvulsant medication)125 mg to be given two times a day for a diagnosis of anxiety. An order dated 1/16/22 for [MEDICATION(S)] (sedative medication) 0.5 mg to be given by mouth every 12 hours as needed (PRN) for a diagnosis of agitation. On 3/21/22 at 12:27 p.m., Resident #57 was observed walking out of her room into the hallway. She was wearing pajamas and was barefoot. A staff member in the hallway approached the resident and hurriedly redirected the resident back into her room while stating, Where are you going? When Resident#57 attempted to reply, the staff member interrupted the resident and stated, You have to put some shoes on. Let's go. Resident #57 did not display any other behaviors. On 3/21/22 at 12:35 p.m., an interview was conducted with Resident #57's assigned Licensed Practical Nurse. The nurse identified Resident #57 as having dementia and wandering behaviors. The nurse stated she was not aware of any other behaviors aside from wandering. She added that the resident had been relocated to the top floor of the facility due to her wandering. On 3/21/22 at approximately 12:47 p.m., Resident #57 was observed sitting in a chair in her room. Her lunch tray was positioned in front of her on the over-bed table. The room lights were off and the window blinds were closed. The room was dark and Resident #57 was not eating. A review of the nursing progress notes revealed an entry dated 1/16/22 at 1:25 p.m. which indicated the resident was wandering in the hallway barefoot with only a brief and a shirt on. The resident stated she was looking for the restroom. She removed her brief and threw it on the floor. The hospice nurse visited and gave new orders for [MEDICATION(S)] (antipsychotic medication) 1 mg to be given every twelve hours and [MEDICATION(S)] 0.5 mg to be given every twelve hours as needed. A review of the hospice provider's documentation revealed a handwritten order dated 1/16/22 for [MEDICATION(S)] 0.5 mg to be given by mouth every 12 hours as needed for agitation. A pharmacy recommendation for Resident #57, dated 2/27/22, indicated, This resident has an order to receive [MEDICATION(S)] for behavior management. Per FDA (Food and Drug Administration) guidelines, the only approved indications for this agent are the treatment of manifestations of psychotic disorders, the short-term treatment of [CONDITION(S)], the treatment of [CONDITION(S)] associated with [CONDITION(S)] disorder, and the treatment of [CONDITION(S)] depression. [MEDICATION(S)] is not approved for aggression, Alzheimer's disease, anger management, anxiety, attention-deficit/[CONDITION(S)] disorder, [CONDITION(S)] maintenance, dementia, depression, mood disorder, post-traumatic stress disorder, or sleeplessness. A second pharmacy recommendation dated 2/27/22 indicated, Previous recommendation to discontinue PRN [as needed] use of [MEDICATION(S)] was not completely addressed by MD [physician], and thus no duration for treatment was given . A psychiatric provider note dated 2/4/2022 was reviewed. The note indicated Resident #57 was receiving [MEDICATION(S)] for management of mood and behavior. A review of Resident #57's Medication Administration Record (MAR) for March 2022, revealed documented administration of PRN [MEDICATION(S)] on 3/11/2022, 3/12/2022, 3/17/2022 and 3/23/2022. A review of Resident #57's Behavior Monitoring Records for March 2022, revealed one instance of a documented behavior identified as continuous crying/vocalizations. The documented attempted interventions were redirection, providing a rest period, and administration of medication. A review of Resident #57's care flow records for March 2022, revealed one documented episode of difficulty sleeping. There were no documented behaviors for the remainder of the month. According to the Mayo Clinic (Accessed 3/24/2022 at 4:15 p.m.) at https://www.mayoclinic.org/drugs-supplements/[MEDICATION(S)]-oral-route/description/drg- 912), [MEDICATION(S)] is an antipsychotic medication that works in the brain to treat [CONDITION(S)] disorder and [CONDITION(S)]. This medicine should not be used to treat behavioral problems in older adult patients who have dementia or Alzheimer's disease. According to the Mayo Clinic (Accessed 3/24/2022 at 4:20 p.m.) at https://www.mayoclinic.org/drugs-supplements/[MEDICATION(S)]-acid-oral-route/description/drg- 931), [MEDICATION(S)] is used to treat the manic phase of [CONDITION(S)] disorder and certain types of seizures. According to the Mayo Clinic (Accessed 3/24/2022 at 4:24 p.m.) at https://www.mayoclinic.org/drugs-supplements/[MEDICATION(S)]-oral-route/description/drg- 296), [MEDICATION(S)] is a medication used to treat anxiety disorders and is used for short-term relief of the symptoms of anxiety. According to the Alzheimer's Foundation (Accessed 3/24/2022 at 5:15 p.m.) at https://www.alz.org/alzheimers-dementia/treatments/treatments-for-behavior), individuals with dementia should use antipsychotic medications only if behavioral symptoms are due to [CONDITION(S)] or [CONDITION(S)], the symptoms present a danger to the person or others, or the person is experiencing inconsolable or persistent distress, a significant decline in function, or substantial difficult receiving needed care. Antipsychotic medications should not be used to sedate or restrain persons with dementia.

