Every finding on record at Fountain Hills Post Acute

Based on interviews, review of clinical record, and review of facility policy and procedure, the facility failed to ensure medication was acquired, received, and administered according to physician orders for one of three sampled residents (#2). The deficient practice could result in a resident not receiving medication as ordered by the physician.-Findings include:Resident #2 was admitted to the facility on [DATE], with diagnoses of secondary malignant neoplasm of the brain, malignant melanoma of skin, cognitive, social, or emotional deficit following nontraumatic intracerebral hemorrhage, visual disturbance, headache, chronic obstructive pulmonary disease, and a personal history of other venous thrombosis and embolism.A discharging hospital progress note dated March 27, 2026, for Resident #2 revealed that the assessment and plan for his brain metastasis included the resident being started on dexamethasone (corticosteroid medication).A physician's order dated March 28, 2026, included for dexamethasone tablet 2 mg, to give 1 tablet by mouth two times a day for cancer, with the first dose scheduled at 8:00 a.m., and the second dose scheduled at 10:00 p.m.A Medication Administration Record (MAR) for April 2026 revealed Resident #2 was administered dexamethasone 2 mg tablet at 8:00 a.m. on April 5, however was not administered the evening dose scheduled at 10:00 p.m. on April 5, and also did not receive the morning dose scheduled at 8:00 a.m. on April 6. The record included 7 on the missed dose administration times, which was coded for other / see nurse notes.An e-MAR (electronic Medication Administration Record) note dated April 5, 2026, revealed dexamethasone was not administered due to not available. There was no evidence that the physician was notified of the missed medication dose or that a pharmacy refill order was placed for the out-of-stock medication.Another e-MAR note dated April 6, 2026, revealed that dexamethasone was not administered due to pending delivery. There was no evidence that the physician was notified of the missed dose.An electronic pharmacy medication order log revealed that dexamethasone 2 mg tablets were ordered from the pharmacy on admission on [DATE], and again on April 6, 2026. There was no evidence of any other refill order for dexamethasone placed.A telephonic interview was conducted with Resident #2's family member on May 29, 2026, at 8:27 a.m., who stated that she was aware that Resident #2 had missed his scheduled steroid medication because the facility ran out of the medication, and that the medication was important because it controlled the swelling in his brain due to the brain tumor.An interview with a Registered Nurse / charge nurse (RN / Staff #12) was conducted on May 29, 2026, at 2:09 p.m., who stated that floor nurses notice when medications are running low in stock and re-order the medications through a contracted pharmacy by calling the pharmacy, faxing the re-order, or placing the re-order directly through the electronic medical record system. The RN stated the contracted pharmacy completes 3 medication runs per day, and can do an additional 4th run if needed. The RN stated that if a resident missed a dose of medication that was ordered by a physician, then that could have a negative impact on the resident's health. The RN stated that if a resident missed a dose of medication due to the dose being out of stock, then the nurse would be expected to notify the provider of the missed dose to keep the provider informed and to determine if the provider recommended a substitute medication to administer. The RN stated that the notification to the provider and any action recommended by the provider should be documented in the resident's medical record.A telephonic interview was conducted with a pharmacy technician from the facility's contracted pharmacy (Staff #70) on May 29, 2026, at 2:56 p.m., who stated that the pharmacy stocked dexamethasone 2 mg tablets. The staff then reviewed records and stated that there was no evidence that the dexamethasone 2 mg tablet was out of stock at any time during April 2026.An interview was conducted on May 29, 2026, at 3:18 p.m. with the Director of Nursing (DON / Staff #24), who stated that her expectation was for floor nurses to administer medications according to physician orders, to ensure the ordered dose matched the medication card in the cart, and to give the medication within an hour before or after the scheduled time. Additionally, the DON stated it was important for floor nurses to follow the facility policy to order medication refills from the pharmacy 3 days prior to running out of the medication so that the medication was available to the resident and no doses would be missed. The DON stated that a missed dose could impact a resident's health, depending on the medication and the indication for treatment. The DON stated that the facility's contracted pharmacy completed 3 medication delivery runs per weekday, 2 scheduled medication runs on Saturday, and one medication run on Sunday, and could perform an additional run if requested. The DON stated that her expectation if a resident's medication dose was missed was for the floor nurse to notify the provider, and to determine if the medication could be refilled from the contracted pharmacy or another local pharmacy, and for the nurse to follow the provider's recommendation either to place the medication on hold, or to give a substitute medication. The DON stated that the nurse's action, along with the provider's recommendation, should have been documented in the medical record. The DON also stated that there could be a risk to the resident, depending on the medication, if the provider was not notified of a missed medication dose.During the interview with the DON (Staff #24), the clinical record for Resident #2 was reviewed and the DON stated that the dexamethasone medication was ordered as a taper, and there were three administration routes scheduled, with the third administration route indicating one tablet twice a day, at 8:00 a.m. and 10:00 p.m. The DON stated that the third order administration route was indefinite with no end date indicated, and was scheduled to start on April 5, 2026, at 8:00 AM. The DON reviewed the MAR for April 2026, and stated that the morning dose on April 5 was administered, however, the evening dose on April 5 and the morning dose on April 6 were not administered. The DON reviewed the progress notes and stated that the nurse documented that the medication was not available due to running out of the medication on the evening of April 5, and that the nurse documented that the dose was missed on the morning of April 6, due to waiting on pharmacy delivery. The DON stated there was no evidence that the provider was notified in either instance. The DON stated that it would not meet her expectation of refilling the medication, nor of communication with the provider, and that the medication should have been there to administer.Review of a written statement by the DON (Staff #24), dated May 29, 2026, revealed the facility had no official policy on refilling medication prescriptions, however, nurses were requested to reorder the medication from the pharmacy 3 days before the last dose of medication.Review of the facility policy titled Medication Administration - Oral, dated September 2024, revealed that it was the policy of the facility to accurately prepare, administer, and document oral medications.Review of the facility policy titled Medication Access and Storage, E-kit Access, dated September 2024, revealed that the provider pharmacy would dispense medication in containers that met legal requirements, and that medications were kept and stored in these containers. The policy further revealed that only licensed nurses, the consultant pharmacist, and those lawfully authorized to administer medications are allowed to access medications.Review of the facility policy titled Physician Orders, dated September 2024, revealed that drugs should be administered only upon the order of a person duly licensed and authorized to prescribe such drugs, and that orders would be implemented accurately.Review of federal regulation CFR S483.45 revealed that the facility must provide routine and emergency drugs and biologicals to its residents, or obtain them under an agreement described in S 483.70(f). A facility must provide pharmaceutical services (including procedures that assure the accurate acquisition, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident.

