Every finding on record at Emerald Healthcare & Rehab of Dublin

Based on observation, resident and staff interviews, and record review, the facility failed to ensure the resident's right to privacy during shower care for one of 29 sampled residents (R) (R36). This deficient practice had the potential to diminish the resident's quality of life and contribute to emotional distress and reduced trust in facility staff. Findings include:Record review of R36's electronic health record (EHR) revealed R36 was admitted on [DATE] with diagnoses including, but not limited to, discitis of the unspecified lumbar region, polyneuropathy, lumbar spinal fusion, and lumbar spinal stenosis without neurogenic claudication.Review of the Quarterly Minimum Data Set (MDS) dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 15 in Section C, indicating little to no cognitive impairment. Section GG documented that the resident required a walker for ambulation, supervision or touching assistance for bathing and showering, and touching assistance for most Activities of Daily Living (ADLs).Observation on 03/13/2026 at 10:56 AM of the Hall 1 Shower Room revealed CNAs BB and AA providing shower care to R36. The resident was observed naked, seated in a shower chair inside a shower stall that was not equipped with any privacy curtains. Continued observation of the shower room showed that none of the shower stalls had privacy curtains in place. The toilet area also lacked any privacy curtains or barriers.Interview on 03/13/2026 at 10:56 AM with R36 revealed that the privacy curtains had been missing for two months or more. The resident stated that the lack of curtains and the possibility of being exposed to anyone entering the shower room made her feel uncomfortable and deprived of personal privacy.Interview on 03/13/2026 at 10:57 AM with CNAs BB and AA confirmed that the privacy curtains were missing from all shower stalls. Both staff acknowledged that there were no hanging privacy curtains in the shower room for any of the shower stalls or the toilet area. CNA BB reported that the curtains had been removed for cleaning weeks ago and had not been replaced.Interview on 03/13/2026 at 11:20 AM with the Administrator and Environmental Supervisor, both staff confirmed the missing privacy curtains and being unaware of the missing privacy curtains for the shower room. The Administrator reported touring the shower room last week and not observing the missing privacy curtains. The Administrator confirmed that providing any resident with a bath/shower without ensuring privacy due to absence of missing privacy curtains was a dignity issue.

Based on observations, resident and staff interviews, and record review, the facility failed to ensure one of 29 sampled residents (R) (R40) did not have unauthorized and unsecured medications at the bedside. This failure had the potential to result in medication errors, improper use, and adverse drug events for the residents. Findings include:Review of R40's Electronic Health Records (EHR) revealed R46 was admitted on [DATE] with diagnoses that included, but were not limited to, bipolar disorder, chronic obstructive pulmonary disease, chronic systolic heart (congestive) failure, and suicidal ideations.Review of R40's Quarterly Minimum Data Set (MDS) assessment dated [DATE] for Section C (Cognitive Patterns) revealed, a Brief Interview of Mental Status (BIMS) score of six which indicated severe cognitive impairment, and Section GG (Functional Abilities and Goals) revealed, impairment on one side to the upper and lower extremities, required substantial/maximal assistance with activities of daily living (ADL).Review of R40's Physician's Orders revealed there were no active orders for eye drops or creams. Further review of the physician orders revealed that there were no physicians' orders authorizing the resident to self-administer medications.Review of R40's EHR revealed there was no evidence that a self-administration of medications assessment had been completed to determine if the resident could not self-administer medications.Observation on 03/13/2026 at 9:05 AM revealed, [Name] prescription topically cream and nystatin cream was sitting on the bedside table.During a concurrent observation and interview on 03/14/2026 at 9:30 AM, the Director of Nursing (DON) confirmed that the [Name] prescription topically cream and nystatin cream was sitting on top of the bedside table inside 40's room. Interview with the DON revealed that R40 had not been assessed to self-administer medications and there was no order in place for R40 to self-administer medications. She revealed her expectation was for the nurses to monitor the resident rooms for unauthorized medications.

Based on staff interviews, record reviews, and review of the facility's Advance Directives policy, the facility failed to ensure residents/representatives/guardians were informed of and provided written notice of the right to accept or decline medical and surgical treatments and their right to formulate an advance directive for two of two sampled residents (R) reviewed (R9 and R42). Findings include:Review of the facility policy titled Advance Directives dated September 2022, revealed under Determining Existence of Advance Directives2. The resident or representative is provided with written information concerning the right to refuse or accept medical or surgical treatment and to formulate an advance directive if he or she chooses to do so.Review of R9 and R42's medical records revealed no documented evidence or signed statement of acknowledgment, the resident and his/her representative were informed or received written information advising of their right to accept or decline medical and surgical treatments and to formulate an Advance Directive.Review of the electronic medical record (EMR) revealed resident R9 was admitted to the facility on [DATE] and pertinent diagnoses including but was not limited to other intervertebral disc degeneration, lumbar region with lower extremity pain only.Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed R9 had moderate cognitive impairment with a Brief Interview for Mental Status (BIMS) of 8.Interview on 03/14/2026 at 9:30 AM with R9 revealed he did not recall if he was given any written information on formulating an advance directive or written information on his right to accept or deny medical or surgical treatment. Review of the electronic medical record (EMR) revealed resident R42 was admitted to the facility on [DATE] and pertinent diagnoses including but was not limited to type 1 diabetes mellitus with diabetic nephropathy.Review of the quarterly MDS dated [DATE] revealed R42's cognition was intact with a BIMS score of 15.Interview on 03/14/2026 at 9:36 AM with the R42 revealed he did not recall the facility giving him any written information regarding formulating an advance directive or his right to refuse or accept medical or surgical treatment.Interview on 03/14/2026 at 9:50 AM with the Admissions Nurse revealed she completes the admission packet which includes obtaining information about a resident's advance directive. She revealed she did not provide written information to the residents or their representative on their right to accept or deny medical surgical treatment or the right to formulate an advanced directive. She stated she was not aware she was supposed to do so.Interview on 03/14/2026 at 11:33 AM with Chief Nursing Officer revealed she had never heard of giving written information to a resident regarding their right to accept or deny medical and surgical treatment or the right to formulate an advance directive. She later stated that she found an old admission packet and that language was included. She confirmed R9 and R42 were not given the written information.

