Every finding on record at Fair Oaks Health & Rehabilitation

Based on staff interview, facility document review, and clinical record review, the facility staff failed to notify a physician of a resident's blood sugar level according to the physician's order for one of 11 residents in the survey sample, Resident #3.The findings include:For Resident #3 (R3), the facility staff failed to notify the physician when the resident's blood sugar was greater than 200 on multiple occasions in June 2025.A review of R3's clinical record revealed the following physician order dated 6/18/25: Blood glucose checks ac and hs before meals and at bedtime for DM (diabetes mellitus). Notify MD if blood glucose >200 (is greater than 200).A review of R3's clinical record revealed the facility staff failed to notify the physician on the following dates for the corresponding blood sugars: 6/19/25 at 8:00 a.m./250; 6/19/25 at 12:00 p.m./267; 6/19/25 at 5:00 p.m./462; 6/21/25 at 8:00 a.m./370; 6/22/25 at 8:00 a.m./391; 6/22/25 at 12:00 p.m./325; 6/22/25 at 5:00 p.m./338; 6/24/25 at 12:00 p.m./318; 6/24/25 at 5:00 p.m./336; 6/25/25 at 8:00 a.m./336.On 10/8/25 at 8:10 a.m., LPN (licensed practical nurse) #2, a unit manager, was interviewed. After reviewing R3's orders, she stated that, according to the order, R3's physician should have been notified each time the resident's blood sugar was over 200. LPN #2 reviewed R3's June MAR and progress notes. She stated that the nurse did not follow the physician's order for physician notification for the dates and times outlined above. She stated if a resident's blood sugar is too high, the resident may need additional insulin to prevent an adverse event. She agreed that it is a professional standard of practice to notify a physician if a resident's blood sugar exceeds the parameter set by the physician in the order.On 10/8/25 at 10:55 a.m., ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing, and ASM #3, the regional director of clinical operations were informed of these concerns.A review of the facility policy Change in a Resident's Condition revealed, in part: The facility will promptly notify the .physician .of a significant change in the resident's condition.No additional information was provided prior to exit.

Based on staff interview, facility document review, and clinical record review, the facility staff failed to implement physicians' orders for three of 11 residents in the survey sample, Residents #6, #3, and #8.The findings include:1. For Resident #6 (R6), the facility staff failed to administer Lantus (long acting insulin) according to the physician's order during a medication administration observation on 10/7/25. On 10/7/25 at 8:03 a.m., RN (registered nurse) #2 was observed preparing insulin for administration to R6. RN #2 prepared the injector pen of Lantus (long acting insulin) by turning the dial to 10. RN #2 confirmed that R6 was to receive 10 units of Lantus to R6. At 8:12 a.m., RN #2 was observed administering 10 units of Lantus to R6. A review of R6's physician orders revealed the following order dated 9/6/25: Lantus SoloStar Subcutaneous Solution Pen-injector 100 UNIT/ML (units per milliliter) (Insulin Glargine) Inject 9 unit subcutaneously one time a day for DM (diabetes mellitus). On 10/8/25 at 9:24 a.m., RN #2 was interviewed. RN #2 stated she remembered administering Lantus to R6 the previous morning. She stated that R6 receives 10 units of Lantus each morning before breakfast. She explained she always checks the order two or three times before administering insulin because it is a high risk medication. She admitted too little insulin can result in a resident's blood sugar climbing too high, and too much insulin can cause a resident's blood sugar to reach a dangerously low level. On 10/8/25 at 10:55 a.m., ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing, and ASM #3, the regional director of clinical operations were informed of these concerns. A review of the facility policy Injectable Medication Administration revealed, in part: Check the order on the Medication Administration Record to see that an injection is currently ordered.Check the 5 Rights (at a minimum) against the order as the medication is selected.Check 5 rights again as dose is prepared.Check 5 rights again after dose is prepared.before injection [is] administered. No additional information was provided prior to exit. 2. For Resident #3 (R3), the facility staff failed to administer Midodrine (1) according to the physician's order multiple times in June 2025. A review of R3's physician orders revealed the following order dated 6/19/25: Midodrine Oral Tablet 5 MG (milligrams) Give 1 tablet by mouth two times a day for hypotension. Hold for SBP (systolic blood pressure) > (greater than) 120. A review of R3's June 2025 MAR (medication administration record) revealed that R3 received Midodrine on the following dates with the following blood pressures: 6/19/25 at 5:00 p.m. – no blood current blood pressure recorded; 6/20/25 at 9:00 a.m. – 132/69; 6/21/25 at 9:00 a.m. – 121/71; 6/23/25 at 5:00 p.m. – 122/78; 6/28/25 at 9:00 a.m. – 122/76. On 10/8/25 at 8:10 a.m., LPN (licensed practical nurse) #2, a unit manager, was interviewed. After reviewing R3's orders, she stated that R3 should not have received Midodrine if his blood pressure was over 120 systolic (upper number). After reviewing R3's June 2025 MAR, LPN #2 agreed that R3 should not have received Midodrine on the dates and times outlined above. She explained that Midodrine is used to raise a resident's blood pressure and should not be given if the upper blood pressure number is over 120 due to the risk of causing an opposite effect of high blood pressure. On 10/8/25 at 10:55 a.m., ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing, and ASM #3, the regional director of clinical operations were informed of these concerns. No additional information was provided prior to exit. (1) Midodrine is used to treat orthostatic hypotension (sudden fall in blood pressure that occurs when a person assumes a standing position). Midodrine is in a class of medications called alpha-adrenergic agonists. It works by causing blood vessels to tighten, which increases blood pressure. This information is taken from the website https://medlineplus.gov/druginfo/meds/a616030.html. 3. The facility failed to administer insulin as ordered for Resident #8 (R8). R8 was admitted to the facility on [DATE] with diagnosis that included ESRD (end stage renal disease), diabetes and osteoarthritis. The most recent MDS (minimum data set) assessment, a quarterly assessment, with an ARD (assessment reference date) of 8/21/25, coded the resident as scoring a 15 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was not cognitively impaired. A review of the comprehensive care plan dated 3/27/25 revealed, FOCUS: The resident is at risk for complications and blood glucose fluctuations related to diagnosis of diabetes mellitus with insulin use. INTERVENTIONS: administer insulin as ordered A review of the physician order dated 4/21/25 revealed Admelog SoloStar 100 UNIT/ML Solution pen-injector Inject as per sliding scale: if 70 - 200 = 2 units INJECT AS PER SLIDING SCALE: IF 151 - 200 = 1 UNIT NOTIFY MD OF BLOOD SUGAR <70. BLOOD SUGAR 70-150; 201 - 250 = 4 units; 251 - 300 = 6 units; 301 - 350 = 8 units; 351 - 400 = 10 units INJECT AS PER SLIDING SCALE: IF 151 - 200 = 1 UNIT NOTIFY MD OF BLOOD SUGAR <70. BLOOD SUGAR 70-150, subcutaneously before meals and at bedtime for DM. A review of the September and October 2025 MAR (medication administration record) reveals insulin not provided and coded as a 15 indicating no insulin required: on the following times and dates: 7:30 AM: 9/9-BS92, 9/18-BS118, 9/13 BS 113, 10/7 BS 93; 11:30 AM: 9/9-BS 100, 9/18-BS 125, 9/23-BS 132; 4:30 PM: 10/3-BS 105 and 9:00 PM: 10/3-BS 115. On 10/8/25 at 8:45 AM, an interview was conducted with LPN (licensed practical nurse) 1, the second-floor unit manager. When asked to review the insulin order of R8, LPN 1 was asked why insulin was not administered, LPN1 stated this order should have been clarified. If the order is not clarified, the insulin could be administered improperly. When asked about the potential outcomes if insulin is not administered properly, LPN 1 stated, the resident could have hyperglycemia or hypoglycemia. On 10/8/25 at 11:40 AM, ASM (administrative staff member) 1, the administrator, ASM #2, director of nursing and ASM #3, the regional director of clinical operations, was made aware of the findings. A review of the facility's Injectable Medication policy reveals, Medications will be administered in a safe and effective manner. Check the order on the Medication Administration Record (MAR) to see that an injection is currently ordered and due. No further information was provided prior to exit.

Based on observation, staff interview, and facility document review, the facility staff failed to maintain a clean, comfortable, home like environment in two of two facility elevators.The findings include:On 10/7/25 at 7:58 a.m. and 12:15 p.m., both facility elevators were observed. Both elevators had large wall surface scrapes and indentations, and the floors on both elevators contained visible areas of dirt and grime. On 10/7/25 at 1:03 p.m., OSM (other staff member) #1, the regional director of maintenance, and ASM (administrative staff member) #1, the administrator, observed both elevators and were interviewed about the condition of the elevators. Both staff members agreed the elevator walls needed cleaning and painting, and the elevator floors needed to be stripped and cleaned. Both staff members agreed that the elevators were used throughout the day and evening by multiple residents, and the elevators did not provide the residents with a clean, home like environment. ASM #1 stated he would begin correcting this immediately.On 10/7/25 at 4:53 p.m., ASM #1, ASM #2, the director of nursing, and ASM #3, the regional director of clinical operations, were notified of these concerns.A review of the facility policy Homelike Environment revealed, in part: Residents will be provided with a safe, clean, comfortable and homelike environment .The facility staff and management maximizes, to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting. These characteristics include .clean, sanitary and orderly equipment.No additional information was provided prior to exit.

Based on review of facility's documentation and staff interview, it was determined that the facility failed to promote and enhance each resident's right to a dignified existence and being respected for one of eleven residents in the survey sample, Resident #11 (R11).The findings include:R11 was admitted to the facility on [DATE] with diagnosis that included but were not limited to dementia, osteoarthritis and metabolic encephalopathy.The most recent MDS (minimum data set) assessment, an annual assessment, with an ARD (assessment reference date) of 9/10/25, coded the resident as scoring a 06 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was severely cognitively impaired. A review of the comprehensive care plan dated 1/22/25 revealed, FOCUS: Resident prefers toparticipate in activities such as BINGO and Group activities. INTERVENTIONS: All staff to converse with him while providing care. On 10/7/25 at 8:28 AM, during medication administration, observation, RN (registered nurse) #1 stated, I just got here. I don't usually work up here. I don't know these residents well or where all their medications are. I am only prn (as needed). I usually work at the hospital.On 10/7/25 at approximately 1:00 PM, observed RN #1 enter R11's room. RN #1 was observed to not be wearing a name tag. When asked his name, RN #1 felt for name tag and then stated, Oh, it dropped off when I was in the break room. When asked how the residents and families are able to identify him without a name badge, RN #1 stated, Oh, they are all long residents, and they know us. RN #1 went to first floor to obtain name badge from break room. On 1/7/25 at 1:15 PM, R11 was sitting in room in his wheelchair. When asked if he knew the male nurse's name R11 stated, No, I do not, and he was not wearing a name badge either. RN #1 was asked if the name tag is part of their uniform, RN #1 stated yes, it is. When asked if no name tag/identification having visible to the resident was demonstrating dignity and respect for the resident, RN #1 stated, no, it is not.On 10/8/25 at 8:45 AM, an interview was conducted with LPN (licensed practical nurse) 1, the second floor unit manager. When asked what identification staff should wear, LPN #1 stated, they should wear their identification badges/name tags as it is part of their uniform. On 10/8/25 at 11:40 AM, ASM (administrative staff member) 1, the administrator, ASM #2, director of nursing and ASM #3, the regional director of clinical operations was made aware of the findings.A review of the facility's Resident Rights policy reveals, Each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being, level of satisfaction with life, and feelings of self-worth and self-esteem.No further information was provided prior to exit.

Based on observation, staff interview, facility document review, and clinical record review, the facility staff failed to follow infection control procedures for one of 11 residents in the survey sample, Resident #7.The findings include:For Resident #7 (R7), the facility staff failed to follow enhanced barrier precautions and to sanitize vital sign equipment before and after use.On 10/7/21 at 8:20 a.m., RN (registered nurse) #1 was observed standing beside R7's bed preparing to take R7's vital signs using a machine. R7 was lying on his back in bed, and RN #1 was not wearing any PPE (personal protective equipment), including gown or gloves. RN #1 did not sanitize the blood pressure cuff or the pulse oximeter prior to applying them to R7's arm and finger. Once the readings were obtained, RN #1 did not sanitize the blood pressure cuff or the pulse oximeter. He turned the machine over to another staff member for use on the next resident.A review of R7's clinical record revealed the following physician's order dated 9/4/25: Enhanced Barrier Precautions r/t (related to) wounds.On 10/7/25 at 3:55 p.m., CNA (certified nursing assistant) #2 was interviewed. She stated enhanced barrier precautions require anyone providing care to a resident should wear a gown and gloves. She stated vital sign equipment should always be sanitized immediately before and immediately after a resident's use. She stated these procedures help to prevent the spread of infection between residents.On 10/8/25 at 8:10 a.m., LPN (licensed practical nurse) #2, a unit manager, was interviewed. She stated vital sign equipment should be sanitized before and after each resident's use. She added that any staff member who is obtaining a resident's vital signs should wear gown and gloves if the resident has an order for enhanced barrier precautions. She stated that these residents have a higher risk of infection because they have some sort of break in the skin or a device which increases the resident's infection risk.On 10/8/25 at 10:55 a.m., ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing, and ASM #3, the regional director of clinical operations were informed of these concerns.A review of the policy Cleaning and Disinfecting Environmental Surfaces revealed, in part: Environmental surfaces will be cleaned and disinfected according to current CDC (Centers for Disease Control) recommendations for disinfection of healthcare facilities .non-critical items are those that come in contact with intact skin but not mucous membranes .most non-critical items can be decontaminated where they are used.No additional information was provided prior to exit.

Based on observation, staff interview, and facility document review, the facility staff failed to store medications safely on one of three medication carts on the second floor, the cart serving room [ROOM NUMBER].The findings include:The facility staff failed to secure the key to the medication cart for room [ROOM NUMBER] when the nurse went to another floor.On 10/7/25 at 8:28 a.m., RN (registered nurse) #1 was observed standing at a medication cart. He explained that he only works a few shifts a month at the facility and was not familiar with the residents or where things were kept on this medication cart. After spending several minutes searching for a resident's medication in the cart, he stated that he needed to go to the emergency medication supply machine on another floor of the facility. He locked the medication cart and placed the keys to the medication cart under a towel on top of the cart. He left the cart in the hallway and went to the first floor to obtain a medication from the emergency supply. He returned to the cart at 8:35 a.m., took the keys from under the towel, unlocked the cart, and continued searching for additional medications. At 8:38 a.m., he stated he needed to go to the emergency medication supply machine again because he could not locate another medication. He locked the medication cart and placed the keys to the medication cart under a towel on top of the cart. He left the cart in the hallway and went to the first floor to obtain a medication from the emergency supply. At 8:40 a.m., two residents walked by the medication cart as they returned their breakfast trays to the meal cart. RN #1 returned to the cart at 8:46 a.m., took the keys from under the towel, unlocked the cart, and continued searching for additional medications. At 8:51 a.m., RN #1 stated he had secured the medication cart by locking it. He acknowledged that the cart was not totally secure because he had left the keys on top of the cart.On 10/8/25 at 8:10 a.m., LPN (licensed practical nurse) #2, a unit manager, was interviewed. She stated if a nurse needs to leave a medication cart for any reason, the keys to the medication cart should be stored in the nurse's pocket once the cart is locked. She explained that keeping the medications locked is for safety reasons, and added that the cart is full of medications, including narcotics. On 10/8/25 at 10:55 a.m., ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing, and ASM #3, the regional director of clinical operations were informed of these concerns.A review of the facility policy Medication Storage revealed, in part: The facility shall store all drugs and biologicals in a safe, secure, and orderly manner .The nursing staff shall be responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner .Compartments .containing drugs and biologicals shall be locked when not in use, and trays or carts used to transport such items shall not be left unattended if open or otherwise potentially available to others.No additional information was provided prior to exit.