Based on clinical record review, resident and staff interviews, hospital records, facility documentation, policies and procedures, the facility failed to ensure physician-ordered diets were followed and implemented for 2 of 10 sampled residents (#9 and #12). This deficient practice resulted in resident #9 choking and requiring hospitalization.Findings include:Regarding Resident #9-Resident #9 was admitted on [DATE], with a diagnosis of heart failure, chronic atrial fibrillation, hypertensive heart and chronic kidney disease, with heart failure and chronic kidney disease, and moderate vascular dementia with anxiety. The Order Summary Report revealed an active physician order dated December 23, 2024, which prescribed a regular diet, regular texture, thin liquids consistency, cut into bite-sized pieces/large protein portions. No food allergies/no isolation. Further review of the Order Summary Report revealed no active order for speech therapy evaluation or treatment. A nutrition care plan, which was initiated on December 30, 2024, revealed that the resident was at risk for malnutrition. Interventions indicated to provide and serve the diet as ordered and specified, a regular diet with large protein portions. However, the care plan did not reflect that the resident required his food to be cut up into bite-sized pieces per the physician's order. A SLP (Speech-Language Pathologist) Evaluation and Plan of Treatment note dated January 9, 2025, documented that treatment approaches may include speech/hearing therapy, evaluation of speech sound production, and language assessment. Per the note, the resident would benefit from skilled speech therapy services to enhance cognitive abilities and develop compensatory strategies for executive functions. A cognition care plan revised on January 11, 2026, revealed that the resident was at risk for impaired cognitive function or impaired thought processes related to diagnoses of dementia. Interventions indicated to communicate with family/caregivers regarding the resident's capabilities and needs. Review of a NP/PA (nurse practitioner/physician assistant) Progress Note dated March 26, 2026, documented a plan for physical therapy (PT), occupational therapy (OT), and speech therapy (ST) evaluation and treatment. However, review of the resident's Order Summary Report revealed no orders for PT/OT/ST evaluation or treatment. A care plan revised on March 31, 2026, revealed that the client has an ADL (activities of daily living) self-care deficit performance related to congestive heart failure. The goal identified was for the resident to safely perform ADLs such as eating through the review date of April 2, 2026. Review of the nutritional quarterly evaluation dated March 31, 2026, indicated a regular diet order and specified cut into bite-sized pieces/large protein portions. Fluid consistency was marked as thin. The assessment identified the resident's dining ability as able to feeds self with a tray set-up. A quarterly MDS (minimum data set) assessment dated [DATE], revealed a brief interview for mental status (BIMS) score of 10, indicating the resident had moderate cognitive impairment with no indicators for mood or behaviors. Further review of the MDS revealed the resident had upper extremity impairment on both sides and required set-up or clean-up assistance with eating. The assessment indicated no identified concerns with swallowing. Per the MDS, the resident had no broken or loosely fitting full or partial dentures, mouth or facial pain, discomfort or difficulty when chewing. Although the MDS indicated no swallowing concerns, the resident had risk factors, including cognitive impairment and physical limitations. The Order Summary Report indicated orders dated April 8, 2026, for the following:- Change of condition for abnormal labs. The order directed to check the resident every shift for 3-days.- Sodium Chloride Solution 0.9%. The order prescribed 125 ml/hr (milliliters per hour) intravenously every shift for dehydration for 2 days x 2 liters. A Nursing note dated April 8, 2026, documented that lab results were reported to the NP and new orders for NS (normal saline) 125cc/hr x 2 liters and BMP (basic metabolic panel) in the morning. Per the note LFA (left femoral artery), PIV (Peripheral Intravenous) was placed, and IVF (intravenous fluids) was administered.A Nursing progress note dated April 11, 2026, documented that at approximately 10:03, the LPN (Licensed Practical Nurse/staff #60) was notified by a CNA (Certified Nursing Assistant) that the resident had possibly aspirated and that the floor nurse was in the room with the resident. Per the note, the resident was observed sitting up in bed with very labored, turbulent rhonchi respirations. The note indicated that the resident was suctioned, and O2 (oxygen) was applied with a non-rebreather. According to the note, the resident was able to open his eyes but was unable to respond or cough when instructed. Per the note, 911 was called. The resident's vitals were 151/92 with an oxygen saturation rate of 90-93% on non-rebreather and 36% when off the rebreather for suctioning, with a pulse of 105, and a respiration rate of 24. The note documented that EMS (emergency medical services) arrived and took residents to the hospital. Another Nursing progress note dated April 11, 2026, documented that when staff #4/LPN went to administer the resident's medication at approximately 9:58 a.m., the LPN found the resident with mooshy food like coming out of his mouth. Per the note, the resident appeared to be sleeping with his food tray in front of him. The note indicated that the LPN called out the resident's name with no response, and help was called. According to the note, food was manually removed from the resident's mouth, and the resident was suctioned. The note indicated that 911 was called. The resident's vitals were 151/92 with a respiration and oxygen saturation rate of 33%. A non-rebreather mask was applied with 25 liters of supplemental oxygen. The resident's oxygen saturation rate increased to 94%, and the resident was sent to the hospital. The Order Summary Report revealed an order dated April 11, 2026, which prescribed an immediate transfer to a higher level of care as required by the resident's urgent medical needs. Emergency Department hospital notes dated April 11, 2026, documented the resident's chief complaint as altered mental status and indicated that the resident was brought in by ambulance. Per the note, the resident was eating eggs with the nurse, the nurse stepped away and came back, and the resident was choking and unresponsive. The resident's Glasgow Coma Scale (GCS) score was 3, indicating deep coma or death. Physical exam revealed temperature 96 degrees Fahrenheit, heart rate 94 beats per minute, blood pressure 119/72, SpO2 (Peripheral Oxygen Saturation) rate of 100% with oxygen device-non-rebreather mask. Physical Exam further revealed GCS 7, indicating severe brain injury or a comatose state. Per the note, during the examination, the resident's eyes were closed; he gave a very weak, mumbled response when his name was called and withdrew in both upper extremities to painful stimulus. The note indicated that eggs were observed on the shirt. Additionally, the resident had shallow and labored respirations, diminished breath sounds at the bases. The note documented that the resident presented as DNR DNI (Do not Resuscitate, Do Not Intubate) status. Per the note, the physician had several follow-up conversations with the resident's daughter about rescinding the DNI, but the daughter decided to keep the DNR/DNI. Diagnosis was documented as aspiration into the airway, respiratory failure with hypoxia and hypercapnia. The note indicated the resident's disposition as deceased . An interview was conducted on April 21, 2026, at 12:44 p.m. with Certified Nursing Assistant (CNA/Staff#24). Staff #24 stated she has been a CNA for more than 20 years. Staff #24 stated she did not provide care to resident #9 on April 11, 2026, and that the resident was under the care of CNA (#6) and CNA (Staff #80). Staff #24 stated that the breakfast meal is served between 8:00 a.m. and 9:00 a.m. Staff #24 stated that when residents are served their meals in bed, they should be positioned at a 90-degree angle. Per the CNA, she checks in on all her assigned residents to ensure they are eating, encourages them to eat their food, ask if they want anything more to drink. Staff #24 said she ensured that the resident had the right food, pureed or not, by reviewing their meal ticket. Staff #24 stated she would inform the nurse of any concerns with chewing their food or any other concerns because she has to chart if her resident ate their food. Staff #24 stated she was aware that resident #9 had choked on his food, but did not observe anything on the date the resident aspirated. An interview was conducted on April 21, 2026, at 1:07 p.m. with sister facility (LPN/staff #4). Staff #4 stated she just picked up a shift on April 11, 2026, for 8:30 a.m.-10:00 p.m. and was assigned to resident #9. Staff #4 stated resident #9 was not on oxygen that day, or had concerns with eating on his own. She stated that the resident was apparently able to eat by himself, he was upright in his bed, tray in front of him, and his food was gone. Staff #4 said she went to give the resident his morning medications at approximately 9:30 a.m. and noticed him in distress. Staff #4 stated that when she arrived at 8:30 a.m., resident #9's breakfast tray was not there, and breakfast came sometime after that. Staff #4 stated that the resident was upright in bed, with a room tray in front of him, and it appeared he had eaten all his food. Staff #4 stated he looked like he was asleep, food was around his chin, and a good amount of food was around his mouth. Staff #4 said the food around his mouth and chin looked like it had been chewed; mushy, but not like he had vomited. Staff #4 stated she called his name, with no response, and that it looked like he was sleeping. She stated she lifted the tray food cover and noticed all his food was gone; his eyes were closed, never opened, and he was grunting and moaning, he was breathing, not labored breathing, and it sounded like he was snoring. Staff #4 stated she went to the dining area right outside of the resident's room and called for his assigned CNA (Staff #6) to ask if this was the resident's baseline or normal. She stated CNA #6 confirmed that it was not how he usually was. Staff #4 stated she was not familiar with the resident and had not worked with him for approximately two years. Staff #4 stated she grabbed the crash cart from the dining room with the suctioning machine and asked CNA #6 to go get the charge nurse (Staff/#60). Staff #4 stated she began to suction the resident's mouth, stating that she was aware the resident was a Do Not Resuscitate (DNR), but needed to suction the food from his mouth. She stated she was able to take as much food as she could as she suctioned him. She stated that not too much food was in his throat and that the food was mostly located in his mouth. She stated that after suctioning, it appeared the resident was breathing a little better. She stated the charge nurse (Staff/#60) arrived to assist and had brought a plunger with her to see if anything else would come out of the resident's chest or throat. She stated Staff #60 called 911 when she entered the resident's room and began to suction and use the plunger apparatus she had brought with her. She stated no more food came out, and when EMS arrived, they continued to suction and could not dislodge any further remnants of food from the resident. She stated EMS placed the resident on oxygen and that his vitals still showed the resident was alive, but his eyes were still closed and not responsive. She stated the resident was transported to the hospital. Staff #4 stated she received a call from the hospital, notifying her that the resident had passed and they could not intubate due to the resident's DNR/DNI wishes. An Interview was conducted on April 21, 2026, at 1:30 pm with (CNA/Staff #6). Staff #6 stated she has been employed with the facility for approximately one year. She stated she was working on April 11, 2026, and was assigned to resident #9. She stated he appeared to be within baseline but had noticed a decline in the last month in terms of energy. The CNA did not indicate whether the decline had been reported to the nurse and stated she was taking back her statement because she is not in the medical field. She stated the resident required assistance to sit in an upright position and required tray set-up assistance. She stated she served him his breakfast that day and provided a tray set-up. She does not remember all the items for breakfast that day, but that he had oatmeal, cranberry juice, and a cut-in-half egg burrito. She stated that she does not know what his diet is, but stated that his meals did not need to be cut up. Per the CNA, she did not cut the burrito for him, and further stated he was not required to have his meal cut up. Staff #6 stated she became aware there was an issue with resident #9 because Staff #4 had asked her what his normal was, then went into the resident's room with the nurse and saw him aspirating. She stated there was food around and, in the resident's mouth, and it looked like the eggs from his burrito, and that the food on the tray was gone, it looked like he had eaten all his food. She stated that staff #4 immediately started to suction the resident and told her it was to help with his aspiration and remove any food stuck in his mouth, and observed food particles come out from the suctioning. Staff #6 stated she went to go get (LPN/Staff #60). She stated that both nurses assisted the resident with suctioning and oxygen needs until EMS arrived. Staff #6 stated she could not recall what time she served the resident his breakfast, but it was around 8:00 a.m. and 9:00 a.m. She stated it was approximately 15-18 minutes between the time she served the resident his meal to the time staff #4 asked about the resident's condition. According to the CNA, she does not review the meal ticket or do anything else to the resident's breakfast. Per the CNA dietary knows the resident's dietary needs, and that the eggs were inside the burrito and the burrito was cut in half for his breakfast. She stated that any changes in a resident's condition, activities of daily living (ADLs), eating, or diet are communicated by the nurse, director of nursing (DON), or care plan. An interview was conducted on April 21, 2026, at 1:56 p.m. with (LPN/Staff #60). Staff #60 stated she has been the charge nurse since 2022. Staff #60 stated she knew resident #9 from being familiar with all the residents' care. She stated resident #9 required quite a bit of assistance recently. Per the LPN, the resident used to get up out of bed on his own, but has had a slow decline since his admission. She was aware of his recent diagnoses, but was unfamiliar with specific recent lab results. She stated his decline did not affect his ability to eat and was able to feed himself with tray set-up assistance. She stated she did not recall any special diets or special instructions. Per the LPN, he would have cut up food, finger foods, and food cut up into small pieces. She stated this was what they did for him, but was not sure that it was recommended. She stated his diet would be in his orders or care plan or under special Instructions on his electronic health record homepage, and in reports from nursing staff regarding the resident's needs. Staff # 60 stated that CNA/staff #6 informed her that she thought resident #9 had aspirated, and LPN/Staff #4 was in the room with the resident. She went to the room and observed Staff #4 actively suctioning the resident. Per Staff #60, she observed some egg on his chest and started oxygenating him. The resident had turbulent breathing with accessory muscles, he would open his eyes to look at her, but could not cough or clear his throat. Per the nurse, this indicated he had aspirated or was choking, but believed it was a partial blockage because he was moving air in and out. Staff suctioned and put him on a non-rebreather, then 911 was called within 2 to 3 minutes. She made the 911 call for possible aspiration. She stated EMS took about 5-10 minutes for them to arrive on scene. She stated both she and the other LPN/Staff#4 used the suction machine and a secondary device (LifeVac) to help remove items in the throat. She stated she had no formal training using the LifeVac Device and had previously used it one other time. She stated she used the device to aid in dislodging more eggs, but that suctioning took most of the egg out. She stated she only noticed egg and mucous secretions coming out. She stated that resident #9 needed his food to be cut up, but that he was eating scrambled eggs. She stated the menu said egg burrito, but either it was cut up or the burrito was taken off because she only saw eggs coming out of the resident's mouth.An interview was conducted on April 21, 2026, at 2:39 p.m. with the Dietary Manager (Staff #34). Staff #34 stated he has been in his role since 2022. Staff #34 stated the process for dietary orders, that he receives dietary notes in the electronic record from nursing, and nursing will provide a slip about a resident's change in nutrition. He stated he is responsible for updating the information, and the new meal ticket will automatically print. Staff #34 stated he was unable to retrieve previous diet slips once a resident was discharged from the facility. Staff #34 stated that any modifications to a resident's diet is relayed to him from nursing, and he will make the changes to the ticket in the system. Staff #34 stated that dietary is responsible for cutting food for the residents, not CNAs. He stated there is a three-part system to ensure the diet order is followed, with the cook who would have the first look, then the cook line member would check the meal for accuracy, then the CNA or nurse. Staff #34 stated finger foods do not need to be cut up, but that bite-sized pieces would also include burritos, and that a resident's food should go to the floor already cut up. The resident Manager stated that the risks of not following the orders on the meal tickets are that the residents will not have what they need or the diet they are supposed to have.An interview was conducted on April 22, 2026, at 9:41 am with a family member of resident #9. Family member stated she has had numerous concerns regarding the facility's care of her father, primarily concerns regarding his food not being cut up. The family member stated that when she visited, she would find his meals were not cut up. The family member stated her father required his food to be cut up due to weakness with his upper body extremities and a decline in his motor skills. The family member stated she hires a companion who would report to her that her father's food was not cut up when served. The family member stated she had filed complaints with the facility and had spoken to Dietary Manager (Staff #34), Charge Nurse (Staff #60), (DON/#46 on multiple occasions regarding his food not being cut up. Review of the grievance logs for February through March 2026 revealed no formal grievances filed by the family member. The family member stated she also voiced her concerns to CNAs (#80) and (#6). The family member stated (Staff #34) informed her that the weekend staff would sometimes miss the order to have his food cut up. The family member further stated that the concern with not having her father's food cut up into bite-sized pieces was also addressed during care plan meetings. She stated that her father preferred to eat in the dining room, but weekends are always the worst, and his wishes were not met by taking him to the dining room as he preferred. The family member stated she was informed telephonically by Charge Nurse (Staff #60) that her father kept putting eggs in his mouth, forgot to swallow, and that the nurse tried to suction, but the food kept breaking apart and going further down his throat, so they sent him out to the emergency room. She stated that when she arrived at the hospital, her father's mouth was filled with tears and blood, most likely from the suctioning. The family member stated that his diet slip and care plan should have indicated that the food be cut up. The family member stated that during visits, she observed him in bed with his tray in front of figuring out how to feed himself. Per the family member, the resident should have been monitored due to his decline. She stated that he was care planned to encourage fluid intake. However, on numerous occasions, she observes his cups empty. She believed that if he had been in the dining room, the staff would have monitored him more closely and prevented this event. An interview was conducted on April 22, 2026, at 10:11 a.m. with Certified Nursing Assistant (CNA/Staff #80). Staff #80 stated he has been a CNA for about one year and has been with the facility for three years. He stated he worked on the weekends and worked on April 11, 2026, with (CNA/Staff #6). He stated breakfast meal trays usually arrive between 8:00 and 8:30 a.m., but sometimes they run a little late. He stated he passed meal trays and started with the 200 rooms, and helped with the 100 rooms that he was assigned to. He stated he was not assigned to resident #9 and did not serve him his tray that morning. He stated that resident #9 did not need aid in eating. Per the CNA, he has helped resident #9 before, and he was pretty good at eating up until the event. He stated he had no food restrictions and was on a regular food diet. He said that some CNAs would cut up the resident's food now and then. He stated that no one informed him of special instructions to cut up food into bite-sized pieces. He stated he only set up the resident's tray. He is aware of a resident diet orders from the meal tray ticket that annotated food intakes and water intakes for a resident. The meal tickets indicated mechanical food or puree for swallowing issues. However, resident #9 had no special instructions that he could recall. Staff #80 stated he has served resident #9 enough to know that his diet was regular and had no special instructions. If there were any changes to a resident's diet, information would be relayed by the speech therapist, dietary manager, and nurses. Staff #80 stated he was informed resident #9 had aspirated on eggs and that they had served egg burritos that day. He said that (CNA/Staff#6) was assigned to the resident. He denied altering resident #9's meal that day and was unaware that any changes needed to be made to his diet. He stated that the resident was found by the nurse, called over CNA#6 with the crash cart, and began suctioning. He stated it was just the nurse and the CNA until the charge nurse (staff #60) was notified. It took about a minute for the charge nurse to arrive and assist the other nurse, who also used a mask to suction the resident. Staff #80 stated he has received training on choking, cardiopulmonary resuscitation (CPR), compressions for choking, but has not received training on a LifeVac. A follow-up interview was conducted on April 22, 2026, at 10:26 a.m. with (CNA/Staff #6). Staff #6 confirmed that resident #9 was served an egg burrito and that it was cut in half on the day of the incident. She stated that she does not recall any special instructions for meals or needing to alter meals for the resident. She stated she did not recall any conversations with the resident's family member regarding needing his food cut into bite-sized pieces. She stated she could not recall if she had looked at the meal ticket before serving the resident. She stated she has worked with resident #9 for a little over 8 months and does not recall ever taking his meal back because the meal ticket was different than what was on the tray or having to cut up any pieces. She was unaware of any special instructions for the resident's food to be cut into bite-sized pieces. She stated she has had CPR training. A follow-up interview was conducted on April 22, 2026, at 1:19 p.m. with (LPN/Staff#60). She verified that she had not received training on the LifeVac, has only used it twice, once on her child and once on resident #9. She stated that the LifeVac is located in the dining room for just-in-case scenarios, and any staff member can use it. If staff are not comfortable, they can use the Heimlich if there is a complete blockage. She stated that resident #9 did not have a complete blockage, was decompressing on oxygen saturation stats, and they would suction and hold the mask over his mouth. She confirmed having conversations with the resident's daughter regarding his food not being cut up. She does not recall if it was an order, but that family prefers his meals cut up. Per the LPN, it is a preference for the resident to have finger foods. She stated that if it were an order, the expectation is that it would be care planned and put under special instructions on his banner in the electronic health record. She stated dietary slips would be changed if orders changed and the changes are relayed to the dietary team. She stated the process for relaying diet order or changes, if it is an actual order, is put into special instructions, and the dietary manager is notified by whoever is making the care plan. Other team members, nurses, and CNAs would be made aware in the report and electronic health record under special instructions, and updated in the care plan. She failed to answer the question about risks for not following the physician's orders, in terms of the resident's food not being cut up into bite-sized pieces. She stated that staff always cut up resident #9's food because it was a preference, and the nurses always check to see if the food is cut up. She further stated she knew the resident, the daughter, and their special requests to have his food cut up. She stated that new staff are made aware of the residents' diets or any changes in diet through report, under special instructions in the electronic health record, and in the resident's care plan. She stated this information should not be missed if the report is done correctly, and there is no reason for this to be missed. Staff #60 stated that if dietary missed the cut-up instructions, then staff would verify, and dietary would cut it up themselves, or the CNAs would cut up the food. She further stated that dietary did not always cut up his meals, so nursing would have to. An interview was conducted on April 22, 2026, at 1:30 p.m. with a senior menu specialist. The specialist stated that the facility utilized the Menu Wizard Program to build menus, tray cart and tray ticket program, budget management tool, shopping lists, menu templates built on customer needs, facility needs based on policy menus, and special dietary menus. The specialist stated the facility uses the tray card for resident information and diet information, and uses electronic records that interface with Menu Wizard for resident management data. Per the specialist, the facility is responsible for entries on orders on the electronic health record, and Menu Wizard data communicates with the electronic health record. The specialist stated that the interface with the electronic health record only pulls over certain critical items, not everything. The program has a list that automatically pulls over from the electronic health record to Menu Wizard. Anything like a preference such as cutting up into small pieces, any additional notes, has to be added in the notes section of the electronic health record to cross over to Menu Wizard and the dietary department is responsible for putting those specialized notes (like cut-up foods) within the notes section in electronic health record and that information like resident name, date of birth , room number, basic information and order for their food goes on automatically. The specialist stated that any special needs, like cutting foods and adaptive equipment to be used by residents, would have to be added manually by the dietary team for it to cross over into Menu Wizard. The specialist stated she was contacted by the dietary manager for help on April 22, 2026, regarding inputting data and using the system that he was unfamiliar with. The specialist was able to review the previous tray card for resident #9. She stated from her records the resident had a diet order for Regular, Regular, Thin Liquid, under Notes; cut into bite-sized pieces and large protein portions. She further stated from her review that this was the only diet order history for the resident from December 23, 2024, at 2:39 p.m. The info remained the same instructions since that date, and the system will automatically state when the note was updated or put in its original. The specialist noted that the tray card she indicated for the resident's food is to be cut into bite-sized pieces. An interview was conducted on April 22, 2026, at 2:59 p.m. with the Director of Nursing (DON/Staff# 46). According to the DON, nurses are responsible for passing on any new information during the report, just like a medication change. The DON stated the family member for resident #9 was involved up until a year ago, and would have meetings with the Ombudsman and whole care plan team; the family member was concerned with the resident's dignity in front of visiting girlfriend and finger food was recommended by the family member, but it was not assessed during ST, OT, this was due to family member wanting the resident to not be embarrassed in front of his girlfriend. The DON stated resident #9 was assessed in April and showed no indication for a speech assessment. The DON stated no assessment was done by OT or ST for the resident's swallowing or eating, maybe just screened. This would not show on the electronic health record, as it was just a screen; this information would be within the records of the therapy team. The DON stated her expectations were that the Nurse and CNA would look at the resident's meal tickets, verify the resident and food matched the ticket, and then deliver the food. The DON stated that the family member asked for finger foods, so that meant the resident could just eat without utensils, cut into small pieces. The DON stated that it was a preference, not an actual physician order. The resident's diet order was reviewed with the DON. The DON stated that the portion of the order about cutting food into bite-sized pieces is not part of the the actual order but rather an additional information indicating the resident's preference. The order states Regular-Regular, Thin Liquid, but the additional information on the order regarding bite-sized pieces is just a preference. The DON stated that the order summary just summarizes the whole order and preferences, but when looking at the specific order for regular texture, regular thin liquids, it does not contain to cut food into bite-sized pieces, which is a preference. The DON reviewed the provider orders in the resident's electronic health record and verified that the only thing that gets transferred to the kitchen and meal ticket would be the actual order; anything under the additional information does not cross over, because it's a preference and not a part of the ordered diet. An interview was conducted on April 22, 2026, at 3:32 p.m. with Medical Doctor (MD/provider/staff #84). The provider stated he was familiar with resident #9, as he had some difficulty with chewing and needed his food cut up. He further stated he was no longer the resident's physician since the resident is now seen by a different group of doctors. A review of the current active diet order was conducted with the provider. The provider confirmed he had prescribed a diet order for regular food, thin liquids, cut into bite-sized pieces, and large protein portions for the resident. The provider stated that when he wrote the order to cut into bite-sized pieces, the expectation was to follow that order and that the whole order is followed by staff; cut into bite-sized pieces, large protein portions are part of the whole order, and that is to be followed. The provider further stated the order is read as written, and it includes the whole order, including being cut into bite-sized pieces, not just the texture and consistency. Regarding Resident # 12 -Resident #12 was admitted on [DATE], and re-admitted on De[TRUN