Based on observations, resident and staff interviews, and a review of resident records, the facility failed to provide medication and treatments as ordered and in accordance with professional standards of practice for one (Resident #121) of one resident who reported problems receiving treatment and medication, out of six residents whose medication regimens were reviewed, from a total of 42 residents in the sample. The findings include: An observation of and an interview with Resident #121 was conducted on 03/22/22 at 10:24 AM. During the interview, she commented that by this time of day, her legs should already be wrapped. They were still not wrapped. She explained that staff were supposed to wrap her legs daily with ace bandages, however, some days it was after 4:00 PM or 5:00 PM by the time they finally applied the wraps. Some days, the staff did not apply them at all. Resident #121 added that her doctor recently prescribed her some nasal spray, but she still had not received it. It was intended for her wheezing and coughing. An observation at this time found no ace bandage wraps on either of Resident #121's lower legs, which were both edematous (swollen due to a buildup of fluid). Resident #121 was observed on 03/22/22 at 1:43 PM and again at 4:21 PM, and the ace wraps had still not been applied. During an observation and interview with Resident #121 on 03/23/22 at 10:08 AM, she had ace bandage wraps to both of her legs below the knees. She reported that Agency Certified Nursing Assistant (CNA) N wrapped her legs this morning before she got out of bed. She had gone to therapy this morning and the bandages were now loose. When asked if the wraps had been applied yesterday (3/23/22) after the 4:21 PM observation, she said, No. A record review for Resident #121 found she was readmitted to the facility on [DATE]. The 5-day minimum data set (MDS) assessment, dated 02/27/22, indicated Resident #121 had a brief interview for mental status (BIMS) score of 14 out of a possible 15 points, indicating she was cognitively intact. She required limited to extensive assistance with activities of daily living (ADLs) and used a walker and wheelchair as mobility aids. Her diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . She received diuretic medications (used to remove excess fluid from the body) on seven days over the assessment look-back period. Resident #121 was care planned on 01/11/22 for her altered cardiovascular status related to diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Interventions included, but were not limited to, medications as ordered and monitor for/document any [CONDITION(S)] (swelling). (Copies obtained) Resident #121 had a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . She also had a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The order was written on 3/14/22 (8 days ago), but said it was still Pending Confirmation instead of Active. (Copies obtained) A review of the electronic Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . There was no explanation of what X meant. On 03/22/22, both signature boxes had nurses' initials in them, indicating the spray was administered at 9:00 AM and 6:00 PM. A review of the electronic treatment administration record (eTAR) found Resident #121's ace wraps had been signed off as applied on 3/22/22, despite multiple observations and an interview with the resident verifying that they had not been put on. (Copies obtained) An interview was conducted with Agency CNA N on 03/23/22 at 10:12 AM. She explained that Resident #121's legs swelled a lot if not wrapped. An interview was conducted with Licensed Practical Nurse (LPN) O on 03/23/22 at 3:09 PM. She confirmed that Resident #121 had [CONDITION(S)] and received ace wraps to her legs each morning. The wraps were removed at night, and this was to be done every day. LPN O reported staff encouraged Resident #121 to keep her feet elevated, but the resident stayed out of her bed all day and late into the night. LPN O was asked why Resident #121's nasal spray was still pending confirmation a week after it was ordered. She explained that Sometimes the physicians write an order, but the electronic medication ordering system does not allow the facility nurses to confirm the order. She speculated that perhaps that was why the order was pending for that long. LPN N said Resident #121's nasal spray just came in, but she had not received it yet. Photographic evidence of the [MEDICATION(S)] spray was obtained on 03/23/22. The medication label said it was filled by the pharmacy on 03/22/22, eight days after it was ordered. A handwritten note indicated the spray was not opened until 03/23/22. The Director of Nursing (DON) was interviewed on 03/24/22 at 2:41 PM and was advised that Resident #121's ace wraps were being signed off by nursing as having been applied when they had not been applied. She had no explanation and acknowledged the findings. She said she would speak with the nurses.

