Every finding on record at Encore at Foulk

Based on interview and observation it was determined that for one (R21) out of one resident reviewed for Activities of Daily Living, the facility failed to ensure that R21 was offered a meal or assistance with eating. Findings include:2/12/26 - R21 was admitted to the facility with diagnoses including paranoid schizophrenia and dementia.2/18/26 - R21's admission MDS assessment documented a BIMS score of 3, indicating that R21 was severely cognitively impaired. The assessment also documented that R21 was dependent on staff to provide assistance with eating.2/25/26 - R21's care plan documented, [R23] is at nutrition/hydration risk related to significant weight loss prior to admission. Intervention/Tasks.Assist with meals for optimal intake.monitor oral intake of food and fluid.4/9/26 8:39 AM - R21 was observed laying in bed sleeping.4/9/26 9:34 AM - R21 was observed laying in bed sleeping.4/9/26 9:47 AM - E6 (CNA) was observed entering R21's room.4/9/26 10:00 AM - During an interview, FM1, R21's family member, stated, [R21] should be up and dressed by now. I want to take her downstairs for the music activity that starts at 10:30 [am].4/9/26 10:07 AM - E6 was observed bringing R21 out of her room. During an interview, E6 stated, I'm assigned to the second floor, I just came to the third floor to assist [R21].4/9/26 10:15 AM - FM1 was observed pushing R21 in a wheelchair down the hallway.4/9/26 10:36 AM - R21's breakfast tray with a covered and untouched plate of food was observed sitting on a third floor dining room table.4/9/26 10:40 AM - During an interview, E5 (RN) stated, [R21]'s assigned CNA [E7, Agency] went home. Another CNA was called to come in.4/9/26 12:22 PM - During an interview FM1 stated, I took [R21] downstairs to the music activity. The Surveyor asked, Did [R21] eat breakfast downstairs or did anyone ask if [R21] ate breakfast? FM1 stated, No. It's time for lunch now anyway. I'm going to get her tray and I'll help [R23] eat in her room.4/13/26 10:30 AM - Finding was reviewed with E1 (ED) and E2 (DON).4/13/26 2:30 PM - Findings were reviewed with E1, E2, E3 (ADON) and E4 (MDSC) during the exit conference.

Based on interview and record review, it was determined that for one (R23) out of one resident reviewed for laboratory services, the facility failed to provide timely laboratory services. Findings include:Review of R23's clinical record revealed:11/15/21 - R23 was admitted to the facility with diagnoses including multiple sclerosis and mood disorder.3/16/23 - A physicians order entered in R23's clinical record documented, .Divalproex Sodium Give 1 capsule by mouth two times a day for mood disorder.7/24/24 - A physician's order entered in R23's clinical record documented, Monitor a Valproic Acid trough concentration in the next lab day and Q6months [every six months] starting on the 28th for 1 day(s) for Valproic level monitoring. 7/28/25 - R23's clinical record lacked evidence that the valproic acid levels were monitored as ordered.12/5/25 - A Pharmacy Consultation Report for R23 documented, [R23] receives Divalproex Sodium but does not have a trough concentration documented in the medical record.please monitor a valproic acid trough on the next convenient lab day.every 6 months thereafter. The report also contained a handwritten physician note documenting, Valproic trough today 1/5/2026.1/5/26 - A physician's order entered in R23's clinical record documented, Valproic acid trough one time.Start Date 01/05/2025 1400 [2:00 PM].1/29/26 - A laboratory results report for R23 documented, .Time/Date Collected 01/29/26 14:20 [2:20 PM].Test Name Valproic Acid.R23's clinical record lacked evidence of valproic acid trough level was laboratory tested as ordered. 4/9/26 2:45 PM - During an interview, E2 (DON) stated, [R23]'s July 2025 six month valproic acid trough lab results could not be found.4/13/26 10:30 AM - Findings were reviewed with E1 (ED) and E2.4/13/26 2:30 PM - Findings were reviewed with E1, E2, E3 (ADON) and E4 (MDSC) during the exit conference.