Based on staff interview and clinical record review, the facility staff failed to complete an accurate MDS (minimum data set) for one of 11 residents in the survey sample, Resident #4.The findings include:For Resident #4 (R4), the facility staff failed to code an MDS accurately regarding the resident's level of consciousness.A review of R4's quarterly MDS with an ARD (assessment reference date) of 9/19/25 revealed he was coded as being in a persistent vegetative state with no discernable consciousness. As a result of this code in Section B, there were no responses to any of the questions in Sections C (cognition), D (Mood), or E (behaviors). A review of R4's previous quarterly MDS with an ARD of 6/19/25 revealed the resident was not in a vegetative state. A review of R4's progress notes corroborated the findings that the resident was not in a vegetative state at any point during his stay at the facility. On 10/8/25 at 7:46 a.m., LPN (licensed practical nurse) #2, the MDS coordinator who completed both of R4's MDS assessments, was interviewed. After reviewing both of R4's quarterly MDS assessments, she stated she made an error in coding on the 9/19/25 assessment. She explained that she miscoded the answer to the question about R4's level of consciousness in Section B, and thereby eliminated the need to answer the subsequent questions in Section B, and all questions in Sections C, D, and E. She stated she remember R4 well, and he was never in a persistent vegetative state while he was at the facility. She stated she uses the RAI (resident assessment instrument) manual that is published by CMS (Centers for Medicare/Medicaid Services) as her guide for completing accurate MDS assessments. A review of the RAI manual dated October 2024 revealed, in part: Section B .The intent of items in this section is to document whether the resident is comatose, the resident's ability to hear (with assistive hearing devices, if they are used), understand, and communicate with others, and the resident's ability to see objects nearby in their environment .Coding Instructions .Code 0, no: if a diagnosis of coma or persistent vegetative state is not present during the 7-day look-back period. Continue to B0200, Hearing .Code 1, yes: if the record indicates that a physician, nurse practitioner or clinical nurse specialist has documented a diagnosis of coma or persistent vegetative state that is applicable during the 7-day look-back period. Skip to GG0100, Prior Functioning: Everyday Activities.On 10/8/25 at 10:55 a.m., ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing, and ASM #3, the regional director of clinical operations were informed of these concerns.No additional information was provided prior to exit.

Based on observation, staff interview, facility document review, and clinical record review, the facility staff failed to place a call bell within a resident's reach for one of 11 residents in the survey sample, Resident #6.The findings include:For Resident #6 (R6), the facility staff failed to place the resident's call bell within reach on 10/6/25 and 10/7/25.On the following dates and times, R6 was observed sitting up and/or lying in bed. At all of these times, R6's call bell was clipped to the bottom sheet more than halfway down the length of the bed, out of the resident's reach: 10/6/25 at 11:17 a.m. and 4:17 p.m.; 10/7/25 at 8:01 a.m. and 8:21 a.m. At 8:21 a.m., RN (registered nurse) #1 went into R6's room, stood beside the resident and spoke to him, and did not place the call bell within R6's reach before RN #1 left the room.On the most recent MDS (minimum data set), a quarterly assessment dated [DATE], R7 was coded as being severely cognitively impaired. He was coded as having range of motion impairment in both arms, and as requiring the assistance of staff for bed mobility.On 10/7/25 at 3:55 p.m., CNA (certified nursing assistant) #2 was interviewed. She stated a resident's call bell should be placed within a resident's reach at all times. She stated this was for the resident's safety in case he needed to call a staff member.On 10/8/25 at 8:10 a.m., LPN (licensed practical nurse) #2, a unit manager, was interviewed. She stated call bells should be within reach of a resident at all times. She explained this is the quickest way for a resident to alert staff if he/she needs assistance.On 10/8/25 at 10:55 a.m., ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing, and ASM #3, the regional director of clinical operations were informed of these concerns.A review of the facility policy Answering the Call Light revealed, in part: The facility will maintain a functional call light system and will make all reasonable efforts to ensure timely responses to the resident's requests and needs .When the resident is in bed or confined to a chair be sure the call light is within easy reach of the resident.No additional information was provided prior to exit.

4. For Resident #132 (R132), a resident with a wound, the facility staff failed to implement enhanced barrier precautions (1). A review of R132's clinical record revealed a physician's order dated 12/27/24 that documented to cleanse the resident's sacral wound with normal saline, pat dry, apply calcium alginate and cover with a foam border dressing every day shift. Further review of R132's clinical record failed to reveal a physician's order for enhanced barrier precautions. On 2/4/25 at 10:11 a.m., an observation of LPN (licensed practical nurse) #4 changing a dressing on R132's sacrum was conducted. LPN #4 wore gloves during the dressing change but did not wear a gown. Also, there was no signage communicating enhanced barrier precautions to staff in the room. On 2/4/25 at 3:51 p.m., an interview was conducted with LPN (licensed practical nurse) #4. LPN #4 stated gloves and a gown should be worn when caring for residents on enhanced barrier precautions. LPN #4 stated enhanced barrier precautions were not implemented for R132 because an employee with the local health department instructed facility staff that enhanced barrier precautions only needed to be implemented for residents with wounds that were draining and R132's wound was not draining. On 2/4/25 at 4:45 p.m. ASM (administrative staff member) #1 (the administrator) and ASM #2 (the director of nursing) were made aware of the above concern. The facility policy titled, Enhanced Barrier Precautions (EBP) Policy documented, The purpose of this policy is to outline the guidelines for implementing Enhanced Barrier Precautions (EBP) in order to reduce the transmission of multidrug-resistant organisms (MDROs) within our facility. EBP will be utilized in conjunction with standard precautions to provide targeted gown and glove use during high-contact resident care activities .1. Criteria for Implementing EBP: Residents with wounds and/or indwelling medical devices, irrespective of MDRO infection or colonization status .4. High-Contact Resident Care Activities Requiring EBP: Wound care (any skin opening requiring a dressing). No further information was presented prior to exit. Reference: 1. Enhanced Barrier Precautions are an infection control intervention designed to reduce transmission of multidrug-resistant organisms (MDROs) in nursing homes. Enhanced Barrier Precautions involve gown and glove use during high-contact resident care activities for residents known to be colonized or infected with a MDRO as well as those at increased risk of MDRO acquisition (e.g., residents with wounds or indwelling medical devices). This information was obtained from the website: https://www.cdc.gov/long-term-care-facilities/hcp/prevent-mdro/faqs.html 5. For Resident #90, a resident with a wound, the facility staff failed to implement enhanced barrier precautions (1). A review of R90's clinical record revealed a physician's order dated 2/4/25 that documented to cleanse the resident's right thigh and perineum wound with soap and water, pat dry, apply gentamicin 0.1% (antibiotic) cream and calcium alginate with AG, and cover with a foam dressing every day shift. Further review of R90's clinical record failed to reveal a physician's order for enhanced barrier precautions. On 2/4/25 at 10:27 a.m., an observation of LPN (licensed practical nurse) #4 changing a dressing on R90's right thigh/perineum was conducted. LPN #4 wore gloves during the dressing change but did not wear a gown. Also, there was no signage communicating enhanced barrier precautions to staff in the room. On 2/4/25 at 3:51 p.m., an interview was conducted with LPN (licensed practical nurse) #4. LPN #4 stated gloves and a gown should be worn when caring for residents on enhanced barrier precautions. LPN #4 stated enhanced barrier precautions were not implemented for R90 because an employee with the local health department instructed facility staff that enhanced barrier precautions only needed to be implemented for residents with wounds that were draining and R90's wound was not draining. On 2/4/25 at 4:45 p.m., ASM (administrative staff member) #1 (the administrator) and ASM #2 (the director of nursing) were made aware of the above concern. No further information was presented prior to exit. Reference: 1. Enhanced Barrier Precautions are an infection control intervention designed to reduce transmission of multidrug-resistant organisms (MDROs) in nursing homes. Enhanced Barrier Precautions involve gown and glove use during high-contact resident care activities for residents known to be colonized or infected with a MDRO as well as those at increased risk of MDRO acquisition (e.g., residents with wounds or indwelling medical devices). This information was obtained from the website: https://www.cdc.gov/long-term-care-facilities/hcp/prevent-mdro/faqs.html 6. For Resident #104 (R104), the facility staff failed to change a sheet which contained blood stains and other debris. On the following dates and times, R104 was observed sitting up in bed. At each observation, his bed linens contained stains of red and dark brown material around both feet and lower legs: 2/3/25 at 12:53 p.m. and 4:01 p.m., 2/4/25 at 9:38 a.m. On 2/4/25 at 9:38 a.m., R104 stated staff had provided care for him multiple times, including incontinence care and applying lotion to his back, giving them opportunity to notice his sheets were soiled. On 2/5/25 at 8:53 a.m., CNA (certified nursing assistant) #6 was interviewed. She stated she checked on R104 multiple times during each shift during which she cared for him. She stated she had the opportunity to see his bed linens whenever she assisted him to turn in bed or to put lotion on his back. She stated if she noticed R104's sheets were blood stained or otherwise dirty, she would change the sheets immediately. She stated dirty sheets were a concern for infection control. On 2/5/25 at 1:40 p.m., ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing, ASM #3, the regional director of clinical operations, and ASM #5, the regional director of operations, were informed of these concerns. No additional information was provided prior to exit. Based on observation, resident interview, clinical record review, staff interview and facility document review it was determined the facility staff failed to maintain a complete infection control program for one of one facility and for five of 48 residents in the survey sample, Residents #123, #65, #132, #90 and #104. The findings include: 1. The facility staff failed to evidence a water management program to minimize the risk of Legionella and other opportunistic pathogens in building water systems. On 2/3/25 at 11:25 a.m., a request was made to ASM (administrative staff member) #2, the director of nursing, for the facility Legionella/water management policy, procedures and assessment. On 2/4/25 at 2:04 p.m., a second request was made to ASM #2 to review the Legionella/water management plan. ASM #2 provided the facility policy Legionella/Water Management Plan which documented in part, .The facility is committed to establishing and maintaining an effective water management system to minimize the occurrence of Legionnaire's Disease . The facility will develop and maintain a water management program that includes the following elements . Describe the building water system using test and diagrams. i. Resident care areas. ii. Clinical support areas. iii. Components and devices that can expose residents to contaminated water; and will iv. Develop an ongoing dialogue with the drinking water provider so that the facility is aware of changes that may affect the building's water supply. c. Identify areas where Legionella could grow and spread. d. Decide where control measures should be applied, monitor and log compliance quarterly . g. Document all activities [i.e. monitoring, response to variances, etc.]. i. Routine safety logs will be maintained . On 2/4/25 at 4:36 p.m., a request was made to ASM #1, the administrator, ASM #2, ASM #3, the regional director of clinical operations, ASM #4, the regional clinical reimbursement director and ASM #5, the regional director of operations for the facility Legionella/water management plan as described in the facility policy. On 2/5/25 at 10:36 a.m., ASM #1 stated that they did not have any additional information regarding the Legionella/water management plan to provide. On 2/5/25 at 10:39 a.m., an interview was conducted with OSM (other staff member) #7, the director of maintenance who stated that they had been at the facility for about three months and had not been doing any water testing or was not aware of any water management interventions being done since he had been at the facility. He stated that at the prior facility he worked at he would have a monthly task that would be completed going to four different areas in the building and testing samples of water and then annually they would send out a sample to the lab for full testing. He stated that he had reached out to his corporate contact about a week ago about getting the supplies to start the water monitoring at the facility and they had been approved to be sent. He stated that the former maintenance director had taken some paperwork when they left and perhaps the water management plan was there, and they had tried to reach out to him, but he was not being cooperative with them. On 2/5/25 at 11:05 a.m., ASM #1, ASM #2, ASM #3, and ASM #5 were made aware of the concern. No further information was presented prior to exit. Reference: (1) Legionella is found naturally in [NAME], such as lakes and [NAME]. It can also be found in soil. But people usually only get sick from it when if it grows and spreads in man-made water systems. These systems can include hot tubs, fountains, and the plumbing systems of large buildings, such as hotels or nursing homes. This information was obtained from the website: https://medlineplus.gov/legionnairesdisease.html 2. For Resident #123 (R123), the facility staff failed to follow contact isolation (1) as ordered. The physician orders for R123 documented in part, Contact Isolation Precautions for +CRE (2) colonized. Order Date: 11/6/2024. The comprehensive care plan for R123 documented in part, Contact isolation: the resident required (Contact Isolation Precautions for +CRE colonized.) Date Initiated: 01/21/2025. Revision on: 02/03/2025. A lab report for R123 dated 10/29/24 documented CPO colonization testing completed with Carbapenem resistance gene detected. On 2/3/25 at 4:25 p.m., an observation was made of R123's room. No signage was observed indicating contact precautions for R123. A PPE (personal protective equipment) (3) was observed in the hallway between neighboring resident rooms. On 2/4/25 at 8:13 a.m., no contact isolation signage was observed on R123's room indicating isolation. No PPE was observed near R123's room at that time. On 2/4/25 at 8:35 a.m., a staff member was observed entering R123's room delivering a breakfast observed to be served in a Styrofoam container. The staff member did not don any PPE prior to entrance. On 2/4/25 at 8:39 a.m., another staff member entered R123's room delivering a breakfast observed to be served in a Styrofoam container. The staff member did not don any PPE prior to entrance. On 2/4/25 at 3:42 p.m., a staff member was observed entering R123's room with linens in their hand and closed the door. The staff member did not don any PPE prior to entrance. On 2/4/25 at 3:06 p.m., an interview was conducted with CNA (certified nursing assistant) #3 who stated that if a resident was on contact precautions there was a sign on the door and a cart in front of the door with PPE inside. CNA #3 stated that this was done so that everyone knew before they went in the room. On 2/4/25 at 3:38 p.m., an interview was conducted with CNA #9 who stated that they were not aware of any resident on the unit on contact precautions. She stated that if a resident was on contact precautions they normally had a yellow cart in front of the room and a sign on the door to tell them what precautions to take and what to wear. On 2/4/25 at 3:43 p.m., an interview was conducted with RN (registered nurse) #5 who stated that if a resident was on contact precautions they put a sign on the door and an isolation cart outside of the room. He stated that he only had one resident on droplet precautions currently which was a new admission that had not arrived yet, but he had set up the room for isolation as a precaution. RN #5 reviewed R123's order and care plan for contact precautions and stated that he thought that the isolation should be discontinued but needed to verify with the infection preventionist. The facility policy Isolation- Categories of Transmission-Based Precautions documented in part, .When a resident is placed on transmission-based precautions, appropriate notification is placed on the room entrance door and on the front of the chart so that personnel and visitors are aware of the need for and the type of precaution. The signage informs the staff of the type of CDC precaution(s), instructions for use of PPE, and/or instructions to see a nurse before entering the room. Signs and notifications comply with the resident ' s right to confidentiality or privacy . Contact precautions are implemented for residents known or suspected to be infected with microorganisms that can be transmitted by direct contact with the resident or indirect contact with environmental surfaces or resident-care items in the resident ' s environment . Staff and visitors wear gloves (clean, non-sterile) when entering the room. While caring for a resident, staff will change gloves after having contact with infective material (for example, fecal material and wound drainage). Gloves are removed and hand hygiene performed before leaving the room. Staff avoid touching potentially contaminated environmental surfaces or items in the resident ' s room after gloves are removed. Staff and visitors wear a disposable gown upon entering the room and remove before leaving the room and avoid touching potentially contaminated surfaces with clothing after gown is removed . On 2/4/25 at 4:36 p.m., ASM #1, the administrator, ASM #2, ASM #3, the regional director of clinical operations, ASM #4, the regional clinical reimbursement director and ASM #5, the regional director of operations were made aware of the concern. No further information was provided prior to exit. Reference: (1) Use Contact Precautions for patients with known or suspected infections that represent an increased risk for contact transmission .Use personal protective equipment (PPE) appropriately, including gloves and gown. Wear a gown and gloves for all interactions that may involve contact with the patient or the patient's environment. Donning PPE upon room entry and properly discarding before exiting the patient room is done to contain pathogens. This information was obtained from the website: https://www.cdc.gov/infection-control/hcp/basics/transmission-based-precautions.html (2) CRE- Enterobacterales are a group of bacteria (germs) that are a normal part of the human and animal gut but can also cause infections. Carbapenem-resistant Enterobacterales (CRE) are germs resistant to one or several antibiotics called carbapenems. In 2017, CRE caused about 13,100 infections in hospital patients and about 1,100 deaths in the United States . How it spreads: Person-to-person contact from dirty hands, wounds, or stool (poop). Contaminated medical equipment and devices . This information was obtained from the website: https://www.cdc.gov/cre/about/?CDC_AAref_Val=https://www.cdc.gov/hai/organisms/cre/cre-patients.html (3) Personal protective equipment (PPE) is special equipment you wear to create a barrier between you and germs. This barrier reduces the chance of touching, being exposed to, and spreading germs. PPE helps prevent the spread of germs in the hospital. This can protect all people including health care workers from infections. This information was obtained from the website: https://medlineplus.gov/ency/patientinstructions/000447.htm 3. For Resident #65 (R65), the facility staff failed to follow contact isolation as ordered. The physician orders for R65 documented in part, Contact Isolation Precautions for +CRE colonized. Order Date: 11/6/2024. The comprehensive care plan for R65 documented in part, Contact isolation precautions for CRO colonization) Date Initiated: 01/22/2025. Revision on: 01/22/2025. A urine C&S (culture and sensitivity) for R65 dated 1/11/25 documented in part, >100,000 CFU/ml Enterobac aerogenes CRE (A), >100,000 CFU/ml Klebsiella aerogenes (A) . On 2/3/25 at 4:25 p.m., an observation was made of R65's room. No signage was observed indicating contact precautions for R65. A PPE (personal protective equipment) was observed in the hallway between neighboring resident rooms. On 2/4/25 at 8:13 a.m., no contact isolation signage was observed on R65's room indicating isolation. No PPE was observed near R65's room at that time. On 2/4/25 at 8:35 a.m., a staff member was observed entering R65's room delivering a breakfast observed to be served in a Styrofoam container. The staff member did not don any PPE prior to entrance. On 2/4/25 at 8:39 a.m., another staff member entered R65's room delivering a breakfast observed to be served in a Styrofoam container. The staff member did not don any PPE prior to entrance. On 2/4/25 at 3:42 p.m., a staff member was observed entering R65's room with linens in their hand and closed the door. The staff member did not don any PPE prior to entrance. On 2/4/25 at 3:06 p.m., an interview was conducted with CNA (certified nursing assistant) #3 who stated that if a resident was on contact precautions there was a sign on the door and a cart in front of the door with PPE inside. CNA #3 stated that this was done so that everyone knew before they went in the room. On 2/4/25 at 3:38 p.m., an interview was conducted with CNA #9 who stated that they were not aware of any resident on the unit on contact precautions. She stated that if a resident was on contact precautions they normally had a yellow cart in front of the room and a sign on the door to tell them what precautions to take and what to wear. On 2/4/25 at 3:43 p.m., an interview was conducted with RN (registered nurse) #5 who stated that if a resident was on contact precautions they put a sign on the door and an isolation cart outside of the room. He stated that he only had one resident on droplet precautions currently which was a new admission that had not arrived yet, but he had set up the room for isolation as a precaution. RN #5 reviewed R65's order and care plan for contact precautions and stated that he thought that the isolation should be discontinued but needed to verify with the infection preventionist. On 2/4/25 at 4:36 p.m., ASM (administrative staff member) #1, the administrator, ASM #2, ASM #3, the regional director of clinical operations, ASM #4, the regional clinical reimbursement director and ASM #5, the regional director of operations were made aware of the concern. No further information was provided prior to exit.

