Every finding on record at Grand Traverse Pavilions

This pertains to intakes 2687925 and 2741873.Based on observation, interview, and record review the facility failed to ensure adequate supervision and/or implement appropriate interventions to prevent falls for three Residents (#1, #3, & #5) of three residents reviewed for falls, resulting in Resident #3 sustaining a right hip fracture which required hospitalization and surgical intervention.Findings include:Resident #3 (R3)A review of a fall report dated 12/9/25, at 5:03 am, indicated R3 fell in the bathroom. The incident description indicated . CNA heard loud sound from room and when he went into room, he observed the resident on the floor in the bathroom. Resident Description: Resident does not remember what happened but thinks she messed up her footing and slipped on the floor. She stated she did not look (sic) consciousness but did hit her head. Other Info: Patient did not have proper footwear on and told CNA she was okay to be left alone before sitting down onto the toilet. Pt (patient) believes she lost her balance and slipped on the floor but doesn't remember exactly what happened. She was admitted partially for orthostatic hypotension.A review of R3's Electronic Medical Record (EMR) indicated R3 was admitted to the facility on [DATE] with diagnoses including weakness, malaise, and orthostatic hypotension (a sudden drop in blood pressure occurring when standing up from a seated or lying position).A review of the Minimum Data Set (MDS) assessment for R3 dated 12/5/25 had a Brief Interview for Mental Status (BIMS) score of 12/15, indicating moderate cognitive impairment. A score of 12/15 according to the Clevelandclinic.org indicates moderate problems with thinking and memory and suggested a resident would need increased assistance with daily activities and monitoring for cognitive decline.A statement provided by the facility from the CNA that ambulated R3 to the bathroom on 12/9/25 stated, I answered the call light, and she (R3) said she needed to use the bathroom. I put her gait belt and ambulated her to the bathroom. When we got there, she pulled her own pants down and told me I could leave. As I was leaving, she missed the toilet and landed on the floor. Several attempts to interview this CNA regarding this event were unsuccessful.A 'Progress Note' documented by Registered Nurse (RN) D on 12/9/25 at 5:28 AM revealed the following: Pt was ambulating to the bathroom with assistance from the CNA but before sitting all the way down, the patient told the CNA she was okay to be left alone. When the CNA closed the door, he heard a loud noise from the behind the door and observed the patient on the floor. RN arrived and observed the patient on the floor laying on her right side with walker laying next to her. CNA and RN were able to get patient up and onto the toilet. Patient stated she did hit her head and that her right hip was painful. Once patient was done using the bathroom, she was wheeled back to her bed in a wheelchair. Vital signs were stable. RN assessed head and hip, no injuries noted, just pain. Tylenol given. Physician notified(sic)On 12/9/26 the on-call physician did a telehealth visit and ordered a right hip x-ray.On 12/9/26 an alert note indicated Xray positive for fracture in right hip, patient notified, provider gave order to send to ER (emergency room).On 2/23/26 at 4:19 PM during a phone interview, RN D stated she was unsure exactly how the fall of R3 went, as she was not present in the room when R3 fell. RN D recalled the CNA had stated he had just about got the door closed when he heard the loud noise from the bathroom. RN D stated R3 complained of pain of about a two, post fall. A review of R3's care plan indicated a focus was initiated on 12/5/25 stating the resident is at a high risk for falls r/t (related to) weakness. Interventions initiated on 12/5/25 included Do not leave resident alone in the bathroom and ensure that the resident is wearing appropriate footwear when resident is ambulating or mobilizing in wheelchair. R3 did not have proper footwear on to ambulate.Resident #1 (R1)A review of the EMR for R1 revealed the latest admission date to the facility on 1/9/24, with diagnoses including neurocognitive disorder with Lewy Bodies (a progressive dementia characterized by abnormal protein deposits (Lewy bodies) in the brain, causing fluctuating cognition, detailed visual hallucinations, sleep disorder, and movement issues), major depressive disorder, bipolar disorder (a chronic mental health condition causing extreme, intense mood swings), Post-Traumatic Stress Disorder (PTSD) (a mental health condition that develops after experiencing or witnessing a traumatic event) and repeated falls. R1 had a Brief Interview for Mental Status (BIMS) score of 5/15, indicating severe cognitive impairment.The EMR indicated R1 had a fall in her room on 2/3/26 while on one-to-one observation by facility staff.An incident witness statement on 2/3/26 from Certified Nursing Assistant (CNA) C stated 1:1 w/(with) res (resident) (sic) in. Resident went to grab phone and slipped of bed. Resident proceeded to climb back in bed.An incident report on 2/4/26 12:22 AM stated in part This nurse was notified by CNA that resident had a fall. Upon arriving to the room, resident was already in bed. Head involvement. No pain or injury reported or observed upon assessment. Initial VS obtained, neuros intact. Resident remained in bed after assessment to rest. Resident Description: I was reaching for my phone and slipped off the bed, but I am good.On 2/24/26 at 9:14 AM, R1 was observed laying across her bed with legs hanging off, head against the wall, making resident half on half off her bed. Tray table to right about 12 inches away from the bed, no phone noted on tray table.On 2/24/26 at 9:31 AM a phone interview was conducted with CNA C, who stated R1 had sat up in bed, stated she was looking for her water, then the remote, and then turned and reached for her phone when R1 started to slide out of bed.R1's care plan was reviewed and revealed a focus was initiated on 10/24/23 R1 is at HIGH risk for falls related to confusion, gait and balance problems. Interventions on 4/28/25 Keep my frequently used items within my reach and on 2/9/26 I require 1:1 supervision due to poor safety awareness were initiated. R1 did not have frequently used items within reach.Resident #5 (R5)A review of the EMR for R5 indicated admission to the facility on 2/17/26, with diagnosis including secondary malignant neoplasm of other specified sites (cancer that has spread), squamous cell carcinoma of skin, scalp and neck (cancer arising from flat cells in a layer of skin), Diabetes Mellitus Type II (body develops insulin resistance and cannot use insulin efficiently, leading to high blood sugar levels), chronic kidney disease stage 4 (kidneys are significantly damaged, functioning at 15-29% of capacity), benign prostatic hyperplasia (enlarged prostate gland), and essential tremor(neurological disorder causing involuntary, rhythmic shaking, in the hands, head, or voice during movement). R5 was responsible for his own medical and financial decisions.On 2/17/26 at 3:00 PM, a fall risk evaluation indicated R5 was . alert oriented x 3.requires use of assistive devices (i.e. cane, wheelchair, walker, furniture). Gait / balance: Gait / balance Normal.Fall Risk Score: 13.0 Indicating R5 as a moderate risk for falls.On 2/17/26 at 3:02 PM, a clinical admission indicated . 'Mental Status: Alert & Oriented x3, communicated verbally, speech is clear, is able to understand and be understood when speaking. Level of cognitive impairment: Alert (some forgetfulness).On 2/18/26 at 1:47 PM a therapy note indicated R5 is Assist of 1 to walk with walker.The fall report was completed on 2/21/26 at 7:34 PM, . Nursing Description: The CNA reported to RN that upon entering the room to do vitals, the patient was observed on the floor next to his bed. Neuro assessment completed. Patient denies hitting his head.Patient is noted to have a small skin tear on his right lateral knee area with scant amount of blood. Patient Description: Patient stated he was trying to get up to go to the bathroom.Other Info: Patient requires assistance with ambulation. Patient does at times ambulate with walker without assistance, but this time walker was left in the bathroom, and he wasn't able to get to it so he attempted to ambulate without it.On 2/21/26 at 8:07 PM an incident report documented a statement which read as follows: Patient fell, no head involvement. Alert with clear speech. Able to move all 4 extremities, Vitals are stable.A review of R5's care plan indicated a focus was initiated on 2/17/25 stating the resident is at high risk for falls r/t poor safety awareness, with interventions including ensure all necessities are within reach of the patient, encourage proper ambulatory assist device if applicable. R5 did not have his walker, a necessity within reach.The facility's policy titled Fall and Injury Reduction Policy dated 7/8/24, stated its purpose was To prevent or minimize resident falls and injury, while promoting the highest level of resident independence possible.