Based on observations, staff interviews, and review of the facility's policy titled Quality of Life - Homelike Environment, the facility failed to maintain a safe, clean, and comfortable environment for residents on two of five halls. Specifically, tripping hazards in front of resident toilets, drawers with chipped and missing paint, and uneven, bulging baseboard tiles along the walls of the shower room on one hall. These conditions created an environment that was not safe or homelike and had the potential to negatively affect residents' safety, dignity, and overall quality of life. Findings include: Review of the facility policy Quality of Life-Homelike Environment undated, revealed 2. The facility staff and management shall maximize, to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting. These characteristics include A. cleanliness and order C. Inviting colors and décor. Observations on 03/13/2026 at 8:16 AM and 03/14/2026 at 8:30 AM in room [ROOM NUMBER] revealed ceiling tiles that were not fitted correctly, resulting in visible gaps, as well as ceiling tiles that were torn or ripped. The headboard of the bed was chipped with missing paint, and the stand up closet had a cabinet door that did not fully close. The dresser drawers were also chipped with missing paint. The bathroom floor was black, discolored, scuffed, and in need of repair. Observations on 03/13/2026 at 9:23 AM and 03/14/2026 at 12:28 PM revealed that in room [ROOM NUMBER], the stand up closet cabinet door and the two drawer dresser had chipped paint on the top drawer and at two locations on each end. In room [ROOM NUMBER], the stand up closet cabinet door had a two foot paint chip near the handle, and several areas of chipped paint were noted on the top of the top drawer. Observation and interviews on 03/14/2026 at 12:28 PM with the Maintenance Director and the Administrator confirmed the identified concerns in rooms [ROOM NUMBER]. Both the Administrator and the Maintenance Director agreed that the issues were not conducive to a home like environment and stated the concerns would be addressed and corrected. 2.Observation on 03/13/2025 at 1:30 PM and 03/14/2026 at 9:00 AM of the shower room on Hall One revealed badly damaged, loose, cracked, and uneven bulging baseboard tiles lining the walls in two areas of the shower room, caused by water infiltration. The unstable structure of the baseboard also resulted in large and small pieces of baseboard tiles lying on the floor. Broken baseboard tiles were observed on the floor in front of the toilet and in front of the shower bed. This created a tripping hazard in the front of the toilet area. The flooring was coated with dark, thick brown substances and debris within the floor grooves. Interview on 03/13/2026 at 1:36 PM with the Administrator and Maintenance Director confirmed the badly damaged baseboard tiles. The Administrator reported that the problem had been identified earlier and was the result of water infiltration causing the baseboard to loosen from the wall and water to coat the floor. The Administrator stated that staff continued to use the shower area but was unsure whether staff were using the toilet area. The Administrator reported that the plan was to make the needed repairs. He also stated that there was no Performance Improvement Plan (PIP) or Quality Assurance Performance Improvement (QAPI) plan in place, although the issue was on the facility's to do list.

Based on staff interview, record review, and review of the Centers for Disease Control and Prevention (CDC) website and Clinical Laboratory Improvement Amendments of 1988(CLIA) regulations, the facility failed to ensure a current Centers for Medicare & Medicaid Services (CMS) CLIA Certificate of Waiver. The facility census was 56. Findings include: Review of the CDC CLIA website revealed The CLIA of 1988 regulations apply to all United States (US) facilities or sites that test human specimens for health or disease assessment. Review of the CLIA of 1988 regulations revealed .Certification of Laboratories . (b) Certificate Requirement: No person may solicit or accept materials derived from the human body for laboratory for laboratory examination or other procedure unless there is effect for the laboratory a certificate issued by the Secretary under this section applicable to the category of examinations or procedures which includes such examinations or procedure. Review of the facility-provided CLIA waiver revealed an expiration date of [DATE]. Record review revealed the facility conducts blood glucose checks for 15 residents per day and urinalysis testing for residents as ordered by the physicians. In an interview on [DATE] at 10:00 am, the Building Manager confirmed that the facility's CLIA certificate was expired. The Building Manager stated there had been a request for renewal that had been denied. Further interview revealed that because the facility was in transition from one company to the next, the CLIA certificate had expired and not been renewed.

Based on staff interviews and facility document review, the facility failed to employ a qualified dietitian. This deficient practice had the potential to place the 56 residents residing in the facility at risk of unmet nutritional needs and a diminished quality of life. Findings include: A job description for the Registered Dietitian was requested and was not provided. Review of the facility-provided document titled Dietary Manager included, Job Summary: The primary purpose of the Dietary Manager position is to assist the Dietitian in planning, organizing, developing, and directing the overall operation of the Dietary Department. An interview on 4/4/2025 at 8:30 am with the Dietary Manager (DM) revealed the facility did not have a Registered Dietitian (RD). She stated that the facility has been without an RD for the past two months. She stated that she communicated with the Minimum Data Set (MDS) nurse about residents' diets. In an interview on 4/4/2025 at 8:52 am, the Administrator revealed the former RD was offering support until an RD was hired. In an interview on 4/5/2025 at 12:43 pm, the former RD stated that her last day of service to the facility was 1/26/2025, she was no longer affiliated with the facility, and was not offering support to the facility. In an interview on 4/5/2025 at 2:23 pm, the MDS Coordinator stated that the facility does not currently have an RD. She stated that she did not communicate with the DM about the residents' diets. In an interview on 4/5/2025 at 1:28 pm, the Administrator revealed she was unaware that there was no RD for the facility. She stated someone would be covering until a new RD was available, and was unable to provide confirmation of the coverage. In an interview on 4/5/2025 at 1:45 pm, the Building Manager stated the facility was in the process of a change in company ownership. He stated he was unaware that the RD's contract had ended.

Based on staff interviews and record review, the facility failed to employ a qualified Social Service Worker on a full-time basis to provide services for the residents in the facility. The facility was licensed for 126 beds. Findings include: Review of the facility's licensure revealed that the facility was licensed for 126 beds. Review of the facility personnel files revealed there was no Social Services Worker employed by the facility to provide consultation or oversight of the facility's resident population. In an interview on 4/5/2025 at 9:28 am, the Human Resources Director revealed that the last day the previous Social Services Director worked at the facility was on February 28, 2025, and there had not been any person working in the capacity of the Social Worker in the facility since that day. In an interview on 4/5/2025 at 1:28 pm, the Administrator revealed that she was aware the facility had not employed a qualified Social Service Worker since February 28, 2025. In an interview on 4/5/2025 at 1:45 pm, the Building Manager revealed that he was unaware that the facility did not have a qualified Social Services Worker working in the facility.

Based on staff interviews and review of the facility-provided document titled CNA/STNA (Certified Nursing Assistant/State tested Nursing Assistant), the facility failed to provide the required in-service training for the CNAs employed by the facility. This deficient practice had the potential to adversely affect the 56 residents residing in the facility. Findings include: Review of the facility-provided document titled, CNA/STNA, dated 11/2023, revealed the Specific Educational/Vocational Requirements section included, Must attend a minimum of 12 continuing education programs provided by the center in order to maintain certification. During an interview on 4/4/2025 at 2:30 pm, the Human Resource Director (HRD) revealed that the Director of Nursing (DON) was responsible for submitting CNA in-service hours to the State Agency to determine compliance. She further stated the DON had not submitted the 2024 in-service hours. During an interview on 4/5/2025 at 10:15 am, the HRD stated she had contacted the State Agency, and the 2024 CNA training hours had not been received by the agency. During an interview on 4/5/2025 at 4:03 pm, the Administrator stated the DON was responsible for providing education, and the HRD was responsible for submitting the CNA in-service hours to the State Agency. The Administrator confirmed that the education records for CNAs for 2024 could not be found and was unable to provide evidence of the required in-service training for the facility's CNAs.