Based on observation and interview, it was determined that for one (R2) out of one resident reviewed for pain management the facility failed to timely and adequately assess the resident's report of pain and failed to offer a non-pharmalogical intervention when the resident reported pain. Findings include: The facility policy related to Pain Management undated, indicated Pain management is a multidisciplinary care process that includes the following: Assessing the potential for pain; Identifying the characteristics of pain; Addressing the underlying causes of pain; Identifying and using specific strategies for different levels and sources of pain. Assess pain using a consistent approach and a standardized pain assesment instrument appropriate to the residents cognitive level. Non-pharmalogical interventions may be appropriate alone or in conjunction with medications. Review of R2's clinical record revealed: 1/29/25 - R2 was admitted to the facility with multiple diagnoses including a pressure ulcer to the sacrum and arthritis. 1/29/25 - A physicians order was written for R2 to be offered non-pharmalogical pain management interventions such as heat, ice, massage, music repositioning, aromatherapy and guided imagery. 1/29/25 - A physician's order was written for R2 to receive Tylenol as needed for mild pain of 1-3. 1/29/25 - A physician's order was written for R2 to receive Morphine as needed every six hours for severe pain; attempt non-pharmalogical interventions first. 2/3/25 - A physician's order was written for R2 to receive oxycodone one time a day for pain. 2/4/25 - An admission MDS assessment documented that R2 experienced severe constant pain. 2/7/25 - A care plan related to increased risks for alteration in comfort related to chronic back pain, anal spasms, and sacral wound was created for R2. Interventions related to the care plan included, monitor/record pain characteristics: quality (e.g. sharp, burning); severity (1 to 10 scale); anatomical location; onset; duration (e.g., continuous, intermittent); aggravating factors; relieving factors. Notify the physician if the interventions are unsuccessful or if the current complaint is a significant change from residents past experience of pain. Provide me my pain medication as ordered, document and evaluate the effectiveness of my pain medication. Coordinate with my MD, PA or NP to manage pain medication for optimum pain control. Monitor/document my side effects of pain medication. Observe for constipation; new onset or increased agitation, restlessness, confusion, hallucinations, dysphagia; nausea; vomiting; dizziness and falls. Report occurrences to the physician. My physician shall be notified promptly for re-evaluation of my pain regimen if it has been determined that my analgesic is ineffective or pain rating has increased or stayed the same. Referral to the Pharmacist for review and options will be done as needed. Non-pharmacological interventions shall be attempted that work for me to decrease my pain. This would include, but not be limited to, snack, repositioning, resting in bed, increased socialization and participation in activities as a therapeutic use of distraction. 3/6/25 - A physician's order was written for R2 to receive morphine for sacral [wound] pain prior to the dressing change. 3/17/25 10:59 AM - During an interview, R2 reported that at times the pain gets really bad with my wound an 8 or 9 at times . 3 - 4 is tolerable but they don't always get it [pain medications] as fast as I want. 3/17/25 11:20 AM - During a dressing change observation, R2 stated to E4 (LPN), My neck hurts. Can I have some Bengay or something? E4 responded, If you get more pain meds now it will put you to sleep. R2 then replied, Well, no, I don't want that. E4 then stated to the surveyor [R2] had Morphine twenty minutes ago, so I can't give her anything. E4 did not assess the characteristics of R2's report of neck pain and did not offer R2 any non-pharmalogical interventions for the report of neck pain. E4 immediately confirmed the finding. 3/20/25 11:45 AM - R2's MAR documented the resident was given an as needed dose of morphine for pain of 8/10. 3/20/25 11:55 AM - R2 walked to nurses' station and stated to E5 (LPN) and E3 (RN/UM), Can you give me something for pain? It hurts very bad. E5 stated, I will check and R2 immediately returned to her room. E5 remained at the nurses' station then administered medications to other residents and lastly reported back to R2 at 12:44 PM. 3/20/25 12:44 PM - E5 (LPN) entered R2's room and asked R2, Are you feeling better? R2 continued to report pain and reported a new complaint of constipation. E5 (LPN) asked, What is the level now? An hour ago you said 8? R2 stated, It's not gotten better. E5 then checked R2's medical record and reported the resident had a bowel movement the prior day. E5 suggested repositioning on the opposite side and a liquid laxative. R2 declined the liquid laxative. E5 then stated she would call R2's provider. 3/20/25 1:05 PM - During an interview, E5 (LPN) confirmed the delay and lack of identification of pain characteristics in the assessment of pain from when R2 reported pain at 11:55 AM to E5's response and assessment of R2's pain at 12:44 PM almost an hour later. E5 stated, I knew she had just gotten Morphine and I was concerned about the time for closeness of the medications, but I will call the provider to see if the easing the constipation will help with the pain. 3/21/25 9:06 AM - During an interview, E3 (RN/UM) confirmed that staff is expected to assess pain severity and other characteristics when a resident complains of pain. 3/21/25 1:15 PM - Findings were reviewed during the exit conference with E2(DON).

Based on observation and interview, it was determined that for one (R2) out of one resident reviewed for pressure ulcers, the facility failed to adhere to infection control practices to reduce risk of infection when performing dressing changes. Findings include: The CDC recommendations for handwashing indicated toWash hands before and after treating a wound .for at least 20 seconds https://www.cdc.gov/clean-hands/about/. The facility infection control policy related to enhanced barrier precautions last reviewed on December 2024 indicated, Enhanced barrier precautions (EBP) refer to infection prevention and control interventions designed to reduce the transmission of multi-drug resistant organisms (MDRO) during high contact resident care activities . Examples of high contact resident care activities requiring the use of gown and gloves for EBP's include wound care (any skin opening requiring a dressing). The facility policy on wound care undated, indicated, Preparation: Assemble the equipment and supplies needed. Equipment and Supplies: PPE. Steps in the Procedure: Place all items to be used during the procedure. Arrange supplies so they can easily be reached. Wash your hands thoroughly. Position Resident. Place disposable cloth next to the resident under the wound. Put on exam gloves, remove the dressing. Pull glove over the dressing and discard. Wash and dry your hands thoroughly. Put on exam gloves Review of R2's clinical record revealed; 1/29/25 - R2 was admitted to the facility with a pressure ulcer that required wound care and dressing changes. 1/29/25 - A physician's order was written for R2 to receive daily dressing changes and to be placed on enhanced barrier precautions related to the sacral wound. 1/29/25 - A care plan was written for R2's potential to spread multi-drug resistant organisms to others related to a pressure ulcer wound. Interventions related to the care plan included enhanced barrier precautions, apply gloves and gowns before performing the high contact resident care. 3/17/25 11:18 AM - During a dressing change observation, E4 (LPN) entered R2's room, performed hand hygiene using hand sanitizer and donned a pair of gloves. E4 did not don any other personal protective equipment. E4 then positioned R2 for removal of clothing to access R2's wound on top of R2's personal comforter. E4 walked into R2's bathroom grabbed the trash-can with four fingers inside the trash-can and thumb outer side of trash-can and placed it at R2's bedside then removed R2's soiled dressing. Next, E4 cleaned R2's wound and replaced a new dressing, E4 continued wearing the same gloves that were donned we entering R2's room. At the conclusion of the dressing change. E4 removed the gloves and performed four seconds of hand washing. 3/17/25 11:28 AM - E4 (LPN) confirmed the findings. 3/21/25 9:25 AM - During an interview, E2 (DON/ICP) stated We did a lot of education with that [EBP]. Dressing changes, high contact activities, residents with catheters and peg tubes. E2 then confirmed that staff was expected to adhere to EBP and wear a gown during dressing changes. 3/21/25 1:15 PM - Findings were reviewed during the exit conference with E2(DON).