Based on record review, interview, and review of facility policy, the facility failed to ensure that an allegation of sexual abuse made by one (Resident #3) of three sampled residents was immediately reported to the administrator and to the appropriate state agency within the required timeframes (within 2 hours for allegations involving abuse or serious bodily injury), as required. This deficient practice had the potential to place residents at risk for ongoing abuse and delayed protective interventions.Findings Include:Resident #3 was admitted [DATE], with diagnoses including metabolic encephalopathy, traumatic brain injury history, depression, anxiety disorder, and muscle weakness.A review of Resident #3's most recent Medicare 5-day, Minimum Data Set (MDS) assessment dated [DATE], revealed that the Brief Interview for Mental Status (BIMS) score of 15, indicating that resident #3 was cognitively intact.Review of the clinical record for Resident #3 revealed a nursing progress note dated November 9, 2025, stating that Resident #3 had altered mental status, slurred speech, and left-sided weakness. The resident was transferred to the hospital at 12:40 PM for evaluation.Another nursing progress note dated November 15, 2025, documented that a sheriff's deputy came to the facility to retrieve personal belongings for Resident #3.On February 18, 2026, at 10:18 a.m., a telephone interview was conducted with Resident #3. Resident #3 stated that on the night of November 8th, during the early morning hours of November 9, 2025, an unknown male staff member touched her breasts and genitals inappropriately. The resident stated she reported the incident to the sheriff's deputy after leaving the facility and being admitted to the hospital.On February 18, 2026, at 11:28 AM, the allegation was reported to the facility Administrator/Abuse Coordinator (Staff #33). Staff #33 stated he was aware of concerns expressed by Resident #3 after discharge.On February 18, 2026, at 11:35 AM, an interview was conducted with the Director of Nursing (Staff #41) stated law enforcement contacted the facility and indicated no further action was required. Staff #41 stated a soft file investigation was completed.On February 18, 2026, at 1:55 PM, a telephone interview was conducted with the sheriff's deputy listed as the contact in the soft file investigation. The deputy stated that Resident #3 had reported sexual assault while hospitalized but refused a physical examination and that he found inconsistencies in her account. The deputy stated he came to the facility and reported the allegations to a staff member.On February 18, 2026, at 2:16 PM, an interview was conducted with Licensed Practical Nurse (LPN Staff #77). Staff #77 stated that on November 15, 2026, a sheriff's deputy came to retrieve belongings and informed the facility that Resident #3 alleged a tall Hispanic male assaulted her on the night of her fall. Staff #77 stated the deputy indicated no further action was required due to the resident's altered mental status.On February 18, 2026, at 3:29 p.m. an interview was conducted with Staff #33 stated the facility became aware of the allegation approximately one week after discharge and worked with the sheriff's office, including providing camera footage. The facility reported that still camera images of males in the hallway were reviewed, and no males were observed entering Resident #3's room on the night in question. Staff #33 further noted that regulations state that reports of alleged abuse should be reported to the State Agency within two hours and the risk of not reporting could be that abuse continues.Review of the facility policy titled Abuse: Prevention of and Prohibition Against, revised February 17, 2025, revealed that allegations of abuse are to be reported outside the facility to appropriate State or Federal agencies within required timeframes.