Based on resident and staff interviews, record review, and review of the facility policy titled, Bed Hold, the facility failed to provide the resident or representative with written information that included the duration of the bed hold policy and the reserve payment amount at the time of transfer to an acute care hospital for one of three residents (R) (R30) reviewed. This failure had the potential to place R30 at risk of denial of re-admission and loss of their room following hospitalization. Findings include: Review of the facility policy titled, Bed Hold, dated 12/1/2014, revealed the Policy section included, All residents are given the option of reserving their bed when leaving the facility with the intent to return. A Bed Hold Authorization Form should be completed and signed by the resident/responsible party each time a resident leaves the facility. The Procedure section included, . 2. Bed Hold Policy and Bed Hold Authorization Form: All residents/responsible parties are given a copy of the State Specific Bed Hold Policy and Bed Hold Authorization Form upon admission. In the case of emergency transfer the resident or responsible party is provided with written notification within 24 hours of the transfer. The requirement is met if the resident's copy of the notice is sent with other papers accompanying the resident to the hospital. Review of R30's admission Record revealed diagnoses including, but not limited to, cerebral infarction, severe protein calorie malnutrition, aphasia, hemiplegia and hemiparesis, dysphagia, aphasia, dysarthria, chronic obstructive pulmonary disease (COPD), congestive heart failure, anemia, generalized muscle weakness, and gastro-esophageal reflux disease. Review of R30's Quarterly Minimum Data Set (MDS) dated [DATE] revealed Section C (Cognitive Pattern) documented a Brief Interview for Mental Status (BIMS) score of 15 (indicating little to no cognitive impairment). Review of R30's electronic medical record (EMR) revealed no documentation that the facility provided the resident with a bed hold agreement for hospital transfers dated 7/6/2024, 7/20/2024, 9/5/2024, and 1/28/2025. In an interview on 4/4/2025 at 10:04 am, R30 revealed that he had several hospital stays since being admitted to the facility. R30 stated that he has had a lot of medical issues. He further stated he did not recall receiving or signing a bed hold agreement at the time of transfers to the hospital. In an interview on 4/5/2025 at 3:17 pm, Licensed Practical Nurse (LPN)AA revealed when residents were transferred to the hospital, after receiving the order from the physician, there was a packet that was sent with them that contained the residents face sheet, physicians' orders, code status, and the bed hold policy. She further stated the original bed hold was sent with the resident, and a copy of the bed hold was given to the Business Office Manager to be placed in the resident's file. In an interview on 4/5/2025 at 3:26 pm, the Revenue Cycle Manager (RCM) revealed that when a resident was sent to the hospital, the bed hold policy was sent with the resident, and a copy was put in the resident's financial file. During the interview, the RCM was unable to locate the bed hold policies for R30 for the hospital transfer dates of 7/6/2024, 7/20/2024, 9/5/2024, and 1/28/2025. The RCM confirmed that R30 did not receive a bed hold agreement during any of the hospital transfers that occurred. In an interview on 4/5/2025 at 3:40 pm, the Administrator revealed that when a resident was transferred to the hospital, the bed hold policy was expected to accompany the resident at the time of the transfer. Further interview revealed that there was also a copy of the bed hold policy that was placed in the residents' financial file, which was kept in the Business Office.

Based on observations, resident and staff interviews, record review, and review of the facility policy titled, Oxygen, Administration-Nasal Canula, the facility failed to follow a physician order for oxygen (O2) therapy for one of 11 residents (R) (R1) receiving O2 therapy. The deficient practice had the potential to place R1 at risk of medical complications and unmet needs. Findings include: Review of the facility policy titled, Oxygen, Administration-Nasal Canula, dated October 2023, revealed the Procedure section included, 1. Check the resident's clinical record for the physician's order. 5. Turn the flow meter to the ordered flow rate. Review of R1's electronic medical record (EMR) revealed diagnoses including, but not limited to, acute and chronic respiratory failure, unspecified asthma, other specified chronic obstructive pulmonary disease (COPD), and pneumonia. Review of R1's Admission Minimum Data Set (MDS) assessment dated [DATE] revealed Section C (Cognitive Patterns) documented a Brief Interview for Mental Status (BIMS) score of 15 (indicating little to no cognitive impairment). Section O (Special Treatments, Therapies, and Programs) documented R1 received O2. Review of R1's Physician's Orders revealed an order dated 4/1/2025 for O2 at 3 liters per minute (LPM) via nasal cannula (NC) as needed for O2 for oxygen therapy Observations on 4/4/2025 at 8:14 am, and 4/5/2025 at 9:15 am and 1:40 pm revealed R1 was receiving O2 via a NC at 4 LPM via an O2 concentrator. During an interview on 4/5/2025 at 1:49 pm, Licensed Practical Nurse (LPN) AA confirmed that R1's O2 was set at 4 LPM. She confirmed the physician's order was for R1's O2 to be set at 3 LPM. During an interview on 4/5/2025 at 3:15 pm, the Unit Manager revealed that she expected staff to follow the physician's orders for O2 and ensure the flow meters were set to deliver the ordered amount of O2.

Based on observations, staff and resident interviews, and record reviews, the facility failed to ensure respiratory equipment was maintained in a sanitary manner for one of 11 residents (R) (R25) receiving oxygen (O2) therapy. This deficient practice had the potential to place R25 at risk of respiratory complications and a diminished quality of life. Findings include: Review of R25's electronic health record (EHR) revealed diagnoses including, but not limited to, respiratory failure, unspecified with hypoxia, chronic obstructive pulmonary disease (COPD), emphysema, systolic (congestive) and diastolic (congestive) heart failure, obstructive sleep apnea, acute respiratory failure, and acute and chronic respiratory failure with hypoxia Review of R25's Annual Minimum Data Set (MDS) assessment, dated 1/9/2025, revealed Section C (Cognitive Patterns) documented a Brief Interview of Mental Status (BIMS) of 15 (indicating little to no cognitive impairment). Section GG (Functional Abilities and Goals) documented R25 was dependent on staff for mobility. Section J (Health Conditions) documented R25 had shortness of breath or trouble breathing when lying flat. Section O (Special Treatments, Procedures, and Programs) documented R25 received O2 therapy and non-invasive mechanical ventilation while a resident. Review of R25's Physician Orders revealed orders dated: 1/30/2025 for O2 at 3 liters per minute (LPM) via nasal cannula (NC) two times a day, 10/25/2024 to apply CPAP (continuous positive airway pressure) at bedtime for O2 therapy and remove CPAP in the morning one time a day for O2 therapy, and 10/21/2024 for ipratropium-albuterol solution 0.5-2.5 (3) MG (milligram)/3ML (milliliter) one vial inhale orally via nebulizer every 8 hours related to COPD and albuterol sulfate HFA [high-flow aerosol] inhalation aerosol solution 108 (90 Base) MCG (microgram)/ACT (actuator) one inhale orally every 4 hours as needed for dyspnea (trouble breathing). Observation on 4/4/2025 at 8:00 am revealed R25 receiving O2 at 3 LPM via a NC. Observation revealed the O2 concentrator was covered with debris, and the nebulizer mask and CPAP mask were lying on the nightstand, uncovered and exposed to the environment. In an interview, R25 revealed that she was unable to turn and reposition herself in bed independently or reach the nightstand. She revealed that the nurses placed and removed the respiratory masks for her. Observation on 4/4/2025 at 12:18 pm revealed R25 receiving O2 at 3LPM via NC. The oxygen concentrator was covered with debris, and the nebulizer mask and CPAP mask were lying on the nightstand, uncovered and exposed to the environment. Observation on 4/5/2025 at 8:58 am revealed R25 receiving O2 at 3LPM via NC. The oxygen concentrator remained covered with debris. In a concurrent observation and interview on 4/5/2025 at 2:10 pm, Licensed Practical Nurse (LPN) AA confirmed R25 was receiving O2 at 3LPM via NC. LPN AA confirmed the O2 concentrator was covered with debris. Observation revealed the respiratory masks were in a protective bag, however, LPN AA confirmed they were not in a protective bag and were uncovered and exposed to air on 4/4/2025. LPN AA verified that R25 was unable to reach her nightstand and that the nurses would have placed the nebulizer and CPAP masks on the nightstand uncovered. LPN AA stated she thought Environmental Services was responsible for cleaning O2 concentrators and that the night nurses were responsible for changing and bagging nebulizer and CPAP masks. During an interview on 4/15/2025 at 3:15 pm, the Unit Manager (UM) confirmed the findings of the O2 concentrator with debris and the respiratory masks being unbagged and exposed to the environment after viewing pictures of the findings. The UM revealed her expectations of staff were that they ensure the O2 concentrator was clean and that respiratory masks were placed in protective bags when not in use. A policy related to oxygen equipment maintenance and storage was requested and not provided.