Based on observations, resident/staff interview, clinical record review and facility document review, it was determined the facility staff failed to ensure residents were free of unnecessary medications for one of 48 residents in the survey sample, R130. The findings include: The facility staff failed to ensure R130 was free of unnecessary medications by monitoring anticoagulant as ordered. R130 was admitted to the facility on [DATE] with diagnosis that included but were not limited to pulmonary embolism, spondylosis and cord compression. The most recent MDS (minimum data set) assessment, a quarterly assessment, with an ARD (assessment reference date) of 1/7/25, coded the resident as scoring a 15 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was not cognitively impaired. A review of the MDS Section GG-functional abilities and goals coded the resident as requiring maximal assistance for mobility/transfers/bathing/dressing and set-up for eating. A review of the comprehensive care plan dated 1/24/25 revealed, FOCUS: CARDIAC: the resident is at risk for cardiac complications secondary to atrial fibrillation. INTERVENTIONS: Administer medications as ordered. Observe for signs and symptoms of cardiac complications. Care plan does not evidence any Anticoagulation information until after end of day on 2/4/25. A review of the physician's order dated 6/30/24 revealed, Rivaroxaban Oral Tablet 20 MG (Rivaroxaban) Give 20 mg by mouth one time a day for A fib take with dinner. R130's MAR (medication administration record) does not evidence any monitoring of anticoagulation monitoring. On 2/3/25 at 2:30 PM, an interview was conducted with R130. When asked what monitoring is provided for his anticoagulation, R130 asked what do you mean. When asked if staff ask him about bruising or bleeding or assess his arms, R130 stated, no, not that I know of. On 2/4/25 at 3:30 PM, an interview was conducted with LPN (licensed practical nurse) #4, the unit manager. When asked if anticoagulation side effects were monitored and where it would be evidenced, LPN #4 stated, no, we do not document anything for anticoagulation monitoring. 02/05/25 07:45 AM, ASM (administrative staff member) #2, the director of nursing, brought in updated order, care plan and MAR (medication administration record) to reflect monitoring for anticoagulation side effects dated 2/4/25 after end of day conference On 2/4/25 at 4:30 PM, ASM (administrative staff member) #1, the administrator, ASM #2, the DON (director of nursing) ASM #3, the regional director of clinical operations, ASM #4, the regional director of clinical reimbursement and ASM #5, the regional director of operations was made aware of the findings. A review of the facility's Medication and Treatment Orders policy, revealed, Orders for anti-coagulants will be prescribed only with appropriate clinical and laboratory monitoring. The attending physician/practitioner must periodically record in the progress notes the results of the laboratory monitoring and the review for potential complications. No further information was provided prior to exit.

2. For R56, facility staff failed to place a C-PAP (continuous positive airway pressure) (1) mask is a plastic bag when not in use. R56 was admitted to the facility with diagnosis that included but not limited to sleep apnea (2). On the most recent comprehensive MDS (minimum data set), an admission assessment with an ARD (assessment reference date) of 01/23/2025, R56 scored 13 out of 15 on the BIMS (brief interview for mental status), indicating R56 was cognitively intact for making daily decisions. On 02/03/25 at approximately 12:19 p.m., an observation revealed R56's C-PAP mask lay on top of bedside table uncovered. On 02/03/25 at approximately 2:49 p.m., an observation revealed R56's C-PAP mask lay on top of bedside table uncovered. On 02/03/25 at approximately 4:25 p.m., an observation revealed R56's C-PAP mask lay on top of bedside table uncovered. On 02/04/25 at approximately 8:20 a.m., an observation revealed R56's C-PAP mask lay on top of bedside table uncovered. The physician's order for R56 documented in part, Apply CPap q (every) hs (night) & (and) PRN (as needed) for naps .as needed for OSA (obstructive sleep apnea). Apply CPap PRN for nap. Oder Date: 1/22/2025. On 02/04/2025 at approximately 3:12 p.m., an observation of R56's C-PAP mask and interview was conducted with RN (registered nurse) #2 regarding the storage of a C-PAP mask when not in use. After observing R56's C-PAP mask on the bedside table RN #3 stated the C-PAP mask should be placed in a plastic bag when not in use to keep it clean and prevent contamination. On 02/04/2025 at approximately 4:35 p.m., ASM (administrative staff member) #1, administrator, ASM #2, director of nursing, ASM #3, regional director of clinical services, ASM #4, director of clinical reimbursement, and ASM # 5regional director of operations, were made aware of the above findings. No further information was provided prior to exit. References: (1) The forced air delivered by CPAP (continuous positive airway pressure) prevents episodes of airway collapse that block the breathing in people with obstructive sleep apnea and other breathing problems. This information was obtained from the website: https://medlineplus.gov/ency/article/001916.htm. (2) a common disorder that causes your breathing to stop or get very shallow. Breathing pauses can last from a few seconds to minutes. They may occur 30 times or more an hour. This information was obtained from the website: https://medlineplus.gov/sleepapnea.html. 3. For R140, the facility staff failed to maintain the oxygen flow rate at three liters per minute according to the physician's orders. R140 was admitted to the facility with diagnoses that included but were not limited to (COPD) chronic obstructive pulmonary disease (1). On the most recent comprehensive MDS (minimum data set), a significant change assessment with an ARD (assessment reference date) of 01/16/2025, R140 scored 6 (six) out of 15 on the BIMS (brief interview for mental status), indicating R140 was severely impaired of cognition for making daily decisions. Section O Special Treatments, Programs and Procedures coded R140 as receiving oxygen therapy while a patient. On 02/03/25 at approximately 12:38 p.m., an observation revealed R140 lying in bed receiving O2 (oxygen) by nasal cannula. Observation of the flow meter on the O2 concentrator revealed a flow rate between two and three liters per minute. 02/03/25 at approximately 2:53 p.m., an observation revealed R140 lying in bed receiving O2 by nasal cannula. Observation of the flow meter on the O2 concentrator revealed a flow rate between two and three liters per minute. 02/03/25 at approximately 4:25 p.m., an observation revealed R140 lying in bed receiving O2 by nasal cannula. Observation of the flow meter on the O2 concentrator revealed a flow rate between two and three liters per minute. 02/03/25 at approximately 7:35 a.m., an observation revealed R140 lying in bed receiving O2 by nasal cannula. Observation of the flow meter on the O2 concentrator revealed a flow rate between two and three liters per minute. The physician's order for R140 documented in part, O2 @ (at) 3 (three) liters per minute via (by) NC (nasal cannula). Every shift for Hypoxia (low level of oxygen) secondary to COPD .Order Date: 12/27/2024. On 02/04/2025 at approximately 3:12 p.m., an interview and observation of R140's O2 flow meter on the O2 concentrator was conducted with RN (registered nurse) #3. When asked to describe how to read the flow meter on the O2 concentrator she stated the liter line should pass through the middle of the float ball inside the flow meter. After observing the flow meter on R140's O2 concentrator RN #3 stated R140 was receiving two-and-a-half liters of O2 per minute. On 02/04/2025 at approximately 4:35 p.m., ASM (administrative staff member) #1, administrator, ASM #2, director of nursing, ASM #3, regional director of clinical services, ASM #4, director of clinical reimbursement, and ASM # 5regional director of operations, were made aware of the above findings. No further information was provided prior to exit. References: (1) Disease that makes it difficult to breath that can lead to shortness of breath. This information was obtained from the website: https://www.nlm.nih.gov/medlineplus/copd.html. 4. For Resident #131, the resident's oxygen tubing was not labeled with the date it was most recently changed. On the following dates and times, R131 was observed lying in bed, receiving oxygen at 2 liters per minute from a concentrator, by way of nasal cannula tubing: 2/3/25 at 12:58 p.m., 1:52 p.m., and 3:45 p.m.; 2/4/25 at 9:50 a.m. and 3:47 p.m. At each of these observations, R131's oxygen tubing did not have any kind of label indicating the date it was last changed. On 2/5/25 at 9:21 a.m., RN (registered nurse) #1 was interviewed. She stated R131 was on continuous oxygen. She stated the tubing is changed every week at a minimum, and more often as needed. When asked how the staff knows the last time the tubing was changed, she stated the staff member who changes the tubing should label the tubing with the date. She stated clean tubing is important to prevent possible respiratory infections for residents who are on oxygen. On 2/5/25 at 9:54 a.m., LPN (licensed practical nurse) #6, a unit manager, was interviewed. He stated oxygen tubing should be changed every week and labeled with the new date it was changed. He stated this is how the staff knows when the tubing is due to be changed again. On 2/5/25 at 1:40 p.m., ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing, ASM #3, the regional director of clinical operations, and ASM #5, the regional director of operations, were informed of these concerns. No additional information was provided prior to exit. 5. For Resident #104 (R104), the facility failed to store his CPAP(1) mask in a sanitary manner, and to clean the mask and tubing regularly. On the following dates and times, R104 was observed sitting up in bed: 2/3/25 at 12:53 p.m. and 4:01 p.m., 2/4/25 at 9:38 a.m., and 2/5/25 at 10:17 a.m. At all observations, R104's CPAP machine was visible on his bedside table. The tubing for the CPAP extended below the top of the table, and ended with the mask at its tip. The mask rested in the top drawer of the bedside table, uncovered. R104 stated he used his BPAP every night to sleep, but no staff member ever cleaned the mask or stored the mask in a sanitary plastic bag. A review of R104's orders revealed he was to use the CPAP to sleep. Further review of these orders revealed no instructions regarding cleaning of the CPAP mask. A review of R104's care plan, MAR (medication administration record) and TAR (treatment administration record) also failed to reveal interventions for cleaning the CPAP mask. On 2/5/25 at 8:53 a.m., CNA (certified nursing assistant) #6 was interviewed. She stated she was not aware that the resident used the CPAP, and did not know anything about cleaning or storing the CPAP mask. On 2/5/25 at 9:21 a.m., RN (registered nurse) #1 was interviewed. She stated R104 used the CPAP for sleep each night, and the mask should always be stored in a plastic bag. She stated the mask should be cleaned after each use, but could not identify who is responsible for cleaning the mask. After reviewing R104's clinical record, she stated she did not see any evidence that R104's CPAP mask was being cleaned regularly. She stated this is dangerous because the mask could collect harmful germs and be an infection control concern. On 2/5/25 at 1:40 p.m., ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing, ASM #3, the regional director of clinical operations, and ASM #5, the regional director of operations, were informed of these concerns. No additional information was provided prior to exit. Reference (1)CPAP (Continuous Positive Airway Pressure) is a treatment that uses mild air pressure to keep your breathing airways open .It involves using a CPAP machine that includes a mask or other device that fits over your nose or your nose and mouth, straps to position the mask, a tube that connects the mask to the machine ' s motor, and a motor that blows air into the tube. CPAP is used to treat sleep-related breathing disorders including sleep apnea. This information is taken from the website https://www.nhlbi.nih.gov/health-topics/cpap. Based on observations, staff /resident interviews facility document review and clinical record review, it was determined the facility staff failed to provide respiratory care services for five of 48 residents, R23, R56, R140, R131 and R104. The findings include: 1. The facility staff failed to provide respiratory care services per physician orders for R23. Observed R23's oxygen setting at 4 liters nasal cannula (lnc) on 02/03/25 at 11:33 AM, 02/03/25 at 3:33 and 02/04/25 at 08:30 AM. R23 was admitted to the facility on [DATE] with diagnosis that included but were not limited to CHF (congestive heart failure), osteoarthritis and CVA (cerebrovascular accident). The most recent MDS (minimum data set) assessment, an annual assessment, with an ARD (assessment reference date) of 11/13/24, coded the resident as scoring a 10 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was moderately cognitively impaired. A review of the MDS Section GG-functional abilities and goals coded the resident as requiring maximal assistance for mobility/transfers/bathing/dressing and set-up for eating. Section O: oxygen: yes. A review of the comprehensive care plan dated 11/29/24 revealed, FOCUS: Has/At risk for respiratory impairment related to SOB due to OSA (obstructive sleep apnea) & chronic respiratory failure with hypoxia, cough. CHF. INTERVENTIONS: Administer oxygen as per physician order: Via nasal cannula for shortness of breath related to CHF. A review of the physician's order dated 11/16/21 revealed, O2 via nasal cannula at 2 liters per minute every shift. An interview was conducted on 2/3/25 at 3:33 PM with R23, when asked her oxygen setting, R23 stated, it is on two. An interview was conducted on 2/4/25 at 9:05 AM with LPN (licensed practical nurse) #2. When asked to verify R23's oxygen order, LPN #2 stated, she is to be on 2 lnc (liters/nasal cannula). When asked to come to the room and verify setting, LPN #2 stated, she is on 4-5 lnc. I will adjust it. When asked where you would read the oxygen setting, LPN #2 stated, you would read it with the line in the middle of the ball. On 2/5/25 at 1:30 PM, ASM (administrative staff member) #1, the administrator, ASM #2, the DON (director of nursing) ASM #3, the regional director of clinical operations, ASM #4, the regional director of clinical reimbursement and ASM #5, the regional director of operations was made aware of the findings. A review of the facility's Equipment Change and Cleansing policy revealed, The following procedures have been developed to emphasize the importance of proper handling and processing of certain equipment. All disposable equipment will be dated and initialed. All patients will receive a complete set-up bag with the necessary equipment associated with Respiratory Care. Items will not be share between patients. No further information was provided prior to exit.