This citation pertains to intake 2726722.Based on interview and record review, the facility failed to treat one Resident (#2) with dignity and respect out of three residents reviewed for resident rights. This deficient practice resulted in Resident #2 experiencing emotional distress and feelings of intimidation.Findings include:Resident # 2 (R2)A review of R2's Electronic Medical Record (EMR) indicated R2 was admitted to the facility on [DATE], with diagnosis including depression. R2 was noted to have a Brief Interview for Mental Status (BIMS) score of 15/15, indicating normal thinking.On 2/23/26 at 10:42 AM, R2 was observed sitting in his recliner with portable cooling unit, and fan with ice filled tub behind it. Thermostat in room indicated it was 76 degrees in the room.During an initial interview on 2/23/26 at 10:43 AM, R2 stated the Nursing Home Administrator (NHA) and two maintenance guys came to his room on the morning of 1/26/26. R2 stated the three men did not knock prior to entering the room. R2 stated he had just had his food tray delivered to his bedside table and was about to eat, when the NHA leaned over the food tray and started yelling at him regarding his window being open, calling R2 by his roommate's name. R2 state the NHA's posture was intimidating to him. R2 stated he corrected the NHA regarding his name, yet the NHA continued to speak to him utilizing his roommate's name. R2 stated the NHA asked where he had come from, so R2 told him the previous facility he had lived at. The NHA proceeded to ask R2 if he was able to open the window at the previous facility, in which R2 stated he could. R2 stated the NHA then told him the facility could see about getting R2 back to his previous facility in a rude way. R2 felt the NHA was trying to kick him out of the facility and R2 had no desire to go back to his previous facility. R2 stated he felt the NHA was condescending, belligerent, and angry when the NHA spoke to him. R2 stated, a few days later, on the morning of 1/30/26, the NHA came back to his room asking if they were cool with everything and stating you aren't going to open your window anymore, in a snide tone. R2 felt threatened and scolded by the NHA and felt if he went out in the hallways, the NHA would see him and yell at him again.On 2/23/26 at 2:28 PM, during an interview, Social Worker A stated it was a few days after the NHA's conversation with R2 before she was aware R2 had a different view on the incident than just a normal conversation. Social Worker A stated R2 felt the NHA spoke to him in an intimating way using an angry and condescending tone.On 2/23/26 at 2:35 PM, during an interview, Assistant Director of Nursing (ADON) B stated R2 reported to her he was talked to by the NHA on 1/26/26 and indicated he did not like the way the NHA had spoken to him.During a follow-up interview on 1/23/26 at 2:51 PM, R2 stated he felt uneasy about getting yelled at or if he would be called by the wrong name again if saw the NHA.Review of the facility's investigation revealed a statement of event in resident room which was provided by the NHA on 1/30/26. The statement read in part. I told the resident as he sat in his chair.with the tray table between us in a firm voice and he (R2) stated that he could hear me and that the window cannot be opened and that it makes the heating system not work well. I further asked him (R2) where he came from and he stated (former facility). I further asked if he (R2) had his window open at (former facility) .he did not respond. Further, if he wanted his window open.then perhaps he would like to go back to (former facility) where they could accommodate his desire.Further review of the incident report indicated a phone interview conducted with a Certified Nursing Assistant (CNA) who had worked R2's unit on 1/29/26 read in part .upon greeting him (R2) he said, I'm alright. She (CNA) continued to explain he (R2) is usually joking around with staff, his (R2) personality felt off. Are you okay? and he (R2) shrugged his shoulders. CNA explained R2 said NHA was loud and aggressive, NHA wouldn't use my name after I (R2) told him what it was, he leaned over my table and yelled at meOn 2/24/26 at 2:14 PM an interview was conducted with the NHA, who stated he went into R2's room with two maintenance men. The NHA stated one of the maintenance men informed him R2 was the roommate's name. The NHA stated he had called R2 by the roommate's name.The NHA stated he had asked R2 where he had lived before and R2 told him (former facility) where R2 could open his window. The NHA stated that perhaps (former facility) was a better place for him.Review of the facility's Abuse Prohibition and Prevention Program policy, stated,Our organization is committed to protecting our residents.f. not limited to, humiliation, harassment, threats of punishment.

This citation pertains to intake 2734782Based on observation, interview, and record review, the facility failed to follow resident choices for one Resident (#7) of three residents reviewed. This deficient practice resulted in feelings of hopelessness and frustration.Findings include:Resident #7 (R7)Review of R7's Electronic Medical Records (EMR) revealed admission to the facility on 2/17/26 with diagnosis including aftercare following joint replacement surgery. R7 was noted self-responsible for his medical and financial decisions.An interview was conducted with R7 on 2/23/26 at 11:01 a.m. R7 stated that he has been feeling very frustrated since his admission, I wake up between 6:00 a.m. and 7:00 a.m. I put on my call light to get dressed and ready for the day. Over the weekend, they did not get me up and dressed until 9:00-9:30 a.m. The staff came in and told me I had to wait because they don't get people up that early, or I wasn't a priority for them to get up. I even missed my shower today because of waiting. Also, I had an accident over the weekend and soiled myself because of staff not getting me up. It was embarrassing. R7 confirmed with this surveyor, he had discussed with staff what time he would like to get up in the morning, They don't listen and they refuse to get me up.A review of R7's Bowel and Bladder record showed R7 was noted to be incontinent of bowel and bladder on 2/22/26. A follow-up interview was conducted with R7 on 2/24/26 at 9:00 a.m. R7 was noted to be sitting in his recliner chair, visibly upset. R7 stated, I woke up again around 6:30 a.m., and they refused to get me up. I didn't receive any help until 7:45 a.m. Then by the time they got me ready my breakfast was here, but they sent me down to get weighed so when I came back it was already cold. I don't understand why they won't help me. Why won't they listen?An interview was conducted with the Director of Nursing (DON) on 2/24/26 at 11:15 a.m. The DON stated the admitting nurse is responsible to interview residents for their preferences on what time to get up, and those preferences would be listed on the residents Kardex sheets. A request was made for R7's Kardex.An interview was conducted with Registered Nurse (RN)/Education Director G on 2/24/26 at 11:35 a.m. RN G stated all staff are educated on resident rights and choices, with the Social Services Directors and Assistant Director of Nursing on each unit responsible for noting residents' personal preferences.Review of R7's Kardex dated 2/24/26 read, in part, Dressing: The resident is totally dependent on (2) staff for dressing. Further review of R7's Kardex did not indicate his preferences regarding what time he would like to get up in the morning.

This citation pertains to intakes 2734782,Based on interview and record review, the facility failed to honor resident food preferences for three Residents (R2, R7, R8) of four residents reviewed for nutritional services. This deficient practice resulted in residents continuing to feel frustrated over their daily meal choices. Findings include:An interview was conducted with R7 on 2/23/26 at 11:01 a.m. R7 stated, The food here is horrible. You never get what you want or ask for, then they try to correct it with an alternate but it's almost too late by the time you get your meal. I am not picky, but when you ask for something and you don't get it, it's frustrating.An interview was conducted with R8 on 2/23/26 at 11:16 a.m. R8 stated, I have issues with the food often. They (staff) either get me something that I don't want or didn't order. Then I have to send my tray back and wait for the kitchen to give me my correct food. It's frustrating.On 2/24/26 at 9:00 AM, an interview was conducted with R2. He stated the kitchen does not get his food preferences correct all the time. He stated he cannot have spinach because of the vitamin K, due to medications he is taking, and he still receives it on his tray. He stated it goes in streaks on whether he gets things he doesn't like or doesn't want, then he will have to send the meal back.An interview was conducted with Nutrition Assistant/Staff H and General Manager (GM)/ Food Director I on 2/24/26 at 10:34 a.m. Staff H stated that upon admission, they will interview residents for their likes/dislikes and food preferences and will prepare an individualized meal ticket based on that interview. Staff H states that they update the residents' preferences yearly. GM I stated that the current procedure in place is to take orders in advance for the next day, with floor staffing utilizing the individual ticket with the menu printed. Then those tickets are to be returned to the kitchen. GM I stated that there have been known issues where either the tickets to not get returned to the kitchen, or floor staff are just circling items without discussing them with the resident. In these instances, GM I stated that the kitchen prepares what was circled or the main meal for that resident. We know there is a margin of error for the system we have right now. We continue to have issues with this including last nights dinner meal and this morning's breakfast meal.An interview was conducted with Registered Nurse (RN)/Education Director G on 2/24/26 at 11:35 a.m. RN G stated that staff are educated to go to each unit's pantry and pick up food order tickets for the following day, and to discuss and help select residents' meal choices in advance. RN G stated that floor staff are responsible for returning the tickets back promptly so the kitchen can prepare enough food for the residents. Education was provided on what a tray ticket looks like, and what staff should be mindful of when taking residents' orders. RN G did state that there have been instances where meal tickets are returned promptly and that the kitchen staff will prepare the main meal for a resident, who may not like that choice, but RN G stated then a call is made to the kitchen to prepare an alternate or ask for additional food for that resident.Review of the facility's Nutritional Assessment and Monitoring revised on 7/2/25 read, in part, The Registered Dietitian or Nutrition Assistant with obtain Food preferences as soon as possible, preferably within 72 hours of admission. Dietary staff will continue to follow up until preferences are completed. Food preferences will be re-viewed periodically.Review of the facility's Food Services policy, undated, read, in part, The Organization provides each resident with a nourishing, palatable and well-balanced diet that meets the daily nutritional and special dietary needs.the administrative staff of the Food Services Department has responsibility for:.integrating the nutritional aspects of resident care through communication and the sharing of specialized information with the interdisciplinary treatment team.identification, monitoring and evaluation of quality indicators to enhance nutritional care and services being delivered to the residents.