Based on staff interviews and record review, the facility failed to notify the physician of a significant change in condition for one of seven sampled residents (R) (R1) related to respiratory distress and the need for further medical treatment. On [DATE], R1 exhibited shortness of breath, tripoding (leaning forward to maximize lung expansion), and a decreased oxygen saturation of 83 percent. On [DATE], a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation had the likelihood to cause serious injury, harm, impairment, or death to residents. The facility's Administrator, Director of Nursing (DON), and Corporate [NAME] President of Compliance and Regulatory Services were informed of the Immediate Jeopardy (IJ) on [DATE] at 4:18 pm. The noncompliance related to the IJ was identified to have existed on [DATE]. At the time of exit on [DATE], an acceptable Immediate Jeopardy Removal Plan had not been received; therefore, the Immediate Jeopardy remained ongoing. Findings include: A review of the Electronic Medical Record (EMR) for R1 revealed a readmitted [DATE] with diagnoses including but not limited to cerebral infarction affecting the left nondominant side, hypertension, type 2 diabetes mellitus, major depressive disorder, and insomnia. A review of the EMR for R1 revealed no evidence that the physician or the Administrator was notified of R1's significant change in condition of respiratory distress or that R1 had expired and was pronounced. Interview on [DATE] at 3:07 pm with Licensed Practical Nurse (LPN) BB revealed that she made a note (progress note dated [DATE]) that stated she had called the DON and the Administrator. However, LPN BB's documentation revealed no evidence that the Administrator was notified. Interview on [DATE] at 3:50 pm with the Registered Nurse (RN) Supervisor revealed that R1 was coughing and saying he was going to stop smoking. RN Supervisor further stated that R1 was stressing, saying he had a hard time breathing, but he was able to talk and repeatedly said he was going to stop smoking. He further revealed that LPN CC had put oxygen on R1 at two liters per minute and took vital signs. He stated he thought LPN CC had stated R1's pulse oxygenation on room air was 89 percent. The RN Supervisor confirmed that he did not call the physician to inform him of the change in condition for R1. An interview on [DATE] at 9:40 am with LPN CC revealed that she did not call the physician because R1 was stable, and a report was given to the assigned night shift nurse. LPN CC stated that if it were an emergency, she would call 911 and then call the physician to tell him what she did for the resident. Interview on [DATE] at 1:34 pm with Physician QQ revealed this was the first he had heard that R1 had expired, and there was no excuse for this. Physician QQ stated that R1 was on his monthly follow-up for next week and further stated that R1 was cognitive and could verbalize his needs and what was wrong. Interview on [DATE] at 2:12 pm with the DON revealed that she was not aware of R1's death circumstances because the RN supervisor told her that the resident had passed in his sleep and was a Do Not Resuscitate (DNR). Interview on [DATE] at 3:18 pm with the Administrator revealed that he was not aware and had not been informed of R1's death circumstances until the surveyor started interviewing the staff. The Administrator stated that when he found out, he held an Ad Hoc meeting and began education on notification and documentation of changes in condition and code status. Cross Reference F600