2. For R98, facility staff failed to implement the use of a Heelzup (1) cushion according to the physician's orders for the prevention of pressure injuries. R98 was admitted with diagnoses that included but were not limited to protein-calorie malnutrition. On the most recent MDS (minimum data set), an admission assessment with an ARD (assessment reference date) of 12/24/202, the R98 scored 13 out of 15 on the BIMS (brief interview for mental status), indicating the resident was cognitively intact for making daily decisions. Section M050 Risk of Pressure Ulcers/Injuries coded R98 as Yes. On 02/03/25 at approximately 12:25 p.m., an observation revealed R98 lying on his back in bed with heels in contact with the surface of the bed. Further observation of R98's room revealed the Heelzup cushion laying on floor next to left side of R98's bed. On 2/4/25 at 1:22 am, an observation revealed R98 was lying on his back in bed. Both feet were propped on a pillow. However, the pillow was flat and insufficient to lift the resident's heels off the bed surface. Both heels rested in contact with the bed surface. On 02/04/25 at approximately 7:35 a.m., an observation revealed R98 was lying on his back in bed. Both feet were propped on a pillow. However, the pillow was flat and insufficient to lift the resident's heels off the bed surface. Both heels rested in contact with the bed surface. The physician's order for R98 dated 01/09/2025 documented, Heelzup cushion [NAME] in bed. The comprehensive care plan for R98 with a revision date of 01/08/2025 documented in part, Focus. Skin Impairment: the resident has a skin impairment of pressure ulcer of sacrum, non-pressure wound to left great toe, and pressure wound to right toe. Revision on: 01/08/2025. Under Interventions it documented in part, Heelz up cushion in place while resident in bed. Revision on: 01/08/2025. On 02/04/2024 at approximately 3:05 p.m., an interview and observation of R98 was conducted with CNA (certified nursing assistant) #5. The observation revealed R98 was lying on his back in bed. Both lower legs (calves) were propped on a pillow. However, the pillow was flat and insufficient to lift the resident's heels off the bed surface. Both heels rested in contact with the bed surface. When asked why the pillow was placed under R98's calves she stated it was to keep R98's heels off the bed to prevent the development of pressure injuries. When asked to describe the position of R98's heels she stated that R98's heels were resting on the bed. CNA #4 then moved the pillow from under R98's lower legs and placed it under R98's heels, putting R98's heels in contact with the surface of the pillow. On 02/05/2024 at approximately 12:23 p.m., an interview was conducted with LPN (licensed practical nurse) #4, unit manager regarding the use of an Heelzup cushion or a pillow placed under a resident's lower legs. LPN #4 stated they would be used for the prevention of pressure injuries and the cushion or pillow would keep the heels above the surface of the bed. On 02/04/2025 at approximately 4:35 p.m., ASM (administrative staff member) #1, administrator, ASM #2, director of nursing, ASM #3, regional director of clinical services, ASM #4, director of clinical reimbursement, and ASM # 5regional director of operations, were made aware of the above findings. No further information was provided prior to exit. References: (1) Designed to aid in the prevention and treatment of heel pressure injuries. HeelZup® Heel Elevators suspend the heels to eliminate pressure, while the patented raised side bolsters serve as a gentle reminder of the edge of the cushion. This information was obtained from the website: https://heelzup.com. Based on observation, staff interview, clinical record review, and facility document review, the facility staff failed to provide care and services to prevent and treat a pressure injury (1) for two of 48 residents in the survey sample, Residents #74 and #98. The findings include: 1. For Resident #74 (R74), the facility staff failed to implement treatment for a pressure injury to the right ischium on 4/30/24. A review of R74's clinical record revealed the following progress note dated 4/30/24: Weekly wound assessment completed. Unstageable Pressure Ulcer to Right ischium. Overall impression: new wound - first observation. A review of R74's Weekly Wound assessment dated [DATE] revealed the following treatment recommendation for the right ischium wound: Calcium alginate and foam dressing. A review of R74's May 2024 TAR (treatment administration record) revealed this order was not implemented until 5/27/24, a total of 27 days after the wound was discovered. On 2/5/25 at 9:21 a.m., RN (registered nurse) #1 was interviewed. She stated when a pressure injury is identified, orders are put in place until the wound practitioner can see the resident. She stated these orders should be entered by a member of the nursing staff and signed by a provider so treatment can begin immediately. She stated: This gives the wound a better chance of getting better instead of worse. When asked how she provides evidence of wound treatments that she has completed, she stated she signs the treatment off on the TAR. On 2/5/25 at 9:54 a.m., LPN (licensed practical nurse) #6, a unit manager, was interviewed. LPN #6 stated there was a signed order for R74's right ischium wound treatment to begin on 5/1/24. However, he stated he could not find evidence in the TAR that the order had been implemented until 5/27/24. On 2/5/25 at 1:40 p.m., ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing, ASM #3, the regional director of clinical operations, and ASM #5, the regional director of operations, were informed of these concerns. A review of the facility policy, Pressure Injury Prevention and Management, revealed, in part: The intent of this organization is to develop and maintain systems and processes to ensure that the resident does not develop pressure ulcers/injuries .unless clinically unavoidable and that the facility provides care and services consistent with professional standards of practice to: Promote the prevention of pressure ulcer/injury development; Promote the healing of existing pressure ulcers/injuries .Preventive interventions will be implemented based on the pressure ulcer/injury risk assessment, other related factors, and resident preferences .Treatments will be ordered by the physician/practitioner. No additional information was provided prior to exit. Reference (1) A pressure ulcer is localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear. This information is taken from the National Pressure Ulcer Advisory Panel website https://cdn.ymaws.com/npiap.com/resource/resmgr/2014_guideline.pdf\.

Based on clinical record review, staff interview and facility document review, it was determined that the facility staff failed to administer medications according to the physician's orders for one of 48 residents in the survey sample, Resident #76 (R76). For R76, the facility staff failed to administer Furosemide (for swelling), Gabapentin (for pain), Lorazepam (for anxiety), Losartan Potassium (for high blood pressure), Metoprolol (for high blood pressure), Mirtazapine (for depression), Oxycodone (for pain), Sertraline (for depression), Tamsulosin (for (BPH) benign prostatic hypertrophy (1)), Aspirin (for (CAD) coronary artery disease (2)), Lidocaine External Patch(for pain), Tylenol (for pain) according to the physician's order. The findings include: R76 was admitted with diagnoses that included but were not limited to depression, high blood pressure, BPH, high cholesterol, anxiety and muscle weakness. On the most recent MDS (minimum data set), an admission assessment with an ARD (assessment reference date) of 01/10/2025, R76 scored 8 (eight) out of 15 on the BIMS (brief interview for mental status), indicating R76 was moderately impaired of cognition for making daily decisions. The POS (physician's order sheet) for R76 dated 02/05/2025 documented in part, Aspirin Oral Tablet Chewable 81 MG (milligram) (Aspirin) Give 81 mg by mouth one time a day for CAD. Oder Date: 01/04/2025. Start Date: 01/05/2025. Furosemide Oral Tablet 20 MG (Furosemide) Give 20 mg by mouth one time a day for EDEMA Oder Date: 01/04/2025. Start Date: 01/05/2025. Gabapentin Oral Capsule 100 MG (Gabapentin) Give 2 capsule by mouth two times a day for NEUROPATHIC PAIN. Oder Date: 01/04/2025. Start Date: 01/04/2025. Lidocaine External Patch 4 % (Lidocaine) Apply to LOWER BACK topically one time a day for PAIN MANAGEMENT and remove per schedule. Oder Date: 01/04/2025. Start Date: 01/05/2025. Lorazepam Oral Tablet 1 MG (Lorazepam) Give 1 mg by mouth every 24 hours as needed for ANXIETY for 3 Week. Oder Date: 01/04/2025. Start Date: 01/05/2025. Losartan Potassium Oral Tablet 25 MG (Losartan Potassium) Give 25 mg by mouth one time a day for HYPERTENSION HOLD FOR SBP (systolic blood pressure) < (less than) 110. Oder Date: 01/04/2025. Start Date:01/05/2025. Metoprolol Tartrate Oral Tablet 50 MG (Metoprolol Tartrate) Give 50 mg by mouth one time a day for HYPERTENSION HOLD FOR SBP < 115 HR (heart rate) < 55. Order Date: 01/04/2025. Start Date: 02/02/2025. Mirtazapine Oral Tablet 15 MG (Mirtazapine) Give 15 mg by mouth one time a day for DEPRESSION. Oder Date: 01/04/2025. Start Date: 01/05/2025. Oxycodone HCl (hydrochloride) Oral Tablet 5 MG (Oxycodone HCl) Give 5 mg by mouth one time a day for PAIN MANAGEMENT. Oder Date: 01/04/2025. Start Date: 01/05/2025. Sertraline HCl Oral Tablet 100 MG (Sertraline HCl) Give 100 mg by mouth one time a day for DEPRESSION. Oder Date: 01/04/2025. Start Date: 01/05/2025. Tamsulosin HCl Oral Capsule 0.4 MG (Tamsulosin HCl) Give 0.4 mg by mouth one time a day for BPH. Oder Date: 01/04/2025. Start Date: 01/05/2025. Tylenol Extra Strength Oral Tablet 500 MG (Acetaminophen) Give 500 mg by mouth two times a day for PAIN MANAGEMENT Do not exceed > 3 (three) gram per day. Oder Date: 01/04/2025. Start Date: 01/05/2025. The eMAR (electronic medication administration record) for R76 dated January 2025 revealed the physician's orders as stated above. Further review of the eMAR revealed blanks on 01/12/2025 for the medications listed above. The facility's nursing progress notes and eMAR notes for R76 dated 01/12/2025 through 01/13/2025 failed to evidence documentation regarding the blanks on 01/12/2025 for the medications listed above. Review of the facility's Omnicell (3) inventory sheet documented the medications Furosemide, Gabapentin, Lorazepam, Losartan Potassium, Metoprolol, Mirtazapine, Oxycodone, Sertraline, and Tamsulosin were available in the Omnicell cabinets. On 02/05/2025 at approximately 12:23 p.m., an interview was conducted with LPN (licensed practical nurse) #4, unit manager. When asked how it is evidenced that medication was administered to a resident, she stated the nurse's initials and a check mark for the date and time on the eMAR. LPN #4 also stated if a medication is not available in the nurse's medication cart, the nurse should check the Omnicell and if it is in the Omnicell or if it is part of the facility's stock of medications it should be administered to the resident. LPN #4 stated if the medication is not available in either the facility stock or the Omnicell, the pharmacy should be notified. On 02/05/2025 at approximately 2:30 p.m., an interview was conducted with ASM (administrative staff member) #2, director of nursing regarding R76's medications. After reviewing the medications from the POS listed above ASM #2 stated the Aspirin, Lidocaine External Patch and Tylenol were facility stock, stored in her office and available to the nurse. When asked about access to her office when she is not in the building, ASM #2 stated the nursing has a key to access the office to obtain the medications. On 02/05/2025 at approximately 1:35 p.m., ASM (administrative staff member) #1, administrator, ASM #2, director of nursing, ASM #3, regional director of clinical services, ASM #4, director of clinical reimbursement, and ASM # 5regional director of operations, were made aware of the above findings. No further information was provided prior to exit. References: (1) An enlarged prostate. This information was obtained from the website: https://www.nlm.nih.gov/medlineplus/enlargedprostatebph.html. (2) A common type of heart disease. This information was obtained from the website: https://www.nlm.nih.gov/medlineplus/coronaryarterydisease.html. (3) automated dispensing cabinets for medications and supplies in hospitals and other healthcare facilities. This technology employs the use of storage units that operate somewhat like vending machines for the medical products, but also have sophisticated software on the back-end that handles patient orders, medication dosing documentation, inventory management, and billing transactions. This information was obtained from the website: https://healthcareitskills.com/automated-dispensing-cabinets-pharmacy-automation/