Based on record reviews, staff interviews and a review of the facility's policy and procedure for Quality Assurance Performance Improvement (QAPI), the facility failed to develop and implement appropriate plans of action to correct identified quality deficiencies, particularly those that cause adverse outcomes. This resulted in a lack of improvement of their systems and processes, which placed 44 residents who required assistance with Activities of Daily Living (ADLs), at risk for serious adverse outcomes similar to that of Resident #1. The facility's actions contributed to Resident #1's serious injuries. On 8/22/2020, Resident #1's Activities of Daily Living (ADL) care was provided by one Certified Nursing Assistant (CNA) rather than by two CNAs as indicated in the nursing and therapy assessments. The resident fell out of bed during ADL care and sustained pelvic and sacral fractures. She required emergent care and was hospitalized . Resident baseline care plans were not individualized for resident needs and CNAs were unaware of how to access that information in the electronic Kardex. Additionally, the facility failed to investigate the fall to determine how to prevent another fall from occurring. This failure resulted in serious harm to the resident and the system-wide practice remained unchanged at the time of the survey. On 3/16/2021, the facility's census was 49. Any residents who required staff assistance with ADL care were at risk. There were 44 residents who required assistance with ADL care at that time. Immediate Jeopardy (IJ) at a scope of J (isolated) began on 8/22/2020, and was identified on 3/15/21 at 4:45 PM, which was ongoing. On 3/17/2021 at 7:45 p.m., the Administrator was notified of the IJ determination. The findings include: Cross reference to F689 and F726 A review of the medical record for Resident #1 revealed she was admitted on [DATE] with a primary diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Her secondary diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . She was 5'8 tall and weighed 209 pounds on 8/14/2020. Resident #1 had a Brief Interview for Mental Status (BIMS) score of 9 out of a possible 15 points, indicating moderate cognitive impairment. A BIMS score of 0-7 indicates severe impairment, 8-12 indicates moderate impairment, and 13-15 indicates no cognitive impairment. A review of the resident's Nursing Admission Assessment revealed a summary, written by the admitting nurse, which indicated the resident required the assistance of two persons for ADLs, including bed mobility, transfers, dressing, personal hygiene, and bathing. The resident was documented as non-ambulatory, requiring a wheelchair for mobility. (Photographic evidence obtained) A review of the Admission Minimum Data Set (MDS) assessment, dated 8/15/2020, revealed that for toileting, the resident was unable to make any effort to complete the activity. She was dependent and required the assistance of two staff members. A review of physical and occupational therapy documentation between 8/13/2020 and 8/22/2020, revealed that a physical therapy screening was completed the day after admission (8/14/2020). The resident was determined to be at her prior level of functioning: Dependent for transfers, bed mobility, and Hoyer lift assistance. According to RehabMart at https://www.rehabmart.com/post/the-5-best-hoyer-lifts (accessed on 4/12/2021): A Hoyer lift is indicated for a patient who requires 90 to 100-percent assistance to get in and out of bed or to transfer to a wheelchair, toilet, or chair. As an assistive medical device, a Hoyer patient lift is an essential safety tool that helps transfer and carry a patient from nearly any surface, enabling them to be moved to a bed, bathtub, wheelchair, toilet, and more. Review of a nursing progress note, dated 8/22/2020 at 7:20 p.m., revealed that during incontinence care provided in Resident #1's bed, the CNA assisted the resident to turn on her side and the resident's legs dangled out of bed, resulting in the resident's fall out of bed onto the floor. The note further indicated that the resident complained of hitting her head during the fall, and she was transferred emergently to an acute care hospital for evaluation. (Photographic evidence obtained) A review of a hospital CT (computed tomography) scan, dated 8/22/2020, revealed the presence of a displaced left superior and inferior pubic ramus fracture (pelvic fractures) and a left hemi-sacral fracture (large, triangular bone at the base of the spine). (Photographic evidence obtained) According to the Mayo Clinic at https://www.mayoclinic.org/tests-procedures/ct-scan/about/pac- 675 (accessed on 4/12/2021): A computerized tomography (CT) scan combines a series of X-ray images taken from different angles around your body and uses computer processing to create cross-sectional images (slices) of the bones, blood vessels and soft tissues inside your body. CT scan images provide more-detailed information than plain X-rays do. A CT scan has many uses, but it's particularly well-suited to quickly examine people who may have internal injuries from car accidents or other types of trauma. Your doctor may recommend a CT scan to help: Diagnose muscle and bone disorders, such as bone tumors and fractures. A review of hospital documentation dated 8/22/2020 at 10:32 p.m., revealed under Diagnosis, Assessment & Plan: [AGE] year-old female, nursing home patient, accidentally rolled out of bed. Level 2 trauma alert. CT demonstrates left super inferior pubic rami fractures. (Photographic evidence obtained) A review of the hospital Trauma Progress Note, dated 8/23/2020 at 11:44 a.m., revealed: Ortho (orthopedics) seeing patient as we were. They state her fractures are nonoperative. Ambulation status: unable to ambulate. (Photographic evidence obtained) A review of a hospital Physical Therapy Evaluation, dated 8/22/2020, revealed: Fall risk. Indications of pain: Yes. Expected pelvic pain. Bed mobility: Attempted with max assist, however, pt (patient) was very lethargic and unable to control extremities enough to complete. (Photographic evidence obtained) A review of Resident #1's comprehensive care plans revealed a focus area for ADL/Self-Care Deficit. The interventions instructed staff to encourage the resident to participate to the fullest extent possible with each interaction but did not identify or instruct the staff about the amount of assistance the resident required for bed mobility. (Photographic evidence obtained) A review of the resident's Kardex (summary of resident care needs) revealed an entry indicating the resident, Requires (1 or 2) person and is (independent, limited, extensive, or total) assist. The Kardex intervention had not been personalized to reflect the resident's individual needs as assessed by the nurse on admission. (Photographic evidence obtained) On 3/15/2021 at 2:04 p.m., an interview was conducted with Employee B, CNA, regarding the facility's process for direct-care staff accessing resident-specific care needs information. The CNA was asked what reference she had available to determine how much assistance a resident may need with tasks such as bed mobility. She stated, It's somewhere in this computer. The CNA attempted to access the care