Based on staff interviews, record review, and review of the facility policy titled Freedom of Abuse, Neglect, and Exploitation; Abuse Prevention: Fast Alerts, the facility failed to protect the resident's right to be free from neglect by staff for one of seven sampled residents (R) (R1). Specifically, R1 had a significant change of condition while in respiratory distress and required further medical treatment. R1 expired less than four hours after being placed in his bed by staff. On [DATE], a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation had the likelihood to cause serious injury, harm, impairment, or death to residents. The facility's Administrator, Director of Nursing (DON), and Corporate [NAME] President of Compliance and Regulatory Services were informed of the Immediate Jeopardy (IJ) on [DATE] at 4:18 pm. The noncompliance related to the IJ was identified to have existed on [DATE]. At the time of exit on [DATE], an acceptable Immediate Jeopardy Removal Plan had not been received; therefore, the Immediate Jeopardy remained ongoing. Findings Include: Review of the policy titled Freedom of Abuse, Neglect and Exploitation; Abuse Prevention: Fast Alerts, dated [DATE], revealed Purpose. The purpose of this written Freedom of Abuse, Neglect, Exploitation: Abuse Prevention Standard is to outline the preventive and action steps taken to reduce the potential for abuse, mistreatment, and neglect of residents and the misappropriation of resident properly and to review practices and omissions which if allowed to go unchecked, could lead to abuse. This standard demonstrates a Zero tolerance of Abuse of any type or manner and will address accordingly. Neglect: Failure of a facility, its employees, or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. Overview: When a nursing home accepts a resident for admission, the facility has assumed the responsibility to 1. Adequately assess the resident's condition. 3. Provide interventions or services to meet the resident's needs from the time of admission. A review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed R1 had a Brief Interview Mental Status (BIMS) score of 15, indicating intact cognition. A review of the care plan for R1, with a canceled date of [DATE], revealed a focus area of Do Not Resuscitate (DNR). The interventions included notifying the medical doctor as needed, communicating resident choice, and comfort measures. A review of the progress notes for R1 dated [DATE] revealed Licensed Practical Nurse (LPN) BB documented that staff was alerted to the resident room in response to R1 being unresponsive. Upon entry to the room, the resident was observed lying supine in the bed with the head of the bed elevated about 30 degrees. The resident had no pulse noted, his eyes were closed with no respirations noted. The resident has a DNR code status. The DON was notified of R1's status. A late entry dated [DATE] revealed a Registered Nurse (RN) Supervisor pronounced R1 deceased at 1:05 am. The RN Supervisor noted that he had attempted to notify the family five different times. The voicemail was not available. (Named) Funeral Home was notified. A review of the Electronic Medical Record (EMR) for R1 revealed that there was no evidence of documentation of vital signs or documentation of the event leading to R1's death. The last documented vital signs were taken on [DATE]. Interview on [DATE] at 7:49 pm with Certified Nursing Aide (CNA) DD revealed that around 8:30 pm, R1 started asking for help. CNA DD stated the agency nurse assigned to R1 had left the building to get food. She stated she and CNA FF wheeled him to the front nursing station because they could not find his nurse. CNA DD further stated that two nurses (RN Supervisor and LPN CC) were at the nurse's station and assessed R1 for pulse oxygenation and vital signs. CNA DD confirmed the RN Supervisor gave R1 oxygen and told R1 to stop talking. CNA DD described the resident as sweating, shaking, and holding his chest, begging for help. CNA DD stated that she held the resident's hand and heard the two nurses discussing who would do the paperwork and stated neither nurse (RN Supervisor nor LPN CC) wanted to do the paperwork. CNA DD further revealed that the RN Supervisor stated that R1 was a DNR anyway, and both nurses (RN Supervisor and LPN CC) rolled R1 back to his room in his wheelchair and put him in the bed. Interview on [DATE] at 10:57 am, the RN Supervisor revealed that he returned to the facility to pronounced R1. The RN Supervisor stated that when he returned to the facility and before pronouncing R1, he did an assessment by checking the carotid pulse, using his stethoscope, and checked the apical pulse and did not find a heartbeat. He stated the resident was cool to the touch. The RN Supervisor explained that at about 8:30 pm on [DATE], the facility was having a staffing issue at shift change. He stated they had initially told LPN BB to go home, but the nurse scheduled to work did not show up, and LPN BB ended up staying at the facility. In a follow-up interview on [DATE] at 3:50 pm, the RN Supervisor revealed that R1 was coughing and talking, saying he was going to stop smoking. RN Supervisor stated that he thought it was a CNA who brought R1 to the front station, and R1 was stressing, saying he had a hard time breathing. He stated he was able to talk and repeatedly said he was going to stop smoking. He stated LPN CC put oxygen on the resident at two liters per minute. RN Supervisor further revealed that he was handling staffing issues, and LPN CC had said she had R1. RN Supervisor stated that R1 was taken back to his room by LPN CC and put to bed. RN Supervisor stated that he went to check on R1 before he left the facility, and his pulse oxygenation was 96 percent on 2 liters of oxygen. RN Supervisor revealed that he did not call the physician. However, a review of the EMR revealed no evidence that the facility staff performed vital signs or an assessment. Interview on [DATE] at 3:07 pm with LPN BB revealed that on [DATE], she was assigned to D Hall, and R1 was on the E Hall. LPN BB stated that when she initially got to work, R1 was at the front station and was receiving care from two nurses she identified as the RN Supervisor and LPN CC. LPN BB stated that she noticed the resident was wearing oxygen. She stated that she proceeded to her assigned area on the D Hall. She further stated that after she passed her medications on D Hall, she went to get something to eat. LPN BB revealed that she came back from lunch, and the RN Supervisor told her that R1 was complaining of being unable to breathe and had shortness of breath and that he had put R1 back in his room. The RN Supervisor had reported to her that R1 had gone out to smoke and that he put oxygen on the resident for shortness of breath and R1 seemed calmer. LPN BB further revealed that she went to pass narcotics for the Certified Medication Assistant (CMA) NN on E Hall and noticed R1 was anxious and yelling that he wanted his bed flat. LPN BB stated R1 was okay with not having the bed flat, and the resident was still talking and wanted his bed flat. LPN BB revealed that CMA NN came to her and told her that R1 was deceased . She stated when she walked into R1's room, he had one hand gripping the rail of the bed, his eyes were closed, and he had the appearance of being asleep. LPN BB stated that she checked his radial pulse and didn't feel a pulse and further revealed that when RN Supervisor and LPN CC put him in bed with oxygen, they made her think he was okay. LPN BB commented that her initial contact with R1 was only about him wanting to have the bed flat. In a follow-up interview on [DATE] at 1:49 pm with LPN BB, she clarified that she arrived at work at about 6:30 pm and normally goes to dinner before it is dark outside. She continued to state that her nursing note was written about 5 to 10 minutes after R1 was without signs of life. She stated when she first went on D Hall, it was during a regular medication pass to give narcotics for CMA NN since that they could not pass narcotics or chart those medications. Interview on [DATE] at 7:17 pm with CNA FF revealed that she was orienting CNA EE and was in a resident room. CNA FF stated she heard someone hollering down the hall, and it was R1 saying he couldn't breathe and wanted to lie down. CNA FF stated R1 was coming down the hall saying help me help me, and he couldn't breathe. CNA FF revealed she rolled him to the front nursing station because she didn't see a nurse on the back hall. CNA FF stated she informed the RN Supervisor and LPN CC that R1 was saying he could not breathe. She stated LPN CC took R1's vital signs, and his oxygenation saturation was 83 percent. She further stated that LPN CC applied oxygen to R1 via a nasal cannula. CNA FF stated that she then returned to her assignment. She stated at the end of her rounds, she observed that the RN Supervisor and LPN CC had put R1 in his bed with oxygen on and R1 was sitting in an upright position in bed. She further stated that at about 8:00 pm or 8:30 pm, she told LPN BB and CMA NN that R1 has a history of heart attacks. She stated that LPN BB stated that she would not send R1 out because the doctors would say why didn't they (nurses) do what could be done in the facility before sending him to the hospital. In a continued interview, CNA FF stated she and CNA EE told LPN BB that R1's oxygen was 83 percent. CNA FF stated that she and CNA EE checked on the resident and then went to get their meal from about 11:00 pm to 11:30 pm. CNA FF revealed when she returned from lunch that LPN BB told her to get R1's vital signs, and R1 had no pulse and no chest rise. Interview on [DATE] at 9:40 am with LPN CC revealed that she was assigned to the A/C Hall from 7:00 am to 7:00 pm. She stated she passed her keys and gave a report to the front hall nurse. LPN CC stated she went to get a sheet to sign off, and R1 was in front of the nursing station with two CNAs. LPN CC further revealed that R1 looked short of breath and was sweaty, and she noticed the RN Supervisor was checking R1's vital signs. LPN CC stated she couldn't recall the specific values of the oxygen saturation but knew it was around 85 percent. She stated that, in general, R1 needed oxygen. LPN CC further stated she got the oxygen, put the resident on 3 liters of oxygen by nasal cannula, and told R1 that he was not alone. LPN CC stated that she was told that R1 was blind and had paralysis on the left side, and she told him to raise his right arm to help him breathe and stated the oxygen was helping. LPN CC further revealed that the RN Supervisor took R1 to the nurse assigned to the resident and she did not know the nurse. LPN CC stated that after 8:00 pm, she walked to the other side of the facility and asked a nurse where R1's room was. She stated the RN Supervisor was in the room alone with R1 and stated that he had reported to the night shift nurse. LPN CC revealed that she and the RN Supervisor assisted R1 into the bed and placed the head of the bed in the up position. When asked why she did not document, she stated that she was clocked out and didn't document because R1 was not her patient, and she thought he was okay. LPN CC stated she was helping the night shift nurse and did not call the physician. LPN CC further revealed that R1 was stable, and a report was given to the assigned night shift nurse. When asked if she discussed the transfer paperwork, LPN CC stated that she discussed the code status of the DNR, and if it were an emergency, she would call 911 and then call the physician to tell him what she did for the resident. Interview on [DATE] at 1:34 pm with Physician QQ revealed that a resident with an 83 percent pulse oxygenation should have been sent out immediately and needed an advanced level of care. Physician QQ stated that R1 had no respiratory care needs, was cognitive, and could verbalize his needs and tell you what was wrong. Physician QQ further revealed that this was the first he had heard that R1 had expired and stated that R1 was on his monthly follow-up for the next week. Physician QQ stated there was no excuse for this, and a DNR does not mean withholding care. Interview on [DATE] at 2:12 pm with the DON revealed that R1 should have been sent to the hospital and the physician should have been called. The DON stated that she was not aware of R1's death circumstances because the RN Supervisor had told her that R1 had passed in his sleep and was a DNR. Interview on [DATE] at 3:18 pm with the Administrator revealed that he was unaware of R1's death circumstances until the surveyor started interviewing the staff. The Administrator stated that once he was made aware, he held an Ad Hoc meeting and began education on notification and documentation of changes in condition and code status.