Based on observation, resident interview, staff interview, facility document review, and clinical record review, the facility staff failed to provide ADL (activities of daily living) care for five of 48 residents in the survey sample, Residents #147, #132, #62, #104, and #70. The findings include: 1. For Resident #147 (R147), the facility staff failed to dress the resident in clothes. R147 was admitted to the facility on [DATE]. On the most recent MDS (minimum data set), an admission assessment with an ARD (assessment reference date) of 1/22/25, the resident scored 2 out of 15 on the BIMS (brief interview for mental status), indicating the resident was severely cognitively impaired for making daily decisions. On 2/3/25 at 11:54 a.m. and 3:48 p.m., R147 was observed sitting in the day room. The resident was dressed in a gown and slipper socks. On 2/4/25 at 1:01 p.m., R147 was observed lying in bed. The resident was dressed in a gown. On 2/4/25 at 3:02 p.m., an interview was conducted with CNA (certified nursing assistant) #3 (the CNA caring for R147). CNA #3 stated residents should be dressed in clothes every day, even if the residents are in their room or in bed. CNA #3 stated R147 did not have clothes so he dressed the resident in a clean gown. CNA #3 stated he was not sure if anyone had attempted to obtain clothes for R147. On 2/4/25 at 3:51 p.m., an interview was conducted with LPN (licensed practical nurse) #4. LPN #4 stated R147 recently transferred to her floor from another unit, she was not sure why the resident did not have clothes, and she planned on discussing this with the resident's son. LPN #4 stated that generally when a resident does not have clothes, the staff try to obtain donated clothes. On 2/4/25 at 4:45 p.m., ASM (administrative staff member) #1 (the administrator) and ASM #2 (the director of nursing) were made aware of the above concern. The facility policy titled, Activities of Daily Living (ADLs) documented, Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene. No further information was presented prior to exit. 2. For Resident #132 (R132), the facility staff failed to dress the resident in clothes. R132 was admitted to the facility on [DATE]. On the most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 11/30/24, the resident scored 0 out of 15 on the BIMS (brief interview for mental status), indicating the resident was severely cognitively impaired for making daily decisions. On 2/3/25 at 12:02 p.m., R132 was observed sitting in the hall. The resident was dressed in a gown and slipper socks. On 2/3/25 at 3:48 p.m., R132 was observed sitting in the day room. The resident was dressed in a gown and slipper socks. On 2/4/25 at 1:01 p.m., R132 was observed lying in bed. The resident was dressed in a gown. On 2/4/25 at 3:02 p.m., an interview was conducted with CNA (certified nursing assistant) #3 (the CNA caring for R132). CNA #3 stated residents should be dressed in clothes every day, even if the residents are in their room or in bed. CNA #3 stated R132 did not have clothes so he dressed the resident in a clean gown. CNA #3 stated he was not sure if anyone had attempted to obtain clothes for R132. On 2/4/25 at 3:51 p.m., an interview was conducted with LPN (licensed practical nurse) #4. LPN #4 stated she has tried to reach out to R132's sister but she never returns her calls. LPN #4 stated that generally when a resident does not have clothes, the staff try to obtain donated clothes. On 2/4/25 at 4:45 p.m., ASM (administrative staff member) #1 (the administrator) and ASM #2 (the director of nursing) were made aware of the above concern. No further information was presented prior to exit. 4. For Resident #104 (R104), the facility staff failed to assist him to transfer from bed to chair, failed to assist him with a haircut and shaving, and failed to maintain his fingernails in a clean and trimmed manner. On the most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 11/24/24, R104 was coded as being cognitively intact for making daily decisions, having scored 15 out of 15 on the BIMS (brief interview for mental status). He was coded as requiring the extensive assistance of staff for grooming and personal care, and for transferring from bed to chair. On the following dates and times, R104 was observed sitting up in bed: 2/3/25 at 12:53 p.m. and 4:01 p.m., 2/4/25 at 9:38 a.m., and 2/5/25 at 10:17 a.m. At all observations, R104's fingernails were approximately two to three centimeters beyond his finger tips, and many of his fingernails had dark material underneath them. R104's hair was long and thin, extending to just below his chin. The resident's beard was grown out to approximately five inches below his chin. R104 stated the staff never offers to get him out of bed, and that he would like to get up each day he feels up to it. He stated sometimes he asks the staff to get him up; sometimes they do it and sometimes they do not. He stated he is accustomed to having short hair and to having his beard trimmed very short. He reported that the staff have told him there is no one to shave him or cut his hair currently working at the facility. He stated he is unable to trim his own fingernails, and staff have never cleaned or trimmed his fingernails. A review of R104's orders, progress notes, and care plan revealed no evidence that the resident refused ADL (activities of daily living) care. On 2/5/25 at 8:53 a.m., CNA (certified nursing assistant) #6 was interviewed. She stated she is familiar with the care of R104. She stated the aides provide fingernail care each time they give the resident a bed bath. She stated: We give him a bed bath all the time; we put cream on his back every day and every night. She stated the resident does not like to get out bed, but added she has not asked him recently if he would like to get out of bed. She stated she does not know who is responsible for cutting his hair or for assisting him to shave. On 2/5/25 at 1:40 p.m., ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing, ASM #3, the regional director of clinical operations, and ASM #5, the regional director of operations, were informed of these concerns. No additional information was provided prior to exit. 5. For Resident #70 (R70), the facility staff failed to get the resident out of bed at any point during the survey. On the most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 12/24/24, R70 was coded as being moderately cognitively impaired for making daily decisions. She was coded as requiring the extensive assistance of staff for transferring from bed to chair. On the following dates and times, R70 was observed to be sitting up in her bed: 2/3/25 at 12:48 p.m. and 3:49 p.m.; 2/4/25 at 9:37 a.m.; and 2/5/25 at 10:47 a.m. On 2/5/25 at 8:53 a.m., CNA (certified nursing assistant) #6 was interviewed. She stated she is familiar with the care of R70. She stated she has never offered or attempted to get R70 out of her bed. She stated: I don't know why she stays in bed. I have only seen her in the wheelchair a few times. On 2/5/25 at 1:40 p.m., ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing, ASM #3, the regional director of clinical operations, and ASM #5, the regional director of operations, were informed of these concerns. No additional information was provided prior to exit. 3. The facility staff failed to provide ADL (activities of daily living) specifically fingernail care for a dependent resident, R62. Observations of nails 3/4 inch long on both hands, and left foot nails 1/2 inch thick and curled over top of toes on 02/03/25 11:45 AM and 02/04/25 09:15 AM. R62 was admitted to the facility on [DATE] with diagnosis that included but were not limited to CVA (cerebrovascular accident) with hemiparesis/hemiplegia, diabetes mellitus and osteomyelitis. The most recent MDS (minimum data set) assessment, a quarterly assessment, with an ARD (assessment reference date) of 1/4/25, coded the resident as scoring a 11 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was moderately cognitively impaired. A review of the MDS Section GG-functional abilities and goals coded the resident as requiring maximal assistance for mobility/transfers/bathing/dressing and set-up for eating. A review of the comprehensive care plan dated 11/4/24 revealed, FOCUS: The resident has an ADL self-care performance deficit. INTERVENTIONS: Physical assist as needed. The ADL record does not evidence fingernail care. An interview was conducted on 2/3/25 at 11:45 AM with R62. When asked about his fingernails, R62 stated, they need trimming bad, they are so long. I have bit them down to get them this short. My toenails are long also. An interview was conducted on 2/4/25 at 8:45 AM with CNA (certified nursing assistant) #1. When asked the process for cutting a resident's nails, CNA #1 stated, we tell the nurse and they are put on the podiatrist list, we are not to cut the nails. An interview was conducted on 2/4/25 at 9:20 AM with RN (registered nurse) #2. When asked the process for getting a resident's nails cut, RN #2 stated, we put them on the podiatrist list for the feet and we can cut their fingernails. When asked how often the podiatrist visits, RN #2 stated, they come monthly, but we do not know the day. When asked to look at R62's finger and toenails, RN #2 stated, yes, they need cut. I will put him on the list for the podiatrist and after I give them meds and he finished his breakfast; I will cut his fingernails. When asked if his nails looked like they were cut a month ago, RN #2 stated no. R62 stated, these are good now, I bit them down to this length. On 2/4/25 at 4:30 PM, ASM (administrative staff member) #1, the administrator, ASM #2, the DON (director of nursing) ASM #3, the regional director of clinical operations, ASM #4, the regional director of clinical reimbursement and ASM #5, the regional director of operations was made aware of the findings. No further information was provided prior to exit.

7. For R76, facility staff failed to follow the comprehensive care plan for the administration of Gabapentin (for pain), Oxycodone (for pain), Lidocaine External Patch (for pain) and Tylenol (for pain), Lorazepam (for anxiety), Mirtazapine (for depression) and Sertraline (for depression). R76 was admitted with diagnoses that included but were not limited to depression, anxiety and muscle weakness. On the most recent MDS (minimum data set), an admission assessment with an ARD (assessment reference date) of 01/10/2025, R76 scored 8 (eight) out of 15 on the BIMS (brief interview for mental status), indicating R76 was moderately impaired of cognition for making daily decisions. The POS (physician's order sheet) for R76 dated 02/05/2025 documented in part, Gabapentin Oral Capsule 100 MG (milligrams) (Gabapentin) Give 2 capsule by mouth two times a day for NEUROPATHIC PAIN. Oder Date: 01/04/2025. Start Date: 01/04/2025. Lidocaine External Patch 4 % (Lidocaine) Apply to LOWER BACK topically one time a day for PAIN MANAGEMENT and remove per schedule. Oder Date: 01/04/2025. Start Date: 01/05/2025. Lorazepam Oral Tablet 1 (one) MG (Lorazepam) Give 1 mg by mouth every 24 hours as needed for ANXIETY for 3 Week. Oder Date: 01/04/2025. Start Date: 01/05/2025. Mirtazapine Oral Tablet 15 MG (Mirtazapine) Give 15 mg by mouth one time a day for DEPRESSION. Oder Date: 01/04/2025. Start Date: 01/05/2025. Oxycodone HCl (hydrochloride) Oral Tablet 5 MG (Oxycodone HCl) Give 5 mg by mouth one time a day for PAIN MANAGEMENT. Oder Date: 01/04/2025. Start Date: 01/05/2025. Sertraline HCl Oral Tablet 100 MG (Sertraline HCl) Give 100 mg by mouth one time a day for DEPRESSION. Oder Date: 01/04/2025. Start Date: 01/05/2025. Tylenol Extra Strength Oral Tablet 500 MG (Acetaminophen) Give 500 mg by mouth two times a day for PAIN MANAGEMENT Do not exceed > 3 (three) gram per day. Oder Date: 01/04/2025. Start Date: 01/05/2025. The eMAR (electronic medication administration record) for R76 dated January 2025 revealed the physician's orders as stated above. Further review of the eMAR revealed blanks on 01/12/2025 for the medications listed above. The facility's nursing progress notes and eMAR notes for R76 dated 01/12/2025 through 01/13/2025 failed to evidence documentation regarding the blanks on 01/12/2025 for the medications listed above. The comprehensive care plan for R76 dated 01/05/2025 documented in part, Focus. The resident has a risk for pain or pain related to a recent fall and depression. Date Initiated: 01/06/2025 Revision on: 01/06/2025. Under Interventions it documented in part, Administer medication as ordered Date Initiated: 01/06/2025. Focus. The resident is at risk for complications related to psychoactive (antidepressant, anxiolytic or hypnotic) medications use secondary to diagnoses of: depressive disorder, insomnia Date Initiated: 01/09/2025. Under Interventions it documented in part, Administer medications as ordered. Date Initiated: 01/09/2025. On 02/04/2025 at 9:05 a.m., an interview was conducted with LPN (licensed practical nurse) #2. When asked the purpose of the care plan, LPN #2 stated, it is to set the goals and interventions for each resident, so it is individualized for them. When asked if the care plan has interventions based on physician orders that are not followed, has the care plan been implemented and followed, LPN #2 stated, no, it is not being followed. On 02/05/2025 at approximately 1:35 p.m., ASM (administrative staff member) #1, administrator, ASM #2, director of nursing, ASM #3, regional director of clinical services, ASM #4, director of clinical reimbursement, and ASM # 5regional director of operations, were made aware of the above findings. No further information was provided prior to exit. Based on observations, staff/resident interviews, facility document review and clinical record review, it was determined the facility staff failed to develop and/or implement the care plan for seven of 48 residents in the survey sample, R47, R46, R130, R23, R59, R62 and R76. The findings include: 1. The facility staff failed to develop the comprehensive care plan for genital warts for R47. R47 was admitted to the facility on [DATE] with diagnosis that included but were not limited to CVA (cerebrovascular accident) with hemiparesis/hemiplegia, diabetes mellitus and epilepsy. The most recent MDS (minimum data set) assessment, a quarterly assessment, with an ARD (assessment reference date) of 11/8/24, coded the resident as scoring a 10 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was moderately cognitively impaired. A review of the MDS Section GG-functional abilities and goals coded the resident as requiring maximal assistance for mobility/transfers/bathing/dressing and set-up for eating. A review of the comprehensive care plan dated 8/13/24 revealed, FOCUS: Urinary & bowel incontinence related to Impaired Mobility, Physical Limitations due to Left hemiparesis/Hemiplegia secondary to CVA & Dementia. INTERVENTIONS: Provide incontinent care as needed. Report changes in skin integrity found during daily care. There was no evidence that a care plan was developed for genital warts. A review of the physician's order dated 10/7/24 revealed, Imiquimod External Cream 5 % (Imiquimod) Apply to genital warts topically at bedtime every Mon, Wed, Fri for genital warts for 16 Weeks Apply to penis/scrotum topically every evening shifts every Mon, Wed, Fri for genital warts apply a thin layer 3 times/week prior to bedtime leave on for 10 hours then remove with mild soap and water. On 2/4/25 at 3:30 PM, an interview was conducted with LPN (licensed practical nurse) #4, the unit manager. When asked if a care plan should be developed for genital warts, LPN #4 stated, yes, there should be a care plan. On 2/5/25 at 1:30 PM, ASM (administrative staff member) #1, the administrator, ASM #2, the DON (director of nursing) ASM #3, the regional director of clinical operations, ASM #4, the regional director of clinical reimbursement and ASM #5, the regional director of operations was made aware of the findings. A review of the facility's Care Plans-Comprehensive Person Centered policy revealed, Each resident's comprehensive care plan will describe the following: services that are to be furnished to attain or maintain the resident's highest practicable, physical, mental and psychosocial well-being. The comprehensive care plan will incorporate identified problem areas and incorporate risk factors associated with identified problems. No further information was provided prior to exit. 2. The facility staff failed to develop the comprehensive care plan for PTSD (post-traumatic stress disorder) for R46. R46 was admitted to the facility on [DATE] with diagnosis that included but were not limited to PTSD (post-traumatic stress disorder), viral hepatitis and pulmonary fibrosis. The most recent MDS (minimum data set) assessment, a quarterly assessment, with an ARD (assessment reference date) of 12/1/24, coded the resident as scoring a 13 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was not cognitively impaired. A review of the MDS Section GG-functional abilities and goals coded the resident as requiring maximal assistance for mobility/transfers/bathing/dressing and set-up for eating. Section I: Active Diagnosis (dated 8/31/24) I6100. Post Traumatic Stress Disorder (PTSD)-coded as yes. A review of the comprehensive care plan dated 6/12/24 revealed, FOCUS: At risk for adverse effects related to use of antianxiety and antidepressant medication. INTERVENTIONS: Report to physician signs of adverse reaction such as decline in mental status, decline in positioning/ambulation ability, lethargy, complaints of dizziness, tremors. Psych consult and follow up as needed. There was no evidence that a care plan was developed for PTSD. A review of the physician's order dated 4/8/24 revealed, Psych consult. On 2/4/25 at 8:30 AM, an interview was conducted with R46. When asked what care and services are provided for her regarding PTSD, R46 stated, there is a psychologist that I see. When asked if social services visits with her to discuss PTSD and her triggers, R46 stated, they do not know my triggers as they have never asked me. When asked her triggers, R46 stated, seeing anything violent, even on television and sometimes loud noises. I get migraines then. On 2/4/25 at 3:30 PM, an interview was conducted with LPN (licensed practical nurse) #4, the unit manager. When asked if a care plan should be developed for PTSD, LPN #4 stated, yes, there should be a care plan. On 2/5/25 at 1:30 PM, ASM (administrative staff member) #1, the administrator, ASM #2, the DON (director of nursing) ASM #3, the regional director of clinical operations, ASM #4, the regional director of clinical reimbursement and ASM #5, the regional director of operations was made aware of the findings. A review of the facility's Care Plans-Comprehensive Person Centered policy revealed, Each resident's comprehensive care plan will describe the following: services that are to be furnished to attain or maintain the resident's highest practicable, physical, mental and psychosocial well-being. The comprehensive care plan will incorporate identified problem areas and incorporate risk factors associated with identified problems. No further information was provided prior to exit. 3. The facility staff failed to develop the comprehensive care plan for anticoagulation monitoring for R130. R130 was admitted to the facility on [DATE] with diagnosis that included but were not limited to pulmonary embolism, spondylosis and cord compression. The most recent MDS (minimum data set) assessment, a quarterly assessment, with an ARD (assessment reference date) of 1/7/25, coded the resident as scoring a 15 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was not cognitively impaired. A review of the MDS Section GG-functional abilities and goals coded the resident as requiring maximal assistance for mobility/transfers/bathing/dressing and set-up for eating. A review of the comprehensive care plan dated 1/24/25 revealed, FOCUS: CARDIAC: the resident is at risk for cardiac complications secondary to atrial fibrillation. INTERVENTIONS: Administer medications as ordered. Observe for signs and symptoms of cardiac complications. Care plan does not evidence any Anticoagulation information until after end of day on 2/4/25. A review of the physician's order dated 6/30/24 revealed, Rivaroxaban Oral Tablet 20 MG (Rivaroxaban) Give 20 mg by mouth one time a day for A fib take with dinner. On 2/3/25 at 2:30 PM, an interview was conducted with R130. When asked monitoring is provided for his anticoagulation, R130 asked what do you mean. When asked if staff ask him about bruising or bleeding or assess his arms, R130 stated, no, not that I know of. On 2/4/25 at 3:30 PM, an interview was conducted with LPN (licensed practical nurse) #4, the unit manager. When asked if a care plan should be developed for anticoagulation, LPN #4 stated, yes, there should be a care plan. On 2/5/25 at 1:30 PM, ASM (administrative staff member) #1, the administrator, ASM #2, the DON (director of nursing) ASM #3, the regional director of clinical operations, ASM #4, the regional director of clinical reimbursement and ASM #5, the regional director of operations was made aware of the findings. No further information was provided prior to exit. 4. The facility staff failed to implement the comprehensive care plan for oxygen therapy for R23. R23 was admitted to the facility on [DATE] with diagnosis that included but were not limited to CHF (congestive heart failure), osteoarthritis and CVA (cerebrovascular accident). The most recent MDS (minimum data set) assessment, an annual assessment, with an ARD (assessment reference date) of 11/13/24, coded the resident as scoring a 10 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was moderately cognitively impaired. A review of the MDS Section GG-functional abilities and goals coded the resident as requiring maximal assistance for mobility/transfers/bathing/dressing and set-up for eating. Section O: oxygen: yes. A review of the comprehensive care plan dated 11/29/24 revealed, FOCUS: Has/At risk for respiratory impairment related to SOB due to OSA (obstructive sleep apnea) & chronic respiratory failure with hypoxia, cough. CHF. INTERVENTIONS: Administer oxygen as per physician order: Via nasal cannula for shortness of breath related to CHF. A review of the physician's order dated 11/16/21 revealed, O2 via nasal cannula at 2 liters per minute every shift. Observed R23's oxygen setting at 4 liters nasal cannula (lnc) on 02/03/25 at 11:33 AM, 02/03/25 at 3:33 and 02/04/25 at 08:30 AM. An interview was conducted on 2/4/25 at 9:05 AM with LPN (licensed practical nurse) #2. When asked to verify R23's oxygen order, LPN #2 stated, she is to be on 2 lnc. When asked to come to the room and verify setting, LPN #2 stated, she is on 4-5 lnc. I will adjust it. When asked where you would read the oxygen setting, LPN #2 stated, you would read it with the line in the middle of the ball. An interview was conducted on 2/4/25 at 9:05 AM with LPN (licensed practical nurse) #2. When asked the purpose of the care plan, LPN #2 stated, it is to set the goals and interventions for each resident, so it is individualized for them. When asked if the care plan has interventions based on physician orders that are not followed, has the care plan been implemented and followed, LPN #2 stated, no, it is not being followed. When asked if the oxygen was at 4 lnc but ordered for 2lnc and care plan was oxygen as ordered, was the care plan being followed, LPN #2 stated, no, it was not being followed. On 2/5/25 at 1:30 PM, ASM (administrative staff member) #1, the administrator, ASM #2, the DON (director of nursing) ASM #3, the regional director of clinical operations, ASM #4, the regional director of clinical reimbursement and ASM #5, the regional director of operations was made aware of the findings. No further information was provided prior to exit. 5. The facility staff failed to implement the comprehensive care plan for communication with dialysis facility for R59. R59 was admitted to the facility on [DATE] with diagnosis that included but were not limited to ESRD (end stage renal disease), CHF (congestive heart failure) and diabetes mellitus. The most recent MDS (minimum data set) assessment, a quarterly assessment, with an ARD (assessment reference date) of 11/28/24, coded the resident as scoring a 11 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was moderately cognitively impaired. A review of the MDS Section GG-functional abilities and goals coded the resident as requiring moderate assistance for mobility/transfers/bathing/dressing and set-up for eating. A review of the comprehensive care plan dated 9/5/24 revealed, FOCUS: Renal insufficiencies related to chronic renal failure. INTERVENTIONS: Confer with physician and/or dialysis treatment center regarding changes in medication administration times/dosage pre-dialysis as needed. A review of the physician's order dated 2/17/22 revealed, Transportation to dialysis center - (Tue/Thu/Sat) at 9:58 AM Hemodialysis. Check AV fistula site thrill/bruit LUE one time a day for AV fistula site thrill/bruit check. Requested dialysis communication sheets 11/1/24 to 2/4/25. Dialysis communication sheets evidenced were on following dates: Communication sheets evidenced for 11/14/24, 12/12, 12/17/12/19/12/21, 12/24, 12/31, 1/7, 1/9, 1/11, 1/16, 1/18, 1/21, 1/23, 1/25, 1/28, 1/30, 2/1, 2/4. No other sheets were found. An interview was conducted on 2/4/25 at 9:05 AM with LPN (licensed practical nurse) #2. When asked the purpose of the care plan, LPN #2 stated, it is to set the goals and interventions for each resident, so it is individualized for them. When asked if the care plan has interventions based on physician orders that are not followed, has the care plan been implemented and followed, LPN #2 stated, no, it is not being followed. 02/05/25 11:21 AM ASM #3 stated, we do not have the missing dialysis sheets. On 2/5/25 at 1:30 PM, ASM (administrative staff member) #1, the administrator, ASM #2, the DON (director of nursing) ASM #3, the regional director of clinical operations, ASM #4, the regional director of clinical reimbursement and ASM #5, the regional director of operations was made aware of the findings. No further information was provided prior to exit. 6. The facility staff failed to implement the comprehensive care plan for ADL (fingernail and toenail) care for R62. R62 was admitted to the facility on [DATE] with diagnosis that included but were not limited to CVA (cerebrovascular accident) with hemiparesis/hemiplegia, diabetes mellitus and osteomyelitis. The most recent MDS (minimum data set) assessment, a quarterly assessment, with an ARD (assessment reference date) of 1/4/25, coded the resident as scoring a 11 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was moderately cognitively impaired. A review of the MDS Section GG-functional abilities and goals coded the resident as requiring maximal assistance for mobility/transfers/bathing/dressing and set-up for eating. A review of the comprehensive care plan dated 11/4/24 revealed, FOCUS: The resident has an ADL self-care performance deficit. INTERVENTIONS: Physical assist as needed. Observations of nails 3/4 inch long on both hands, and left foot nails 1/2 inch thick and curled over top of toes on 02/03/25 11:45 AM and 02/04/25 09:15 AM. An interview was conducted on 2/3/25 at 11:45 AM with R62. When asked about his fingernails, R62 stated, they need trimming bad, they are so long. I have bit them down to get them this short. My toenails are long also. An interview was conducted on 2/4/25 at 9:05 AM with LPN (licensed practical nurse) #2. When asked the purpose of the care plan, LPN #2 stated, it is to set the goals and interventions for each resident, so it is individualized for them. When asked if the care plan has interventions based on physician orders that are not followed, has the care plan been implemented and followed, LPN #2 stated, no, it is not being followed. On 2/5/25 at 1:30 PM, ASM (administrative staff member) #1, the administrator, ASM #2, the DON (director of nursing) ASM #3, the regional director of clinical operations, ASM #4, the regional director of clinical reimbursement and ASM #5, the regional director of operations was made aware of the findings. No further information was provided prior to exit.