Based on observation, interview, review of clinical record, and review of facility policy and procedure, the facility failed to ensure medication was administered and stored according to policy for two of four sampled residents (#4 and #2). The deficient practice resulted in residents accidentally ingesting medication.Findings Include:-Regarding Resident #4:Resident #4 was admitted to the facility on [DATE], with diagnoses that included hyperlipidemia, anemia, type 2 diabetes mellitus, chronic pain syndrome, pressure ulcer of right buttock, and pressure ulcer of right ankle.An admission minimum data set (MDS) assessment dated [DATE], revealed Resident #14 had a brief interview for mental status (BIMS) score of 14, indicating intact cognition.A physician order dated September 30, 2025, for arformoterol tartrate inhalation nebulization solution 15 mcg/2ml indicated for 2 ml, to inhale every 12 hours as needed for chronic obstructive pulmonary disease (COPD).The clinical record revealed no evidence of a physician order for albuterol inhaler or for cortisone cream.Additionally, there was no evidence of a Self-Administration of Medication assessment or any other medication self-administration assessment completed for Resident #4.The facility visitor sign-in log was reviewed on October 15, 2025, and revealed that Resident #4's most recent visitor signed into the facility on October 11, 2025.An observation was conducted on October 15, 2025, at 8:11 A.M. of Resident #4 in bed in his room. On the bedside table next to Resident #4 was a clear plastic bag with an albuterol inhaler and a tube of cortisone cream. An interview with Resident #4 was conducted on October 15, 2025, at 8:11 AM, and Resident #4 stated that the inhaler and cortisone cream were his medications from home. The observation continued on October 15, 2025, at 8:11 AM, and a staff member knocked on the resident's door, greeted the resident, and then stated that the staff was delivering the resident's breakfast tray. The staff member brought in the resident's breakfast tray, and set up the breakfast tray on the resident's bedside table, right next to the clear plastic bag with the medications. An interview was conducted on October 15, 2025, at 9:27 A.M. with the Registered Nurse (RN / Staff #8) assigned to Resident #4's unit. Staff #8 stated that nurses store medications in the medication cart, and during medication pass nurses administer medications as ordered to the residents. Staff #8 stated that nurses watch the residents take the medications and sign off on the Medication Administration Record (MAR). Staff #8 stated that medications are not left at bedside for residents. Staff #8 stated that residents can be assessed to self-administer their medications if they are deemed safe and appropriate to do so. Staff #8 stated that Resident #4 is not allowed to self-administer medications. Staff #8 then entered Resident #4's room and picked up the albuterol inhaler and cortisone cream from the resident's bedside table and brought them to the hallway for further inspection. Staff #8 stated that it was an albuterol sulfate inhaler and cortisone cream, and that she did not see the medications before. Staff #8 reviewed the clinical record and then stated that the resident did not have physician orders for either medication, and that the facility's process would be to take the medications and store them in the medication cart until they could be returned to the resident's family.-Regarding Resident #2:Resident #2 admitted to the facility on [DATE], with diagnoses that included vascular dementia, heart failure, chronic atrial fibrillation, severe chronic kidney disease, and presence of cardiac pacemaker.A quarterly MDS assessment dated [DATE], revealed that Resident #2 had a BIMS score of 14, indicating intact cognition.Review of the clinical record revealed no evidence of a Self-Administration of Medication assessment completed for Resident #2.A physician order for melatonin oral tablet 3 mg indicated to give one tablet by mouth at bedtime at 7:00 P.M.A physician order for tamsulosin HCl oral capsule 0.4 mg indicated to give one capsule by mouth at bedtime for benign prostatic hyperplasia (BPH) at 7:00 P.M.A physician order for rivastigmine tartrate capsule 3 mg indicated to give 1 capsule by mouth two times a day for dementia as evidenced by aggressive behaviors, at 8:00 AM and at 7:00 P.M.Another physician order for acidophilus oral tablet indicated to give one tablet by mouth two times a day for gastrointestinal health, at 8:00 A.M. and 8:00 P.M.Review of the MAR for September 2025 revealed that an RN (Staff #29) had signed on the MAR that Resident #2 had refused the following medications on the evening of September 12, 2025: melatonin oral tablet, tamsulosin HCl oral capsule, rivastigmine tartrate capsule, and acidophilus oral tablet.Additionally, the MAR for September 2025 revealed that a Licensed Practical Nurse (LPN / Staff #55) had signed the MAR that Resident #2 received his morning medications as ordered on the morning of September 13, 2025.Also, the MAR for September 2025 revealed that on September 13, 2025, Resident #2 was placed on change of condition monitoring every shift for three days for a medication error.In addition, on September 13, 2025, the MAR revealed that Resident #2 received a one-time dose of midodrine HCl oral tablet 10mg for a blood pressure of 67/35 at 1:16 P.M. Resident #2 also received sodium chloride 0.9% 500 ml intravenously for blood pressure of 67/35 on September 13, at 1:17 P.M.Review of the clinical record revealed no progress notes completed on September 12, 2025 for Resident #2.A progress note dated September 13, 2025, revealed that the nurse (Staff #55) was alerted by a certified nursing assistant (CNA) that a visitor found medications at bedside in Resident #2's room, and administered them to Resident #2. The nurse immediately proceeded outside to where Resident #2 and the visitor were to obtain vital signs. The resident's vital signs were assessed, with blood pressure of 67/35, pulse of 62 bpm, O2 91%, and the resident was brought back inside. The provider was notified and gave orders to give 10 mg dose of midodrine, and 500 ml IV fluid bolus to be followed by 100 ml/hr for a total of 1000 ml. An IV was started in the resident's right hand. The progress note also revealed that Staff #55 had already administered the resident's morning medications earlier in the day with a CNA present. The Director of Nursing (DON) was called and notified.A BIMS assessment dated [DATE], revealed Resident #2 had a BIMS score of 12, indicating moderately impaired cognition.A signed statement dated October 15, 2025, from the facility administrator (Staff #40) revealed that visitor sign-in logs are generally scanned and digital copies are stored electronically, and once scanned, the visitor sign-in logs are then shredded. The statement revealed that the visitor sign-in logs for September 7-14, 2025 were missed during the scanning process and were shredded.An interview was conducted on October 15, 2025, at 9:12 A.M with Resident #2. Resident #2 stated that now the facility staff administer medications and watch him take the medications, however recently there was a problem with a staff member leaving medication on the counter and that he got a double dose of medication by accident. Resident #2 stated that when that happened, he felt weak and as if he could not move.An interview was conducted with an RN (Staff #61), who was the unit nurse for Resident #2 on October 15, 2025, at 10:30 A.M. Staff #61 stated that the process for administering oral medications to residents is that a nurse checks the orders, checks the dosage, checks the resident's allergies, and checks the resident's name. Then, Staff #61 stated that the nurse performs hand hygiene, issues the medications in a cup, and then stays with the resident to make sure the medications are administered and to ensure the resident does need help or does not choke. Staff #61 stated that medications are never left with the resident because the resident may get confused and forget to take the medications or they could get knocked over and missed, or hidden and taken together with the next dose. Staff #61 stated that no residents on the unit are allowed to self-administer medications.A telephonic interview was conducted with Resident #2's power of attorney (POA) on October 15, 2025, at 10:36 A.M. The POA stated that there was an incident on September 12, 2025 where the nurse left Resident #2's evening medications on a bedside table in the resident's room. The POA stated that the following morning, on September 13, 2025, Resident #2 was given his usual morning medications by a nurse, and that a family friend was visiting Resident #2 and saw the cup of medications left out from the night before and thought that Resident #2 had not taken his morning medications. The family friend then encouraged Resident #2 to take the medications, which he did. The POA stated that this was a potential double dose of medications, and that she was notified of this incident by the family friend and by the facility. The POA stated that when Resident #2 confronted the nurse (Staff #29) about leaving the medications on the bedside table, that the nurse told Resident #2 that the resident was arguing with him, so he left the medications on the table.A telephonic interview was conducted on October 15, 2025, at 11:03 A.M. with the family friend who visited Resident #2 on September 13, 2025. The visitor stated that she should have double-checked with the nurse about the pills that she found at bedside. The visitor stated that when she arrived, between 11:00 A.M. to 1:00 P.M., Resident #2 was in his room, and that she saw the cup of 3-4 pills on the nightstand, and she said to Resident #2 that he missed his pills, and then Resident #2 took the pills. The visitor stated that she wanted to double-check afterward, so she called the resident's POA, who then stated that the pills could have been left from the night before. The visitor stated that, at that time, Resident #2 seemed a little off and more fatigued than usual. The visitor stated that she then notified facility staff. Additionally, the visitor stated that she was informed that Resident #2 had already received his morning medications, and the staff acted right away and assessed the resident's vital signs. The visitor stated that the resident's blood pressure dropped. Then, the visitor stated that Resident #2 received IV fluids and afterward Resident #2 seemed ok. The visitor stated that afterward, the facility staff were monitoring Resident #2.A telephonic interview was conducted with Resident #2's nurse practitioner (NP / Staff #99) on October 15, 2025, at 11:14 A.M. Staff #99 stated that if a resident had a medication error, that she would expect the nurse to notify her. Regarding Resident #2, Staff #99 stated that the nurse notified her of the medication error promptly, and that Staff #99 was informed that Resident #2 had low blood pressure, so Staff #99 gave orders for Resident #2 to receive IV fluids and that the resident tolerated it well.A telephonic interview was conducted with a CNA (Staff #80) on October 15, 2025, at 12:25 P.M. Staff #80 stated she usually works on Resident #2's unit and that she heard about the incident of Resident #2's medication error when she came back from her days off. Staff #80 stated that she heard in report that Resident #2 had a visitor who found medication on the resident's bedside table and gave him those medications, and the nurse had already given the resident his morning medications that day.A telephonic interview was conducted on October 15, 2025, at 12:54 P.M. with an LPN (Staff #55), who was Resident #2's nurse on September 13, 2025. Staff #55 stated that in the morning on September 13, she entered Resident #2's room with a CNA. Staff #55 stated that she gave Resident #2 his morning medications and that the CNA witnessed this. Staff #55 stated that several hours later, the same CNA notified her that there was an issue, that the resident's visitor found medications at bedside and had given them to the resident. Staff #55 stated that Resident #2's vitals were assessed and that his blood pressure was low. Then, Staff #55 stated that she notified the provider, who ordered midodrine and IV fluids for Resident #2, and that Staff #55 also notified the resident's POA of the incident.A telephonic interview was conducted on October 15, 2025, at 1:35 P.M. with an RN (Staff #29). Staff #29 stated that he was the nurse for Resident #2 on September 12, 2025, and that Staff #29 went to give Resident #2 his evening medications, and that Resident #2 was refusing the medications. Staff #29 stated that he set the medications in the cup down on the nightstand because he was going to check on the resident later, but accidentally left the medications there. Staff #29 stated that the next day, the DON called him about the incident, and that is when he realized he forgot the medications there. Staff #29 stated that he had to do some training on medication administration after the incident.An interview was conducted with the DON (Staff #72) on October 15, 2025, at 1:41 P.M. The DON stated that her expectation for nurses administering oral medications would be for staff to verify the order, the dose, and the time, pull the pill card, and pop the pill from the pill card into a cup, and then go into the resident's room and administer the medications. The DON stated that the medications should absolutely not be left at bedside for residents. Regarding Resident #2, the DON stated that the nurse (Staff #29) admitted that he left the medications at bedside on September 12, 2025. Then, the DON stated that the next day, Resident #2 received his morning medications and did not realize the medications were there, and that the visitor administered the medications that were left in the cup and then notified the nurse. The DON stated that the nursing staff then acted quickly and notified the provider and monitored Resident #2's blood pressure, and that the resident stabilized. The DON stated that Staff #29 had a write-up and received supplemental training regarding the incident.Review of the facility policy titled Medication Administration - Oral, revised May 2017, revealed it is the policy of the facility to accurately prepare, administer and document oral medications. Procedures for administering unit doses included: identify resident electronic MAR orders, remove unit dose medications from cards into med souffle cup for resident, administer drugs to resident, document administration of medication, and keep med cart locked when away from cart. The policy also included that no medication is to be administered without a physician's written order, medicine room doors are to be kept locked at all times, the nurse preparing the drug administers it, and the person administering medication must remain with the resident until all medication has been swallowed. Review of facility policy titled Self Administration of Medications, revised May 2022, revealed it is the policy of the facility to respect the wishes of alert, competent residents to self-administer prescribed as allowable under state regulations. The purpose of the policy revealed to determine the ability of alert residents to participate in self-administration of medications, and to maintain the safety and accuracy of medication administration. If a resident desire to participate in self-administration, the interdisciplinary team will assess and periodically re-evaluate the resident based on change in the resident's status. The residents cognitive, communication, visual, and physical ability to carry out this responsibility will be evaluated. If the interdisciplinary team determines that this resident is unable to carry out this responsibility, the interdisciplinary team may withdrawal this right. If the resident is a candidate for self-administration of medications, this will be indicated in the chart. Nursing will be responsible for monitoring self-administered doses in the resident's medication administration record (eMAR). Storage and location of drug administration (e.g., resident's room, nurses' station, or activities room) will comply with state and federal requirements for medication storage.Review of federal regulation 42 CFR 483.45 (h), revealed that in accordance with State and Federal laws, the facility must store all drugs and biologicals in locked compartments under proper temperature controls, and permit only authorized personnel to have access to the keys.

Based on observations, staff interviews and policy review, the facility failed to ensure that medications were not left at the bedside for one resident (#9). The deficient practice could result in harm to the residents, and/or visitors who have access to medications. Findings include: During an initial observation of Resident #9's room on May 27, 2025 at 09:38 a.m., a tube of voltaren arthritis pain relieving cream was observed on the resident's bed side table. Resident #9 was admitted to the facility on [DATE] with diagnoses that included type 2 diabetes mellitus, paroxysmal atrial fibrillation, and muscle weakness. A physician order dated April 10, 2025 was written: voltaren external gel 1 % (diclofenac sodium (topical) apply 2 grams(gm) twice daily to back topically for back pain. Administered by clinician only. A care plan, initiated on April 10, 2025 revealed that the Resident #9 had an acute/chronic pain related to spinal stenosis and pressure ulcers to buttocks/coccyx region. Further, review of care plan revealed no evidence regarding the Resident #9 self-administration of medication. An initial admission record dated April 10, 2025 revealed that the Resident #9 did not desired to self-administer drugs. A Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview of Mental Status (BIMS) score of 09, which indicated moderately cognitive impaired. The May 2025 Medication Administration Record (MAR) reflected that voltaren 2gm was administered twice daily during 8 a.m. and 8 p.m. as ordered. There was no evidence in the progress notes of an interdisciplinary team (IDT) meeting related to medication self-administration. An interview was conducted with Resident #9 in her room on May 27, 2025 at 09:38 a.m., she stated that she used voltaren medication for pain. She then stated that nurses also applied voltaren medication to her lower back for pain. A staff member was called by Resident #9 using call light button. A registered nurse (RN, staff #80) came to Resident #9's room. She observed voltaren arthritis pain relieving cream on the Resident #9's bed side table and stated that voltaren medication shouldn't be left at resident bed side table. RN further stated that she was not aware of Resident #9's self-administration assessment as she did not work in the 100 hallways and called nurse who worked in the unit. An interview was conducted on May 27, 2025 at 09:38 a.m., with a licensed practical nurse (LPN, staff #54) who stated that he observed voltaren arthritis pain relieving cream on the Resident #9's bed side table which was not supposed to be left at the bedside. The LPN then stated that voltaren medication was applied by nurses to Resident #9 for her arthritis. The LPN further stated that resident was not assessed for self-administration. The LPN was then observed to remove the medications from the resident's room and placed them in the medication cart. The LPN then reviewed the resident's clinical record and stated that resident had an order for voltaren medication and would be administered by the clinician only. The LPN further stated that the risks of leaving medications unattended at the bedside could result in resident may overdose, ingestion or a different resident could go into the room and take the medication. An interview was conducted on May 28, 2025 at 12:41 p.m. with the Director of Nursing (DON/Staff#35) who stated that residents were not allowed to self-administer medication unless they were assessed by the IDT team regarding medication dosage, storage and how to safely administer medication. After, the resident was assessed for self -administration of medication, the IDT team would notify the doctor and get an order for self-administration. The DON further stated that currently the facility did not have any resident with self-administration of medications. The DON then pulled the Resident #9's clinical record and stated that resident had an order for voltaren external gel 1 % (diclofenac sodium) apply 2 grams twice daily for back pain administered by the clinician only. The DON also stated that voltaren medication should not be left on resident bed side tables and risk would be resident may ingest the medication or apply the wrong dose of voltaren medication. Review of the policy titled, Medication access and storage, revised date September 2024 revealed that only licensed nurses, the consultant pharmacist and those lawfully authorized to administer medications (e.g., medication aides) are allowed access to medications. Medication rooms, carts, and medication supplies are locked or attended by persons with authorized access. Review of the policy titled, Self-Administration of Medications, reviewed date May 2025 revealed that if a resident desired to participate in self-administration, the interdisciplinary team would assess and periodically re-evaluate the resident based on change in the resident's status. The policy further revealed that if the resident is a candidate for self-administration of medications, this will be indicated in the chart and nursing will be responsible for monitoring self-administered doses in the resident's medication administration record (eMAR).