Based on staff interviews, record reviews, and review of the Administrator and Director of Nursing (DON) job descriptions titled Title: License Nursing Home Administrator and Title: Director of Nursing, the facility Administration failed to ensure that one of seven sampled residents (R) (R1) was free from neglect by staff when R1 was in respiratory distress asking for help. In addition, the facility Administration failed to provide oversight and monitoring of care and services to R1 for further medical treatment. This failure resulted in R1 expiring in his room alone and gripping the handrails. On [DATE], a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation had the likelihood to cause serious injury, harm, impairment, or death to residents. The facility's Administrator, Director of Nursing (DON), and Corporate [NAME] President of Compliance and Regulatory Services were informed of the Immediate Jeopardy (IJ) on [DATE] at 4:18 pm. The noncompliance related to the IJ was identified to have existed on [DATE]. At the time of exit on [DATE], an acceptable Immediate Jeopardy Removal Plan had not been received; therefore, the Immediate Jeopardy remained ongoing. Findings include: Review of the job description titled Title: Licensed Nursing Home Administrator revealed Job summary: The primary purpose of the Nursing Home Administrator position is to oversee the day-to-day operation of the facility and to review organizational performance. Job Duties & Responsibilities: Resident Care & Quality of Life. Oversee that residents receive care in a manner and in an environment that maintains or enhances their quality of life without abridging the safety and rights of other residents. Working conditions: Maintains a liaison with residents, their families, support personnel, etc., to assure that the residents' needs are continually met. Review of the job description titled Title: Director of Nursing revealed Job Summary: The primary purpose of the Director of Nursing position is to plan, organize, develop and direct the overall operation of the Nursing Department to ensure that the highest degree of quality care is maintained at all times. Job Duties & Responsibilities: Administrative Functions. Review and ensure that charting documentation procedures for nursing are met according to Vanguard, state, and federal guidelines. Nursing Care Functions: Review nurses' notes to ensure that they are informative, descriptive of the nursing care, and consistent with therapy care being provided, that they reflect the resident's response to the care, and that such care is provided in accordance with the resident's wishes. Make daily rounds to observe residents and to determine if nursing needs are being met in accordance with the resident's requests. Ensure that residents who are unable to call for help are checked frequently. Facility Administration, specifically the Administrator and the DON, failed to protect residents and effectively oversee areas of the facility that were included in their job descriptions. 1. The facility failed to ensure R1 was free from neglect by facility staff while he was experiencing respiratory distress, asking for help, and needing further medical treatment. R1 expired in the facility. Cross refer F600. 2. The facility failed to notify the physician of a significant change in condition for R1 who exhibited shortness of breath, tripoding (leaning forward to maximize lung expansion), and had a decreased oxygen saturation reading of 83 percent on room air. Cross refer F580. Interview on [DATE] at 1:34 pm with Physician QQ revealed that a resident with an 83 percent pulse oxygenation should have been sent to the emergency room (ER) immediately and needed an advanced level of care. Physician QQ stated that R1 had no respiratory care needs, was cognitive, and could verbalize his needs and tell you what was wrong. Physician QQ further revealed that this was the first he had heard that R1 had expired and R1 was on his monthly follow-up for the next week. Physician QQ stated there was no excuse for this, and a Do Not Resuscitate (DNR) status does not mean withholding care. An interview on [DATE] at 2:12 pm with the DON revealed that R1 should have been sent to the hospital and the physician should have been called. The DON stated that she was not aware of R1's death circumstances. The DON further revealed that the RN Supervisor told her in the morning meeting that R1 had passed in his sleep and was a DNR. An interview on [DATE] at 3:18 pm with the Administrator revealed he was not aware of R1's death circumstances until the surveyor started interviewing the staff. The Administrator stated that once he was made aware, he held an Ad Hoc meeting and began education on notification and documentation of changes in condition and code status.

Based on staff interviews, record review, and review of the facility documents titled Resident Fund Management Service and Burial Account, the facility failed to ensure that one of seven sampled residents (R) (R2's) burial account funds were not used to pay the care cost balance. This deficient practice had the potential to affect all residents who had a trust funds account with the facility. Findings include: A review of the Resident Fund Management Service document, dated [DATE], revealed that the Resident Fund Account was a transferring account (automatic transfer of care cost payments due the facility) with a $70.00 monthly allowance amount. A review of the Burial Account document revealed that it was a deposit-only account for money to be used for burial expenses only and was revocable (it may be closed prior to death). A review of the Resident Statement Landscape revealed that R2 had a trust fund account for care costs and a burial account. Further review revealed on [DATE], R2's trust fund account balance was $4185.83. On [DATE], $4115.00 was transferred from the trust fund account to the burial account, leaving a balance of $70.00 in the trust fund account. A review of the Close Transaction Report, dated [DATE] (to close R2's trust account), revealed that $70.83 was due to R2 to close the trust fund account. A check numbered 003614, dated [DATE], from the Resident Fund Management Service (RFMS) Petty Cash Account revealed the check was made payable to R2 and had the facility's address. A review of the Close Transaction Report dated [DATE] (to close R2's burial account) revealed a balance of $4115.00. There were two checks for the burial disbursement dated [DATE], check numbered 003613 for $1998.52 with R2 as the payee and check numbered 003615 for $2116.48 with the facility as the payee. A review of the Trial Balance dated [DATE] revealed R2's burial account was closed on [DATE], with a zero balance. A review of the facility's Petty Cash bank account statement dated [DATE], through [DATE], revealed that check numbers 003613 and 003614 were cleared as paid on [DATE], and check 003615 was cleared as paid on [DATE] from the facility's petty cash account. There was no evidence that the Responsible Party authorized the facility to transfer money from the burial account to pay an outstanding balance of care cost. A review of medical records revealed that R2 expired on [DATE]. In an interview on [DATE] at 12:57 pm, the Business Office Manager (BOM) revealed that the only authorization she had was to transfer money from R2's trust account to his burial account and that she was not aware that the burial account funds could not be used to pay the care cost balance.