Based on observation, resident interview, staff interview and clinical record review and facility document review, the facility staff failed to accommodate resident's needs for three of 48 residents in the survey sample, Residents #121, (R121), R144, R99 and R72. provide accommodations of resident needs by ensuring the call bell was within reach The findings include: 1. For R121, the facility staff failed to keep the call bell (a device with a button that can be pushed to alert staff when assistance is needed) within reach. R121 was admitted to the facility with a diagnosis that included by not limited to muscle weakness. On the most recent comprehensive MDS (minimum data set), an admission assessment with an ARD (assessment reference date) of 01/01/2025, R121 scored 7 (seven) out of 15 on the BIMS (brief interview for mental status), indicating R121 was moderately impaired of cognition for making daily decisions. On 02/03/25 at approximately 11:59 a.m., an observation revealed R121's call bell was placed inside the top drawer of the bedside table. When asked to locate and activate the call bell R121 stated he was unable to locate it. On 02/03/25 at approximately 2:31p.m., an observation revealed R121's call bell was placed inside the top drawer of the bedside table. When asked to locate and activate the call bell R121 stated he was unable to locate it. On 02/03/25 at approximately 4:25 p.m., an observation revealed R121's call bell was placed inside the top drawer of the bedside table. When asked to locate and activate the call bell R121 stated he was unable to locate it. On 02/04/2025 an interview was conducted with CNA (certified nursing assistant) #5 about the placement of a resident's call bell. She stated the call bell should always be placed within reach of the resident. When how often the call bell placement should be checked CNA #5 stated it should be checked each time someone goes into the resident's room. The facility's policy Answering the Call Light documented in part, General Guidelines - 5. When the resident is in bed or confined to a chair be sure the call light is within easy reach of the resident. On 02/04/2025 at approximately 4:35 p.m., ASM (administrative staff member) #1, administrator, ASM #2, director of nursing, ASM #3, regional director of clinical services, ASM #4, director of clinical reimbursement, and ASM # 5regional director of operations, were made aware of the above findings. No further information was provided prior to exit. 2. For R144, facility staff failed to provide a communication aide to effectively express needs and wants. R144 was admitted to the facility with a diagnosis that included by not limited to anxiety (fear). On the most recent MDS (minimum data set) assessment, an admission assessment, with an ARD (assessment reference date) of 01/07/2025, R144 was coded as having both short and long term memory difficulties and was coded as being severely impaired of cognition for making daily decisions. Under section GG Functional Abilities - Admission R144 was coded as being dependent, requiring the assistance of two staff members for toileting hygiene, showering/bathing, lower body dressing and putting on/off footwear. R144 was coded as requiring maximal assistance with oral hygiene, upper body dressing and personal hygiene including combing hair, applying makeup, washing/drying face and hands. On 02/03/25 at approximately 4:04 p.m., an observation during the initial screening of R144 revealed R144 was unable to speak English and did not understand simple yes/no questions. Further observations of R144's room failed to evidence a communication aid. On 02/05/2025 at approximately 9:27 a.m., an interview was conducted with CNA (certified nursing assistant) #8. When asked about R144's language she stated that she thought R144 spoke Arabic. When asked if she could speak Arabic to R144 CNA #8 stated no. When asked how she communicates to meet the daily needs and/or wants of R144, CNA #8 stated R144's son translates using Video Chat on R144's cell phone. CNA #8 further stated it was not the most effective or efficient way to communicate with R144. On 02/05/2025 at approximately 9:35 a.m., a video chat was conducted with R144's son. He stated he had concerns about the language barrier between orrR144 and the facility staff. When asked about R144's primary language he stated it was a Moroccan dialect. The son further stated he had concerns about R144 using the bathroom by herself and being unable to communicate her needs. The facility's policy Translation and/or Interpretation Of Facility Services documented in part, POLICY: The organization is committed to offering a language access program to ensure that individuals with limited English proficiency (LEP) will have meaningful access to information and services provided by the facility. On 02/04/2025 at approximately 4:35 p.m., ASM (administrative staff member) #1, administrator, ASM #2, director of nursing, ASM #3, regional director of clinical services, ASM #4, director of clinical reimbursement, and ASM # 5regional director of operations, were made aware of the above findings. No further information was provided prior to exit. 3. For R99, facility staff failed to provide a communication aide to effectively express needs and wants. R99 was admitted to the facility with a diagnosis that included by not limited to muscle weakness. On the most recent MDS (minimum data set) assessment, an admission assessment, with an ARD (assessment reference date) of 12/23/2024, R99 was coded as having both short and long term memory difficulties and was coded as being severely impaired of cognition for making On 02/03/25 at approximately 12:57 p.m., an observation during the initial screening of 99 revealed R99 was unable to speak English and did not understand simple yes/no questions. Further observations of R99's room failed to evidence a communication aid. On 02/04/2025 at approximately 3:00 p.m., an interview was conducted with CNA (certified nursing assistant) #5 regarding R99's ability to communicate her needs and/or wants effectively. CNA #5 stated she was usually assigned to R99. When asked if R99 spoke English, she stated no and R99 spoke Spanish. When asked if she spoke or understood Spanish CNA #5 stated no. When asked about communicating with R99 she stated R99's roommate would translate at times, R99 would use some gestures. When asked if R99 used a communication aid CNA #5 stated she was not aware of any communication device or system for R99 and offered to look in R99's room for a communication aid. After looking in R99's room, CNA #5 stated she was unable to find a communication aid for R99. On 02/04/2025 at approximately 4:35 p.m., ASM (administrative staff member) #1, administrator, ASM #2, director of nursing, ASM #3, regional director of clinical services, ASM #4, director of clinical reimbursement, and ASM # 5regional director of operations, were made aware of the above findings. No further information was provided prior to exit. 4. For Resident #4 (R4), the facility staff failed to provide laboratory services at a time of the resident's preference. On 2/3/24 at 12:11 p.m., R4 was interviewed. He stated he was concerned that staff came to draw blood at all hours of the night, and added that this usually occurred between 2:00 a.m. and 4:00 a.m. He stated it startled him to be awakened at this time, and interrupted his sleep in such a manner that he could not get back to sleep. He stated he would prefer blood to be drawn during the day or afternoon when he was already awake. On 2/4/25 at 1:48 a.m., OSM (other staff member) #13, a contract phlebotomist, was observed entering the facility and obtaining a cart with phlebotomy supplies from behind a nurses' desk. She stated: I'm here to draw labs. OSM #13 stated she comes to the facility Monday through Friday at about this time. She stated she understands that it might not be a desirable time for residents, and stated she would not want to be awakened at 2:00 a.m. to have her blood drawn, but she has no control over her schedule. She stated she cannot worry about that part because this is her job. On 2/4/25 at 4:36 p.m., ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing, ASM #3, the regional director of clinical operations, ASM #4, the regional clinical reimbursement director, and ASM #5, the regional director of operations, were informed of these concerns. These staff members agreed that they would not want to be awakened in the middle of the night to have their blood drawn. No additional information was provided prior to exit.