Based on record review and interview, it was determined that for one (R1) out of six residents reviewed for accident hazards and falls, the facility failed to ensure R1's environment was free from accident hazards as possible. On 6/28/23, while being driven back to the facility in a borrowed transport van from another facility, an accident occurred which resulted in R1 sustaining multiple fractures. The unsafe facility transport caused R1 harm. Based on review of the facility's evidence to correct the non-compliance and the facility's substantial compliance at the time of the current survey, the deficiency was determined to be past non-compliance as of 7/5/23. Findings included: R1's record revealed: 9/8/21 - R1 was admitted to the facility with diagnoses including, but not limited to, cancer and difficulty in walking. 5/31/23 - A significant change MDS assessment documented that R1 was cognitively intact with a BIMS of 15. 6/28/23 - The facility's incident report and investigation revealed that after attending a social outing, R1 was being driven back to the facility when the transport van driver tapped the brake causing R1's wheelchair to propel forward and R1 to slide out of the wheelchair onto the van's floor. R1 was returned to the facility where 911 was called and fire company EMS (Emergency Medical Services) transported R1 to the hospital. 6/28/23 11:08 AM - Per C1's (hospital Forensic Nurse Examiner) notes, R1 arrived at the hospital after a motor vehicle collision with complaints of right and left leg pain. Reportedly R1 stated, I fell out of my wheelchair when the bus stopped short. 6/28/23 1:17 PM - The hospital record documented, [R1] was on a transportation van when it came to a sudden stop causing [R1] to fall out of [R1's] wheelchair striking [R1's] head and bilateral lower extremities. The record documented findings of a frontal contusion and abrasion no active bleeding left lower extremity medial aspect of calf large laceration with exposed adipose tissue measuring approximately 15 cm by 10 cm. [R1's] right lower extremity with 2 linear lacerations to the lateral aspect of [R1's] lower leg approximately 10 cm in length bleeding noted dressing applied .[R1] is complaining of significant pain to [R1's] left lower extremity with any movement. 6/28/23 3:00 PM - R1's facility progress note documented, At around 10:20 (AM) received a call from the receptionist that 'a resident fell in the van outside'. Rushed to the assisted living entrance and the transportation van pulled up and noticed [R1] lying on the foot bed of the van supine in front of her wheelchair. [R1] verbalized that she slid from the wheelchair during the van transport and that her legs hurt. Denies any LOC (loss of consciousness), or head injury. [R1] was awake and oriented to person, place, time and situation. Laceration noted laterally on bilateral shins. Scant amount of blood noted, no active bleeding noted. Nurse Practitioner [E30] in the building made aware, ordered to ok to send [R1] to the hospital. Emergency Service called and [R1] picked up by . fire company EMS (Emergency Medical Service). [R1's family member] . made aware of the incident and verbalized that she would meet [R1] at the hospital. 6/28/23 11:34 PM - Per the hospital record, R1 was transferred to another hospital after the previous facility noted bilateral open tibia-fibula fractures that occurred earlier that day when R1 was being transported in a wheelchair and not strapped in causing [R1] to fall out of the wheelchair. The hospital record documented a need for surgical repair. 6/28/23 - The facility's documented immediate actions in response to R1's transport accident included the following: - canceled all other appointments and resident transport for the day; - suspension of the driver [E18] because the preliminary investigation indicated that [E18] did not follow safety protocol .; - observation of the van and wheelchair immediately after the incident revealed that the shoulder strap was not fastened; - training initiated and completed by the plant manager [E21] on proper and safe medical transport; and - initiation of an investigation of the incident. 6/28/23 - The facility's in-service training documentation included the following: - Loading and Unloading Non-Ambulatory Wheelchair Passenger Policy (operating the wheelchair lift, positioning the wheelchair in the vehicle, attaching the two rear securement straps, attaching the two front securement straps, attaching the lap belt, attaching the shoulder belt); - Wheelchair Securement Checklist; and - Training (must include and frequency). The in-service training was completed on the same day, 6/28/23, of R1's accident. 6/29/23 - The hospital records documented that R1 was . going to the operating room for ORIF bilateral periprosthetic proximal tibia fractures today. 7/5/23 - R1 was readmitted to the facility from the hospital. 7/5/23 - The facility's documented plan of correction as a result of the investigation was: - the van driver [E18] was terminated; - root cause analysis - was determined to be related to driver's [E18] negligence by breaching his duty of care to the resident by not applying a restraint device when it was ordinary, prudent and reasonable. This action resulted in the resident sliding out of the wheelchair when the transportation van slowed down; - care plan changes - residents care plan was updated to include safe resident transport. Interventions for this goal was to have resident properly fastened in the wheelchair transportation vehicle; - systemic changes - trained drivers with best practices for loading and unloading non-ambulatory wheelchair passengers to safety. Specifically, all drivers returned demonstration of attaching the shoulder belt. Before each transport the driver must utilize wheelchair securement checklist to ensure residents are secured in transport vehicle. 2/26/24 10:23 AM - During an interview with E1 (DON, interim NHA), with E2 (ADON) and E4 (Corporate Clinical Specialist) present, On 6/28/23, we received a call from the front desk asking if nurses could come to the parking lot STAT. We went outside and I [E1] saw [R1] sitting in the van on the floor, the wheelchair was behind [R1] and [R1] was half lying and half sitting, and both legs were crooked and bleeding. I immediately called 911 and we tried to stop the bleeding. R1 was asked if she was in any pain and R1 denied pain. R1 did say that the van floor was hard on her back. I noticed that the wheelchair was stuck In the van and that R1 was not strapped in. I immediately asked the driver [E18] if he strapped [R1] in, he said that he did not and that he didn't know why he did not. I called her daughter . We did vital signs which were normal and wrapped her legs to stop the bleeding. The fire company was here quickly - they got here before the paramedics. 2/26/24 2:53 PM - During a follow-up interview with E1, with E2 and E4 present, the plan of correction was initiated on 6/28/23 and completed on 7/5/23. 2/26/24 at 2:55 PM - Based on the Surveyor's review of the facility's thorough investigation, documented response, completion of audits from 7/7/23 to 11/24/23, staff interviews and no further transportation incidents, R1's accident was determined to be past non-compliance harm. 2/26/24 3:15 PM - Findings were reviewed at the exit conference with E1, E2 and E4.