This deficient practice pertains to Intake 2641153.Based on interview and record review, the facility failed to effectively monitor, report, and respond to a change in condition for one Resident (#1) of three residents reviewed for quality of care. This deficient practice resulted in Resident #1 receiving delayed medical treatment leading to hospitalization and subsequent death.Findings include:Resident #1 (R1)Review of R1's Hospital Transfer Form, dated 10/10/25 at 7:16 PM, read, in part: .Reason(s) for transfer: hypoxic. BP [blood pressure] 158/88. HR [heart rate] 121. RR [Respiratory Rate]: 31. O2 Sat [Oxygen Saturation] 85% .Review of the Emergency Medical Service (EMS) Transfer form, dated 10/10/25 at 10:01 AM, read, in part: .Upon arrival.[R1] has visible labored breathing.and tachypnea. Upon auscultation, inspiratory and expiratory wheezing was present in all fields, as well as crackles.Review of Discharge Documents from an acute care hospital dated 10/13/25 at 6:11 PM, read, in part: [R1].presents to [acute care hospital] ED from the [facility name] for [NAME] [difficulty in breathing] & hypoxia. admitted .under pulmonary critical care. [R1] had made it clear she did not want to be on any life support. With her increased pain and confusion daughters did decide to pursue comfort measures only. [R1] passed peacefully with her daughters at bedside on 10/11/2025.Review of R1's Electronic Medical Record (EMR) revealed initial admission to the facility on [DATE] with diagnoses including chronic obstructive pulmonary disease (COPD), disorders of the diaphragm (a major muscle used in respiration), and history of a malignant neoplasm (cancerous tumor) of the lung. Review of R1's St. Louis University Mental Status (SLUMS) Examination, dated 10/8/25, revealed a score of 19, indicative of dementia.Review of R1's Plan of Care revealed the following Focus, undated: My name is [R1] and I am staying on the Rehab Pavilion to complete therapies.Review of R1's EMR revealed the following physician's order, initiated 10/9/25: Continuous oxygen @ [at] 6-8 L/min [liters/minute] via NC [nasal cannula].R1's EMR revealed the following Health Status Note written on 10/10/25 at 3:25 AM by Registered Nurse (RN) C: CNA [Certified Nursing Assistant] called out to RN's [sic] for assistance, Patient on toilet with SpO2 [oxygen saturation] reading 53%, very SOB [short of breath], stating I can't breath [sic]. Patient assisted back into bed via [mechanical lift aide], this RN then observed that the adapter tubing that leads from the oxygen concentrator and onto the water humidifier had become disconnected. Connections fixed and SpO2 quickly improved upwards and dyspnea [difficulty breathing] improved quickly as well. O2 [oxygen] increased from 6 L to 8 L, SpO2 now ranging 87-89% . Albuterol inhaler provided.On 10/14/25 at 5:57 PM, a telephone interview was conducted with CNA J who confirmed she assisted R1 to the toilet in the early morning hours of 10/10/25. CNA J stated she checked on R1, who was lying in bed, around 3:30 AM when R1 requested to use the restroom. CNA J verified she independently transferred R1 to the bathroom using a mechanical lift when R1 soon became short of breath after sitting on the toilet. CNA J recalled, She [R1] was struggling. CNA J reported she notified RN C and RN H who took R1's vitals and assisted R1 back to bed via the mechanical lift. CNA J stated she was unaware of R1 vitals at the time of the incident and was not informed R1's oxygen tubing had become disconnected from the concentrator. When asked if she should have independently transferred R1 to the toilet using a mechanical lift, CNA J replied, Yes, she's [R1] a one person assist.Review of R1's Plan of Care reviewed the following undated interventions:TOILET USE: The resident is (Dependent) by (2) staff for toileting. TRANSFER: The resident is totally dependent on (2) staff for transferring.On 10/14/25 at 4:53 PM, a phone interview was conducted with RN H who confirmed she was the first one to assess R1 in the restroom in the early morning hours of 10/10/25. RN H recalled increasing the oxygen flow rate from 6L to 8L, but R1's oxygen saturation remained around 54%. RN H stated RN C then arrived on scene who turned the flow rate to 10L and helped transfer the resident back to bed, at which point they noticed the oxygen tubing had become disconnected from the concentrator.Review of R1's EMR revealed the following Health Status Notes written by Registered Nurse (RN) C:10/10/25 at 4:10 AM: This RN contacted Patient's daughter, [Family Member (FM) A] regarding the change in condition and incident that lead to her [R1's] SpO2 dropping. This RN is still waiting for on-call provider to respond. O2 now reading around 78%, Patient would like to avoid rehospitalization. [FM A] is in agreeance with keeping [R1] here and seeking more comfort medications for her. 10/10/25 at 4:35 AM: Still no call from Telehealth provider after 53 minutes. On-call [physician's group] number utilized and provider contacted regarding situation. Approval given to give another dose of her PRN [as needed] Ativan early, provider to follow-up later today. Okay given to keep Patient at 10 L of O2. [R1] is agreeable to utilizing the PRN Ativan again and seeking comfort rather than transferring to the hospital.On 10/14/25 at 4:34 PM, a phone interview was conducted with RN C who verified she was the primary nurse responsible for the care of R1 from the evening of 10/9/25 to the morning of 10/10/25. RN C confirmed the incident where R1's oxygen tubing was disconnected from the concentrator and stated R1's oxygen saturation had plummeted to around 54%. RN C stated, We were only able to get her back to 87%, which is better, but still not great. RN C stated she notified FM A of the incident and attempted to contact a Telehealth provider for further medical direction but did not get an answer. RN C recollected, I think it was a connectivity issue. I had issues earlier in the shift. RN C stated R1's oxygen saturation was unstable and kept dipping as low as 78% following the incident. RN C decided to call the on-call provider after 53 minutes after the initial attempt to contact the Telehealth provider. When asked if there was a protocol for an acceptable wait time for a response from a telehealth provider before contacting and on-call provider, RN C stated, I don't think there's any standard protocol, but they [on-call physicians] usually get mad [if contacted].Review of R1's EMR revealed the following Transfer to Hospital Summary written by Registered Nurse (RN) D on 10/10/25 at 7:47 AM: Patient noted with increased O2 demand. Patient placed on 10L [oxygen] via face mask with minimal improvement in saturation. Patient appeared dyspneic [severe breathlessness] and tachypneic [rapid breathing] with labored breathing noted, VS [vital signs] taken as noted. On call provider notified and ordered to be sent out to [acute care hospital] ER [emergency room] as requested by patient, [FM A] updated.Review of R1's EMR revealed no documented monitoring of symptoms or vital signs for the approximate 3-hour period between 4:35 AM and the transfer to the emergency room at 7:47 AM.During the interview on 10/14/25 at 4:34 PM, RN C was asked about the absence of documentation in R1's EMR between 4:35 and 7:47 AM. RN C stated the care assistants working the floor were providing verbal reports of R1's condition but it was not recorded in the medical record. RN C recalled R1's oxygen saturation was, unstable. On 10/15/25 at 1:22 PM, an interview was conducted with Physician Assistant (PA) P who verified she was the provider on call the morning of 10/10/25. PA P was asked if 53 minutes was an appropriate duration of time to wait to contact an on-call provider after R1's oxygen saturation dropped to 54% and continued remain as low as 78%. PA P replied, No, they should have contacted me sooner. PA P stated she was contacted around 4:35 AM and provided orders with directions to call back if R1's symptoms were ongoing. When asked what symptoms should have been monitored, PA P stated, If a resident isn't on comfort care, we'd be looking at oxygen saturation. When a resident is on comfort care, we're looking at things like anxiety, dyspnea, air hunger, and pain. PA P was asked if R1 wished to stay at the facility instead of being sent to the hospital to which she replied, That's what I was told, I personally did not talk to the resident or her daughter. When PA P was asked if hypoxia could affect one's decision making, she replied, Yes, absolutely. That's why I think it was important the [FM A] was involved in decisions and on board [with avoiding hospitalization]. When asked if [FM A] was updated on R1's condition throughout the early morning hours, PA P was unsure. PA P stated, When they [the facility] called me again at 7:30 AM for more comfort measures I said let's circle back to the resident and the family to make sure that's what they want, and they wanted to be sent out [to the hospital].On 10/14/25 at 12:06 PM, a phone interview was conducted with FM A regarding the incident on 10/10/25. FM A stated, I got a call around 4:00 AM explaining what had happened with her oxygen getting disconnected. They said they increased her oxygen and were doing some breathing treatments and her oxygen was improving so I agreed not to send her to the hospital. I didn't get any more calls, so I assumed no news was good news. Next thing I knew, I got a call three hours later telling me they're shipping her to the hospital. I didn't get any updates. nothing.Review of a R1's EMR revealed a document titled Five Wishes (an advanced directive document) that read, in part: .My wish for how comfortable I want to be. If I show signs of depression, nausea, shortness of breath, or hallucinations, I want my care givers to do whatever they can to help me.On 10/24/25 at 2:33 PM, at phone interview was conducted with RN D who verified she was the oncoming day-shift nurse on R1's unit on 10/10/25. RN D stated she learned during shift change report, R1 had an incident overnight which required her to be on 10L of oxygen, and nursing staff were having a hard time keeping her oxygen saturation above 80%. RN D recollected the off-coming nurse was talking about comfort care regarding R1 for which RN D was unaware. RN D stated, As soon as I heard R1 had been hypoxic most of the night, I advised CNA S to immediately check on R1 in the middle of report. CNA S reported back she was concerned with the current state of R1, so RN D left shift change report to assess the situation. RN D recollected, She [R1] was in distress. She was still having shortness of breath. she was anxious because she's having trouble breathing. the incident happened around 3:30 AM and now it's around 7:00 AM and her oxygen is still in 73% .that is hard for [R1] to be so low for that long. If I was the nurse who gave 10L, I would check and see if her oxygen didn't improve. she shouldn't be less than 88% . On 10/15/25 at 1:42 PM, an interview was conducted with the Director of Nursing (DON) regarding the duration of time she would expect to elapse between not getting a call from a telehealth provider and contacting an on-call physician in an acute medical emergency. The DON stated there is not a set protocol but stated, Me, personally, I wouldn't have waited that long [53 minutes]. When asked if a negative response by an on-call provider after contact during off-hours is a viable reason to delay communication, the DON replied, No. The DON agreed hypoxia could affect a resident's ability to make a sound decision and understood the concern regarding the lack of documented monitoring for R1's condition for approximately 3-hours.Review of guidance from a cardiovascular specialty hospital titled, Blood Oxygen Levels: Everything you Need to Know, dated 5/19/2022, read, in part: .Blood oxygen levels:.Below 91%: low blood oxygen level. Below 85%: Very low oxygen levels (Hypoxemia).Below 80%: Severe Hypoxemia.if the oxygen saturation drops below 85%, the severe lack of oxygen affects the brain. The person may experience vision changes and lose consciousness.When the blood oxygen levels drop below 80%, the brain, liver, and other vital body organs get affected. (https://www.medanta.org/)Review of an article titled Hypoxia written by the Cleveland Clinic and reviewed on 5/12/2022, read, in part: .Hypoxia is when the tissues of your body don't have enough oxygen. While some of your tissues can adjust to temporary dips in oxygen levels, prolonged hypoxia can cause organ damage. hypoxia symptoms vary depending on the severity, underlying cause and what parts of your body are affected . Some hypoxia symptoms include: .Confusion, Anxiety, Rapid heart rate (tachycardia), Rapid breathing (tachypnea), Difficulty breathing or shortness of breath (dyspnea). If you experience symptoms like confusion, rapid heart rate or breathing.you should seek medical attention immediately. Hypoxia should be treated right away to prevent permanent organ damage.Hypoxia can be a life-threatening condition. Go to the emergency room if you have any symptoms of hypoxia or if others notice a sudden change in your behavior or awareness. (https://my.clevelandclinic.org/health/diseases/23063-hypoxia)Review of the facility policy titled, Telemedicine dated 9/1/24, read, in part: A physician will be contact promptly in the following situations: a resident change in condition. if telehealth services are unable to provide assistance, please refer to the [physician ground] on-call calendar to contact a provider.