3. For Resident #147 (R147), the facility staff failed to dress the resident in clothes prior to the resident sitting in a common area. R147 was admitted to the facility on [DATE]. On the most recent MDS (minimum data set), an admission assessment with an ARD (assessment reference date) of 1/22/25, the resident scored 2 out of 15 on the BIMS (brief interview for mental status), indicating the resident was severely cognitively impaired for making daily decisions. On 2/3/25 at 11:54 a.m. and 3:48 p.m., R147 was observed sitting in the day room. The resident was dressed in a gown and slipper socks. On 2/4/25 at 3:02 p.m., an interview was conducted with CNA (certified nursing assistant) #3 (the CNA caring for R147). CNA #3 stated residents should be dressed in clothes every day. CNA #3 stated R147 did not have clothes so he dressed the resident in a clean gown. CNA #3 stated he would not feel too good if he was dressed in a gown while in the hall or day room because he was not dressed like other people. On 2/4/25 at 4:45 p.m., ASM (administrative staff member) #1 (the administrator) and ASM #2 (the director of nursing) were made aware of the above concern. No further information was presented prior to exit. 4. For Resident #132 (R132), the facility staff failed to dress the resident in clothes prior to the resident sitting in common areas. R132 was admitted to the facility on [DATE]. On the most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 11/30/24, the resident scored 0 out of 15 on the BIMS (brief interview for mental status), indicating the resident was severely cognitively impaired for making daily decisions. On 2/3/25 at 12:02 p.m., R132 was observed sitting in the hall. The resident was dressed in a gown and slipper socks. On 2/3/25 at 3:48 p.m., R132 was observed sitting in the day room. The resident was dressed in a gown and slipper socks. On 2/4/25 at 3:02 p.m., an interview was conducted with CNA (certified nursing assistant) #3 (the CNA caring for R147). CNA #3 stated, Residents should be dressed in clothes every day. CNA #3 stated R147 did not have clothes so he dressed the resident in a clean gown. CNA #3 stated,He would not feel too good if he was dressed in a gown while in the hall or day room because he was not dressed like other people. On 2/4/25 at 4:45 p.m., ASM (administrative staff member) #1 (the administrator) and ASM #2 (the director of nursing) were made aware of the above concern. No further information was presented prior to exit. Based on observation, resident interview, staff interview, facility document review, and clinical record review, the facility staff failed to provide dignity in caring for four of 48 residents in the survey sample, Residents #104, #112, #147, and #132. The findings include: 1. For Resident #104, the facility failed to provide dignity to the resident by keeping his hair cut and his beard groomed. On the most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 11/24/24, R104 was coded as being cognitively intact for making daily decisions, having scored 15 out of 15 on the BIMS (brief interview for mental status). He was coded as requiring the extensive assistance of staff for grooming and personal care. On the following dates and times, R104 was observed sitting up in bed: 2/3/25 at 12:53 p.m. and 4:01 p.m., 2/4/25 at 9:38 a.m., and 2/5/25 at 10:17 a.m. At all observations, R104's hair was long and thin, extending to just below his chin. The resident's beard was grown out to approximately five inches below his chin. He stated he is accustomed to having short hair and to having his beard trimmed very short. He reported that the staff have told him there is no one to shave him or cut his hair currently working at the facility. He stated: I have never had to look this bad in my life. On 2/5/25 at 8:53 a.m., CNA (certified nursing assistant) #6 was interviewed. She stated, I am familiar with the care of R104. She stated she does not know who is responsible for cutting his hair or for assisting him to shave. She stated it would not be dignified care if the resident was accustomed to having short hair and a trimmed beard. On 2/5/25 at 1:40 p.m., ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing, ASM #3, the regional director of clinical operations, and ASM #5, the regional director of operations, were informed of these concerns. A review of the facility policy, Dignity, revealed, in part: Each resident shell be cared for in a manner that promotes and enhances his or her sense of well-being, level of satisfaction with life, and feelings of self-worth and self-esteem .Residents will be treated with dignity and respect at all times .When assisting with care, residents are supported in exercising their rights. For example, residents are groomed as they wish to be groomed (hair styles, nails, facial hair, etc.). No additional information was provided prior to exit. 2. For Resident #112 (R112), the facility staff failed to provide dignity when they delayed answering a call bell on 2/4/25. On 2/5/25 at 1:16 a.m., CNA (certified nursing assistant) #10 was observed sleeping in the first floor dining/activity room. On 2/5/25 at 1:48 a.m., observation revealed R112 had activated her call light. At this time, CNA #10 was still sleeping in the first floor dining/activity room, and four other staff members were observed sitting behind the nurses' desk closest to R112's room. LPN (licensed practical nurse) #7, the charge nurse, was asked if any staff members were currently on dinner break. She stated dinner breaks had not yet started, and no staff was on break. At 1:56 a.m., CNA #10 emerged from the dining/activity room and sat behind the nurses' desk with the other staff members. Between 1:48 a.m. and 2:08 a.m., while R112's call bell continued to ring, between four and five staff members were behind the nurses' desk at all times. Some looked at their phones, while one nurse worked on the computer. At 2:08 a.m., CNA #10 got up from her chair behind the nurses' desk and went in to answer R112's call bell. On 2/5/25 at 9:54 a.m., LPN (licensed practical nurse) #6, a unit manager, was interviewed. He stated it was unacceptable for a staff member to sleep while on duty, and stated R112's call bell should have been answered by anyone in the immediate area once the bell rang initially. He stated that a delay in answering a call bell can be seen as a matter of dignity. On 2/5/25 at 1:40 p.m., ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing, ASM #3, the regional director of clinical operations, and ASM #5, the regional director of operations, were informed of these concerns. No additional information was provided prior to exit.

Based on staff interview, clinical record review, and facility document review, the facility staff failed to provide required notification to the ombudsman following resident discharge for four of 48 residents in the survey sample, Residents #74, #104, #26, and #62. The findings include: 1. For Resident #74 (R74), the facility staff failed to notify the ombudsman in writing of the resident's discharge to the hospital on [DATE]. A review of R74's clinical record revealed he was discharged to the hospital on [DATE]. Further review of his record failed to reveal evidence that the ombudsman was notified in writing of the resident's discharge. On 2/5/25 at 10:36 a.m., OSM #10, the director of social services, was interviewed. She stated she thought she had faxed a written notification to the ombudsman of R74's discharge, but she had not retained any records to evidence this. She stated: I don't have it. I haven't kept a notebook as I should have. On 2/5/25 at 1:40 p.m., ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing, ASM #3, the regional director of clinical operations, and ASM #5, the regional director of operations, were informed of these concerns. A review of the policy, Facility Initiated Transfer, revealed, in part: The facility will consistently deploy systems to identify resident needs and preferences .The facility will send a copy of the [discharge] notice to a representative of the Office of the State Long-Term Care Ombudsman. No additional information was provided prior to exit. 2. For Resident #104 (R104), the facility staff failed to notify the ombudsman in writing of the resident's discharge to the hospital on [DATE]. A review of R104's clinical record revealed he was discharged to the hospital on [DATE]. Further review of his record failed to reveal evidence that the ombudsman was notified in writing of the resident's discharge. On 2/5/25 at 10:36 a.m., OSM #10, the director of social services, was interviewed. She stated she thought she had faxed a written notification to the ombudsman of R104's discharge, but she had not retained any records to evidence this. She stated: I don't have it. I haven't kept a notebook as I should have. On 2/5/25 at 1:40 p.m., ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing, ASM #3, the regional director of clinical operations, and ASM #5, the regional director of operations, were informed of these concerns. No additional information was provided prior to exit. 3. For Resident #26 (R26), the facility staff failed to notify the ombudsman in writing of the resident's discharge to the hospital on [DATE]. A review of R26's clinical record revealed he was discharged to the hospital on [DATE]. Further review of his record failed to reveal evidence that the ombudsman was notified in writing of the resident's discharge. On 2/5/25 at 10:36 a.m., OSM #10, the director of social services, was interviewed. She stated she thought she had faxed a written notification to the ombudsman of R26's discharge, but she had not retained any records to evidence this. She stated: I don't have it. I haven't kept a notebook as I should have. On 2/5/25 at 1:40 p.m., ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing, ASM #3, the regional director of clinical operations, and ASM #5, the regional director of operations, were informed of these concerns. No additional information was provided prior to exit. 4. The facility staff failed to evidence provision of required written ombudsman notification at the time of discharge for R62. R62 was transferred to the hospital on [DATE] and 11/28/24. R62 was admitted to the facility on [DATE] with diagnosis that included but were not limited to CVA (cerebrovascular accident) with hemiparesis/hemiplegia, diabetes mellitus and osteomyelitis. The most recent MDS (minimum data set) assessment, a quarterly assessment, with an ARD (assessment reference date) of 1/4/25, coded the resident as scoring a 11 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was moderately cognitively impaired. A review of the MDS Section GG-functional abilities and goals coded the resident as requiring maximal assistance for mobility/transfers/bathing/dressing and set-up for eating. A review of the comprehensive care plan dated 11/4/24 revealed, FOCUS: The resident has an ADL self-care performance deficit. INTERVENTIONS: Physical assist as needed. On 2/5/25 at 10:35 AM, an interview was conducted with OSM (other staff member) #10, the director of social services. When asked about the ombudsman notification for R62, OSM #10 stated, the ombudsman has been called and I am trying to get confirmation from them. There is a fax receipt of the transfers/discharges that are sent monthly to the ombudsman but I have not been keeping them in a notebook. I am changing that process now. When asked how long she had been in the role, OSM #10 stated, one year. On 2/5/25 at 1:30 PM, ASM (administrative staff member) #1, the administrator, ASM #2, the DON (director of nursing) ASM #3, the regional director of clinical operations, ASM #4, the regional director of clinical reimbursement and ASM #5, the regional director of operations was made aware of the findings. No further information was provided prior to exit.

Based on resident and staff interview, clinical record review and facility document review, it was determined the facility staff failed to provide dialysis care and services for one of 48 residents in the survey sample, R59. The findings include: The facility failed to provide evidence of communication with dialysis facility for R59. R59 was admitted to the facility on [DATE] with diagnosis that included but were not limited to ESRD (end stage renal disease), CHF (congestive heart failure) and diabetes mellitus. The most recent MDS (minimum data set) assessment, a quarterly assessment, with an ARD (assessment reference date) of 11/28/24, coded the resident as scoring a 11 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was moderately cognitively impaired. A review of the MDS Section GG-functional abilities and goals coded the resident as requiring moderate assistance for mobility/transfers/bathing/dressing and set-up for eating. A review of the comprehensive care plan dated 9/5/24 revealed, FOCUS: Renal insufficiencies related to chronic renal failure. INTERVENTIONS: Confer with physician and/or dialysis treatment center regarding changes in medication administration times/dosage pre-dialysis as needed. A review of the physician's order dated 2/17/22 revealed, Transportation to dialysis center - (Tue/Thu/Sat) at 9:58 AM Hemodialysis. Check AV fistula site thrill/bruit LUE one time a day for AV fistula site thrill/bruit check. Facility to dialysis center communication sheets evidenced for 11/14/24, 12/12, 12/17/12/19/12/21, 12/24, 12/31, 1/7, 1/9, 1/11, 1/16, 1/18, 1/21, 1/23, 1/25, 1/28, 1/30, 2/1, 2/4. The remaining sheets for 11/1/24-2/4/25 were missing. On 2/4/25 at 8:10 AM an interview was conducted with R59, when asked if his dialysis communication book contains communication for each dialysis visit, R59 stated, not sure what they put in there, if there are forms for every treatment or not. On 2/05/25 at 11:21 AM, ASM #3, the regional director of clinical operations stated, we do not have the missing dialysis sheets. On 2/5/25 at 1:30 PM, ASM (administrative staff member) #1, the administrator, ASM #2, the DON (director of nursing) ASM #3, the regional director of clinical operations, ASM #4, the regional director of clinical reimbursement and ASM #5, the regional director of operations was made aware of the findings. A review of the facility's End Stage Renal Disease-Care of Resident policy, reveals, Agreements between the facility and the contracted ESRD facility will include all aspects of how the resident's care will be managed including but not limited to the communication process between the nursing facility and the dialysis center that will reflect ongoing communication, coordination and collaboration. No further information was provided prior to exit.

Based on staff interview, clinical record review and facility document review, it was determined the facility staff failed to provide evidence of the frequency of physician visits at least every 60 days for two of 48 residents in the survey sample, R59 and R46. The findings include: 1. R59 was admitted to the facility on [DATE] with diagnosis that included but were not limited to ESRD (end stage renal disease), CHF (congestive heart failure) and diabetes mellitus. The most recent MDS (minimum data set) assessment, a quarterly assessment, with an ARD (assessment reference date) of 11/28/24, coded the resident as scoring a 11 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was moderately cognitively impaired. A review of the MDS Section GG-functional abilities and goals coded the resident as requiring moderate assistance for mobility/transfers/bathing/dressing and set-up for eating. A review of the comprehensive care plan dated 9/5/24 revealed, FOCUS: Renal insufficiencies related to chronic renal failure. INTERVENTIONS: Confer with physician and/or dialysis treatment center regarding changes in medication administration times/dosage pre-dialysis as needed. R59 was transferred to the hospital on 3/14/24 and readmitted to the facility on [DATE]. There is no evidence of either nurse practitioner or physician notes from 6/5/24 to 2/4/25. On 2/5/25 at 11:50 AM, ASM #3, the regional director of clinical operations, stated, we do not have any evidence of nurse practitioner or physician visits from 6/5/24 to 2/4/25 for R59. On 2/5/25 at 1:30 PM, ASM (administrative staff member) #1, the administrator, ASM #2, the DON (director of nursing) ASM #3, the regional director of clinical operations, ASM #4, the regional director of clinical reimbursement and ASM #5, the regional director of operations was made aware of the findings. A review of the facility's Attending Physician Responsibilities policy which reveals, The Attending Physicians shall be the primary practitioners responsible for providing medical services and coordinating the healthcare of each resident in the facility. The Attending Physician will visit residents in a timely fashion, consistent with applicable state and federal requirements, and depending on the individual's medical stability, recent and previous medical history, and the presence of medical conditions or problems that cannot be handled readily by phone. The visit schedule will be at least every 30 days for the first 90 days after admission, and then at least every 60 days thereafter. No further information was provided prior to exit. 2. R46 was admitted to the facility on [DATE] with diagnosis that included but were not limited to PTSD (post-traumatic stress disorder), viral hepatitis and pulmonary fibrosis. The most recent MDS (minimum data set) assessment, a quarterly assessment, with an ARD (assessment reference date) of 12/1/24, coded the resident as scoring a 13 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was not cognitively impaired. A review of the MDS Section GG-functional abilities and goals coded the resident as requiring maximal assistance for mobility/transfers/bathing/dressing and set-up for eating. Section I: Active Diagnosis (dated 8/31/24) I6100. Post Traumatic Stress Disorder (PTSD)-coded as yes. A review of the comprehensive care plan dated 6/12/24 revealed, FOCUS: At risk for adverse effects related to use of antianxiety and antidepressant medication. INTERVENTIONS: Report to physician signs of adverse reaction such as decline in mental status, decline in positioning/ambulation ability, lethargy, complaints of dizziness, tremors. Psych consult and follow up as needed. There is no evidence of either nurse practitioner or physician notes from 6/19/24 to 12/8/24. On 2/5/25 at 11:50 AM, ASM #3, the regional director of clinical operations, stated, we do not have any evidence of nurse practitioner or physician visits from 6/19/24 to 12/8/24 for R46. On 2/5/25 at 1:30 PM, ASM (administrative staff member) #1, the administrator, ASM #2, the DON (director of nursing) ASM #3, the regional director of clinical operations, ASM #4, the regional director of clinical reimbursement and ASM #5, the regional director of operations was made aware of the findings. No further information was provided prior to exit.