Based on record review, facility documentation, staff and resident interviews, and facility policy and procedures, the facility failed to protect the right of one resident(#10) to be free from abuse by staff. The deficient practice could result in residents being abused. Findings include: Resident #10 was admitted to the facility on [DATE] with diagnoses that included post traumatic stress disorder, generalized muscle weakness, and bipolar disorder. Review of the care plan for activities of daily living (ADLs) dated November 26, 2023 revealed that the resident had a performance deficit related to weakness. The resident required extensive assistance with bed mobility and was totally dependent with transfers, toileting, and dressing. The bowel and bladder incontinence care plan dated December 3, 2023 included the interventions to use disposable briefs and change as needed; check as required for incontinence; wash, rinse and dry perineum; and, change clothing as needed after incontinence episodes. The Minimum Data Set (MDS) assessment dated [DATE] included a Brief Interview for Mental Status (BIMS) score of 13 indicating the resident was cognitively intact. The MDS also revealed that the resident required substantial/maximal assistance with rolling left to right while lying in bed. Review of the task sheet for bowel incontinence dated dated February 27, 2024 at 5:59 p.m. revealed that the resident was incontinent of bowel and was provided assistance by a certified nursing assistant (CNA/staff #13). Review of a brief interview for mental status dated March 2, 2024 revealed a score of 15 indicating the resident was cognitively intact. Review of a written interview conducted on March 4, 2024 at 9:00 a.m. by the Director of Nursing (DON/staff #1) with staff #13, revealed that he provided resident #10 with continence care on February 27, 2023 and she was soaked, so he changed her bed linens and her clothes. He stated that he cleaned her back up to the shoulders and used the back of one hand to lift her breast while cleaning underneath with the other hand and this is the way he handled female breasts. The written interview revealed that staff #13 stated that he never massaged the resident or any other residents, but acknowledged that he probably spends more time in the resident's room than he should to talk to her. An interview was conducted on March 5, 2024 at 2:12 p.m. with resident #10, who stated that on March 27, 2024 in the late afternoon, she pressed her call-light. Resident #10 stated that CNA/staff #13 came into her room and she requested that he change her brief. She stated that staff #13 removed her brief, wiped her gential area, and put on a clean brief. Resident #10 then stated that staff #13 removed her top because it was wet at the back a few inches from the bottom of the shirt and she was not wearing a bra. She stated that she was still on her left side and staff #13 was standing behind her when he began wiping her with a new clean wipe on her back all the wall up to her armpit area and she did not feel that that area needed to be cleaned. The resident (#10) stated that she was talking about how stressed she was on her wedding day and staff #13 began massaging her neck and shoulders and was talking about stress. Resident #10 continued and said staff #13 then rolled her on to her back and began wiping up her belly and stopped just below the breasts, and began wiping her arms, the bicep area, and under her arms. She stated that he then began wiping under her breasts and on top of her breasts and said, we can't forget the breasts. She stated that she was very uncomfortable and shut down. She stated that after he was done, he acted like nothing happened and stated that this has affected her sleep patterns because she was afraid that he was going to come back. -Resident #36 was admitted to the facility on [DATE] with diagnoses that included disassociative and conversion disorder, post traumatic stress disorder, and generalized muscle weakness. Review of the care plan dated July 19, 2023 revealed that the resident had an Activities of Daily Living (ADL) self care performance deficit related to rheumatoid arthritis. Interventions included a one person assist with bed mobility, transfers, toileting, dressing, and eating. The MDS dated [DATE] included a BIMS score of 15 indicating the resident was cognitively intact. The MDS also included that the resident had no hallucinations or delusions during the look-back period and the resident required partial/moderate assistance with showering. Review of the shower task sheet dated dated February 27, 2024 at 8:05 a.m. revealed that the resident was provided assistance with showering by a certified nursing assistant (CNA/staff #13). An interview was attempted on March 5, 2024 at 3:19 p.m. with staff #13, who stated that this was a legal matter and declined to interview. An interview was conducted on March 6, 2024 at 8:09 a.m. with resident #36, who stated that she was watching a detective show in her room and staff #13 came in and tried to massage her arms, but she told him that she did not need anyone massaging her arms. She stated that staff #13 was always hanging around their room. She stated that one time, she could see staff #13's shoes when she looked underneath the curtain between her and resident #10's side of the room. She stated that she asked him what he was doing and he told her that he was going to change the resident, but didn't want to bother her because resident #10 was sleeping. She stated that staff #13 remained in the room for approximately 5 more minutes, but she did not know what he was doing. She was not able to verify when this occurred. An interview was conducted on March 6, 2024 at 9:35 a.m. with (CNA/staff #58), who stated that she has had training on continence care and had provided care for resident #10. She stated that the resident was able to tell staff when she was soiled. Staff #58 stated that the resident's shirt do get wet, but it was usually in the back and if it was wet in the front, it was usually only a little bit. However, she would still clean the abdominal area and if she needed to clean under the resident's breasts, she would ask the resident to hold them up, while she cleaned underneath. She stated that she usually gives the resident a wipe to clean her arms and underarms because the resident was able to do this for herself, but struggled under the breast area. Staff #58 stated that she did not feel comfortable cleaning the resident's actual breast area and the resident was capable of cleaning the breast area herself. She stated that the resident told her that she did not want a male providing pericare and she reported it to the nurse. The resident told her that she had been molested by a male CNA. An interview was conducted with on March 6, 2024 at 1:11 p.m. with the (DON/staff #1), who stated that staff #13 had been terminated for refusing to interview and follow facility protocol. She stated that CNAs are taught to use massage to alleviate pain, but massage is not appropriate during continence care and the resident should be clothed. The facility policy, Freedom From Abuse, Neglect, Exploitation revised October 2023 states that it is the policy of this facility that each resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation.

Based on review of clinical records and policy, observations, and staff interviews the facility failed to ensure a complete anti-seizure medication regimen was administered to Resident # 295 within accepted professional standards of practice. The deficient practice of incomplete medication administration does not align with accepted professional standards of practice and may result in undesirable quality of care. Findings Include: Resident # 295 was admitted on [DATE] with diagnoses of burn of unspecified degree of buttock, essential hypertension, and unspecified convulsions. The most recent Admission Minimum Data Set (MDS) assessment revealed a Brief Interview for Mental Status (BIMS) score of 13 which indicated the resident was cognitively intact. On admission, Resident # 295 had the following anti-seizure medication regimen: Vimpat (Lacosamide) oral tablet 200 milligrams, give 1 table by mouth two times a day for seizures, dated January 22, 2024 and Lamotrigine oral tablet 25 milligrams, give 2 tablets by mouth one time a day for seizure, dated January 19, 2024. Review of the Medication Administration Record with Staff #23 revealed that Lacosamide had initially been added the medication onto the facility's system on January 19, 2024. Lacosamide (Vimpat) oral tablets were entered on January 22, 2024 but no dispensed documentaton was provided for administration. Review of medication dispensing machine/emergency kit on January 24, 2024 at 11:02 AM revealed Lacosamide was not included in the list of available medications. During an interview conducted with Resident # 295, she stated she had not been receiving one of her two anti-seizure medications for 3 days. This prompted a review of the Medication Administration Records (MAR) on January 22, 2024 at 12:42 PM. The MAR revealed Lacosamide medication order had not been administered to her since her admission on January 19, 2024. Additionally, the MAR revealed 5 attempts of medication administrations had passed before a hold and discontinue was placed on the initial order of Lacosamide. MAR revealed Lacosamide medication was later re-ordered January 22, 2024 at 0927. During an interview conducted on January 24, 2024 at 10:05 AM with a Registered Nurse (RN/Staff # 48) who stated that nurses input medication orders onto the electronic records prior to admissions. Staff # 48 further stated this allows planning ahead so medications are on hand upon admission of new residents. However, electronic orders are always verified by the medical doctor prior to getting sent to pharmacy. She stated that medications have always gotten here when we needed them, pharmacy makes multiple runs in a day, and if we call they will make an extra run. Staff # 48 also reviewed the MAR and determined resident should be taking the medication based on her orders which listed Lacosamide was part of her anti-seizure regimen. Staff # 48 noted upon review of the MAR that Lacosamide should have been administered on admission day or by the next medication pass, and it did not meet expectations that the Lacosamide was unavailable to the resident since her admission. During an interview conducted on January 24, 2024 at 10:35 AM with the Medical Director (Staff # 82) he stated that when residents are sent to this facility, the discharging facility who is sending the resident over, is responsible for sending all electronic orders to pharmacy. Staff # 82 also stated since Resident #295 had not had seizures recently and felt comfortable waiting for the medication to arrive. Staff # 82 further stated if there was a chance of seizure, Ativan could always be given if needed. Staff # 82 stated he also contemplated the option of sending Resident #295 to the emergency department to obtain the medication, however he believed they would be sending her back immediately. During an interview conducted on January 24, 2024 at 1:37 PM with a Pharmacy Representative (Staff # 91) who stated that the first Lacosamide prescription sent to the Pharmacy was January 21, 2024 at 11:25 PM after the facility learned it could not be processed due to not having an electronic signature per auditing records. Staff #91 further stated that although the facility's records showed the Lacosamide was added onto the facility's system, the medication was never sent over to the Pharmacy because it required a signature. During an interview conducted on January 25, 2024 at 11:36 AM with Registered Nurse (RN/Staff # 23) in the presence of Director of Nursing (DON/Staff # 46), Staff # 23 stated we input all orders, however they have to be verified by the doctor. If a resident does not receive their order: we will call the doctor and pharmacy, and obtain the medication from the medication dispensing machine/emergency kit if available. Staff #23 revealed she had a secure communication with the Medical Director on January 21, 2024 when she noted that Lacosamide was unavailable to Resident # 295, Hi again. Pt was admitted on ,d+[DATE] and was sent with orders for Lacosamide 200 mg 1 tab BiD for seizures. We have not received any medication. I called Pharmacy and they do not have any prescriptions in their system. Could you escribe it over?. Staff # 23 the stated she was unavailable to communicate with Medical Director prior to January 21, 2024 because she was not working in the facility prior to January 21, 2024. A second interview was conducted on January 25, 2024 at 12:00 PM with Staff #82 while he reviewed medical records. Staff #82 stated we do not get many residents from the county. Now I see county did not send the medications over to pharmacy they only listed them on her discharge documents. Staff # 82 stated normally there is a picture of signed scripts on the discharge documentation. Staff #82 stated it does not meet expectations, and that Resident #295 should have received medication next scheduled administration after her admission. The policy and procedure document titled Nursing Clinical, Nursing Services - Physician Orders (reviewed Aug/2023) revealed that Admission orders are reviewed with the Physician upon admission based on the discharge instructions from the discharging facility and are transcribed accordingly. The policy and procedure document titled, Clinical - Medication Management (reviewed July/2023) revealed unless otherwise specified by the resident's attending physician, routing medications will be administered per the facility time ranges within 1 hour before and 1 hour after the ordered time frame. Should a drug be withheld, refused, or given other than the scheduled time, the staff administering must indicate the reason on the MAR. Medication that has not arrived from the pharmacy should be pulled from the Stat Safe if available. If not available in the Stat Safe, the provider should be notified to determine if alternative medication, that is available in Stat Safe, should be given and order written for temporary medication, if applicable. It is the policy of this facility, medication shall be administered as prescribed by the resident's physician, nurse practitioner, or physician's assistant.

Based on review of clinical records and policy, observations, and staff interviews the facility failed to ensure cautionary slippery-floor safety signs were present near a hazardous area for Resident #295. The deficient practice of reduced safety measures may result in a higher likelihood of accidental falls. Findings Include: Resident #295 was admitted on [DATE] with diagnoses of burn of unspecified degree of buttock, muscle weakness, abnormalities of gait and mobility, and unspecified convulsions. The most recent Admission Minimum Data Set (MDS) assessment revealed a Brief Interview for Mental Status (BIMS) score of 13 which indicated the resident was cognitively intact. Care plan initiated on January 19, 2024, revealed a goal for Resident #295 was not to sustain serious injury due to risk for falls related to impaired mobility. On January 22, 2024 at 9:34 AM, Resident #295 was observed walking in front of room [ROOM NUMBER] with Physical Therapist (PT/Staff #81). On January 22, 2024 at 9:34 AM, an observation of room [ROOM NUMBER] revealed pooling of liquid on the floor at the doorway and into the facility's hallway. The pooled liquid covered approximately 75% of the door's width and extended a distance outside of the door which was approximately 25-33% of the width of the hallway. This liquid appeared to be water due to its transparency, however it was the facility's cleaning solution that was being used to mop the floor inside room [ROOM NUMBER] by Housekeeping/Staff #67. No cautionary slippery-floor safety signs were present in this area. An interview was conducted with Staff #67 who stated caution signs are always required when cleaning the floor. Staff #67 stated that the cleaning cart she was using was her usual cart and did not have a caution sign. On January 22, 2024 at 9:52 AM, an interview was conducted with Physical Therapist (PT/Staff #81) who stated making the initial therapy evaluation of Resident #295. She stated while walking the hallway earlier she saw the water on the floor outside of room [ROOM NUMBER] and tried to keep Resident #295 on the other side of the wet area. She added that having water on the floor where the residents are walking did not meet her expectations. On January 24, 2024 at 9:01 AM, an interview was conducted with Maintenance Supervisor/Staff # 45 who stated rooms are mopped daily with a cleaner of prediluted bleach and water. Staff #45 stated the cleaning process includes mopping the solution slightly past the resident's room door into the hallway. Staff #45 stated that it is expected to have the sign, caution slippery when wet sign placed at all times while mopping. Staff #45 stated if there are no wet floor caution signs residents may slip. On January 24, 2024 at 2:15 PM, an interview was conducted with Director of Nursing (DON/Staff # 46) who stated staff should have a caution sign when the floor is being mopped. The DON stated she would not want residents walking near a wet area. She further stated that the expectation is that a cone is out there whenever the floor is wet. The policy and procedure document titled Nursing, Resident Assessment - Fall Management System (reviewed Nov/2023) revealed that the facility is committed to promoting resident autonomy by providing an environment that remains free of accident hazards as possible. Furthermore, the policy of this facility to provide each resident with appropriate assessment and interventions to prevent falls and to minimize complications if a fall occurs.