This deficient practice pertains to Intake 2641153.Based on interview and record review, the facility failed to provide the necessary oxygen therapy as prescribed by a physician for one Resident (#1) of three Residents reviewed for respiratory services.Findings include:Resident #1 (R1)Review of R1's Electronic Medical Record (EMR) revealed initial admission to the facility on [DATE] with diagnoses including chronic obstructive pulmonary disease (COPD), disorders of the diaphragm (a major muscle used in respiration), and history of a malignant neoplasm (cancerous tumor) of the lung. Review of R1's St. Louis University Mental Status (SLUMS) Examination, dated 10/8/25, revealed a score of 19, indicative of dementia.Review of Intake 2641153 submitted to the State Agency (SA) on 10/13/25 read, in part: .On 10/7/25, [facility] staff transported [R1] to her orthopedic doctor's appointment. [R1's] daughter, [Family Member (FM) B], accompanied [R1]. [The facility] provided one oxygen tank .During the appointment, [R1] ran out of oxygen.On 10/14/25 at 12:19 PM, a telephone interview was conducted with FM B who confirmed she was present at the time of R1's appointment on 10/7/25. FM B stated the facility transported R1 to her appointment in the facility bus with one portable oxygen E-cylinder. FM B recalled toward the end of the appointment, R1 was running low on oxygen and eventually ran out while waiting in the lobby for transport back to the facility. FM B stated the transport driver [Transport Driver (TD) R] said there were no back-up oxygen cylinders on the bus, and he would have to make a trip back to the facility to retrieve another tank. FM B recalled staff at the orthopedic clinic were assisting as best as they could as R1's oxygen saturation dropped to around 70% while waiting for supplemental oxygen.Review of an Incident Witness Statement written by TD R on 10/14/25 read, in part: Arrived at [orthopedic facility] to pick up [R1] and [FM B].Once I arrived, [FM B] came out in a slight panic, asking if I had an extra O2 (oxygen) tank. I said no and she told me her mother did not have any more in her tank. I imedietly [sic] drove back and grabbed a new tank.Review of R1's plan of care revealed the following Focus: The resident has oxygen therapy r/t (related to) COPD and chronic hypoxic respiratory failure. An undated intervention read, OXYGEN SETTINGS: O2 via (nasal prongs) @ [at] (6-8) L [liters] (continuous). Humidified.On 10/14/25 at 2:05 PM, a telephone interview was conducted with Medical Assistant (MA) G of the orthopedic facility who stated he assisted R1 when she ran out of oxygen at her appointment. MA G recalled, [R1's] oxygen dropped as low as 70% . she was extremely anxious. we waited longer than 10 minutes for extra oxygen. MA G noted R1's oxygen canister was set at 8L and noticed R1 was wearing a normal nasal cannula. MA G stated, At that point, the oxygen delivery isn't effective. [R1] should have had a high flow cannula or a mask.On 10/14/25 at 1:14 PM, an interview was conducted with Registered Nurse (RN) E who stated she was on duty at the time of R1's orthopedic appointment on 10/6/25. When asked who was primarily responsible for getting R1 oriented and ready for her appointment, RN E responded, I don't think I ever saw her [R1] go. The CNAs [certified nursing assistants] are usually the ones responsible for getting residents ready for appointments, including making sure oxygen tanks are full. RN E stated she thought R1's prescribed oxygen flow rate was 6L. When asked if R1 was sent to her appointment with more than one tank, she replied, I didn't think she [R1] would need a backup tank. Oxygen will go fairly quickly with 6L, but not that quickly. maybe a couple hours. RN E recollected when R1 returned to the facility she vocalized that the experience of running out of oxygen was, really scary.On 10/14/25 at 1:35 PM, an interview was conducted with CNA F who verified she assisted R1 in getting ready for her appointment on 10/7/25. CNA F acknowledged a 6L flow rate would run out pretty quickly but did not believe backup tanks were allowed to be sent out with residents per facility policy.On 10/15/25 at 12:15 PM, an interview was conducted with Environmental Services Director (EVD) I regarding portable oxygen cylinders who confirmed the transport vehicles are not equipped with stationary racks, but back-up tanks could be transported in cylinder cart carriers. Review of a document titled Oxygen duration with Tanks from the facility's portable oxygen vendor revealed the E-tank duration for a 6 LPM [liter per minute] flow rate equaled 75 minutes. No data was available for an 8 LPM flow rate.On 10/15/25 at 1:42 PM, an interview was conducted with the Director of Nursing (DON) who understood the concerns related to accessibility of respiratory equipment and services at all times for oxygen dependent residents. The DON verified a flow rate of 6 LPM or above would necessitate a high flow nasal cannula. Review of guidance from a cardiovascular specialty hospital titled, Blood Oxygen Levels: Everything you Need to Know, dated 5/19/2022, read, in part: .Blood oxygen levels:.Below 91%: low blood oxygen level. Below 85%: Very low oxygen levels (Hypoxemia).Below 80%: Severe Hypoxemia.if the oxygen saturation drops below 85%, the severe lack of oxygen affects the brain. The person may experience vision changes and lose consciousness.When the blood oxygen levels drop below 80%, the brain, liver, and other vital body organs get affected. (https://www.medanta.org/)Review of the facility policy titled, Transportation, dated, 1/29/25, read, in part .Resident scheduled for transportation will need to be ready at the time indicated in the transportation scheduled with.any assistive devices needed.Review of the facility policy titled, Oxygen Therapy, dated, 2/2/23, read, in part: .Nasal cannula is to be used when low to medium concentration of oxygen is required and accuracy is not essential. Do not use for flow rates in excess of six (6) liters. when flow rate in excess of six (6) liters is ordered, use the simple face mask.

Based on observation, interview, and record review the facility failed to prevent the development and progression of two stage 4 pressure ulcers for one resident (Resident #68) out of five residents reviewed for pressure ulcer development. This deficient practice resulted in Resident #68 experiencing severe pain during dressing changes and subsequently required wound debridement and antibiotics. Findings include: Resident #68 (R68) On 6/10/25 at 2:00 PM, an observation was made of R68 sitting up in his wheelchair eating lunch. R68 was asked if they had a pressure sore on their bottom and replied, Yes. Review of R68's progress note, dated 3/12/25 at 5:49 PM, read in part, A DTI (deep tissue injury) was observed to residents scrotum measuring 1.1 x 0.7 cm (centimeters) .Resident was observed to be sitting on the tubing from his wound vac. Review of R68's wound assessment, dated 3/12/25, revealed the following: Pressure - Medical Device Related Pressure Injury - Deep Tissue Injury, Body Location: Scrotum. New - Minutes old. Acquired: In-House Acquired. Measured: Length 1.13 cm x Width 0.72 cm. Progress: Notes 1.5 x 0.7 cm. CNA (certified nurse aide) staff reports wound vac cord was pressing against area. Review of R68's wound assessment, dated 3/19/25, revealed after seven days the wound on the scrotum worsened and measured length 1.09 cm x width 1.01 cm x depth 0.1 cm. Review of R68's wound assessment, dated 4/2/25, revealed after 14 days the wound on the scrotum measured length 1.34 cm x width 0.49 cm x depth 0.1 cm. Review of R68's wound assessment, dated 4/9/25, revealed after one month the wound on the scrotum worsened into a stage 4 pressure injury and measured length 0.85 cm x width 0.62 cm x depth 1.1 cm with tunneling 2.0 cm at 7 o'clock (location of the tunneling if a clock face were superimposed over the wound). Review of R68's electronic medical record (EMR) revealed initial admission to the facility on 5/28/19 with diagnoses including hypertension, diabetes mellitus, pressure ulcer stage 4, depression, and spastic hemiplegia (paralysis) affecting the left nondominant side. Review of R68's minimum data set (MDS), dated [DATE], revealed under Section M: Skin conditions. Current number of unhealed pressure ulcers at each stage. Number of Stage 4 (full thickness tissue loss with exposed bone, tendon or muscle) pressure ulcers: 1. Number of these Stage 4 pressure ulcers that were present upon admission/reentry: 0. Number of Unstageable pressure ulcers due to coverage of wound bed by slough and/or eschar: 1. Number of these Unstageable pressure ulcers that were present upon admission/reentry: 0. Review of R68's wound assessment, dated 4/9/25, revealed the following: Pressure - Stage 4: Full-thickness skin and tissue loss. Location: Left Ischium. Exact date: 11/14/23. Acquired In-House. Measured: Length 0.3 cm x Width 0.3 cm, and Depth 0.9 cm with undermining 1.0 cm. Goal of Care: Slow to Heal: wound healing is slow or stalled but stable, little/no deterioration. Review of R68's Medical Professional Note, dated 6/6/25, read in part, .Per wound care notes it appears the scrotal wound has worsened and went from 0.1 cm in April to 0.7 cm in diameter this month . Review of R68's Medical Professional Note, dated 5/23/25, read in part, .Wound care following for two stage four PI's (pressure injuries) to L (left) ischium and scrotum .Debridement performed by wound care notes on 5/21/25 .Erythema improved around scrotal wound with antibiotic use . Review of R68's Medical Professional Note, dated 4/4/25, read in part, .Pressure injury of left hip, stage 4 .Wound vac over area. Debridement performed by wound care note 4/2/25 .Scrotal infection active acute wound to scrotum. Treated and packed by wound care .