Based on observation, staff interview and review of other documentation, it was determined that the facility failed to ensure food was stored in a sanitary manner; failed to ensure the dishwasher operated at the correct temperature level to sanitize the residents' dishes; failed to maintain dishwasher temperature logs; failed to ensure food stored in a container was maintained in a clean and sanitary manner and failed to ensure the kitchen area was maintained in a sanitary condition, and failed to maintain refrigerator temperature logs. Findings include: Review of the facility policy for Preventing Foodborne Illness, last updated 2017 indicated, Food and nutrition employees will follow appropriate hygiene and sanitary procedures to prevent the spread of food borne illness .Employee's must wash their hands .Functioning of the refrigeration and food temperatures will be monitored. 1. During the follow up tour conducted on 2/20/24 at 11:30 AM the following was observed: -Empty soap dispenser at the hand washing sink in the food preparation area with slow drain and pooling water. -Wall adjacent to the hand washing sink in the food preparation area visible black substance on wall and wall and siding separating. -E25 (FSD) and E27 (cook) observed without beard restraints. -E26 (cook) wearing hair unsecured and on collar. -Flour handle inside bin, not on holder immediately confirmed by E28 (dietary staff) -February 2024 Production refrigerator near kitchen line temperature log last dated as completed on 2/8/24. 2. During a second follow up tour conducted 2/21/24 at 9:33 AM the following was observed: -E25 (FSD), E29 (dishwasher) and E27 (cook) observed without beard restraints. -E26 (cook) observed wearing hair unsecured and on collar. 3. During observation of the function of the facility's dish machine on 2/21/24 at 9:41 AM - 10:09 AM the facility dish machine failed to reach temperatures required for heat sanitization of 165 degrees. E25 confirmed that the facility used a high temperature process dish sanitization. E25 then reported that the dish machine function display screen has been malfunctioning off and on and that the facility did not have a maximum registering thermometer to run through the dish washing cycle. During repeated dish washing cycles the following was observed: - 9:51 AM - 9:54 AM Wash cycle 133 degree's and rinse cycle 115 degree's. second wash 135 45 seconds. -9:55 AM -9:56 AM Wash cycle 126 degree's, rinse cycle 118 degrees with display screen readingwarning too low, wash cycle 126 degree warning too low, rinse cycle 113. -9:57 AM - 9:58 AM Wash cycle 131 degree's, rinse cycle 133 degree's. -9:59 AM - 10:01 AM Wash cycle 141 -139 degree fluctuation. -10:02 AM - 10:03 AM Wash cycle 149 -150 degree's, rinse cycle 155 - 157 degree's. -10:04 AM - 10:06 AM Wash cycle 156-159 degree fluctuation. -10:09 AM - E25 stated that When this happens repeatedly we sanitize again using chemicals. I'm going to call and try to get someone out. Observations from both follow up kitchen visits were discussed and E25 confirmed the findings. 2/21/24 11:07 AM - Review of maintenance records revealed service calls and completion of repairs to the facility's dish machine on the following dates: 10/2/23 ,11/7/23,11/16/23, 11/17/23 and 1/21/24. 2/21/24 11:30 AM - Review of dish machine temperature logs revealed the following: -December 2023 lacked evidence of log entries from 12/4/23 - 12/20/23, then 12/22/23-12/31/23. A hand handwritten note on the log indicated, Display Malfunctioning in the spaces without entries. -January 2024 lacked evidence of log entries on 1/4, 1/11, 1/12, 1/14 -1/21 and 1/23-1/31. -February 2024 lacked evidence of log entries from 2/1 - 2/15, 2/17 and 2/18. 2/21/24 1:51 PM - Kitchen tour findings were reviewed with E1 (DON) who reported maintenance workers have been contacted regarding dish washing machine repairs. 2/22/24 - A maintenance repair person repaired the facility dishwashing machine. The report documented Not hitting temperature, and rinse motor running constantly .replaced the main control board as it was faulty. Machine is now hitting temperature . 2/26/24 3:15 PM Findings were reviewed at the exit conference with E1 (DON, Interim NHA), E2 ADON, and E4 (Clinical Specialist).

Based on observation, interview and record review it was determined that for one (R36) out of twenty-six medication administration observations, the facility failed to provide accurate labeling to facilitate consideration of precautions and safe administration. For (R36), the medication label was not updated with the new order. Findings include: 2/23/24 8:31 AM - During an observation with E17 (LPN) for medication administration, the medication packet label for quetiapine Seroquel a medication used to treat certain mental/mood disorders was noted to read as quetiapine 25 MG tablet - give 1 tablet by mouth 3 times a day. However, the order and MAR (medication administration record) documented that the order was updated to be given two times a day beginning 1/29/24. During the observation E17 was interviewed and it was revealed the label should have been updated to reflect the change. E17 did confirm the new versus old order. 2/26/24 - During an interview E16 (LPN) revealed that when there is a medication change, the nurse who receives the communication would have been responsible for placing an FYI label on the medication packet. Then when it's time for a new blister pack, the medication will come from the pharmacy with a changed label. The change would also be documented in a communication log book and the change would be communicated to each shift and for multiple days until everyone knows about it. 2/26/24 3:15 PM - Findings were reviewed at the exit conference with E1 (DON, Interim NHA), E2 ADON, and E4 (Clinical Specialist).