Based on the clinical record reviews, resident and staff interviews, facility document, and facility assessment, the facility failed to ensure that there was sufficient nursing staff to meet the needs of multiple residents (#s 11, 19, 27, 85, 129, and 180). The census was 27. The deficient practice could result in residents' care needs not being met. Findings include: -Resident #11 was admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the admission MDS (Minimum Data Set) assessment dated [DATE] revealed the BIMS (Brief Interview for Mental Status) was not completed. The MDS stated the resident was totally dependent on two staff with toilet use, and extensive assistance with personal hygiene, and eating. During an interview conducted with the resident on October 18, 2022 at 11:25 a.m., the resident stated that he put on his call light during the night and waited 12 hours for a staff member to come in to change his wet brief. -Resident #19 was admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . An admission MDS assessment dated [DATE] revealed a BIMS score of 11 which indicated the resident had moderate cognitive impairment. The MDS revealed the resident needed extensive assistance with bed mobility, transfer, and personal hygiene. An interview was conducted with resident #19 on October 18, 2022 at 10:14 a.m. Resident #19 stated he had a fall with injuries but he does not recall when. The resident stated the staff answered his call bell, turned off the call bell, but the staff did not come back to provide his needs, and that it happens more frequently on weekends. -Resident #27 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the admission MDS assessment dated [DATE] revealed a BIMS score of 14 indicating the resident had intact cognition. The MDS stated the resident needed supervision with activities of daily living. An interview was conducted on October 18, 2022 at 9:18 a.m. with resident #27. The resident stated that during the first week of his admission, he attempted to call 911 because he was having severe pain in the spine, and that he pressed the call bell but no staff responded for more than one hour. Resident #27 stated there was not enough staff especially on the weekend, it was impossible to get help. The resident stated the staff told him there was only one CNA (certified nursing assistant), and one nurse for the entire facility. The resident stated he does go to the dining room but the staff made him feel like he was a bother. The resident stated the staff would bring coffee but did not offer condiments. -Resident #85 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the admission MDS assessment dated [DATE] revealed a BIMS score of 15 indicating the resident had intact cognition. The MDS stated the resident always had urinary incontinence, and frequent bowel incontinence. The MDS also revealed the resident required extensive assistance with toilet use, bed mobility and transfer. An interview was conducted with resident #85 on October 18, 2022 at 9:51 a.m. Resident #85 stated she pressed her call light at 10:00 p.m., but the staff did not come until 4:00 a.m. -Resident #129 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the admission MDS assessment dated [DATE] revealed a BIMS of score 6 indicating the resident had severely impaired cognition. The MDS stated the resident needed extensive assistance with transfer and toilet use, supervision with eating, and limited assistance with personal hygiene. An interview was conducted with resident #129 on October 18, 2022 at 9:42 a.m. Resident #29 stated he was admitted to receive therapy because he cannot stand up or walk due to [CONDITION(S)]. Resident #29 stated there were times that he was hungry, he ordered more food from the staff, but the staff just walked away and the staff did not come back. Resident #29 stated he did not have to wait long for the call light to be answered when he wanted snacks. However, even though the staff answers the call bell, they do not come back. -Resident #180 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the resident's admission MDS assessment dated [DATE] revealed a BIMS score of 15 indicating the resident had intact cognition. The MDS stated the resident had urinary incontinence occasionally, and needed extensive assistance with transfer and toilet use, and supervision with personal hygiene. An interview was conducted with the resident on October 18, 2022 at 12:49 p.m. Resident #180 stated the call bell is not answered timely. The resident stated it takes more than one hour to get a response. Review of the facility assessment revealed the average daily census is 25, and that the facility averages 30 admissions and 25 discharges per month. The assessment also revealed the facility considers both census numbers and acuity levels that impact staffing needs, and staffs accordingly. The staffing assessment plan included one full time DON (director of nursing), one ADON (assistant director of nursing), one wound nurse, one full time MDS nurse, two RNs (registered nurse) for the morning shift and two RNs for the evening shift, 4 - 6 CNAs (certified nursing assistant) for the morning and evening shift, and one RNA (restorative nursing assistant). Review of the daily staffing documentation revealed the staff works 12-hour shift and revealed the following: October 19, 2022 - 3 CNAs for the morning shift, and 2 CNAs for the evening shift. October 20, 2022 - 2 CNAs for the morning shift, and 2 CNAs for the evening shift. October 21, 2022 - 2 CNAs for the morning shift, and 2 CNAs for the evening shift. During an interview conducted with a staff member (anonymous), the staff member stated skilled residents have higher acuity because they have complex care. The staff member stated it is very busy. The staff member stated with regards to adequate staffing, the level of attention and care needed is not being provided. An interview was conducted with the staffing coordinator (staff #17) on October 20, 2022 at about 9:30 a.m. Staff #17 stated the facility staffing was based on the census, not the facility assessment. An interview was conducted with the DON (staff #11) on October 20, 2022 at 10:00 a.m. Staff #11 stated the facility assessment is their emergency staffing plan. Staff #11 stated that since the acquisition, the facility changed the process to a new staffing grid and resident's acuity. Another interview was conducted on October 20, 2022 at 12:35 p.m. with the DON (staff #11). Staff #11 stated that she recognized the weekends are more of an issue because of lower coverage, and because of less core staff and more agency staff used in the facility. The DON stated the facility is more reliant with agencies on the weekend, and the facility is working on that.

Based on clinical record review, staff interviews, and policy review, the facility failed to ensure one resident (#21) was informed in advance of the risks and benefits of psychoactive medications. The sample size was 2. The deficient practice could result in residents and/or their representatives not being made aware of the risks and benefits of psychoactive medications. Findings include: Resident #21 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A care plan initiated on September 26, 2022 stated the resident was on antidepressant medication use related to depression as evidenced by sad affect, sleeplessness and social isolation. The interventions stated to educate the resident, family/caregivers about risks, benefits and the side effects of medication. Review of the admission MDS (minimum data set) assessment dated [DATE] revealed a BIMS (Brief Interview of Mental Status) score of 15 indicating the resident had intact cognition. The active diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the MARs (Medication Administration Records) dated September 2022 and October 2022 revealed resident #21 received the two antidepressant medications [MEDICATION(S)] and [MEDICATION(S)] per physician order. However, continued review of the clinical record revealed no evidence that the resident or the responsible party was informed of the risks and benefits for the use of the two antidepressant medications [MEDICATION(S)] and [MEDICATION(S)]. On October 19, 2022 at 10:33 a.m., the DON (Director of Nursing/staff #11) stated the consents for these two antidepressant medications were not available. An interview was conducted on October 20, 2022 at 12:35 p.m. with a registered nurse (RN/staff #10). Staff #10 stated [CONDITION(S)] medications that are given routinely must have a physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Staff #10 further stated that even if a physician ordered a [CONDITION(S)] medication, if the resident did not give a consent, the physician had to be notified to discontinue the order. An interview was conducted on October 20, 2022 at 1:04 p.m. with the DON (staff #11). Staff #11 stated her expectation with regards to [CONDITION(S)] medications is that it must have consent. Staff #11 stated the [CONDITION(S)] medication cannot be given without consents, and that she would call the physician to discontinue the order. The DON stated that with regards to the medications [MEDICATION(S)] and [MEDICATION(S)] for resident #21, she cannot locate the consents. A facility policy, Psychoactive Medication, stated it is the policy of the facility to maintain every resident's right to be free from use of psychoactive medication. The use of a psychoactive medication must first be explained to the resident, family member, or legal representative. A consent is to be obtained either from the resident or responsible party if the resident is unable to give consent.

Based on clinical record review, staff interviews, and review of policy and procedures, the facility failed to ensure the provider received notification of an unwitnessed fall regarding one resident (#84). The sample size was 12. The deficient practice could result in delayed care. Findings include: Resident #84 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A risk for falls care plan was initiated on 10/14/22 related to dementia, psychoactive drug use, and weakness. The goal was for the resident not to sustain serious injury. Interventions included encouraging the resident to participate in activities that promote exercise and physical activity for strengthening and improved mobility. The Fall Risk Evaluation dated 10/14/22 revealed the resident was assessed to be at high risk for falls. The nursing progress note dated 10/17/22 at 7:24 a.m. revealed the resident was found on the floor by the bedside during the midnight round. The note stated that upon assessment, no injuries were found and the resident was assisted back to bed. The note included the resident was not able to say how the fall occurred, that the resident had altered mental status, and mostly spoke another language other than English. The note stated the resident was medicated with as needed pain and antianxiety medications, and that attempts to reach the resident's representative were unsuccessful. Review of the Neurological Worksheet dated 10/17/22 beginning at 12:45 a.m. revealed neurological checks were completed. A Fall Risk Evaluation dated 10/17/22 at 11:59 p.m. revealed the resident was assessed to be at high risk for falls. The care plan was revised on 10/17/22 to include frequent visual checks by staff. However, review of the clinical record revealed no evidence the provider had been notified of the resident's fall. On 10/20/22 at 9:29 a.m., an interview was conducted with a Registered Nurse (RN/staff #10). She stated that when a resident has a fall, the process includes assessing the resident and obtaining vital signs before the resident is moved/assisted back into bed. The RN stated if the resident is disoriented and/or cannot state whether they hit their head or not, she will begin neuro checks. The RN stated that she will call the provider and the Director of Nursing (DON). She stated that she will document a progress note in the resident's clinical record. The RN stated that a fall is considered a change of condition and that follow up would continue for 3 days. An interview was conducted on 10/20/22 at 11:21 a.m. with the DON (staff #11). She stated that her expectations regarding the nurse responding to a fall would include completing a head-to-toe assessment, taking the resident's vital signs, assessing range of motion and cognition changes, and beginning neuro checks. She stated the nurse should assess the situation and determine what may have happened. The DON stated the nurse should notify the provider and family members, and that she would be notified by text. She stated the nurse should obtain any new orders and address the injuries and/or pain. The DON stated the nurse should make sure the resident is safe, and that new interventions are input into the resident's care plan. She stated that all of this should be documented in a progress note. The DON stated the interdisciplinary follow-up note would be completed after the risk management note and will show up in the progress notes. Review of the facility policy titled Fall Management System, reviewed 05/2022, revealed the facility is committed to promoting resident autonomy by providing an environment that remains as free of accident hazards as possible. Each resident is assisted in attaining or maintaining their highest practicable level of function through providing the resident adequate supervision, assistive devices and functional programs as appropriate to prevent accidents. It is the policy of the facility to provide each resident with appropriate assessment and interventions to prevent falls and to minimize complications if a fall occurs. When a resident sustains a fall, a physical assessment will be completed by a licensed nurse, with results documented in the nursing progress notes. The attending physician and family/responsible party shall be notified of the fall and the resident status. Review of the fall incident will include investigation to determine probable causal factors considering environmental factors, resident medical condition, resident behavioral manifestations, and medical or assistive devices that may be implicated in the fall. The investigation will be reviewed by the interdisciplinary team. Results of the investigation will be documented in the resident's clinical record.

Based on clinical record review, staff interviews, State Agency (SA) database, review of facility records, and review of policies and procedures, the facility failed to report an allegation of abuse regarding one sampled resident (#130), to the law enforcement agency within the required time frame. The deficient practice could result in more reasonable suspicions of crime not being reported. Findings include: Resident #130 was admitted to the facility on [DATE] with diagnoses that included wedge compression fracture of unspecified lumbar vertebra, contusion of left forearm, and generalized muscle weakness. An admission Minimum Data Set (MDS) assessment dated [DATE] included a BIMS (Brief Interview of Mental Status) score of 15 indicating resident #130 had intact cognition. The assessment stated the resident required extensive assistance with bed mobility, transfer, toilet use and personal hygiene with one-person physical assistance. Review of the State Agency (SA) Complaint/Incident Investigation Report, dated February 10, 2022 at 11:35 a.m. revealed the SA received a self-reported abuse allegation from the facility. The SA Complaint/Incident Investigation Report stated the resident and family member felt an agency aide and student had purposely kicked resident #130 during a transfer, and purposely mistreated the resident. Review of facility records did not reveal any documented evidence that the alleged abuse regarding resident #130 that occurred February 10, 2022 had been reported to law enforcement. On October 19, 2022 at 10:06 a.m., an interview was conducted with the current DON (director of nursing/staff #11). The DON stated that she reached out to the previous DON and facility leaders, and was told they could not find a facility investigation related to the alleged abuse. An interview was conducted with the current facility administrator (staff #51) on October 20, 2022 at 1:47 p.m. Staff #51 stated it is his expectation that the abuse policy is implemented and followed thoroughly. The facility's abuse policy, revised November 2018 stated the policy of the facility is that each resident has the right to be free from abuse, neglect, misappropriation of resident property, exploitation, and mistreatment. Ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported to the administrator of the facility, the State Survey Agency, Adult Protective Services. Review of the facility's policy regarding Prevention of and Prohibition Against Abuse reviewed 9/2020, revealed it is the policy of the facility that each resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation. Allegations of abuse, neglect, misappropriation of resident property, or exploitation will be reported outside the facility and to the appropriate State or Federal agencies in the applicable timeframes, per this policy and applicable regulations.

Based on clinical record review, staff interviews, facility documentation, the State Agency (SA) database, and policy review, the facility failed to ensure that an allegation of abuse was investigated regarding one sampled resident (#130). The deficient practice could result in further allegations of abuse not being investigated. Findings include: Resident #130 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident was discharged [DATE]. An admission Minimum Data Set (MDS) assessment dated [DATE] included a BIMS (Brief Interview of Mental Status) score of 15 indicating resident #130 had intact cognition. The assessment stated the resident required extensive assistance with bed mobility, transfer, toilet use and personal hygiene with one-person physical assistance. Review of the State Agency (SA) Complaint/Incident Investigation Report, dated February 10, 2022 at 11:35 a.m. revealed the SA received a self-reported abuse allegation from the facility. The allegation included that the resident and family member felt an agency aide and student had purposely kicked resident #130 during a transfer, and purposely mistreated the resident. Review of the facility documentation revealed no evidence that the facility completed an abuse investigation related to the alleged physical and mental abuse. On October 19, 2022 at 10:06 a.m., an interview was conducted with the Director of Nursing (DON/staff #11), who stated that she had reached out to the previous DON and leaders, and was told they could not find the facility investigation related to the alleged abuse. An interview was conducted with the facility administrator (staff #51) on October 20, 2022 at 1:47 p.m. Staff #51 stated it is his expectation that the abuse policy is implemented and followed thoroughly, including the investigation process. The facility's abuse policy, revised November 2018 revealed each resident has the right to be free from abuse, neglect, misappropriation of resident property, exploitation, and mistreatment. All allegations of abuse, neglect, misappropriation of resident property, and exploitation will be promptly and thoroughly investigated by the administrator or his/her designee.