(brand name antibiotic) sulfamethoxazole and trimethoprim and (brand name antifungal) metronidazole initiated for scrotal infection . Review of R68's care plan, dated, 3/12/25, read in part, .Focus (Braden Score less than or equal to 18) The resident is at a heightened risk for skin breakdown .Goal: The resident will not develop any new skin breakdown. The resident's skin will remain intact .Interventions: Keep bed linens clean, dry, and wrinkle free. Ensure resident is not laying on medical devices or tubing (dated 5/6/25) .Focus: The resident has a Stage 4 pressure injury to scrotum. Goal: The resident's (sic) will have no complications r/t (related to) pressure injury of the scrotum through the review date. Interventions .Educate resident/family/caregivers of causative factors and measures to prevent skin injury. Encourage good nutrition and hydration in order to promote healthier skin. Follow facility protocols for treatment of injury. Keep skin clean and dry. Use lotion on dry skin. Do not apply on scrotum. Monitor/document location, size and treatment of skin injury. Report abnormalities, failure to heal, s/sx (signs and symptoms) of infection, maceration . Review of R68's wound clinic progress notes, read in part: 11/22/24: .Left ischial is a stage 4 pressure injury pressure ulcer and has received a status of not healing. Subsequent wound encounter measurements are 0.3 cm length x 0.6 cm width x 1.2 cm depth .Muscle and bone are exposed .Undermining has been noted at 9:00 and ends at 3:00 with a maximum distance of 1 cm .The wound is deteriorating .When reading patient dressing orders from the (facility name) it appears that they are adding .cream .onto the foam. I am afraid this is clogging the pores of the foam and is resulting in his increased in maceration around the wound and periwound (skin area surrounding wound) . Procedures .left ischial. A selective debridement . 12/6/24: .He does have pain to the left ischial wound bed .Left ischial is a stage 4 pressure injury pressure ulcer and has received a status of not healing. Subsequent wound encounter measurements are 0.3 cm length x 0.5 cm width x 1.5 cm depth .Muscle and bone are exposed .Assessment .Upon assessment patients ROHO cushion is deflated .is unsure of when it was last inflated .Procedures .left ischial. A selective debridement .I did inflate ROHO cushion and demonstrated this . 12/16/24: .Left ischial is a stage 4 pressure injury pressure ulcer and has received a status of not healing. Subsequent wound encounter measurements are 0.3 cm length x 0.5 cm width x 1.7 cm depth .Muscle and bone are exposed .Undermining has been noted at 10:00 and ends at 2:00 with a maximum distance of 2 cm .Procedures .left ischial. A selective debridement .Additional orders .the patients wound appears worse today .antibiotics for proper bacterial coverage . 1/2/25: .Left ischial is a stage 4 pressure injury pressure ulcer and has received a status of not healing. Subsequent wound encounter measurements are 0.3 cm length x 0.5 cm width x 1.5 cm depth .Muscle and bone are exposed .Undermining has been noted at 10:00 and ends at 2:00 with a maximum distance of 1.9 cm . Procedures .left ischial. A selective debridement . 1/29/25: .Left ischial is a stage 4 pressure injury pressure ulcer and has received a status of not healing. Subsequent wound encounter measurements are 0.4 cm length x 0.5 cm width x 1.7 cm depth .Muscle and bone are exposed .Undermining has been noted at 10:00 and ends at 2:00 with a maximum distance of 2 cm .Procedures .left ischial. A selective debridement .Wound orders .Wound like to initiate negative pressure wound vac . 2/19/25: .Patient states they did not initiate the wound vac .Left ischial is a stage 4 pressure injury pressure ulcer and has received a status of not healing. Subsequent wound encounter measurements are 0.4 cm length x 0.5 cm width x 1.6 cm depth .Muscle and bone are exposed .Undermining has been noted at 10:00 and ends at 2:00 with a maximum distance of 2 cm . Procedures .left ischial. A selective debridement .Wound orders .Wound like to initiate negative pressure wound vac . 3/12/25: .His wound vac externally is not correctly applied. Patient states he had a new staff member apply it on Monday .Wound Orders .Place black foam bridge over to patients' hip form the wound opening (to avoid any suction/tubing compromise .I will call (facility name) to ensure management knows there is a need for wound vac training. Vac taken down today included layer: white foam, Tegaderm, black foam, pieces of black foam, not connected, bridging over to patients' hip, final Tegaderm, and vac seal. These layers are incorrect, block the flow of exudate, and does not provide proper suctions to the wound base .there were 2 visiting nurses to their unit who do not have vac training that cared for (R68) recently and placed his vac Monday . 4/14/25: .Left ischial is a stage 4 pressure injury pressure ulcer and has received a status of not healing. Subsequent wound encounter measurements are 0.4 cm length x 0.4 cm width x 1.0 cm depth .posterior scrotum is a stage 4 pressure injury pressure ulcer acquired on 3/19/25 and has received a status of not healed. Subsequent wound encounter measurements are 1 cm length x 0.5 cm width x 2.2 cm depth . 4/30/25: .Left ischial is a stage 4 pressure injury pressure ulcer and has received a status of not healing. Subsequent wound encounter measurements are 0.4 cm length x 0.4 cm width x 1.2 cm depth .posterior scrotum is a stage 4 pressure injury pressure ulcer acquired on 3/19/25 and has received a status of not healed. Subsequent wound encounter measurements are 1 cm length x 0.5 cm width x 1.8 cm depth . Procedures .left ischial. A selective debridement .Procedures .posterior scrotum. A selective debridement .with a pain level of 2 throughout . 5/14/25: .Patient seen for a follow up examination of ischial pressure injury and scrotal ulceration .Left ischial is a stage 4 pressure injury pressure ulcer and has received a status of not healing. Subsequent wound encounter measurements are 0.5 cm length x 0.5 cm width x 1.2 cm depth .posterior scrotum is a stage 4 pressure injury pressure ulcer acquired on 3/19/25 and has received a status of not healed. Subsequent wound encounter measurements are 1 cm length x 0.5 cm width x 1.5 cm depth .Procedures .left ischial. A selective debridement .posterior scrotum. Review of R68's order summary, dated 2/20/25, revealed an order for a pressure injury: Stage 4 Left Ischium as needed Left Ischial wound vac, dressing to be changed M/W/F (Monday/Wednesday/Friday). On 6/11/25 at 5:03 PM, an interview was conducted with Licensed Practical Nurse (LPN) C who was asked about R68's pressure injury to their scrotal area and replied, R68 got that from their wound vac tubing. Another nurse did not apply the wound vac correctly and bridge the tubing properly. On 6/12/25 at 10:00 AM, an interview was conducted with Assistant Director of Nursing (ADON) L who was asked if R68 should have developed the pressure injury to their scrotal area and replied, No. The wound vac tubing was not placed properly. ADON L was asked if therapy had assessed R68's wheelchair after they developed a pressure injury to their left ischial area and replied, I think so. Therapy usually evaluates equipment in cases like that. ADON was asked to provide therapy evaluation notes. ADON L was asked if the nurse who improperly applied the wound vac dressing was educated or disciplined and ADON replied, I believe so. ADON was asked to provide the education and disciplinary action. Review of employee file dated 4/28/25, for LPN U, revealed an ongoing unsatisfactory work performance for a wound vac dressing change completed on 4/25/25 indicating that the bridging on the wound vac was incorrectly done which led to the wound not receiving the appropriate suction that was ordered. Note that R68 developed their scrotal pressure injury on 3/19/25. Review of R68's occupational therapy (OT) progress note, dated 4/18/25 through 5/17/25, revealed diagnoses of spastic hemiplegia affecting left nondominant side and muscle weakness. Current referral (reason for referral) was, referred to OT services to address L (left) hand contracture and current interventions as client reports minimal carryover with L hand brace, overall difficulties with positioning of LUE (left upper extremity) impacting hygiene care and progressing of contractures. Recommendations: Splint / Orthotic recommendations: It is recommended the patient wear a resting hand splint on left hand. R68's wheelchair or cushion system was not re-assessed during this OT evaluation. Review of policy titled, Pressure Injury Prevention, dated 9/8/22, read in part, Purpose: To prevent pressure injuries . Review of policy titled, Pressure Injury Care, dated 9/8/22, read in part, Purpose: To properly care for pressure injuries .The licensed nurse is responsible for seeing that the treatments prescribed by the physician are carried out as ordered and recorded.