Based on record review and interview, it was determined that for one (R42) out of one resident reviewed for hospitalization , the facility failed to notify the resident and the resident's representative in writing, of R42's transfer to the hospital, including the reason for the transfer. Findings include: Review of R42's clinical record revealed: 1/11/24 - R42 was admitted to the facility. 1/16/24 - R42 was transferred to the hospital because of a decline in physical and mental condition. R42 was admitted to the hospital and was discharged back to the facility on [DATE]. 2/22/24 2:20 PM - During an interview, E23 stated that she provided a verbal communication to R42's representative of R42's hospital transfer, including the reason for the transfer. E23 stated that a written communication was not provided. 2/26/24 3:15 PM - Finding was reviewed at the exit conference with E1 (DON, Interim NHA), E2 (ADON), and E4 (Clinical Specialist).

Based on record review and interviews, it was determined that for one (R3) out of one reviewed for PASARR, the facility failed to refer R3 for a PASARR level II evaluation when R3 was diagnosed with delusional disorder in June 2023. Findings include: R3's clinical record revealed: 12/29/21 - R3's Preadmission Screening and Resident Review (PASARR) documented, .No Level II required . There is no evidence of a PASRR (sic) condition of an intellectual/developmental disability or serious behavioral health condition. If changes occur or new information refutes these findings, a new screen must be submitted. 6/15/23 - R3 was admitted to the facility with diagnoses, including but not limited to, dementia, heart disease and delusional disorder. 6/16/23 - R3's care plan documented, .I have impaired cognitive function or impaired thought processes r/t (related to) dementia and delusional d/o (disorder). 12/15/23 - R3's Minimum Data Set (MDS) assessment Section I Active diagnoses documented I5950 Psychotic Disorder (other than schizophrenia). 2/21/24 3:52 PM - During an interview, E23 (Social Worker) stated that she relies on Nursing or the MDS/ RNAC to notify her if there is a new diagnosis that requires a new PASARR evaluation. Once notified, she completes the online PASARR application requesting an evaluation. 2/21/24 4:02 PM - Surveyor requested and was provided all known copies of R3's PASARRs by the facility. The facility was only able to produce the PASARR evaluation dated 12/29/21. 2/26/24 3:15 PM - Findings were reviewed at the exit conference with E1 (DON, Interim NHA), E2 (ADON) and E4 (Corporate Clinical Specialist).

Based on record review and interview, it was determined that for one (R1) out of six residents reviewed for accident hazards and falls, the facility failed to ensure R1's received immediate medical attention following a bus accident that caused a fall from the wheelchair. Findings included: Cross refer F689 The facility policy titled Individual Safety Responsibilities: Authorized Driver Last revised 6/15/07 documented: 12. Traffic Accident: In the event of a traffic accident: Help anyone who is injured, call an ambulance if necessary . R1's record revealed: 9/8/21 - R1 was admitted to the facility with diagnoses including, but not limited to, cancer and difficulty in walking. 5/31/23 - A significant change MDS assessment documented that R1 was cognitively intact with a BIMS of 15. 6/28/23 - The facility's incident report and investigation revealed that after attending a social outing, R1 was being driven back to the facility when the transport van driver tapped the brake causing R1's wheelchair to propel forward and R1 to slide out of the wheelchair onto the van's floor. While resident was on the floor of the transportation van E19 (Housekeeping Manager) who was in the front passenger seat stated he saw that E18 (van driver, former employee) was in a panic, E19 asked E18 to stay with the resident while he drove back to the facility 1.3 miles away very slowly. E19 called the facility's receptionist and informed her they were in an accident and they would need help once they got to the facility. 6/28/23 3:00 PM - R1's facility progress note documented, At around 10:20 (AM) received a call from the receptionist that 'a resident fell in the van outside'. Rushed to the assisted living entrance and the transportation van pulled up and noticed [R1] lying on the foot bed of the van supine in front of her wheelchair. [R1] verbalized that she slid from the wheelchair during the van transport and that her legs hurt. Denies any LOC (loss of consciousness), or head injury. [R1] was awake and oriented to person, place, time and situation. Laceration noted laterally on bilateral shins. Scant amount of blood noted, no active bleeding noted. Nurse Practitioner [E30] in the building made aware, ordered to ok to send [R1] to the hospital. Emergency Service called and [R1] picked up by . fire company EMS (Emergency Medical Service). [R1's family member] . made aware of the incident and verbalized that she would meet [R1] at the hospital. 2/26/24 10:23 AM - During an interview with E1 (DON, interim NHA), with E2 (ADON) and E4 (Corporate Clinical Specialist) present, On 6/28/23, we received a call from the front desk asking if nurses could come to the parking lot STAT. We went outside and I [E1] saw [R1] sitting in the van on the floor, the wheelchair was behind [R1] and [R1] was half lying and half sitting, and both legs were crooked and bleeding. I immediately called 911 and we tried to stop the bleeding. R1 was asked if she was in any pain and R1 denied pain. R1 did say that the van floor was hard on her back. I noticed that the wheelchair was stuck In the van and that R1 was not strapped in. I immediately asked the driver [E18] if he strapped [R1] in, he said that he did not and that he didn't know why he did not. I called her daughter . We did vital signs which were normal and wrapped her legs to stop the bleeding. The fire company was here quickly - they got here before the paramedics. Review of the incident report and facility investigation lacked evidence as to why the van driver did not call for emergency help at the time of the accident and instead drove back to the facility where emergency services were called. 2/26/24 3:15 PM - Findings were reviewed at the exit conference with E1, E2 and E4.