Based on clinical record review, resident and staff interviews, and review of policies, the facility failed to ensure two sample residents (#3 & #14) were consistently provided care and services to maintain acceptable parameters of nutritional status. The deficient practice could result in residents with unplanned weight loss and dehydration. Findings include: -Resident #3 admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A nutritional problem/potential nutritional problem care plan dated 05/03/21 related to abnormal labs, impaired cognition, and leaving 25% or more at meals, had a goal for the resident to maintain adequate nutritional status as evidenced by no significant weight changes. Interventions stated for the registered dietician to evaluate and make diet change recommendations. A physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . The annual Minimum Data Set assessment dated [DATE] revealed the resident had been assessed to have severely impaired cognition, and required total 1-person physical assistance for most activities of daily living, including eating. Review of a Quarterly Nutrition Review dated 08/25/22 revealed the resident weighed 115.4 pounds on 08/09/22. Per the review, the resident's weight had been stable for the past 90 days, with a 7% weight gain within the previous 180 days. The Weight Summary revealed the resident weighed 116.2 pounds on 09/06/22. The Weight Summary revealed the resident weighed 94.0 pounds on 09/20/22, for a loss of 19.10% within a 30-day period. The potential nutritional problem care plan was revised 09/23/22 to include a note regarding the significant weight loss in the previous 30 days, which was stated to be a possible error. The resident's skin was described as intact and according to the note, there were no new labs for review. Continued review of the clinical record revealed no evidence the resident had been assessed by the registered dietitian and/or the provider to address the significant loss of weight. In addition, no new interventions were identified in the resident's care plan. A physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Further review of the clinical record revealed the resident's weight was not obtained until 10/18/22, when the resident's weight was documented at 96.3 pounds. On 10/20/22 at 9:17 a.m., an interview was conducted with a Registered Nurse (RN/staff #10). She stated that weekly weights are obtained to identify significant weight loss, meaning 5 pounds or more. She stated that she works in the facility regularly, so even if the weights were not being completed she would notice whether the residents looked different (e.g., sunken cheeks or lack of skin turgor). She stated that she would also ask the Certified Nursing Assistants (CNAs) about the resident's appetite. The RN stated that if she noticed that a resident was not being weighed as ordered, she would take the weight immediately. She stated that it would not be appropriate not to follow the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The RN stated that if the resident had a significant weight change, the weight on the resident's electronic profile would be red. The RN stated that before she panicked, she would re-weigh the resident. The RN stated the process for significant weight loss would include calling the doctor to report, obtaining new orders, following recommendations, and referral to the dietician. An interview was conducted on 10/20/22 at 10:21 a.m. with the Registered Dietician Nutritionist (RDN/staff #45). She stated that in order to conduct a good nutritional assessment, she would need to obtain the resident's height, weight, labs, and history data. She stated the residents who may be at risk for nutritional deficiencies will be identified. She stated that typically, she will rely on a gatekeeper, in this case the food service manager. She stated that if it was not identified previously, and weights were not being monitored, they will review the intake records, and complete a visual assessment (nutrition focused physical exam) if there was a lot of data. The RDN stated the only way she would have known the resident had lost weight would be for the resident's weight to have been triggered in red on the clinical record. The RDN stated that now the resident has been weighed and has triggered in the red, she would know the resident has had a significant weight change. She stated that it will be imperative to involve the provider as well. On 10/20/22 at 11:21 a.m., an interview was conducted with the Director of Nursing (DON/staff #11). She stated if the physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . She stated that if the resident refused, it should be documented. The DON stated the risks for not following the physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . The facility policy titled Nutrition, reviewed 07/2022, revealed it is the policy of the facility to ensure that all residents maintain acceptable parameters of nutritional status, such as body weight and protein levels, unless the resident's clinical condition demonstrates that this is not possible. Each resident's nutritional status is assessed on admission and at least quarterly thereafter. Each resident is to be weighed upon admission, weekly weights for 4 weeks, and monthly weight thereafter unless otherwise specified by the attending physician. Monthly weights are to be completed and reviewed by the Registered Dietician, Dietary Technician and/or designee. Any resident weight that varies from the previous reporting period by 5% in 30 days, 7.5% in 90 days, and 10% in 180 days will be evaluated by the interdisciplinary team to determine the cause of weight loss/gain, interventions required, and need for further recommendation and/or referral. The family member/responsible party and attending physician will be notified. Care plans will be updated or revised as needed. -Resident #14 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed the resident scored 14 on the Brief Interview for Mental Status (BIMS) assessment, indicating intact cognition. The resident required extensive 2+ person physical assistance for most activities of daily living (ADLs), and received anticoagulant medication for 7 out of the 7 days in the lookback period. A potential fluid deficit care plan dated 10/14/22 related to nothing by mouth status had a goal for the resident to be free from symptoms of dehydration, to maintain moist mucous membranes and good skin turgor. Interventions stated to monitor/document/report to the medical doctor as needed for any signs or symptoms of dehydration. A physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . The order indicated the request had been received from Speech Therapy. Review of the October 2022 Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . However, the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] On 10/18/22 at 9:37 a.m., an interview was conducted with resident #14. She stated that she is supposed to receive ice chips 3 times per day, but that staff will not give it to her unless she keeps asking multiple times. The resident stated that she feels the staff do not take her need for ice as seriously as other residents who receive food. The resident stated that she had been assessed by the speech therapist as safe to receive ice chips, and that now that she is unable to eat, getting ice chips was a big deal to her. Review of the October 2022 MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] An interview was conducted on 10/19/22 at 1:49 p.m. with a Licensed Practical Nurse (LPN/staff #25). She stated that the resident had been cleared to receive ice chips, but that she aspirates on them. She stated that staff need to stay with the resident while she eats them. She stated that it was hard to stay in the resident's room because she did not have time to sit in there with the resident. The LPN stated that the nursing process and expectation is that she would call the provider to make a recommendation and explain her rationale. The LPN stated that it was not acceptable to not provide the ice chips as ordered. On 10/20/22 at 11:21 a.m., an interview was conducted with the Director of Nursing (DON/staff #11). She stated that if there is a physician order, she expects it to be followed. The DON stated that if nursing needs clarification, she expects clarification to be sought from the provider. She stated that she thought the nurses would know this process. The facility's policy regarding Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] .

Based on clinical record review, staff interviews, and policy reviews, the facility failed to ensure respiratory care was provided consistent with professional standards of practice for one resident (#19) by failing to ensure there was a physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . The sample size was 2. The deficient practice could result in residents not having an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Findings include: Resident #19 was admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . An admission MDS (minimum data set) assessment dated [DATE] revealed resident #19 BIMS (brief interview of mental status) score was 11 which indicated moderate cognitive impairment. A physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . Per the physician note, the resident is also using a [CONDITION(S)] machine. A physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . However, further review of the clinical record revealed no evidence of a physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . An observation was conducted on October 18, 2022 at 1:04 p.m. Resident #19 was observed seated in a wheelchair, with no oxygen on. There was an oxygen concentrator by the bedside that had oxygen tubing without a nasal cannula. A [CONDITION(S)] machine was observed on the nightstand. Resident #19 stated that he uses oxygen at night at 2 liters. The resident stated the physician told him to use the oxygen all the time to help him breathe better. Resident #19 stated the oxygen was not offered by the staff during the day, there is no nasal cannula. Resident #19 stated there is only a tubing on the oxygen because he had to attach it on the [CONDITION(S)] machine at night. Per resident #19, the nursing staff watches him when he attaches the oxygen on the [CONDITION(S)] machine every night. An interview was conducted on October 20, 2022 at 12:35 p.m. with a registered nurse (RN/staff #10). Per staff #10, the use of a [CONDITION(S)] machine must have a physician order, otherwise the staff would not know when to apply the device, how to maintain it such as putting in water, and how to prevent infection such as cleaning and replacing the mask, and the water reservoir. An interview was conducted on October 20, 2022 at 1:04 p.m. with the DON (Director of Nursing/staff #11). Staff #11 said her expectation for a [CONDITION(S)] machine and oxygen is there must be a physician order, per the facility policy. The DON stated if a physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . The facility's policy Oxygen Administration stated it is the policy of the facility that oxygen therapy is administered as ordered by the physician. A facility policy, [CONDITION(S)]/[CONDITION(S)] Monitoring and Management-Guideline, stated it is the policy of this facility that: 1. [CONDITION(S)]/[CONDITION(S)] devices are administered as ordered by the physician for conditions such as Chronic Respiratory Failure, Respiratory Distress, and Sleep Apnea. 2. Interventions are implemented to minimize risks associated with [CONDITION(S)]/[CONDITION(S)]. Obtain a physician order, and verify machine settings. For machines using humidification, fill the appropriate chamber, clean the chamber every evening before usage per manufacturer directions, and reassess the resident as needed in response to changes in physician orders, changes in the resident's condition, and in response to ventilator alarms.

Based on observations, staff interviews, the CDC (Centers for Disease Control and prevention) and policy review, the facility failed to ensure visual alerts were posted to ensure everyone was aware of the recommended infection control practices in the facility. The deficient practice could result in the spread of infection. Findings include: Upon entrance into the facility on [DATE] at approximately 7:24 AM, it was observed that there was no signage posted on the door regarding infection prevention and control (IPC) practices in the facility. Review of the facility's resident matrix revealed residents in the facility had COVID. Observations conducted throughout the survey revealed no signage to inform visitors of appropriate IPC actions to take while in the facility. An interview was conducted on 10/20/22 at 9:09 AM with the Infection Control Prevention Specialist (staff #44) who stated there used to be signage that instructed what personal protective equipment (PPE) to wear while in the facility. An interview was conducted with the Director of Nursing (DON/staff #11) on 10/20/22 at 12:05 PM. The DON stated that the screening at the front desk is the signage of infection prevention practices for the facility. The DON stated individuals attest to the precautions for COVID when they screen in. The DON stated there is a physical posting by the double doors. On 10/20/22 at 12:20 PM, signage was observed on the outside wall of the facility that had a picture mask and said mask up. The CDC Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic updated September 23, 2022 stated to ensure everyone is aware of recommended IPC practices in the facility, post visual alerts (e.g., signs, posters) at the entrance and in strategic places (e.g., waiting areas, elevators, cafeterias). These alerts should include instructions about current IPC recommendations (e.g., when to use source control and perform hand hygiene). Review of the facility policy, Infection Prevention and Control Program revised 5/2022 revealed the infection prevention and control program is a facility-wide effort of all disciplines and individuals and is an integral part of the quality assurance and performance improvement program. The elements of the infection prevention and control program consist of coordination/oversight, policies/procedures, surveillance, data analysis, antibiotic stewardship, outbreak management, prevention of infection, and employee health and safety.

Based on observations, family and staff interviews, clinical record review, and review of policy, the facility failed to ensure the call light for one resident (#84) was appropriately placed within the resident's reach. The sample size was 12. The deficient practice could result in residents not having the means to communicate with staff and not receiving care or services in a timely manner. Findings include: Resident #84 was admitted to the facility on [DATE] with diagnoses that included [CONDITION(S)], unspecified dementia, severe, anxiety, and [CONDITION(S)]. A risk for falls care plan initiated on 10/14/22 related to dementia, psychoactive drug use, and weakness, had a goal the resident would not sustain serious injury. Interventions included keeping needed items, such as water, etc., in reach. On 10/18/22 at 10:17 a.m., an interview was conducted with the resident's representative. She stated the resident had fallen out of bed in the morning of the previous day. The representative stated that she did not know where the resident's call light was. There was no call light observed to be plugged into the wall over the resident's bed. After looking around the bed and the room for several minutes, the resident's representative stated the call light was in the drawer of the resident's bedside table. The bedside table was identified to be located across the room, approximately 4-5 feet from the resident's bed. An observation was conducted on 10/19/22 at 8:57 a.m. The resident was observed lying in bed with eyes closed. The resident's call light was observed in the drawer of the bedside table, across the room, disconnected, and not within the reach of the resident. On 10/19/22 at 8:59 a.m., an interview was conducted with a Certified Nursing Assistant (CNA/staff #28). She stated that she had been hired as a sitter for resident #84 beginning that morning at 6:00 a.m. She stated that she would be with the resident until 6:00 p.m. that evening. She stated that she had not noticed where the resident's call light was. An interview was conducted on 10/20/22 at 11:21 a.m. with the Director of Nursing (DON/staff #11). She stated that she would expect the call light to be within reach. The DON stated the call light should not be placed in a drawer, and that the risks to the resident would include falls and/or injuries. The facility policy titled Call Light/Bell, reviewed 05/2022, stated it is the policy of this facility to provide the resident a means of communicating with nursing staff. Place the call device within the resident's reach before leaving the room. If the call light/bell is defective, immediately report this information to the unit supervisor and communicate to the maintenance department immediately and complete a work order.