Based on observation, interview, and record review, the facility failed to provide pain management as prescribed by the physician for one Resident (#431) of two residents reviewed for pain. This deficient practice resulted in unrelieved pain and required Resident #431 to be subsequently transfer to the emergency department (ED). Findings include: Resident #431 (R431) Review of R431's EMR revealed initial admission to the facility on 6/4/25 with diagnoses including fracture of the left acetabulum (a break in the socket portion of the hip joint), fracture of the left ulna (a break in one of the two bones of the forearm), fracture of the left tibia (a break in the large bone in the lower leg), displaced fracture of the left acromial process (a break in the bony projection of the shoulder blade), and fractures of facial bones. ). Review of R431's Minimum Data Set (MDS) assessment, dated 6/10/25, revealed a Brief Interview for Mental Status (BIMS) score of 15, indicative of intact cognition. On 6/10/25 at 12:20 PM, R431 was observed in his room standing at a platform walker with his left leg immobilized. An interview was conducted with R431 regarding his level of satisfaction with care at the facility. R431 stated he was admitted to the facility for rehabilitation following a motor vehicle accident (MVA) in which he sustained several injuries including fractures of his left arm, left leg, and face. R431 stated over the weekend, the facility ran out of his prescribed pain medication and he had to be transferred to the ED at a local acute care hospital for pain management. R431 recalled, My pain level was a 12 out of 10 . I suffered all weekend to get my pain back under control. R431 stated he waited in the ED for several hours in a wheelchair without appropriate positioning of his immobilized left leg due to the facility's inability to locate a proper footrest prior to the transfer. Review of R431's EMR revealed the following physician's orders initiated on 6/4/25: 1. Morphine Sulfate ER [Extended Release] Oral Tablet 30 MG [milligrams]. Give 1 tablet by mouth two times a day for PAIN. 2. Morphine Sulfate Oral Tablet 15 MG. Give 2 tablet by mouth every 4 hours as needed for Moderate-Severe Pain. Review of a Telehealth visit (a virtual appointment which allows patients to consult with healthcare providers remotely using digital communication) on 6/7/25 at 16:39 [4:39 PM] revealed the following: Patient admitted 6/4 with script for PRN [as needed] Morphine IR [immediate release] 1-2 tablets q4 [every 4 hours]. No more pills/fills left. New script needed to be able to fill. Patient is requesting PRN's [as needed medication] about every four hours . Pharmacy can't deliver until Monday morning . Willing to try Oxycodone 20 mg .facility doesn't have enough oxycodone also . Morphine can't be delivered until Monday .facility doesn't have enough oxycodone. Will send him [R431] to hospital as he can't go without pain medication . On 6/12/25 at 11:26 AM, an interview was conducted with Licensed Practical Nurse (LPN) V who verified she was the nurse responsible for R431's care on 6/7/25. LPN V stated R431 was consistently requesting ordered morphine every four hours since admission for pain control. LPN V recalled on 6/7/25, when R431 requested his next dose of morphine around 4-5:00 PM, she discovered no more pills were left in the medication cart. LPN V indicated there was no additional morphine in the back-up medication room and another script had not been ordered from the pharmacy. LPN V stated his medication blister pack indicated there were 0 refills remaining and there were no providers in the facility on the weekend, so she contacted a telehealth doctor. LPN V stated the telehealth physician recommended a substitute pain medication, oxycodone 20 MG, but the facility only carried 5 MG tablets in back-up which were not sufficient to last the weekend. LPN V stated the telehealth physician recommended R431 be sent to the ED to obtain the proper pain medication. LPN V stated upon R431's return to the facility, he had a telehealth appointment with a different physician who wrote a script for morphine. However, because it was the weekend, the script had to be sent to a down-state pharmacy, approximately 2 hours away, and couriered to the facility via vehicle. LPN V stated her shift ended but received in report that the medication arrived at the facility around midnight. When asked the typical process, LPN V stated nurses on the night shift are supposed to ensure medications are ordered in advance but somehow R431's medication got missed. LPN V stated, Ultimately, it was [the facility's] fault . we should have had the med [medication] re-ordered. Review of R431's EMR revealed the following Health Status note on 6/7/25 at 20:20 [8:20 PM]: Resident has returned from [local hospital] ER [emergency room] . waiting to get VS [vital signs] and contact telehealth provider regarding need for Rx [prescription] for controlled med. Review of a Telehealth visit on 6/7/25 at 20:55 [8:55 PM] revealed the following: .patient has chronic pain. has been taking morphine. has run out of medication and needs refill . morphine 15 mg immediate release tablet . 2 tablet(s) every 4 hours as needed for 3 Day(s), oral route . Review of R431's EMR revealed the following notes: 1. Health Status Note on 6/7/25 at 21:02 [9:02 PM]: Spoke with [physician's name] via TELEHEALTH regarding need for new Rx for morphine 15 mg IR tab 1-2 tab q4h [every four hours] . Rx to be faxed to [pharmacy] within next 10 mins. Per [pharmacy] waiting fax w/ [with] Rx to send courier from [downstate city] with medication. 2. Behavior Note on 6/7/25 at 23:28 [11:28 PM]: What behavior(s) are observed? Accusing of others, Express Frustration/Anger at Others, Agitated, Restless, Insomnia, Not Sleeping, Panic. 3. Administration Note on 6/8/25 at 1:16 AM: Morphine Sulfate Oral Tablet 15 MG Give 2 tablet by mouth every 4 hours as needed for Moderate-Severe Pain. Resident c/o [complains of] 10/10 pain. 4. Administration Note on 6/8/25 at 4:11 AM: Anxiousness, restlessness, and agitation assessed this shift. Resident reports behaviors are 2/2 [secondary to] uncertainty of PRN morphine tablet delivery from [pharmacy]. Resident was reassured throughout shift that courier was in route to facility w (with)/ medication. Resident continued to anxiously use call light and ask for ETA [estimated time of arrival]/any updates . Visibly upset - short periods of crying/tears in moments of increased agitation. The following pain levels (out of 10) were recorded following R431's return from the ED on 6/7/25: 1. 6/7/2025 at 21:05 [9:05 PM] - 10 2. 6/8/2025 at 1:16 AM - 10 3. 6/8/2025 at 5:34 AM - 10 4. 6/8/2025 at 8:17 AM - 9 5. 6/8/2025 at 11:30 AM - 8 6. 6/8/2025 at 13:38 [1:38 PM] - 8 7. 6/8/2025 at 17:35 [5:35 PM] - 8 8. 6/8/2025 at 21:38 [9:38 PM] - 10 9. 6/9/2025 at 00:44 [12:44 AM] - 7 10. 6/9/2025 at 1:40 AM - 10 11. 6/9/2025 at 5:59 AM - 10 12. 6/9/2025 at 10:04 AM - 10 13. 6/9/2025 at 14:20 [2:20 PM] - 10 14. 6/9/2025 at 15:41 [3:41 PM] - 7 15. 6/9/2025 at 18:21 [6:21 PM] - 9 16. 6/9/2025 at 20:22 [8:22 PM] - 8 17. 6/9/2025 at 22:57 [10:57 PM] - 9 Review of a facility physician note dated 6/10/25 at 3:59 PM read, in part: .Apparently there was some issues with his morphine prescriptions this past weekend. He ran out of both extended release and immediate release morphine. On- call provider had been contacted but prescribed oxycodone instead. Patient ended up in the emergency room where he was given a dose of morphine and sent back to this facility. Second on-call provider was contacted and per patient's report did send a new prescription for his morphine. He is quite upset about this, states he felt very worried for his safety at this facility . On 6/11/25 at 12:56 PM, an interview was conducted with Assistant Director of Nursing (ADON) O regarding the facility pharmacy protocol and pain control expectations. ADON O stated upon initial admission, a resident is typically sent with 3-5 days' worth of narcotic medications. After the resident is evaluated by the facility provider, longer scripts are written. ADON O stated R431 ran out of the prescription written by the acute care hospital and there was not an in-house provider over the weekend to write a new script. ADON O stated the prescription should have been re-ordered when it was getting low. In the event a medication did run out, ADON O stated the protocol would be to first call the pharmacy to check for any available refills and then contact a telehealth provider for a new script if no refills remained. ADON O said, [R431] should have never been sent to the ER. On 6/12/25 at 1:06 PM, an interview was conducted with the Director of Nursing (DON) regarding the facility pharmacy protocol and pain control expectations. The DON verified the prescription should have been ordered prior to running out. The DON confirmed the pharmacy should have been contacted first and in the event no refills remained, the telehealth provider should have been asked for a script. Review of the facility policy titled, Pain Management, dated 12/1/23, read, in part: It is the policy of [facility name] to promote the best quality of life for each resident by managing each resident's pain through person-centered care . Review of the facility policy titled, Medication and Treatment Administration, dated 3/17/22, read, in part: .Each shift is responsible to maintain the medication cart in a sanitary, well organized condition at all times, and to replace depleted supplies . Medication/treatment ordered on an as needed basis (prn) will be administered in accordance with the physician's order .

Based on observation, interview, and record review, the facility failed to maintain best practices in accordance with professional standards for food service safety. This deficient practice has the potential to result in food borne illness among all residents that consume food from the kitchen. Findings include: During the initial tour of the kitchen, at 11:47 AM on 6/10/25, and interview with Dietary Manager (DM) R found that the plastic bag covering the mixer means it is clean. When asked how often the mixer gets used, DM R stated it gets used four to five times a week. Observation of the large mixer found an accumulation of white debris stuck on the under arm of the unit. During the initial tour of the kitchen, at 11:49 AM on 6/10/25, observation of the inside of the blue ice scoop holder found black debris in the bottom corner of the holder. During the initial tour of the kitchen, at 11:50 AM on 6/10/25, observation of two clean utensil bins, in the back prep area, found mechanical scoops and spoons stored in an accumulation of crumb debris. Further observation of two pull out utensil drawers found increased accumulation of debris in the back of the drawers. During the initial tour of the kitchen, at 11:54 AM on 6/10/25, an interview with DM R found that the bag on the slicer means its clean. When asked how often it gets used Chef S stated that its rarely used. Observation of the slicer found dried meat debris on the backside bottom of the blade and an accumulation of meat debris on the top back portion of the blade. Chef S acknowledge the accumulation upon inspection. During a revisit to the kitchen, at 7:37 AM 6/11/25, observation of the sheet pan under the large mixer found attachments and utensils for the large mixer. At this time, it was observed that the sheet pan was found with an accumulation of crumb debris According to the 2022 FDA Food Code section 4-601.11 Equipment, Food-Contact Surfaces, Nonfood-Contact Surfaces, and Utensils. (A) EQUIPMENT FOOD-CONTACT SURFACES and UTENSILS shall be clean to sight and touch. (B) The FOOD-CONTACT SURFACES of cooking EQUIPMENT and pans shall be kept free of encrusted grease deposits and other soil accumulations. (C) NonFOOD-CONTACT SURFACES of EQUIPMENT shall be kept free of an accumulation of dust, dirt, FOOD residue, and other debris. During the initial tour of the kitchen, at 11:50 AM on 6/10/25, observation of the clean utensil bin used for storing metal spoons found some spoons stored upright with water accumulation in the basin of the spoons. During the initial tour of the kitchen, at 12:09 PM on 6/10/25, it was observed that three half pans were found stacked and stored wet with noticeable water accumulation between the clean pans. According to the 2022 FDA Food Code section 4-901.11 Equipment and Utensils, Air-Drying Required. After cleaning and SANITIZING, EQUIPMENT and UTENSILS: (A) Shall be air-dried or used after adequate draining as specified in the first paragraph of 40 CFR 180.940 Tolerance exemptions for active and inert ingredients for use in antimicrobial formulations (food-contact surface SANITIZING solutions), before contact with FOOD . During the initial tour of the kitchen, at 11:57 AM on 6/10/25, observation of a shelf under and off to the side of the three-compartment sink, found two spray bottles roughly a quarter full, with no common name designation for what solution was in the spray bottles. According to the 2022 FDA Food Code section 7-102.11 Common Name. Working containers used for storing POISONOUS OR TOXIC MATERIALS such as cleaners and SANITIZERS taken from bulk supplies shall be clearly and individually identified with the common name of the material. During the initial tour of the kitchen, at 12:01 PM on 6/10/25, observation of the back corner main kitchen hand sink, between the three-compartment sink and the short cook line, found a wheeled cart stored in front of the hand sink full of dirty pots and pans waiting to be washed in the three-compartment sink. At this time, the hand sink was not accessible for use. According to the 2022 FDA Food Code section 5-205.11 Using a Handwashing Sink. (A) A HANDWASHING SINK shall be maintained so that it is accessible at all times for EMPLOYEE use . During a revisit to the kitchen, at 7:25 AM on 6/11/25, observation of the walk-in cooler found excess food and crumb debris under the storage racks and in the crevices and perimeter of the room. Further observation found that there was no base coving around the perimeter of the room that would act as a barrier to protect accumulation on the juncture of the wall and the floor. According to the 2022 FDA Food Code section 6-501.11 Repairing. PHYSICAL FACILITIES shall be maintained in good repair. According to the 2022 FDA Food Code section 6-501.12 Cleaning, Frequency and Restrictions. (A)PHYSICAL FACILITIES shall be cleaned as often as necessary to keep them clean .