guide but was unable to locate it in the computer system. The CNA was then asked how she would determine the amount of assistance a resident required if the care guide instructed her to provide assistance as necessary. She stated, We pretty much know the residents but if I think I'll need help, I'll ask for it. On 3/15/2021 at 2:30 p.m., an interview was conducted with the Director of Nursing (DON). She was asked how the residents' level of assistance for each ADL care area was determined. She explained that Nursing and Physical Therapy made that determination, and that the care plan and Kardex should be updated to reflect that amount of assistance. The DON acknowledged that the Initial Admission Assessment conducted by the nurse indicated that the resident required the assistance of two staff members for ADLs, and that the resident's care plan and Kardex had not been personalized to reflect the resident's individual care needs. She further explained that the Nurse Managers and Minimum Data Set (MDS) Coordinator were responsible for revising the care plans. When asked why Resident #1's care plan had not been revised, the DON stated, Because physical therapy didn't say the resident required two-person assist. The DON was asked to review a sample of resident Kardexes. She acknowledged that the interventions had not been personalized and stated, It really should be written out for them. On 3/16/2021 at 11:25 a.m., an interview was conducted with the Physical Therapist. He stated he remembered Resident #1 and that he conducted the physical therapy screening upon her return from the hospital. He was asked to explain the level of assistance Resident #1 required when he conducted the screening. He stated the resident initially refused to participate in the screening, but that he eventually was able to encourage the resident to complete the screening. He further explained that he determined the resident required 1-2 person assistance. When asked how direct-care staff made the determination of when to use one versus two staff members during resident care, he clarified his statement and said, specifically related to Resident #1, She required two-person assist with bed mobility due to a high risk for falls. He further explained that the dependent selection on the physical therapy screen indicated that assistance by two staff members was required for that particular care area. On 3/17/2021 at 2:30 p.m., an interview was conducted with the Administrator, Director of Nursing, Regional Nurse Consultant, and the Physical Therapist. The Physical Therapist explained that he misunderstood the question during his previous interview on 3/16/2021 at 11:25 a.m., and that he wanted to clarify that Resident #1 required the assistance of one person with bed mobility. However, when asked to clarify the definition of dependent on the physical therapy assessment, he again acknowledged that two-person assistance was required. During the interview, the Regional Nurse Consultant indicated that he felt the care plan and Kardex were appropriate, because the care plan was fluid and that each resident's status was subject to change. During an interview with Employee C, CNA, on 3/17/2021 at 6:30 p.m., she was asked to explain the facility's process for how direct-care staff should access resident-specific care needs information. The CNA explained that she thought it was somewhere in the computer. She attempted to access the care information on a portable kiosk but was unable to do so. She then explained that she would ask the nurse if she was unsure of the level of assistance a resident required. During an interview with Employee D, Licensed Practical Nurse (LPN), on 3/17/2021 at 6:45 p.m., she was asked to explain the facility's process for how direct-care staff should access resident-specific care needs information. The nurse explained that she would review the resident's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . After accessing a resident's profile, the nurse was unable to locate a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the medical record for Resident #3 revealed she was admitted to the facility on [DATE] with a primary medical diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident required extensive assistance with ADLs. A review of the resident's Kardex revealed an intervention which indicated, Bed mobility 1. Requires (1 or 2) person and is (independent, limited, extensive, or total). The Kardex had not been updated to reflect the resident's actual care needs. A review of the medical record for Resident #4 revealed she was admitted to the facility on [DATE] with a primary medical diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident required extensive assistance with ADLs. A review of the resident's Kardex revealed an intervention which indicated, Bed mobility 1. Requires (1 or 2) person and is (independent, limited, extensive, or total). The Kardex had not been updated to reflect the resident's actual care needs. A review of the facility's Quality Assurance and Performance Improvement policy titled The five elements of quality assurance and performance improvement was reviewed. Step #5 of the policy explained that systematic analysis and systemic action was the approach the facility used to create a performance improvement plan. The policy further explained that in an order to attempt to solve an issue, the facility must become proficient in the process of root cause analysis. This problem-solving technique involves looking at any problem and drilling down by asking 'why'. Systemic actions look comprehensively across all involved systems to prevent future negative events and to promote continual improvement. On 3/16/2021 at 4:25 p.m., an interview was conducted with the Director of Nursing (DON). She was asked about the facility's process for investigating incidents. She explained that the incident wa logged by the nurse on duty at the time of the incident, and that a subsequent investigation was conducted and documented to determine the root cause of the incident. She explained that she was unable to recall whether a root cause analysis was conducted for Resident #1's fall, and she was unable to produce investigative materials such as witness statements, staff interviews, or record reviews. On 3/16/2021 at 4:39 p.m., an interview was conducted with the Administrator regarding the facility's process for conducting a root cause analysis. When asked whether Resident #1's fall with injuries had been discussed with the quality assurance team, he explained that she would have been discussed as part of the numbers trending, but that the facility did not generally discuss incidents in detail during the monthly meetings. The Administrator further explained that he believed the fall had been reviewed, and that the facility determined no action was required as result of the review. However, he was unable to produce any investigative materials such as witness statements, staff interviews, or record reviews for this incident that resulted in serious injuries. During the interview, the Administrator was asked whether the facility had any active performance improvement plans. He stated the facility had no current, active performance improvement plans.