Based on record review and interview, it was determined that for one (R195) out of one resident reviewed for physician services, the facility failed to ensure that R195 was seen for the required physician visits. Findings include: Review of R195's clinical record revealed: 4/30/2019 - R195 was admitted to the facility. Review of the electronic medical record (EMR), revealed the following alternating physician/ nurse practitioner visits were made to R195 from June 2022 thru February 3, 2023: 6/3/22 - E3 (MD) 8/3/22 - E30 (NP) 9/21/22 - E30 12/7/22 - E30 2/3/23 - E30. E3 did not visit the R195 in October 2022, which was the month R195 should have received a required physician visit. 2/26/24 3:15 PM - Finding was reviewed at the exit conference with E1 (DON, Interim NHA), E2 (ADON), and E4 (Clinical Specialist).

Based on observation and interview, it was determined that for one (R18) out of one reviewed for food, the facility failed to maintain appetizing food temperatures for food trays that are delivered to third floor residents in their rooms. Findings include: R18's clinical record revealed: 3/24/23 - R18 was admitted to the facility. 2/7/24 - E3 (MD) updated R18's diet order to regular diet, regular texture and regular/thin liquid consistency. 2/21/24 3:28 PM - During an interview, R18 stated that she takes all her meals in her room and her, food is delivered cold all the time. 2/23/24 11:30 AM - The Surveyor went to the kitchen to request a test lunch tray for the hot entree. 2/23/24 12:07 PM - The Surveyor observed food being plated for the third floor food truck. 2/23/24 12:35 PM - The third floor food truck arrived on the third floor. 2/23/24 12:36 PM- The Surveyor and E25 (Food Service Director) observed the CNAs delivering food trays to the residents in the dining room. 2/23/24 12:52 PM - The Surveyor and E25 observed food tray being delivered to room [ROOM NUMBER]. 2/23/24 12:55 PM - The Surveyor and E25 observed food tray being delivered to room [ROOM NUMBER]. 2/23/24 12:59 PM - The Surveyor and E25 observed food tray being delivered to R18's room. 2/23/24 12:59 PM - E25 obtained food temperatures for the test tray. The salmon tested at 121 degrees F (Fahrenheit), the rice at 118 degrees F, the soup at 123 degrees F and the vegetables at 127 degrees F. 2/23/24 1:00 PM - The Surveyor tasted the food tray. The food was presented in a very appetizing manner; however the salmon, rice and veggies was were very unpalatable as they were cool. The soup was also cool to taste and therefore, not enjoyable. 2/26/24 3:15 PM - Findings were reviewed at the exit conference with E1 (DON, Interim NHA), E2 (ADON) and E4 (Corporate Clinical Specialist).

Based on observation, it was determined that the facility did not properly ensure that the facility was properly maintained to prevent pests. Finding include: During the initial kitchen tour on 5/19/2022 at approximately 10:00 AM, the outside dumpster was observed to be in disrepair with a hole on the top which could allow pests to enter. This finding was reviewed and confirmed by E32 (Food Service Director) on 5/19/22 at approximately 11:50 AM.

Based on observation, it was determined that the facility did not properly ensure that the facility was properly maintained to prevent pests. Finding include: During the initial kitchen tour on 5/19/2022 at approximately 10:00 AM, the outside dumpster was observed to be in disrepair with a hole on the top which could allow pests to enter. This finding was reviewed and confirmed by E32 (Food Service Director) on 5/19/22 at approximately 11:50 AM.

Based on observation, interview, and review of facility documentation, the facility failed to ensure that staff were fit tested for N-95 masks creating an unsafe environment by not implementing appropriate infection control practices as recommended by the Centers for Disease Control and Prevention (CDC). Findings include: 9/3/21 (last reviewed) - On the CDC website, the document entitled Fit Test FAQ included, You should be fit tested at least annually to ensure your respirator continues to fit you properly. 2/2/22 (last updated) - On the CDC website, the document entitled Strategies for Optimizing the Supply of N95 Respirators included, .Proper use of respiratory protection by HCP requires a comprehensive program (including medical clearance, training, and fit testing) . September 2021 (last revised) - The facility policy, entitled Contingency and Crisis Use of N-95 Respirators, indicated conventional capacity measures include adopting just in time fit testing. September 2021 (last revised) - The facility policy, entitled Using Personal Protective Equipment included Personnel who enter the room of a resident with suspected or confirmed SARS-CoV-2 infection .use a NIOSH-approved N95 or equivalent or higher respirator, gowns, gloves, and eye protection. Of the eight staff sampled for compliance with infection prevention and control national standards, the facility was not able to provide evidence of N-95 mask fit testing in the past year. Two staff members (E28 Dietary and E30 LPN) were last fit tested in December of 2020. The facility had no records of fit testing for the following six staff: E4 (Social Services), E24 (OTA), E25 (hairdresser), E26 (CNA), E27 (CNA), and E29 (dietary). 5/25/22 3:30 PM - During an interview, E3 (ADON) confirmed that the last time fit testing was completed for facility staff was in December of 2020, and therefore any staff that were hired since then have not been fit tested . E3 confirmed that during the January 2022 COVID-19 outbreak, staff wore full PPE (personal protective equipment) including N-95 masks to provide care to residents. 5/26/22 11:45 AM - During an interview, E2 (DON) confirmed that none of the agency or contract staff have been tested by their agency. E2 explained that the facility has contracted with a vendor to perform N-95 mask fit testing for all staff members. 5/26/22 2:00 PM - During an interview, the above findings were reviewed and confirmed with E3 (ADON). 5/27/22 4:00 PM - Findings were reviewed with E2 (DON) and E3 (ADON) during the Exit Conference.