Based on observation, interview, and record review, the facility failed to provide sufficient staff to meet the needs of three sampled Residents (R9, R169 and R430), and eight Residents in a confidential group interview within the facility population of 181 Residents. This deficient practice resulted in actual and potential avoidable episodes of incontinence, frustration and helplessness with call lights going unanswered and needs not being addressed. Findings include: A review of the Resident Council minutes included: - 2/20/25 Discussion regarding call lights being answered in a timely manner . The time seems to be worse at night and early morning . - 3/20/25 Discussion regarding call lights being answered in a timely manner . There were a few concerns about call light times . - 4/17/25 Discussion regarding call lights being answered in a timely manner . When I push mine I have to wait and wait, a good 5 or more minutes during the day . - 5/22/25 Discussion regarding call lights being answered in a timely manner . o I had to wait for 15 minutes the other night for the bathroom and it made me upset. o To (SIC) slow getting to rooms to help you o At lunch a resident had to go to the bathroom but was told by the CNA (Certified Nurse Aide) that she was feeding and cant (SIC) help right now and they'll have to wait for another staff member The facility was asked to offer alert and cognitively intact residents the opportunity to meet and share meaningful discussion regarding their home in the facility. A confidential group meeting took place on 6/11/25 at 11:00 AM, and it was noted the residents stressed their desire to remain anonymous. The group for the most part had Brief Interview for Mental Status (BIMS) scores of 13-15 indicating intact cognition. The group voiced a main concern that the facility was understaffed. Resident C5 stated, The staff try really hard but there are not enough. C3 said the facility was often short staffed and they don't always listen. R9 stated, Sometimes I have to wait so long after asking for help I wet my pants. C2 said, I have to wait over a half hour to get help. C1 had an experience in the dining room when a resident said they needed to use the bathroom. There was an aide there feeding a resident and the aide said, I can't help I am feeding. C1 added, I felt they should help the person go to the bathroom, but no one did. C1 and C5 said there usually was only one woman passing out the trays. It takes more than that. The food cart comes, and it can sit for a half an hour while we wait. We just sit. C8 gave an example when they needed the oxygen tubing put on their face and the aide came in and said, I will be right back, and she never came back. C8 continued, I had to call out to the maintenance man who was walking by, and he helped me. C5 stated, I pooped my pants, and I tried to clean myself, but it went down my leg. An aide came in and said, 'I guess we got a mess here.' She washed up my butt and left. I put the call light on, but she did not come back. C2 stated, When I go to bed, I press my call light, and no one shows up. Resident #169 (R169) Review of R169's electronic medical record (EMR) revealed initial admission to the facility on 5/2/25 with diagnoses including left-sided hemiplegia (loss of movement) following a cerebral infarction (stroke). Review of R169's MDS assessment, dated 5/8/25, revealed a BIMS score of 15, indicative of intact cognition. MDS Section GG (Functional Abilities and Goals) revealed R169 required moderate assistance for functional transfers to the toilet and maximum assistance for toileting hygiene. On 6/10/25 at 1:41 PM, an interview was conducted with R169 who stated she admitted to the facility for rehabilitation following a stroke which affected her left side. R169 stated staffing at the facility was problematic, revealing one night she called 911 from her room because her call light went unanswered for approximately two hours after activating it for toileting assistance. R169 stated following the event she was given a facility number to call from her cell phone in the event of a delayed response time in the future. Review of R169's EMR revealed a Behavior Note dated 5/4/25 at 23:33 [11:33 PM] which read: Resident [#169] called 911 stating she had an emergency and was unable to reach someone. This nurse went to check on resident and she stated her call light was on for over an hour and half, and she needed to use the bathroom. Resident stated she called the building, but it was a recording, so she hung up and called 911. Rehab office number given to resident along with a bell to ding if unable to get ahold of staff. Resident #430 (R430) Review of R430's EMR revealed initial admission to the facility on 5/27/25 with diagnoses including a displaced fracture of the right olecranon process (the bony prominence of the elbow) and repeated falls. Review of R430's MDS assessment, dated 6/2/25, revealed a BIMS score of 13, indicative of intact cognition. On 6/10/25 at 11:40 AM, an interview was conducted with R430 regarding her satisfaction with the level of care at the facility. R430 voiced her concern over extended call light wait times indicating it typically takes, well over 20 minutes for a response to an activated light. R430 stated, That's a long time when you have to use the bathroom. R430 admitted she often negotiated to the bathroom independently instead of waiting for help due to urgency despite requiring help due to fall risk. Review of R430's Plan of Care revealed a Focus reading, The resident is at high risk for falls r/t [related to] poor safety awareness, weakness with the following intervention: Ensure the resident's call light is within reach and encourage resident to use it for assistance as needed. Further review of R430's Plan of Care read, AMBULATION: The resident requires (partial/moderate) assistance of 1 to transfer and ambulate in room . Review of the facility document titled Past Calls from 5/27/25 to 6/12/25 revealed the following call light date, time, and to room elapsed time that were greater than 25 minutes: -5/30/25 at 10:01 AM - 00:27:17 -6/7/25 at 7:35 AM - 00:27:57 -6/7/25 at 9:07 AM - 00:30:30 -6/8/25 at 12:27 PM - 00:27:52 -6/8/25 at 2:26 PM - 00:29:29 -6/10/25 at 6:23 AM - 00:31:38 -6/10/25 at 7:32 AM - 00:54:27 On 6/12/25 at 1:06 PM, an interview was conducted with the DON regarding call light response time expectations. The DON indicated the facility goal was to respond to call lights in 15 minutes or less. The DON stated extended wait times were something the facility was working on and were, unacceptable. Resident #9 (R9) Review of the (Minimal Date Set) MDS assessment dated [DATE], revealed R9 was admitted to the facility on [DATE], with active diagnoses that included gastroenteritis and colitis, type 2 diabetes mellitus with diabetic neuropathy, Gastrointestinal Esophageal Reflux Disease (GERD), and non-pressure chronic ulcer of skin. Section H revealed R9 was always incontinent, and Section GG revealed R9 was dependent (needs assistance) with toileting. R9 scored a 15 of 15 on the BIMS reflective of intact cognition. During an interview on 6/10/25 at 11:51 a.m., R9 reported, I have to wait for at least 45 minutes for the Certified Nurse Aide (CNA) to help me. I lay in my diarrhea for a long time because they are short staffed, and I don't want to get sore down there. Sometimes food feels like it gets stuck in my throat because of my GERD, what would happen to me if they don't come and help me in time. Review of the facility document titled Past Calls from 5/21/25 to 6/11/25 revealed the following call light date, time, and to room elapsed time that were greater than 25 minutes: - 5/21/25 at 6:16 p.m. - 00:33:55 - 5/22/25 at 5:04 p.m. - 00:47:11 - 5/22/25 at 7:58 p.m. - 00:32:07 - 5/23/25 at 2:19 p.m. - 00:27:45 - 5/25/25 at 6:28 a.m. - 00:26:41 - 5/25/25 at 9:28 a.m. - 00:56:28 - 5/25/25 at 12:47 p.m. - 00:50:25 - 5/26/25 at 11:23 a.m. - 00:57:00 - 5/26/25 at 4:44 p.m. - 00:26:24 - 5/26/25 at 6:31 p.m. - 00:34:17 - 5/26/25 at 9:37 p.m. - 00:59:27 - 5/28/25 at 7:06 a.m. - 00:37:34 - 5/28/25 at 10:28 a.m. - 00:26:50 - 5/31/25 at 7:14 a.m. - 00:34:25 - 6/1/25 at 8:29 a.m. - 00:30:39 - 6/1/25 at 2:27 p.m. - 00:58:22 - 6/2/25 at 10:55 a.m. - 00:50:27 - 6/2/25 at 9:28 a.m. - 00:33:05 - 6/3/25 at 2:22 p.m. - 00:32:06 - 6/3/25 at 7:40 p.m. - 00:34:05 - 6/4/25 at 11:59 a.m. - 00:37:31 - 6/4/25 at 3:18 p.m. - 01:00:00 - 6/4/25 at 6:26 p.m. - 00:32:55 - 6/4/25 at 8:17 p.m. - 00:33:15 - 6/6/25 at 2:13 p.m. - 00:28:33 - 6/6/25 at 4:06 p.m. - 00:42:17 - 6/7/25 at 9:19 a.m. - 01:02:49 - 6/7/25 at 1:48 p.m. - 00:53:28 - 6/7/25 at 6:13 p.m. - 00:29:50 - 6/7/25 at 10:07 p.m. - 00:29:29 - 6/8/25 at 11:22 a.m. - 00:43:57 - 6/8/25 at 9:08 p.m. - 00:32:18 - 6/10/25 at 9:28 p.m. - 00:25:43 During an interview on 6/12/25 at 9:23 a.m., CNA I reported, We are short today and people get pulled to help in other areas . we are doing the best we can . During an interview on 6/12/25 at 9:40 a.m., CNA J reported, There is not enough help on the weekends. During an interview on 6/12/25 at 11:10 a.m., CNA K reported, Staffing here is not good, there is a problem . last week there was an aide on light duty and she was not supposed to work but had to help us get people out of bed anyway.