Based on observations, interviews, and record reviews, the facility failed to ensure Nurses and Certified Nursing Assistants (CNAs) had the appropriate competencies and skills sets to provide resident-specific care ensuring resident safety as determined by resident assessments. This involved two (Employees B and C) of four CNAs and one (Employee D) of two nurses interviewed at the time of the survey. On 8/22/2020, Resident #1's Activities of Daily Living (ADL) care was provided by one CNA rather than by two CNAs as indicated in the nursing and therapy assessments. The resident fell out of bed during ADL care and sustained pelvic and sacral fractures. Employees B and C were interviewed and were unable to access resident care needs in the electronic Kardexes. Upon interview, Employee D stated residents' specific care needs were found in the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . None were made specific according to each resident's individual needs. On 3/16/2021, the facility's census was 49. Any residents who required staff assistance with ADL care were at risk. There were 44 residents who required assistance with ADL care at that time. Immediate Jeopardy (IJ) at a scope of J (isolated) began on 8/22/2020, and was identified on 3/15/21 at 4:45 PM, which was ongoing. On 3/17/2021 at 7:45 p.m., the Administrator was notified of the IJ determination. The findings include: Cross reference to F689 and F867 A review of the medical record for Resident #1 revealed she was admitted on [DATE] with a primary diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Her secondary diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . She was 5'8 tall and weighed 209 pounds on 8/14/2020. Resident #1 had a Brief Interview for Mental Status (BIMS) score of 9 out of a possible 15 points, indicating moderate cognitive impairment. A BIMS score of 0-7 indicates severe impairment, 8-12 indicates moderate impairment, and 13-15 indicates no cognitive impairment. A review of the resident's Nursing Admission Assessment revealed a summary, written by the admitting nurse, which indicated the resident required the assistance of two persons for ADLs, including bed mobility, transfers, dressing, personal hygiene, and bathing. The resident was documented as non-ambulatory, requiring a wheelchair for mobility. (Photographic evidence obtained) A review of the Admission Minimum Data Set (MDS) assessment, dated 8/15/2020, revealed that for toileting, the resident was unable to make any effort to complete the activity. She was dependent and required the assistance of two staff members. A review of physical and occupational therapy documentation between 8/13/2020 and 8/22/2020, revealed that a physical therapy screening was completed the day after admission (8/14/2020). The resident was determined to be at her prior level of functioning: Dependent for transfers, bed mobility, and Hoyer lift assistance. According to RehabMart at https://www.rehabmart.com/post/the-5-best-hoyer-lifts (accessed on 4/12/2021): A Hoyer lift is indicated for a patient who requires 90 to 100-percent assistance to get in and out of bed or to transfer to a wheelchair, toilet, or chair. As an assistive medical device, a Hoyer patient lift is an essential safety tool that helps transfer and carry a patient from nearly any surface, enabling them to be moved to a bed, bathtub, wheelchair, toilet, and more. Review of a nursing progress note, dated 8/22/2020 at 7:20 p.m., revealed that during incontinence care provided in Resident #1's bed, the CNA assisted the resident to turn on her side and the resident's legs dangled out of bed, resulting in the resident's fall out of bed onto the floor. The note further indicated that the resident complained of hitting her head during the fall, and she was transferred emergently to an acute care hospital for evaluation. (Photographic evidence obtained) A review of a hospital CT (computed tomography) scan, dated 8/22/2020, revealed the presence of a displaced left superior and inferior pubic ramus fracture (pelvic fractures) and a left hemi-sacral fracture (large, triangular bone at the base of the spine). (Photographic evidence obtained) According to the Mayo Clinic at https://www.mayoclinic.org/tests-procedures/ct-scan/about/pac- 675 (accessed on 4/12/2021): A computerized tomography (CT) scan combines a series of X-ray images taken from different angles around your body and uses computer processing to create cross-sectional images (slices) of the bones, blood vessels and soft tissues inside your body. CT scan images provide more-detailed information than plain X-rays do. A CT scan has many uses, but it's particularly well-suited to quickly examine people who may have internal injuries from car accidents or other types of trauma. Your doctor may recommend a CT scan to help: Diagnose muscle and bone disorders, such as bone tumors and fractures. A review of a hospital Physical Therapy Evaluation, dated 8/22/2020, revealed: Fall risk. Indications of pain: Yes. Expected pelvic pain. Bed mobility: Attempted with max assist, however, pt (patient) was very lethargic and unable to control extremities enough to complete. (Photographic evidence obtained) A review of Resident #1's comprehensive care plans revealed a focus area for ADL/Self-Care Deficit. The interventions instructed staff to encourage the resident to participate to the fullest extent possible with each interaction but did not identify or instruct the staff about the amount of assistance the resident required for bed mobility. (Photographic evidence obtained) A review of the resident's Kardex (summary of resident care needs) revealed an entry indicating the resident, Requires (1 or 2) person and is (independent, limited, extensive, or total) assist. The Kardex intervention had not been personalized to reflect the resident's individual needs as assessed by the nurse on admission. (Photographic evidence obtained) On 3/15/2021 at 2:04 p.m., an interview was conducted with Employee B, CNA, regarding