Based on observation, interview, and review of facility documentation, the facility failed to ensure that staff were fit tested for N-95 masks creating an unsafe environment by not implementing appropriate infection control practices as recommended by the Centers for Disease Control and Prevention (CDC). Findings include: 9/3/21 (last reviewed) - On the CDC website, the document entitled Fit Test FAQ included, You should be fit tested at least annually to ensure your respirator continues to fit you properly. 2/2/22 (last updated) - On the CDC website, the document entitled Strategies for Optimizing the Supply of N95 Respirators included, .Proper use of respiratory protection by HCP requires a comprehensive program (including medical clearance, training, and fit testing) . September 2021 (last revised) - The facility policy, entitled Contingency and Crisis Use of N-95 Respirators, indicated conventional capacity measures include adopting just in time fit testing. September 2021 (last revised) - The facility policy, entitled Using Personal Protective Equipment included Personnel who enter the room of a resident with suspected or confirmed SARS-CoV-2 infection .use a NIOSH-approved N95 or equivalent or higher respirator, gowns, gloves, and eye protection. Of the eight staff sampled for compliance with infection prevention and control national standards, the facility was not able to provide evidence of N-95 mask fit testing in the past year. Two staff members (E28 Dietary and E30 LPN) were last fit tested in December of 2020. The facility had no records of fit testing for the following six staff: E4 (Social Services), E24 (OTA), E25 (hairdresser), E26 (CNA), E27 (CNA), and E29 (dietary). 5/25/22 3:30 PM - During an interview, E3 (ADON) confirmed that the last time fit testing was completed for facility staff was in December of 2020, and therefore any staff that were hired since then have not been fit tested. E3 confirmed that during the January 2022 COVID-19 outbreak, staff wore full PPE (personal protective equipment) including N-95 masks to provide care to residents. 5/26/22 11:45 AM - During an interview, E2 (DON) confirmed that none of the agency or contract staff have been tested by their agency. E2 explained that the facility has contracted with a vendor to perform N-95 mask fit testing for all staff members. 5/26/22 2:00 PM - During an interview, the above findings were reviewed and confirmed with E3 (ADON). 5/27/22 4:00 PM - Findings were reviewed with E2 (DON) and E3 (ADON) during the Exit Conference.

Based on interview and record review, it was determined that the facility failed to develop a comprehensive care plan for one (R1) out of one sampled resident for hospice investigation. Findings include: Cross refer F697 Review of R1's clinical record revealed: 11/16/21 - R1 was admitted to the facility under Hospice services. 11/16/21 - The Admission Nursing Comprehensive Pain Assessment documented that R1 verbalized abdominal pain. 11/29/21 - The Admission MDS Assessment documented that R1 was receiving scheduled routine and as needed pain medications and was not receiving non-medication intervention(s) for pain. 12/8/21 - The facility developed and implemented a care plan which stated that R1 was on pain medication therapy, however, there was lack of evidence of interventions to address R1's abdominal pain that was verbalized and documented on the admission nursing pain assessment dated [DATE]. The care plan lacked both pharmacological and non-pharmacological interventions for pain. 2/16/22 - The facility developed and implemented a care plan that R1 was at increased risk for alteration in comfort, however, there was lack of evidence of the location of the pain, what specific pharmacological and non-pharmacological interventions were to be utilized, as well as the goal for pain management. 5/26/22 - The above findings were reviewed and confirmed with E2 (DON) and E3 (ADON). Findings were reviewed with E2 (DON) and E3 (ADON) during the Exit Conference on 5/27/22, beginning at 4:00 PM.

Based on interview and record review, it was determined that the facility failed to develop a comprehensive care plan for one (R1) out of one sampled resident for hospice investigation. Findings include: Cross refer F697 Review of R1's clinical record revealed: 11/16/21 - R1 was admitted to the facility under Hospice services. 11/16/21 - The admission Nursing Comprehensive Pain Assessment documented that R1 verbalized abdominal pain. 11/29/21 - The admission MDS Assessment documented that R1 was receiving scheduled routine and as needed pain medications and was not receiving non-medication intervention(s) for pain. 12/8/21 - The facility developed and implemented a care plan which stated that R1 was on pain medication therapy, however, there was lack of evidence of interventions to address R1's abdominal pain that was verbalized and documented on the admission nursing pain assessment dated [DATE]. The care plan lacked both pharmacological and non-pharmacological interventions for pain. 2/16/22 - The facility developed and implemented a care plan that R1 was at increased risk for alteration in comfort, however, there was lack of evidence of the location of the pain, what specific pharmacological and non-pharmacological interventions were to be utilized, as well as the goal for pain management. 5/26/22 - The above findings were reviewed and confirmed with E2 (DON) and E3 (ADON). Findings were reviewed with E2 (DON) and E3 (ADON) during the Exit Conference on 5/27/22, beginning at 4:00 PM.