Based on observation, resident interview, staff interview, facility document review and clinical record review the facility staff failed to ensure 2 (two) of 7 (seven) residents with impaired swallowing function were provided a therapeutic diet as prescribed by the physician, (Residents' #11 and #18). This constituted an Immediate Jeopardy situation. 1. Resident # 11 had a physician's order for nectar thickened liquids. The resident was observed drinking non thickened water with ice through a straw and coughing after each intake of water. This constituted an Immediate Jeopardy situation. 2. Resident #18 had a physician's order for nectar thickened liquids. The resident was provided a carton of skim milk which was not thickened to the physician's ordered consistency. This constituted an Immediate Jeopardy situation. The findings included: 1. Resident # 11 was an [AGE] year old gentleman that was admitted to the facility on [DATE] with a readmission on 06/10/10 with [DIAGNOSES REDACTED]. The most recent MDS (minimum data set) assessment, a Medicare 14 day assessment, with an ARD (assessment reference date) of 06/20/10 coded the resident as having no short or long term memory problems. Resident # 11 was coded as being capable of making daily decisions without difficulty. The resident was coded as requiring extensive assistance of one to two staff members for his activities of daily living. Resident # 11 was coded in section K1 of the MDS as having swallowing problems. The resident was coded for extensive assistance of two staff members for movement in the bed and transfers from one surface to another surface. The MDS coded that the resident did not walk in the room or corridor during the look back period. The resident was coded as continent of bowel and occasionally incontinent of urine. Resident # 11 was observed on 06/28/10 at 6:25 p.m. The resident was sitting in bed with the head of the bed elevated. The resident's dinner tray was in front of the resident on the over the bed table. The resident had in his right hand a 12 ounce Styrofoam cup with a lid and straw on it. The cup had written on it, 06/28/10 7-3 (7:00 a.m. to 3:00 p.m. shift). The resident was observed drinking the contents of the cup. The resident drank from the straw three times. With each drink the resident was observed coughing. The gentleman in the bed next to him (Resident # 27) stated, "He's not supposed to have water like that". When asked who gave him the water, Resident # 27 could not identify the staff, other than stating, "One of the aides must have given it to him by mistake". Resident # 27 was coded on the most recent MDS with an ARD date of 6/10/10, as having no short or long term memory problems. Resident # 27 was coded as having no difficulty making daily decisions. An interview was conducted with CNA (certified nursing assistant) # 8 on 06/28/10 at 6:28 p.m. CNA # 8 was asked if Resident # 11 was on thickened liquids. CNA # 8 stated, "Yes, he's on nectar thick liquids". CNA # 8 and the surveyor went to the resident's room. When the CNA observed the resident drinking out of the white Styrofoam cup she immediately took the cup from the resident. The lid of the cup was opened and revealed the contents of the cup to be water with ice cubes. The cup was approximately half full. When asked how the resident obtained the cup of ice water, CNA # 8 stated, "I gave the roommate a water cup but didn't give any to (Resident #11)." An interview was conducted with LPN (licensed practical nurse) # 1 on 06/28/10 at 6:42 p.m. When asked if Resident # 11 was on thickened liquids, LPN # 1 stated, "Yes, he's on nectar thick". When asked how the resident received liquids, LPN # 1 stated, "He gets the thickened liquids on his tray and we leave him some at his bedside". LPN # 1 stated, "He can have ice chips also". When asked how the staff gives the resident ice chips, LPN # 1 stated, "We give him a small cup with ice chips and a spoon". When asked how the resident got a cup with ice water and a straw, LPN # 1 stated, "I don't know, I'm not sure". At 6:47 p.m. on 06/28/10, CNA # 8 was asked if she had passed ice and water for the shift. CNA # 8 stated, "I passed water to the roommate but not to him". When asked if she had heard the resident cough, CNA # 8 stated, "No". Review of the clinical record was conducted. The record revealed a "Telephone Order - Diet/Tube Feeding" that was dated, 06/22/10 and signed by the physician on 06/24/10 that documented, "Mechanical soft diet, nectar like thick liquids". A telephone order written on 06/24/10 at 3:20 p.m. by the speech therapist documented, "Ice chips on request". Review of the physician progress notes [REDACTED]. Barron ' s Dictionary of Medical Terms for the Non Medical Reader. 5th edition, 2006, page178): mechanical soft, nectar thickened liquids". A review of the speech therapist "Eating & Swallowing Evaluation" dated 06/14/10 was conducted. The form documented under the heading of "Symptoms: Cough after swallow, Wet vocal Quality, Throat Clearing". There was a check mark in the column next to these symptoms. The column instructed the therapist to "check if present". The checked documented "Treatment approaches" were, "Dysphagia treatment". "Diet Recommendation: Solids - Mechanical soft; Liquids - nectar-like". Review of the comprehensive care plan initiated on 06/24/10 and revised on 06/28/10 documented, "Altered nutrition r/t (related to) s/p (status [REDACTED]..chewing and/or swallowing difficulties". The approaches documented, "Diet/snacks as ordered; Altered liquids as ordered; may have ice chips per family request with supervision". Review of the facility policy on Thickened Liquids documented, "Description: Thickened liquids compensate for swallowing disorders and allow patients to safely enjoy a variety of beverages". The policy documented under the "Guidelines for use: The thickened beverages to be served with meals are included on the tray ticket. Thickened liquids are also provided at times other than meals. These include but are not limited to the following: Thickened water and or beverages may be provided to patients with morning afternoon and bedtime nourishments or supplements. This gives patients access to fluids at bedside and replaces the need for a water pitcher. Beverages at bedside are changed at least every eight hours". Review of the facility policy on "Water Pitcher Delivery" documented, "Guidelines: Have nurse supervisor identify: patients with specific orders or requests, patients with fluid restrictions, hydration needs, NPO (nothing by mouth), tube feedings, thickened liquids, I & 0 (intake and output), no ice. If patient is on thickened liquids or other fluid restrictions, check with licensed nurse and provide thickened water or other liquid per type or amount as ordered by physician". The survey team met at approximately 7:00 p.m. on 06/28/10 to discuss the concern for at risk residents. The team notified the LTC (long term care) supervisor at approximately 7:04 p.m. on 06/28/10 of concerns of residents being at risk for harm related to ingesting the incorrect fluid consistency per physician orders. The LTC supervisor notified the team at 7:55 p.m. that the facility was in Immediate Jeopardy and substandard quality of care due to the potential danger to at risk residents. The facility Administrator was notified of the Immediate Jeopardy at approximately 8:05 p.m. on 06/28/10. At approximately 9:45 p.m., on 6/28/10, the facility Administrator presented the survey team with a "Plan of Removal/Plan of Correction (POC)." The facility POC documented the following 5 points: Corrective Action for resident cited: The melted ice chips were immediately removed for room of resident identified. A respiratory assessment was completed on resident to identify any abnormal respiratory signs by the licensed nurse and physician, the family was notified. Resident's orders for ice chips were clarified with the physician to include administration only under staff supervision. A speech therapy consult was obtained to identify the resident's continued need for thickened liquids. The resident and family were educated on the risk associated with the use of ice chips and drinking non-thickened liquids. Identification of Like Residents: Facility rounds were completed on residents with orders for thickened liquids to validate that there were no thin liquids at bedside. Patient information sheets were reviewed and revised if needed to reflect the correct type of liquids to be administered to residents. Systematic Change: Staff were educated on the use of thickened liquids and identification system for patients that have orders for thickened liquids. Ongoing education will continue for staff before they start their next shift. Ongoing Monitoring: The ADNS or DCD will round on units daily x 4 weeks then weekly x 3 months to validate no thin liquids are left at the bedside of those who are to receive only thickened liquids. Any staff found to be non-compliant will be re-educated. Findings of rounds will be submitted to the QAA committee to identify trends or the need for further education or systematic changes. An interview was conducted on 06/29/10 at 7:55 a.m. with the Director of Nursing (DON). The DON was asked what the expectations of a nurse are with a resident on thickened liquids and receiving ice chips. The DON stated, "(Name of Resident # 11) is the only resident currently on thickened liquids that can have ice chips". The DON was asked how she would expect the staff to give the resident ice chips. The DON stated, "Ice chips should be placed in a small cup with a spoon. They should be spoon fed to the resident". A policy for the administration of ice chips was requested at this time. The DON stated that there is no policy for the administration of "ice chips". An interview was conducted with OSM (other staff member) # 12 on 06/29/10 at 9:10 a.m. OSM # 12 was asked to describe her evaluation of Resident # 11 on 06/29/10. OSM # 12 stated, "I saw him yesterday. He was very confused. He was refusing to eat unless he got a coke. He can't have coke because it can't be thickened correctly. I tried him on water yesterday but he still needed much prompting to do a chin tuck. His coughing was better with even a slight chin tuck. His eating is okay with even a slight chin tuck . When asked what the plan would be, OSM # 12 stated, "I want to start him on the Frazier Water Protocol* with water only, no other thinned liquids". When asked when and how the water was to be given to the resident, OSM # 12 stated, "It can only be given between meals and with supervision. I will use a Provale **cup with him. It limits the amount of water that the person receives each time the cup is lifted to the mouth". * Frazier Water Protocol: Per Swallowing and Swallowing Disorders, 2006 "For patients on oral diets, water is permitted between meals. Water intake is unrestricted prior to a meal and allowed 30 minutes after meal." This information was obtained from the web site: www.slpnetwork.org. ** Provale Cup: made by the Reliant Medical Products. The package insert was reviewed and documented, "Instructions for use: The Provale cup will deliver the specified amount of liquid, either 5 cc (cubic centimeters) or 10 cc with every normal drinking motion. The patented 'anti-suck' feature prevents over-delivery of the liquid when the Provale cup is used properly. The Provale cup must be returned to an upright position after each drinking motion to meter the next dose of liquid". Interviews were conducted with CNA # 4 and LPN # 13 on 06/29/10 between 10:35 a.m. and 10:50 a.m. They were interviewed regarding any in-service education they received on 06/29/10. Both the CNA and LPN stated that they were in-serviced on the policy regarding thickened liquids. CNA # 4 stated, "No handouts were given we were just talked to". An interview was conducted with the DON on 06/29/10 at 10:43 a.m. The DON was asked what information was taught in the in-service educations. The DON stated, "We used the written policy for thickened liquids as the in-service teaching tool". 2. Resident #18 was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. The most current minimum data set (MDS) was a 14-day Medicare assessment which coded Resident #18 as having no long or short term memory loss, and as being able to make her own independent daily life decisions. Resident #18 required extensive assistance from staff for the performance of activities of daily living and was coded as needing set-up and supervision for eating. On 6/29/10 at 8:15 a.m., during the medication pass observation, the surveyor observed Resident # 18 in bed with the head of the bed elevated. Her breakfast tray was on the overbed table in front of her with the meal prepared ready for her to eat. At that time, it was observed by the surveyor that the resident's tray contained a small container of nectar thickened orange juice, nectar thickened water, and a container of "Dairy Thick" nectar thickened milk product. The surveyor observed that there was also a carton of fat-free skim milk on the tray which was opened with a straw placed in the container for the resident to drink. After obtaining permission from the resident, the surveyor picked up the container of the fat-free skim milk and observed that it was of regular consistency (thin) not of nectar consistency. The diet card which was on the tray documented the resident's name (Resident #18) and "Nectar thick liquids". At 8:55 a.m. on 6/29/10, the surveyor accompanied Registered Nurse (RN) # 2 into Resident #18's room and inquired as to why there was fat-free skim milk which was unthickened on the resident's tray. RN #2 stated, "Oh no! She is not supposed to have that. It says it right here on the diet sheet. She is supposed to have thickened liquids. She is not supposed to have this." The surveyor inquired as to how the milk was delivered to the resident on her tray. RN #2 stated, "Dietary does not put the milk on the tray. The CNA (certified nursing assistant) must have done that." The surveyor then asked to speak to the CNA who delivered the tray to Resident #18. RN #2 left the room and returned with CNA # 13. CNA #13 stated, "She is not supposed to have that (thin milk)." When asked how the milk got onto the tray, CNA #13 stated, "I must have done that." On 6/29/10 at 9:00 a.m., the facility Administrator was informed of the finding and stated, "Let me check with the director of nursing about the audits." On 6/29/10 at 9:30 a.m. the facility Administrative/Corporate staff #'s 1, 2, 3, and #4 were notified of the observations and findings. The survey team explained to the facility administration that according to the observation made at 8:55 a.m., the facility remained in Immediate Jeopardy and an immediate plan of removal was requested. At that time, the facility administrative staff was also notified that the facility remained in substandard quality of care. On 6/29/10 at 9:44 a.m., the surveyor was presented with a list of staff who had been inserviced regarding the prior plan of removal for the events of 6/28/10. The surveyor noted that CNA #13 was the 26th person on the sign-in list as having been inserviced regarding the thickened liquids and the prior plan of removal on 6/29/10 for "day'' shift. No times were listed for the inservice. At that time, the facility Administrative/Corporate staff # 3 was notified of this finding. The clinical record for Resident #18 was reviewed and revealed a physician's order dated 6/18/10 for "Change diet to mechanical soft/nectar (liquid consistency)..." Further review of the clinical record revealed a "Eating & Swallowing Evaluation" dated 6/18/10 which documented, "Pt (patient) presents with (arrow pointing downward meaning decreased) [MEDICATION NAME] manipulation, delayed initiation of swallow, (circle with a plus sign meaning positive) oral stasis, (circle with a plus sign meaning positive) cough, and (circle with a plus sign meaning positive) throat clear /c (with) thin liquids...mild/moderate oral dysphagia with (arrow pointing downward meaning decreased) ROM (range of motion), strength, (arrow pointing downward meaning decreased) vocal quality, delayed swallow...Safety concerns: Aspiration...Short term goals: mechanical soft/nectar..." Another document "Physician Orders Speech-Language Pathology" dated 6/18/10 documented, "Diet consistency recommendations: Mechanical soft nectar-like liquids...Precautions: Aspiration." The "Care Plan" dated 6/2/10 with an undated hand-written revision documented, "Nectar" under the section for "Altered Nutrition." On 6/29/10 at 12:15 p.m., the facility Administrator presented an "Amended Plan of Removal" to the survey team. Review of this "Plan of Removal" evidenced the following: Corrective Action for resident cited: The melted ice chips were immediately removed from the room of resident identified. A respiratory assessment was completed on resident to identify any abnormal respiratory signs by the licensed nurse and physician, the family was notified. Resident's orders for ice chips were clarified with the physician to include administration only under staff supervision. A speech therapy consult was obtained to identify the resident's continued need for thickened liquids. The resident and family were educated on the risk associated with the use of ice chips and drinking non-thickened liquids. The resident with milk on her tray had the milk immediately removed, she did not consume any of this milk, stating that she is aware that she is on thickened liquids and knows that she is not to take any. The Certified Nursing Assistant responsible for placing the milk on the tray was educated on 6/28/10, re-educated on 6/29/10 and suspended pending further investigation of her actions. Identification of like Residents: Facility rounds were completed on residents with orders for thickened liquids to validate that there were no thin liquids at bedside. Patient information sheets were reviewed and revised if needed to reflect the correct type of liquids to be administered to residents. Facility rounds were completed the morning of 6/29/10 during breakfast and again after the identification of milk on the tray to validate that no other residents were affected. Systematic Change: Staff were educated on the use of thickened liquids and identification system for patients that have orders for thickened liquids. Ongoing education will continue for staff before they start their next shift. Staff were re-educated on thickened liquids and the identification of patients that have orders. Ongoing Monitoring: The ADNS or DCD will round on units daily x4 weeks then weekly x3 months to validate no thin liquids are left at the bedside of those who are to receive only thickened liquids. Any staff found to be non-compliant will be re-educated. Findings of rounds will be submitted to the QAA committee to identify trends or the need for further education or systematic changes. Prior to serving trays of patients on thickened liquids, the contents of the tray will be reviewed by a licensed nurse of interdisciplinary team member to validate that the appropriate consistency of liquid is on the tray, this will occur daily for 2 weeks, weekly for 2 weeks, then monthly for two months. Findings will be reported to the QAA committee for trending and identification of further education and or systematic change. This "Amended Plan or Removal" was tentatively accepted by the survey team pending further observation and validation due to the observation of the survey team that the facility was still non-compliant after presentation of the first plan of removal. The survey team observed the delivery of meal trays and hydration rounds from 6/29/10 through 6/30/10 during this time, the following was evidenced: On 6/30/10 at 7:40 a.m., staff were observed distributing breakfast trays for the residents. Special attention was given to observation of residents on thickened liquids by the survey team. Staff were observed to be carrying a list of residents who had physician's orders for thickened liquids and before trays were taken into the resident's rooms, a licensed nurse or department head was observed verifying the tray contents. At 7:50 a.m., Certified Nursing Assistant (CNA) # 2 stated, "We have a list of resident's who are on thickened liquids. We are to check the tray carefully, and are not to take the tray into the room until the nurse checks it." CNA # 1 stated, "The nurse has to verify the tray before it can be taken into the room. We have a list of all residents who get thickened liquids and we must be sure to go by that list. It has to be checked and verified." The survey team was provided a list of residents who were receiving thickened liquids and observed these residents to ensure the correct diet was being followed per the physician's orders. The survey team observed the residents to be receiving the prescribed diet and liquids as ordered by the physician. These observations were conducted on 6/29/10 at 11:30 a.m., 2:10 p.m., 4:45 p.m., and on 6/30/10 at 7:30 a.m. and 9:00 a.m. These observations were made during meals and hydration rounds. On 6/30/10 at 9:40 a.m., the survey team again met with the facility administrative/corporate staff #1, 2, 3, 4, and 5. The "Plan of Removal" was discussed along with the removal of the Immediate Jeopardy. At that time the Immediate Jeopardy situation was lifted by the survey team.