the facility's process for direct-care staff accessing resident-specific care needs information. The CNA was asked what reference she had available to determine how much assistance a resident may need with tasks such as bed mobility. She stated, It's somewhere in this computer. The CNA attempted to access the care guide but was unable to locate it in the computer system. The CNA was then asked how she would determine the amount of assistance a resident required if the care guide instructed her to provide assistance as necessary. She stated, We pretty much know the residents but if I think I'll need help, I'll ask for it. On 3/15/2021 at 2:30 p.m., an interview was conducted with the Director of Nursing (DON). She was asked how the residents' level of assistance for each ADL care area was determined. She explained that Nursing and Physical Therapy made that determination, and that the care plan and Kardex should be updated to reflect that amount of assistance. The DON acknowledged that the Initial Admission Assessment conducted by the nurse indicated that the resident required the assistance of two staff members for ADLs, and that the resident's care plan and Kardex had not been personalized to reflect the resident's individual care needs. She further explained that the Nurse Managers and Minimum Data Set (MDS) Coordinator were responsible for revising the care plans. When asked why Resident #1's care plan had not been revised, the DON stated, Because physical therapy didn't say the resident required two-person assist. The DON was asked to review a sample of resident Kardexes. She acknowledged that the interventions had not been personalized and stated, It really should be written out for them. On 3/16/2021 at 11:25 a.m., an interview was conducted with the Physical Therapist. He stated he remembered Resident #1 and that he conducted the physical therapy screening upon her return from the hospital. He was asked to explain the level of assistance Resident #1 required when he conducted the screening. He stated the resident initially refused to participate in the screening, but that he eventually was able to encourage the resident to complete the screening. He further explained that he determined the resident required 1-2 person assistance. When asked how direct-care staff made the determination of when to use one versus two staff members during resident care, he clarified his statement and said, specifically related to Resident #1, She required two-person assist with bed mobility due to a high risk for falls. He further explained that the dependent selection on the physical therapy screen indicated that assistance by two staff members was required for that particular care area. On 3/17/2021 at 2:30 p.m., an interview was conducted with the Administrator, Director of Nursing, Regional Nurse Consultant, and the Physical Therapist. The Physical Therapist explained that he misunderstood the question during his previous interview on 3/16/2021 at 11:25 a.m., and that he wanted to clarify that Resident #1 required the assistance of one person with bed mobility. However, when asked to clarify the definition of dependent on the physical therapy assessment, he again acknowledged that two-person assistance was required. During the interview, the Regional Nurse Consultant indicated that he felt the care plan and Kardex were appropriate, because the care plan was fluid and that each resident's status was subject to change. During an interview with Employee C, CNA, on 3/17/2021 at 6:30 p.m., she was asked to explain the facility's process for how direct-care staff should access resident-specific care needs information. The CNA explained that she thought it was somewhere in the computer. She attempted to access the care information on a portable kiosk but was unable to do so. She then explained that she would ask the nurse if she was unsure of the level of assistance a resident required. During an interview with Employee D, Licensed Practical Nurse (LPN), on 3/17/2021 at 6:45 p.m., she was asked to explain the facility's process for how direct-care staff should access resident-specific care needs information. The nurse explained that she would review the resident's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . After accessing a resident's profile, the nurse was unable to locate a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the medical record for Resident #3 revealed she was admitted to the facility on [DATE] with a primary medical diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident required extensive assistance with ADLs. A review of the resident's Kardex revealed an intervention which indicated, Bed mobility 1. Requires (1 or 2) person and is (independent, limited, extensive, or total). The Kardex had not been updated to reflect the resident's actual care needs. A review of the medical record for Resident #4 revealed she was admitted to the facility on [DATE] with a primary medical diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident required extensive assistance with ADLs. A review of the resident's Kardex revealed an intervention which indicated, Bed mobility 1. Requires (1 or 2) person and is (independent, limited, extensive, or total). The Kardex had not been updated to reflect the resident's actual care needs. A review of the facility's policy titled Baseline, Resident Centered Comprehensive Care Plans, & Care Plan Summary was reviewed. The policy indicated that the baseline care plan must be developed within the first 48 hours of admission and must include the health care information necessary to properly care for each resident immediately upon their admission. The policy also indicated that baseline care plan areas will trigger from questions answered on the nursing admission evaluation and directed staff to make edits to any items that require personalization or require changes. (Photographic Evidence Obtained)