Based on observations, clinical record reviews, interviews, and policy, the facility failed to ensure that residents, their representatives, and family members were notified of the COVID-19 status of the building for four residents (#100, #104, #105, and #102). The census was 27 residents. The deficient practice could result in residents and their representatives/families not being aware of new COVID-19 cases in the facility. Findings include: -Resident #100 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the admission Minimum Data Set (MDS) assessment dated [DATE] included that the resident scored a 15 on the Brief Interview for Mental Status (BIMS) indicating the resident was cognitively intact. During an interview with the resident on June 15, 2022 at 9:29 a.m., there were two letters dated June 9, 2022 and June 14, 2022, notifying the resident of new cases of COVID-19 among residents or staff observed on the resident's bedside table. The resident stated that she has never been informed by staff of anyone testing positive for COVID-19 in the building until yesterday when staff came into her room and put the two letters on her tray. She said that the staff put the letters on her tray, did not say anything, and then left. -Resident #104 was admitted to the facility on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the admission MDS assessment dated [DATE] included that the resident scored a 10 on the BIMS indicating the resident had moderate cognitive impairment. An interview was conducted with the resident on June 15, 2022 at 9:45 a.m. She stated that she was given two letters yesterday and pointed to her tray. It was observed that the dates on the letters were June 9, 2022 and June 14, 2022 and both letters were notification of COVID-19 cases in the building. She stated that staff came in her room and put the letters on her tray and then left the room. She read the letters herself and stated that she has never received letters regarding COVID-19 being in the building before. She said that no one has talked to her about this before, and she is very interested in knowing about this. -Resident #105 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the admission MDS assessment dated [DATE] included that the resident was coded as being rarely/never understood on the BIMS. The staff interview indicated that the resident had both short-term and long-term memory problems. During an interview with the resident on June 15, 2022 at 9:57 a.m. she stated that she was given two letters yesterday. The letters were observed sitting on top of her side dresser. She stated that she had not read the letters and no one talked to her about the letters. The letters were dated June 9, 2022 and June 14, 2022 and were in regards to notification of new COVID-19 cases of staff or residents in the facility. -Resident #102 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the admission MDS assessment dated [DATE] included that the resident scored a 15 on the BIMS indicating the resident was cognitively intact. An interview was conducted on June 15, 2022 at 10:07 a.m. with the resident. She stated she currently has COVID-19 and has never received a letter notifying her of COVID-19 positive staff or residents in the building. She said that the only time she knew there was COVID-19 in the building is when she was moved from the other room to this room and that is because staff were telling her why she was being moved. She said there were some papers left at her door yesterday and she pointed to them. Review of the papers did not reveal notifications of COVID-19 positive staff or residents. Review of COVID-19 testing documentation revealed that a staff member (#48) tested positive on May 23, 2022, a resident (#106) tested positive on May 25, 2022, a resident (#17) tested positive on June 2, 2022, a resident (#26) tested positive on June 3, 2022, a staff member (#42) tested positive on June 9, 2022, and a resident (#102) tested positive on June 14, 2022. During an interview on June 14, 2022 at 9:50 a.m. with the Infection Preventionist (IP/staff #80), she stated that the facility has been in outbreak mode for COVID-19 since May 23, 2022. She said that she went to the residents' rooms to speak with residents and notify them that staff or residents tested positive for COVID-19 and she notifies the representatives by phone. She said she would see if she kept documentation showing residents and representatives were notified. She stated that they have had positive staff and/or residents almost weekly and she acknowledged the COVID-19 testing documentation and the positive cases listed on there. A second interview was conducted on June 14, 2022 at 10:40 a.m. with the IP (staff #80) and she stated that she had one letter dated May 23, 2022 notifying residents and family members/representatives about a COVID-19 positive result, but did not have documentation to show the letter was given to the residents. She stated that the letters are completed by the marketing coordinator (staff #81), the nurses hand out the letter/notification to the residents, and a letter is mailed to the family members/representatives. During the interview, she also provided a checklist and stated the checklist showed that she contacted the family by phone or left a message and also went to talk to each resident on May 26, 2022. She said that she did not have any other documentation to show that residents and family members/representatives were being notified of staff or residents testing positive for COVID-19. On June 14, 2022 at 12:06 p.m., an interview was conducted with the IP (staff #80) and the marketing coordinator (staff #81) joined via phone. During the interview, the marketing coordinator stated that she has been instructed to type a letter each Thursday and forward the letter to the director of programming (staff #64) and the director of human resources (staff #53). She said that the letter is addressed to residents, family, and skilled nursing family members advising them of COVID-19 positive staff or residents in the facility. She said that she had been typing the letter/notification at least once a week since the facility went into outbreak mode on May 23, 2022, but didn't know who was responsible for ensuring the letter/notification was given to the residents in the skilled nursing section of the facility. The IP stated that the skilled nursing section of the facility doesn't have an activity person at this time, so the director of programming (staff #64) has been running the activity program for skilled nursing and she said she would find out whether the director of programming (staff #64) or the director of human resources (staff #53) had been notifying the residents, family, and staff when staff or residents have tested positive for COVID-19. An interview was conducted on June 14, 2022 at 1:07 p.m. with the director of human resources (staff #53), who stated that she has an employee roster and notifies the staff every Thursday via an emailed letter regarding staff and residents testing positive for COVID-19. She said that the director of programming (staff #64) delivers the letters/notifications to the assisted living and independent living mailboxes. At 1:24 p.m., the director of programing (staff #64) joined the interview and stated that she has not passed out any letters/notifications to the residents in skilled nursing or mailed any letters to the family/representatives. An interview was conducted on June 15, 2022 at 9:01 a.m. with a Certified Nursing Assistant (CNA/staff #31), who stated that it is her understanding that the IP (staff #80) notifies the residents and family members when there is a COVID-19 positive staff or resident. She said, she saw the IP giving out letters/notification yesterday. On June 15, 2022 at 10:20 a.m., an interview was conducted with the IP (staff #80), who stated she handed out one letter dated June 14, 2022 to the residents, then she said she may have handed out two letters yesterday one dated June 9, 2022 and the other dated June 14, 2022, but thought she only had one letter. She stated that the letters were emailed to her by the marketing coordinator (staff #81) yesterday. She reviewed her email and confirmed that both letters were included in the email. Then she said that she thinks the nurses were supposed to hand out the letter/notification on May 23, 2022 when the facility went into outbreak mode, but it was her understanding that the letter would be handed out by the director of programming (staff #64). She acknowledged that staff #64 was not handing out the letter/notification to the residents and thinks notification did not occur due to a miscommunication. She stated that there was no documentation that the residents were notified about the COVID-19 positive cases on May 23, 2022, which was the initial outbreak and for the case on June 2 and June 3. She stated that the facility doesn't document in the resident's record that the resident was notified of COVID-19 positive cases. During this time, the Director of Nursing (DON/staff #66) joined the interview and stated that she had notified the residents about the staff testing positive on May 23, 2022. Both staff reviewed clinical records for the above residents and found documentation that residents were notified on May 25, 2022. Both staff agreed that the notification on May 25, 2022 was regarding resident (#106) who tested positive on May 25, 2022. An interview was conducted on June 15, 2022 at 11:15 a.m. with a Licensed Practical Nurse (LPN/staff #38), who stated that she helped to pass out letters regarding notification of COVID-19 staff or residents yesterday and helps when the IP asks for help. She said she doesn't document that she gave a letter or notified the resident regarding a COVID positive staff or resident. She was not able to remember when she helped pass out letters to the residents. She thinks that the IP documents that residents and family have been notified. Review of the facility's COVID-19 communication policy, dated March 2020, revealed that to assure transparency of communication to residents and family members of identified COVID-19 cases within the facility are occurring, the facility will report COVID-19 status within the nursing home by 5:00 p.m. of the next calendar day following the occurrence of a single, confirmed COVID-19 infection among residents or staff. The policy noted that the facility will provide weekly cumulative updates to residents, resident representatives and families.

Based on clinical record review, staff interviews, and policy review, the facility failed to ensure an order for a PRN (as needed) [CONDITION(S)] medication included a 14 day stop date and/or documentation by the prescribing practitioner regarding the rationale for extended use that indicated the duration for the PRN order, for one resident (#18). The sample size was 5. The deficient practice could result in residents receiving [CONDITION(S)] medications that may not be necessary. Findings include: Resident #18 was admitted to the facility on [DATE] with diagnoses that included urinary tract infections site not specified, [CONDITION(S)] [CONDITION(S)], Type 2 Diabetes Mellitus without complications, and unspecified dementia with behavioral disturbances. A review of the clinical record revealed a physician order dated September 9, 2021 for Lorazepam (anxiolytic) concentrate 2mg/ml (milligrams/milliliters) give 1 mg by mouth every 4 hours as needed for restlessness. Review of the Medication Administration Record (MAR) for September 2021 revealed the resident was administered PRN Lorazepam once on September 12, and twice on September 15 & 22. A review of October 2021 MAR revealed PRN Lorazepam was administered to the resident once on October 8 & 12. However, further review of the physician orders did not reveal an order for the duration of the PRN Lorazepam. In an interview conducted with a Registered Nurse (RN/staff #21) on October 14, 2021 at 12:51 p.m., the RN stated PRN [CONDITION(S)] medications should have a stop date which is 14 days unless the resident is receiving hospice. An interview was conducted with the Assistant Director of Nursing (ADON/staff #1) on October 14, 2021 at 1:24 p.m. The ADON stated that PRN [CONDITION(S)] medications should be ordered for 10-14 days and then a physician has to review it. Staff #1 reviewed the clinical record for staff #18 and acknowledged the PRN Lorazepam order did not have a stop date. The ADON stated that the resident is receiving hospice services and that their physician writes the orders. She stated that the PRN Lorazepam is an order from the hospice agency. The ADON also stated the hospice nurses comes to the facility 1 to 2 times a week to monitor the resident's medications. Review of the facility's Antipsychotic Medication Use policy revised December 2016, revealed residents will not receive PRN doses of [CONDITION(S)] medications unless that medication is necessary to treat a specific condition that is documented in the clinical record. The need to continue PRN orders for [CONDITION(S)] medications beyond 14 days requires that the practitioner document the rationale for the extended order and the duration of the PRN order will be indicated in the order.

Based on clinical record review, facility documentation and a staff interview, the facility failed to ensure one resident's (#79) credit cards were not misappropriated. Findings include: Resident #79 was admitted to the facility on (MONTH) 20, (YEAR), with [DIAGNOSES REDACTED]. Review of an admission Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 13, which indicated the resident had intact cognition. Review of a facility's investigative report revealed that on 1/28/19 at 1:40 p.m., resident #79 reported that two credit cards and $40 in cash were missing from her purse. The police were notified and the credit cards were canceled. The police came out to the facility and started an investigation. On 2/19/19, the administrator (staff #36) and the Director of Nursing (staff #25) met with police, who showed them video footage of two females at a register using the resident's credit card at a local grocery store. The two people were identified as housekeepers that worked at the facility. The report further included the police determined that one of the housekeepers was innocent, and the other housekeeper (staff #84) was the one who used the credit card. Staff #84 was terminated. The report also included that the police had additional evidence that staff #84 had used the resident's credit card at other locations. An interview was conducted on 7/23/19 at 1:00 p.m. with staff #36, who stated that she did identify staff #84 in the video.

Based on closed clinical record review, staff interviews, and facility policy review, the facility failed to ensure an assistive device was in place to help prevent a fall with injury, as physician ordered for one resident (#149). This resident sustained [REDACTED]. Findings include: Resident #149 was admitted to the facility on [DATE], and readmitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of the Tinetti Assessment Tool by physical therapy dated November 25, 2011, revealed a balance score of two out of 16, gait score of two out of 12, and a balance and gait score of four out of 28. This assessment determined that the resident was at high risk for falling. Review of the Change of Condition dated December 1, 2011, revealed that the resident was found on the floor at the end of her bed with a large hematoma on the back of her head. The resident was transported by ambulance to the hospital and was admitted . The resident was readmitted to the facility on [DATE]. Review of the resident's Admission Data Collection dated December 6, revealed a fall risk assessment score of 14; a score of ten or greater represented high risk. The interim fall care plan dated December 6, included the following interventions: right upper grab bar and tab alarm for bed and chair. Review of the History and Physical dated December 8, 2011, revealed that the resident had three staples in the right scalp from her fall on December 1. The Minimum Data Set (MDS) revealed that an admission assessment was completed on December 13, 2011. Section J. noted that the resident had a history of [REDACTED]. noted that the resident required extensive assistance with bed mobility, toileting, and personal hygiene, and total dependence with dressing and locomotion. Despite the resident's recent fall with injury and MDS assessment documentation regarding a history of falls, no fall care plan was developed based on the comprehensive assessment. Review of the Nurses Daily Progress Note dated December 13, 2011, revealed that the resident was alert and oriented with some confusion, was occasionally incontinence of bowel and bladder, and was able to make needs known. Review of the Change of Condition-Alert Charting investigation dated January 23, 2012, revealed the resident was found sitting on the floor at her bedside, crying out in pain. The bed/chair alarm was not attached. The resident was complaining of right hip pain, and was unable to move her right lower extremity. Review of the Reportable Event Record/Report revealed that the resident was found sitting on the floor next to her bed at 5:15 p.m. The resident stated that she was trying to walk to the bathroom. She immediately complained of right hip/leg pain and was unable to move her right leg. The resident was transported by ambulance to the emergency department for evaluation, where she was treated for [REDACTED]. An interview was conducted with a certified nursing assistant (CNA) on October 3, 2012. The CNA stated that she gave the resident a shower on January 23, 2012, and that there was no tab alarm on the resident. She also stated that she had been off for four days and when she took over from the night shift, no tab alarm was on the resident. She stated that she had planned to ask the nurse if the resident was supposed to still have a tab alarm, but got busy with other residents and forgot. After the resident had fallen and fractured her hip, the tab alarm was found in the resident's night stand. A telephone interview was conducted on October 4, 2012, with a registered nurse (RN). The RN stated that this resident was alert and oriented, but frequently forgot to call for help and was weak. She also stated that the resident continued to require the use of a tab alarm for her safety, but had frequently taken off her tab alarm and would set it aside. An interview was conducted with the director of nursing (DON) on October 4, 2012. The DON stated that she was not working at the facility at the time of the incident, but stated that the resident should have had her tab alarm on at the time of the fall. The facility did provide Quality Assessment (QA) documentation of staff inservice's and training that occurred due to this incident. However, the documentation did not identify the concern that the safety device (bed/chair alarm) was not in place prior to the fall and the staff training documentation did not address the need to ensure safety devices are in place to prevent further falls. Review of the facility's policy on Falls Management Program revealed "...The facility will have a system in place to ensure that the community's residents are assessed on admission for their potential fall risk and to guide in the implementation of interventions to assist in decreasing the frequency or severity in the event a fall does occur...Avoidable accident: implement interventions, adequate supervision (consistent with the resident's needs), goals, plan of care, and current standards of practice in order to reduce the risk of an accident...The facility is obligated to provide adequate supervision to prevent accidents..."