Based on record review and interview, it was determined that for two (R1 and R15) out of 22 sampled residents, the facility failed to ensure that the care plan was prepared by an IDT (Interdisciplinary Team) and held with the Attending Physician or his/her designee, the Nurse's aide with responsibility for the resident, a staff member from Nutrition/Food Service staff, and other professionals in disciplines as determined by the resident's needs. Findings include: Review of the facility's policy titled Care Plan, with a revision date of 9/2013, stated that IDT includes other appropriate staff or professionals as determined by the resident's needs or as requested by the resident. 1. Review of R1's clinical records revealed: 11/16/21 - R1 was admitted to the facility under Hospice services. 11/29/21 - The Admission MDS Assessment was completed. 12/9/21- Review of the Plan of Care Conference Summary lacked evidence that R1's Attending Physician or designee, the Nurse's Aide responsible for the resident, and staff from the Hospice Agency participated in the IDT care planning process. 3/1/22 - The Quarterly MDS Assessment was completed. 3/17/22 - Review of the Plan of Care Conference Summary lacked evidence that R1's Attending Physician or designee, the Nurse's Aide responsible for the resident, and staff from the Hospice Agency participated in the IDT care planning process. 5/23/22 1:10 PM - An interview with HOS RN1 (Hospice RN) revealed that she has been providing skilled nursing services on a weekly basis and verbalized that she has not been invited or attended any of the IDT Care Plan meetings since R1's admission to the facility on [DATE]. 5/24/22 11:16 AM - An interview with E4 (Social Worker) revealed it was the facility's practice to invite staff of Hospice agencies to the IDT Care Plan meeting either verbally or via email. E4 stated that for R1, the Hospice Liaison was informed of the IDT Care Plan meetings. The Surveyor requested evidence of the invitation for the IDT Care Plans meetings held on 12/9/21 and 3/17/22. 5/25/22 10:15 AM - A follow-up interview with E4 (SW) revealed that the facility was unable to provide evidence that R1's Hospice Agency was invited to the IDT Care Plan meeting. 2. Review of R15's clinical records revealed: 6/4/21 - R15 was admitted to the facility. 6/17/21 - The Admission MDS Assessment was completed. There was lack of evidence that the facility conducted an IDT Care Plan meeting after completion of the admission MDS assessment dated [DATE]. 9/17/21 - The Quarterly MDS Assessment was completed. 9/23/21 - Review of the Plan of Care Conference Summary lacked evidence that R15's Attending Physician or designee, the Nurse's Aide responsible for the resident, and staff from Nutrition/Food Services participated in the IDT care planning process. 12/17/21 - The Quarterly MDS Assessment was completed. There was lack of evidence that the facility conducted an IDT Care Plan meeting after completion of the quarterly MDS assessment dated [DATE]. 3/10/22 - The Quarterly MDS Assessment was completed. 3/24/22 - Review of the Plan of Care Conference Summary lacked evidence that R15's Attending Physician or designee and the Nurse's Aide responsible for the resident participated in the IDT care planning process. 5/26/22 1:45 PM - An interview with E4 (SW) confirmed that the facility was unable to provide evidence that a IDT Care Plan meeting was held after completion of the MDS Assessments on 6/17/21 and 12/17/21. In addition, the facility was unable to provide evidence that R15's Attending Physician/designee and the Nurse's Aide responsible participated in the IDT care planning process. 5/26/22 - The above findings were reviewed and confirmed with E2 (DON) and E3 (ADON). Findings where reviewed with E2(DON) and E3 (ADON) during the Exit Conference on 5/27/22, beginning at 4:00 PM.

Based on record review and interview, it was determined that for two (R1 and R15) out of 22 sampled residents, the facility failed to ensure that the care plan was prepared by an IDT (Interdisciplinary Team) and held with the Attending Physician or his/her designee, the Nurse's aide with responsibility for the resident, a staff member from Nutrition/Food Service staff, and other professionals in disciplines as determined by the resident's needs. Findings include: Review of the facility's policy titled Care Plan, with a revision date of 9/2013, stated that IDT includes other appropriate staff or professionals as determined by the resident's needs or as requested by the resident. 1. Review of R1's clinical records revealed: 11/16/21 - R1 was admitted to the facility under Hospice services. 11/29/21 - The admission MDS Assessment was completed. 12/9/21- Review of the Plan of Care Conference Summary lacked evidence that R1's Attending Physician or designee, the Nurse's Aide responsible for the resident, and staff from the Hospice Agency participated in the IDT care planning process. 3/1/22 - The Quarterly MDS Assessment was completed. 3/17/22 - Review of the Plan of Care Conference Summary lacked evidence that R1's Attending Physician or designee, the Nurse's Aide responsible for the resident, and staff from the Hospice Agency participated in the IDT care planning process. 5/23/22 1:10 PM - An interview with HOS RN1 (Hospice RN) revealed that she has been providing skilled nursing services on a weekly basis and verbalized that she has not been invited or attended any of the IDT Care Plan meetings since R1's admission to the facility on [DATE]. 5/24/22 11:16 AM - An interview with E4 (Social Worker) revealed it was the facility's practice to invite staff of Hospice agencies to the IDT Care Plan meeting either verbally or via email. E4 stated that for R1, the Hospice Liaison was informed of the IDT Care Plan meetings. The Surveyor requested evidence of the invitation for the IDT Care Plans meetings held on 12/9/21 and 3/17/22. 5/25/22 10:15 AM - A follow-up interview with E4 (SW) revealed that the facility was unable to provide evidence that R1's Hospice Agency was invited to the IDT Care Plan meeting. 2. Review of R15's clinical records revealed: 6/4/21 - R15 was admitted to the facility. 6/17/21 - The admission MDS Assessment was completed. There was lack of evidence that the facility conducted an IDT Care Plan meeting after completion of the admission MDS assessment dated [DATE]. 9/17/21 - The Quarterly MDS Assessment was completed. 9/23/21 - Review of the Plan of Care Conference Summary lacked evidence that R15's Attending Physician or designee, the Nurse's Aide responsible for the resident, and staff from Nutrition/Food Services participated in the IDT care planning process. 12/17/21 - The Quarterly MDS Assessment was completed. There was lack of evidence that the facility conducted an IDT Care Plan meeting after completion of the quarterly MDS assessment dated [DATE]. 3/10/22 - The Quarterly MDS Assessment was completed. 3/24/22 - Review of the Plan of Care Conference Summary lacked evidence that R15's Attending Physician or designee and the Nurse's Aide responsible for the resident participated in the IDT care planning process. 5/26/22 1:45 PM - An interview with E4 (SW) confirmed that the facility was unable to provide evidence that a IDT Care Plan meeting was held after completion of the MDS Assessments on 6/17/21 and 12/17/21. In addition, the facility was unable to provide evidence that R15's Attending Physician/designee and the Nurse's Aide responsible participated in the IDT care planning process. 5/26/22 - The above findings were reviewed and confirmed with E2 (DON) and E3 (ADON). Findings where reviewed with E2(DON) and E3 (ADON) during the Exit Conference on 5/27/22, beginning at 4:00 PM.