Based on record reviews and interviews, the facility failed to ensure residents received adequate supervision and assistance to prevent accidents for one (Resident #1) of one resident reviewed for accidents and supervision. On 8/22/2020, Resident #1's Activities of Daily Living (ADL) care was provided by one Certified Nursing Assistant (CNA) rather than by two CNAs as indicated in the nursing and therapy assessments. The resident fell out of bed during ADL care and sustained pelvic and sacral fractures. On 3/16/2021, the facility's census was 49. Any residents who required staff assistance with ADL care were at risk. There were 44 residents who required assistance with ADL care at that time. Immediate Jeopardy (IJ) at a scope of J (isolated) began on 8/22/2020, and was identified on 3/15/21 at 4:45 PM, which was ongoing. On 3/17/2021 at 7:45 p.m., the Administrator was notified of the IJ determination. The findings include: Cross reference to F726 and F867 A review of the medical record for Resident #1 revealed she was admitted on [DATE] with a primary diagnosis of coronavirus disease 2019 (COVID-19). Her secondary diagnoses included dementia, urinary tract infection, high blood pressure and [CONDITION(S)] (irregular, rapid heart rate). She was 5'8 tall and weighed 209 pounds on 8/14/2020. Resident #1 had a Brief Interview for Mental Status (BIMS) score of 9 out of a possible 15 points, indicating moderate cognitive impairment. A BIMS score of 0-7 indicates severe impairment, 8-12 indicates moderate impairment, and 13-15 indicates no cognitive impairment. A review of the resident's Nursing Admission Assessment revealed a summary, written by the admitting nurse, which indicated the resident required the assistance of two persons for ADLs, including bed mobility, transfers, dressing, personal hygiene, and bathing. The resident was documented as non-ambulatory, requiring a wheelchair for mobility. (Photographic evidence obtained) A review of the Admission Minimum Data Set (MDS) assessment, dated 8/15/2020, revealed that for toileting, the resident was unable to make any effort to complete the activity. She was dependent and required the assistance of two staff members. A review of physical and occupational therapy documentation between 8/13/2020 and 8/22/2020, revealed that a physical therapy screening was completed the day after admission (8/14/2020). The resident was determined to be at her prior level of functioning: Dependent for transfers, bed mobility, and Hoyer lift assistance. According to RehabMart at https://www.rehabmart.com/post/the-5-best-hoyer-lifts (accessed on 4/12/2021): A Hoyer lift is indicated for a patient who requires 90 to 100-percent assistance to get in and out of bed or to transfer to a wheelchair, toilet, or chair. As an assistive medical device, a Hoyer patient lift is an essential safety tool that helps transfer and carry a patient from nearly any surface, enabling them to be moved to a bed, bathtub, wheelchair, toilet, and more. Review of a nursing progress note, dated 8/22/2020 at 7:20 p.m., revealed that during incontinence care provided in Resident #1's bed, the CNA assisted the resident to turn on her side and the resident's legs dangled out of bed, resulting in the resident's fall out of bed onto the floor. The note further indicated that the resident complained of hitting her head during the fall, and she was transferred emergently to an acute care hospital for evaluation. (Photographic evidence obtained) A review of a hospital CT (computed tomography) scan, dated 8/22/2020, revealed the presence of a displaced left superior and inferior pubic ramus fracture (pelvic fractures) and a left hemi-sacral fracture (large, triangular bone at the base of the spine). (Photographic evidence obtained) According to the Mayo Clinic at https://www.mayoclinic.org/tests-procedures/ct-scan/about/pac- 675 (accessed on 4/12/2021): A computerized tomography (CT) scan combines a series of X-ray images taken from different angles around your body and uses computer processing to create cross-sectional images (slices) of the bones, blood vessels and soft tissues inside your body. CT scan images provide more-detailed information than plain X-rays do. A CT scan has many uses, but it's particularly well-suited to quickly examine people who may have internal injuries from car accidents or other types of trauma. Your doctor may recommend a CT scan to help: Diagnose muscle and bone disorders, such as bone tumors and fractures. A review of hospital documentation dated 8/22/2020 at 10:32 p.m., revealed under Diagnosis, Assessment & Plan: [AGE] year-old female, nursing home patient, accidentally rolled out of bed. Level 2 trauma alert. CT demonstrates left super inferior pubic rami fractures. (Photographic evidence obtained) A review of the hospital Trauma Progress Note, dated 8/23/2020 at 11:44 a.m., revealed: Ortho (orthopedics) seeing patient as we were. They state her fractures are nonoperative. Ambulation status: unable to ambulate. (Photographic evidence obtained) A review of a hospital Physical Therapy Evaluation, dated 8/22/2020, revealed: Fall risk. Indications of pain: Yes. Expected pelvic pain. Bed mobility: Attempted with max assist, however, pt (patient) was very lethargic and unable to control extremities enough to complete. (Photographic evidence obtained) A review of Resident #1's comprehensive care plans revealed a focus area for ADL/Self-Care Deficit. The interventions instructed staff to encourage the resident to participate to the fullest extent possible with each interaction but did not identify or instruct the staff about the amount of assistance the resident required for bed mobility. (Photographic evidence obtained) A review of the resident's Kardex (summary of resident care needs) revealed an entry indicating the resident, Requires (1 or 2) person and is (independent, limited, extensive, or total) assist. The Kardex intervention had not been personalized to reflect the resident's individual needs as assessed by the nurse on admission. (Photographic evidence obtained) On 3/15/2021 at 2:04 p.m., an interview was