Based on staff interviews and record review, the facility failed to ensure vital signs were obtained as ordered for two of seven sampled residents (R) (R1 and R3). This deficient practice had the potential to negatively affect R1 and R3's physical health and well-being. Findings include: 1. A review of R1's medical records revealed admission to the facility on [DATE], with a readmitted [DATE]. Diagnoses included but were not limited to hypertension and type 2 diabetes mellitus. A review of the Order Summary for R1 revealed an order dated 5/4/2023 with a start date of 5/8/2024 for vital signs to be obtained every Monday, every day shift. A review of the Weight and Vitals Summary revealed no vital signs were documented on any dates in May 2024. Two entries of vital signs were recorded for June 2024, dated 6/1/2024 and 6/3/2025. There was no evidence of vital signs recorded for 6/10/2024 and 6/17/2024. 2. A review of R3's medical records revealed admission to the facility on [DATE] with a readmitted [DATE]. Diagnoses included but were not limited to hypertension and major depressive disorder. A review of the Order Summary for R3 revealed an order dated 1/14/2024 with a start date of 1/15/2024 to obtain vital signs every day shift every Monday for monitoring. A review of the Weights and Vitals Summary dated 1/1/2024 through 7/1/2024 revealed no evidence that vital signs were obtained on any dates in May 2024. In an interview on 7/11/2024 at 2:12 pm, the Director of Nursing (DON) revealed that staff should document vital signs during the shift and that missing documentation should be entered within 24 hours.

Based on staff interviews, record reviews, and review of the facility policy titled Clinical Documentation, the facility failed to ensure clinical records contained complete and accurate documentation for one of seven sampled residents (R) (R1). Findings include: A review of the facility's policy titled Clinical Documentation, dated [DATE], revealed the section titled Clinical Documentation Overview stated, Facility nursing staff documents the provision of nursing care according to nursing standards and regulatory requirement. Documentation tools are designed to demonstrate the clinical care provided to the resident and to ensure the appropriate information is available to all interdisciplinary team members regarding treatment interventions and responses. Frequency of nursing documentation is based on resident clinical status, clinical need and regulatory requirements. Components of the nursing documentation proves include but are not limited to documentation in progress notes that reflect the ongoing clinical condition of the resident. A review of R1's Progress Notes dated [DATE] through [DATE] revealed an entry dated [DATE] that Licensed Practical Nurse (LPN BB) was alerted by staff to the resident's room in response to the resident being unresponsive. Upon entry to the room, the resident had no pulse noted and his eyes were closed with no respiration noted. The Director of Nursing (DON) was notified of resident status. A late entry dated [DATE] revealed Registered Nurse (RN) AA pronounced R1 deceased at 1:05 am. A review of R1's medical records revealed that there was no evidence of documentation of vital signs or documentation of the events prior to R1's death. The last documented vital signs were dated [DATE]. In an interview on [DATE] at 7:49 pm, Certified Nursing Assistant (CNA) DD revealed on [DATE] around 8:30 pm, R1 asked for assistance. She stated she assisted him to the nurse's station, and two nurses assessed him, including checking his pulse, oxygenation, vital signs, and administering oxygen. She stated R1 exhibited sweating, shaking and holding his chest. She further stated the two nurses took R1 to his room and placed him in his bed. In an interview on [DATE] at 2:12 pm, the Director of Nursing revealed that staff should document during the shift and enter missing documentation within 24 hours.

Based on staff interviews, record review, and review of the facility policy titled Clinical Staffing Standard, the facility failed to ensure that a Registered Nurse (RN) other than the Director of Nursing (DON) was assigned to direct nursing care of the residents for 27 of the 28 days reviewed. The facility census was 77 residents. This failure had the potential to negatively impact all residents residing at the facility. Findings include: A review of the facility policy titled Clinical Staffing Standard, dated October 2023, revealed the Procedure section documented 4. Staffing will include a Registered Nurse 8 hours a day. A review of the Facility Two Week Staffing Grid dated 3/19/2024 through 4/1/2024 and 4/2/2024 through 4/15/2024 revealed that an RN was assigned to direct nursing care for eight or more hours each day. Twenty-four of the 28 days documented an RN for eight hours per day, three days documented an RN for eight and one-half hours per day, and one day documented an RN for 23 hours per day. However, the facility was unable to provide timesheets for an RN who provided direct nursing care for the 28 days from 3/19/2024 through 4/15/2024. The RN time documented on the two-week staffing grids was the former DON's hours. There was no evidence that an RN, who was not the DON, worked as a direct care nurse on the dates from 3/19/2024 through 4/15/2024. In an interview on 4/24/2024 at 6:17 pm, the Regional [NAME] President of Operations revealed the eight hours per day of RN hours listed on the two-week staffing grids for the dates from 3/19/2024 through 4/15/2024 were the former DON's hours. The Regional [NAME] President of Operations offered an explanation that other facilities also list the DON as the RN on the two-week staffing grids.

Based on observation, staff interviews, and review of the facility document titled CNA/STNA (Certified Nursing Assistant/State tested Nursing Assistant), the facility failed to ensure that one resident (R) (R11) of 16 sampled residents was provided perineal care. This failure placed R11 at risk for unmet needs and a diminished quality of life. Findings include: A review of the facility document titled CNA/STNA, dated November 2023, revealed the Responsibilities section stated, Provide resident care in a manner conducive to safety and comfort. Resident care includes but is not limited to assist resident with or performs Activities of Daily Living (ADL). A review of the Significant Change Minimum Data Set (MDS) Assessment, dated 2/6/2024, revealed section GG (Functional Abilities and Goals) documented that R11 required partial/moderate assistance with toileting and was dependent for personal hygiene, section H (Bladder and Bowel) documented R11 was always incontinent of bladder and bowel, section I (Active Diagnoses) included Alzheimer's disease, dementia, and anxiety, section O (Special Treatments and Programs) documented R11 received Hospice care. A review of the care plan, dated 3/27/2024, revealed that R11 has episodes of incontinence of the bladder and bladder. The interventions included performing incontinent care as needed. During an observation on 4/24/2024 at 9:56 am, R11 was observed lying in bed, and her bed sheets were soaked with urine. Her incontinent brief was heavily soiled with brownish substance with a stagnant urine odor. The bed pad was heavily saturated with urine, and the back of her sweatshirt was wet from the lower back to the upper back with urine. At 10:14 am, CNA KK provided perineal care to R11. A review of an in-service on perineal care dated 4/1/2024 revealed no evidence that CNA KK attended the in-service. In an interview on 4/24/2024 at 10:14 am, CNA KK stated that this was the first time she had entered R11's room on this date. She further stated she arrived at work at 6:40 am. She continued to state that the resident had a bath scheduled for that morning by the hospice CNA. She explained that the hospice CNA would have changed R11 during the bath. In an interview on 4/24/2024 at 11:39 am, Hospice CNA LL revealed that incontinent care provided to the resident depended on the person assigned to the hospice residents and that mostly the night shift on the weekend, specifically on Monday, was the worst about not providing incontinent care. She further stated that R11 was always soaked when she arrived to provide care. In an interview on 4/24/2024 at 6:17 am, the Regional [NAME] President of Operations revealed that the CNAs are to check and make rounds every two hours to check for dryness and reposition the resident.