conducted with Employee B, CNA, regarding the facility's process for direct-care staff accessing resident-specific care needs information. The CNA was asked what reference she had available to determine how much assistance a resident may need with tasks such as bed mobility. She stated, It's somewhere in this computer. The CNA attempted to access the care guide but was unable to locate it in the computer system. The CNA was then asked how she would determine the amount of assistance a resident required if the care guide instructed her to provide assistance as necessary. She stated, We pretty much know the residents but if I think I'll need help, I'll ask for it. On 3/15/2021 at 2:30 p.m., an interview was conducted with the Director of Nursing (DON). She was asked how the residents' level of assistance for each ADL care area was determined. She explained that Nursing and Physical Therapy made that determination, and that the care plan and Kardex should be updated to reflect that amount of assistance. The DON acknowledged that the Initial Admission Assessment conducted by the nurse indicated that the resident required the assistance of two staff members for ADLs, and that the resident's care plan and Kardex had not been personalized to reflect the resident's individual care needs. She further explained that the Nurse Managers and Minimum Data Set (MDS) Coordinator were responsible for revising the care plans. When asked why Resident #1's care plan had not been revised, the DON stated, Because physical therapy didn't say the resident required two-person assist. The DON was asked to review a sample of resident Kardexes. She acknowledged that the interventions had not been personalized and stated, It really should be written out for them. On 3/16/2021 at 11:25 a.m., an interview was conducted with the Physical Therapist. He stated he remembered Resident #1 and that he conducted the physical therapy screening upon her return from the hospital. He was asked to explain the level of assistance Resident #1 required when he conducted the screening. He stated the resident initially refused to participate in the screening, but that he eventually was able to encourage the resident to complete the screening. He further explained that he determined the resident required 1-2 person assistance. When asked how direct-care staff made the determination of when to use one versus two staff members during resident care, he clarified his statement and said, specifically related to Resident #1, She required two-person assist with bed mobility due to a high risk for falls. He further explained that the dependent selection on the physical therapy screen indicated that assistance by two staff members was required for that particular care area. On 3/17/2021 at 2:30 p.m., an interview was conducted with the Administrator, Director of Nursing, Regional Nurse Consultant, and the Physical Therapist. The Physical Therapist explained that he misunderstood the question during his previous interview on 3/16/2021 at 11:25 a.m., and that he wanted to clarify that Resident #1 required the assistance of one person with bed mobility. However, when asked to clarify the definition of dependent on the physical therapy assessment, he again acknowledged that two-person assistance was required. During the interview, the Regional Nurse Consultant indicated that he felt the care plan and Kardex were appropriate, because the care plan was fluid and that each resident's status was subject to change. During an interview with Employee C, CNA, on 3/17/2021 at 6:30 p.m., she was asked to explain the facility's process for how direct-care staff should access resident-specific care needs information. The CNA explained that she thought it was somewhere in the computer. She attempted to access the care information on a portable kiosk but was unable to do so. She then explained that she would ask the nurse if she was unsure of the level of assistance a resident required. During an interview with Employee D, Licensed Practical Nurse (LPN), on 3/17/2021 at 6:45 p.m., she was asked to explain the facility's process for how direct-care staff should access resident-specific care needs information. The nurse explained that she would review the resident's physician's orders. The nurse was asked to demonstrate the process. After accessing a resident's profile, the nurse was unable to locate a physician's order that dictated the amount of assistance a resident would need with ADLs. A review of the medical record for Resident #3 revealed she was admitted to the facility on [DATE] with a primary medical diagnosis of [CONDITION(S)] (fainting) and collapse. The resident required extensive assistance with ADLs. A review of the resident's Kardex revealed an intervention which indicated, Bed mobility 1. Requires (1 or 2) person and is (independent, limited, extensive, or total). The Kardex had not been updated to reflect the resident's actual care needs. A review of the medical record for Resident #4 revealed she was admitted to the facility on [DATE] with a primary medical diagnosis of metabolic [CONDITION(S)]. The resident required extensive assistance with ADLs. A review of the resident's Kardex revealed an intervention which indicated, Bed mobility 1. Requires (1 or 2) person and is (independent, limited, extensive, or total). The Kardex had not been updated to reflect the resident's actual care needs. A review of the facility's policy titled Baseline, Resident Centered Comprehensive Care Plans, & Care Plan Summary was reviewed. The policy indicated that the baseline care plan must be developed within the first 48 hours of admission and must include the health care information necessary to properly care for each resident immediately upon their admission. The policy also indicated that baseline care plan areas will trigger from questions answered on the nursing admission evaluation and directed staff to make edits to any items that require personalization or require changes. (Photographic Evidence Obtained)