Based on observation, staff interview, and review of the facility-provided document titled Licensed Nursing Home Administrator, the facility failed to ensure that a Licensed Administrator was present in the facility to oversee daily operations and management on four of four days observed. The facility census was 77 residents. Findings include: A review of the facility-provided document titled Licensed Nursing Home Administrator, dated 1/14/2018, revealed the section titled Job Summary documented, The primary purpose of the Nursing Home Administrator position is to oversee the day-to-day operation of the facility and to review organizational performance. The section titled Leadership and Management documented Ensure administrative oversight of the survey process. Observations on 4/17/2024, 4/22/2024, 4/23/2024, and 4/24/2024 revealed that the facility did not have a Licensed Administrator in the facility. A review of a facility-provided document titled Worksite Employee Separation Form, dated 4/10/2024, revealed the most recent Licensed Administrator's last day worked was 4/8/2024. The facility did not provide the State notification documentation for a change in Administrators. During an interview on 4/24/2024 at 6:17 pm, the Regional [NAME] President of Operations revealed that she is not a Licensed Administrator. She stated that she was just overseeing the daily operations and that the Interim Administrator lives in South Carolina. She further stated that the Interim Administrator had not physically been in the facility before 4/19/2024 and had worked on 4/20/2024 and 4/21/2024. The Interim Administrator was unavailable for an interview.

Based on staff interview, record review, the facility failed to follow the Care Plan for pain or discomfort interventions during wound care for two (2) residents (Resident P and Resident T ) census sample of six (6) residents. There are eight (8) total residents with pressure ulcers. Total Facility census is ninety-five (95). Findings Include: 1. Resident P was admitted to the facility on [DATE] and the medical records revealed the following Diagnosis: [REDACTED]. Review of the Quarterly Minimum Data Set ((MDS) dated [DATE] revealed Section C Cognitive Patterns Brief Interview for Mental Status (BIMS) is 15 which reveals the resident P is cognitively intact. Section M - Skin Conditions reveals the resident P has one stage III pressure ulcer. During review of the Care Plan with a Target dated 10/26/16 revealed resident P is Care Plan as being at risk for altered comfort which include a contributing diagnose of [MEDICAL CONDITION]; a contributing of medications: [REDACTED]. The Care Plan was updated on 7/22/16 to Proceed with Plan of Care (no changes). The Care Plan has an intervention to Keep Medical Doctor (MD) informed of pain management efforts and possible need for re-evaluation. 2. Resident T was admitted to the facility on [DATE] and the medical records revealed the following Diagnosis: [REDACTED]. Review of the Thirty Day Scheduled Assessment Minimum Data Set ((MDS) dated [DATE] revealed Section C Cognitive Patterns Brief Interview for Mental Status (BIMS) is 12 which reveals the resident T is cognitively intact. Section M - Skin Conditions reveals the resident T has one stage IV pressure ulcer During review of the Care Plan with a Target dated of 10/26/16 revealed resident T is Care Plan as being at risk for pain from diagnose of wound, fracture, and [MEDICAL CONDITION]. Resident has varied complaint of pain over body, chronic complaints of stomach pain was referred for Gastroenterlogist consult. The Care Plan has interventions to observed resident for sign and symptoms of breakthrough pain, decreased mobility and constipation; [MEDICATION NAME] as orders; [MEDICATION NAME] as ordered; notify MD as needed; encourage resident to participate in activities of choices to divert from pain. An interview on 8/17/16 at 317 p.m. the Director of Nursing (ADON) revealed it is not acceptable to perform wound care to resident with pain. Nor to give pain medication one (1) minute before wound care to a stage III wound. Cross Reference to F 314

Based on observation , staff interview and Dressing Change Policy, the facility failed to prevent cross contamination of wounds for two (2) (Resident #1 and #2) of three (3) residents from a sample of ten (10) residents. Findings Include: 1. Review of the medical record for resident #1 revealed the following Diagnosis: [REDACTED]. Resident # 1 has six (6) areas that requires daily dressing changes which includes right inner buttock, right heel, right hip, left inner foot, left hand and abdominal percutaneous endoscopic gastrostomy (peg) dressing During an observation on 7/13/16 at 7:32 a.m., Licensed Practical Nurse (LPN) AA did not change gloves between providing treatment to the right heel and the right hip. LPN AA removed the soiled dressing from the right hip with the same gloves and continued to clean the right hip wound with wound cleanser. Using the same gloves, he/she began to open [MEDICATION NAME] non-adhesive pad. LPN AA placed the wrapper in the red biohazard bag and still wearing the same gloves pushed the wrapper further into the red bag and did not change the gloves. LPN AA continued to apply the adhesive dressing to the wound. After the adhesive dressing was applied he/she removed and discarded the gloves. During an interview on 7/13/16 at (:36 a.m. LPN AA stated he/she had forgot to change the gloves between the right heel and right hip wound treatment and that the policy stated to wash hands between dressings. LPN AA stated that he/she knew better not to put his/her hand in the red biohazard bag to push down the discarded wrappers. LPN AA stated that previously he/she had worked as a weekend treatment nurse and did not have any additional training in wound care. 2. Review of the medical records for resident #2 revealed the following Diagnosis: [REDACTED]. During an observation on 7/13/16 at 9:25 a.m., LPN AA, removed the soiled dressing from the sacral wound and as he/she placed it in the red biohazard bag his/her gloved hand touched the inside of the biohazard bag. LPN AA continued to wear the same gloves to clean the wound with wound cleanser, to fold a piece of calcium alginate and to pack the alginate into the wound bed. After he/she packed the wound with the calcium alginate, opened an adhesive padded dressing and applied the dressing to the sacral wound, he/she then removed the gloves and discarded them in the red biohazard bag. LPN AA then exited the room without washing his/her hands. An interview on 7/13/16 at 9:36 a.m. LPN AA stated he/she thought it was okay to use the same glove throughout the entire treatment change if the resident only had one wound. He/she could not say why he/she placed the soil dressing in the red bag instead of dropping it. LPN AA stated that previously he/she had worked as a weekend treatment nurse and did not have any additional training in wound care. Review of the facilities Nursing Procedure Manuel for Dressing Change revealed: The Purpose: To prevent contamination of wound, To protect adjacent skin surfaces from irritation due to wound drainage, To promote wound healing. Procedure: 6. Wash hands and apply gloves 7. Remove soiled dressing 8. Observe amount, color and odor of drainage and condition of wound bed or incision 9. Place soiled dressing and gloves in plastic bag 10. Remove gloves and wash hands 12. Apply gloves (to continue wound care) 19. Remove gloves and wash hands.