This citation has two deficient practice statements. DPS A Based on observation, interview, and record review, the facility failed to have an active and ongoing plan for reducing the risk of Legionella and other opportunistic pathogens of premise plumbing (OPPP). This deficient practice has the increased potential to result in waterborne pathogens to exist and spread in the facility's plumbing system and an increased risk of respiratory infection among any or all the residents in the facility. Findings include: During the initial tour of the kitchen pantry's, starting at 12:31 PM on 6/10/25, found the following areas with unused water lines protruding from the wall: Birch Pantry, Cherry Pantry, Dogwood Pantry, and Maple Pantry. During a tour of the Birch Hall soiled utility room, at 9:33 AM on 6/11/25, an interview with Environmental Services Assistant Director (ESAD) Q, found that staff should be using the hopper to clean linen before sending it to laundry. Observation of the hopper found discolored water dispensed from the over hopper faucet hot and cold water fixtures. ESAD Q stated that we would like staff to use them more. During a tour of the Cherry Hall soiled utility room, at 9:48 AM on 6/11/25, it was found that the foot pedals for the hopper spray were not in use and turned off at the source, indicating a stagnant line. During an interview with Environmental Services Director (ESD) P, at 9:53 AM on 6/11/25, it was found that the facility does annual Legionella samples but does not test for free chlorine or other disinfection levels in their water supply which could reduce the risk of Legionella or other OPPP. During a tour of the Dogwood soiled utility room, at 10:05 AM on 6/11/25, observation of the hopper spray found discolored water when sprayed into the basin of the hopper. During a tour of the Elm activity pantry, at 10:10 AM on 6/11/25, with the Nursing Home Administrator (NHA), two unused water lines were found protruding from the wall on the counter. The NHA stated the room used to be a pantry years ago and those water lines were probably hook ups for juice or coffee. During an interview with ESD P and ESAD Q, at 11:40 AM on 6/11/25, it was found that they are the only two on the water management team. When asked if any testing is done at the facility, ESD P stated that they send out annual Legionella samples and are due to take them soon. When asked about the flushing of minimal use or unused fixtures, ESD Q stated that they currently flush fixtures in the hall that's down, but the census is pretty high, so other fixtures are getting used regularly. When asked if the hot water boilers were set at 140 F or higher to achieve a kill step in the domestic hot water supply, ESD Q stated no, we keep the boilers set around 115 F. During a review of the facilities Water Management Program policy, not dated, found A water management team has been established to develop and implement the facility's water management program, the Infection Preventionist, maintenance employees, and administrative representatives. Further review of the facility provided document entitled Water Management Program Facility Assessment, not dated, found that Regular flushing of hot and cold water at outlets (e.g., sink taps, showers), particularly not in routine use or which experience low water flow, is necessary to ensure that engineering controls are maintained at sufficient levels for Legionella growth inhibition throughout the water distribution systems and at fixtures. Irregular use or low flow fixtures must be flushed at least twice per week to prevent water stagnation for extended period of time. DPS B Based on observation, interview, and record review, the facility failed to implement infection prevention practices and the appropriate use of personal protective equipment (PPE) for two Residents (#56 and #101) of six residents reviewed for infection prevention and control. Findings include: Resident #56 (R56) R56 was admitted to the facility 4/14/21 with a primary diagnosis of hereditary spastic paraplegia. A Minimum Data Set (MDS) assessment dated [DATE] documented R56 was non-ambulatory and dependent on staff for activities of daily living (ADL) including but not limited to toileting, hygiene, bed mobility, and transfers. R56 received hospice care for end-of-life services related to a terminal prognosis. On 6/10/25 at 1:48 PM, a meal tray with open food was observed on the overbed table in R56's room next to the bed. A stained, yellowed urinal was on the overbed table next to the food tray. On 6/10/25 at 4:09 PM, R56 was observed sleeping in bed. The stained urinal remained atop the overbed table with no barrier beneath it next to a white, Styrofoam cup of water and a plastic mug with lid and straw. The overbed table containing the urinal was at the foot of R56's bed. The Director of Nursing (DON) was interviewed on 6/11/25 at 2:19 PM. The DON said urinals, bedpans, and wash basins were to be kept in a cabinet in resident rooms or bathrooms. The DON said urinals should not be placed next to meal trays of food because it was an infection control concern. The DON said if a resident wanted a urinal on an overbed table the resident would be educated, and it would be care planned to indicate the resident elected to keep the urinal on the overbed table. The DON said the facility had been reviewing products intended to keep urinals within reach of residents without having the urinal on the overbed tables from which the residents were eating. The care plans for R56 were reviewed on 6/11/25. The care plans did not indicate the urinal was maintained on the overbed table at the request of R56. The care plans did not include maintaining the urinal on the overbed table or next to open food. On 6/12/25 at 8:36 AM, R56 was sleeping in bed. The overbed table was at the foot of the bed out of R56's reach. The urinal remained directly on the overbed table without a barrier. On 6/12/25 at 9:26 AM, a certified nurse aide (CNA) entered R56's room and obtained the urinal from the overbed table near the foot of the bed to assist R56 with toileting. When the CNA exited the room, the urinal was observed to have been placed back on the overbed table without a barrier beneath it. The overbed table remained near the foot of the bed out of R56's reach. The nurse manager, Registered Nurse (RN) AA was interviewed on 6/12/25 at 12:57 PM. RN AA said R56 wanted the urinal on his overbed table next to his meal trays. RN AA reviewed the EMR of R56 and acknowledged there was no care plan or documentation indicating the urinal was on the overbed table by R56's choice. RN AA said a privacy holder that attached to the side of the bed was ordered to keep the urinal off the bedside table but within the reach of R56. On 6/12/25, an untitled, undated document was supplied by the DON that read, in part: . our policy states 'return bedpan or urinal to resident's drawer' . Resident #101 (R101) On 6/11/25 at 12:13 PM, Licensed Practical Nurse (LPN) E was observed administering medications on the Dogwood unit. LPN E put on gloves and administered insulin to R101. LPN E exited the room of R101 wearing the gloves worn during the administration of the insulin. LPN E went to the medication cart wearing the gloves and began moving items atop the cart including the plastic medication cups and the water pitcher before removing the gloves and performing hand hygiene. During medication administration observation on the Cherry unit on 6/12/25 at 7:17 AM, RN G picked up a stack of plastic medication cups and began separating the cups by placing her bare, uncleansed fingers on the rim of each cup to pull them apart. The Assistant Director of Nursing (ADON), RN L, was interviewed on 6/12/25 at 8:13 AM. RN L said nurses were expected to refrain from touching the rims of med cups where residents place their mouths. The DON was interviewed on 6/12/25 at 12:09 PM. The DON said it was not permissible for staff to wear gloves from a resident's room into the hallway. The DON said LPN E should have removed her gloves and performed hand hygiene before leaving the room of R101. The policy MEDICATION AND TREATMENT ADMINISTRATION dated 3/17/22 read, in part: . Infection control standards will be maintained at all times during medication/treatment preparation and administration which includes first and foremost, good handwashing techniques . Appropriate gloving procedures will be maintained .

Based on observation, interview, and record review, the facility failed to ensure medications were safely secured and stored in three of six medication carts reviewed for medication storage and properly dispose of medications in one of six medication carts reviewed for medication storage. Findings include: During an environmental tour on the Maple Unit with the Nursing Home Administrator (NHA) on [DATE] at 3:36 PM, five loose medications were found between the seat cushions on the left side of a chair in the hallway. The medications consisted of a semicircular, orange-colored tablet, a pink and turquoise capsule, an elongated oval tablet, and two circular orange tablets. The NHA did not provide an explanation for the medications found in an unsecured and public location accessible to residents in the facility. The NHA said he would follow up with the nurse manager on the unit. Five medication carts were reviewed on [DATE] at 1:02 PM which included three medication carts (Green, Violet, and Orange) on the Maple Unit, and two medication carts on the Cherry unit (300-319 and 320-339). Observations revealed the following: The Maple unit [NAME] Cart had one loose white, round tablet with imprint EP/117 in the medication cart. The Orange Cart contained five loose medications at the bottom of the drawers: a round white tablet with imprint EP/117, a yellow oblong tablet with imprint 152, a white round tablet with imprint 428SG, an oblong blue tablet with imprint 461G, and a tan round tablet with imprint 1154. The Cherry unit cart 300-319 contained an expired insulin pen. The pen was dated as opened [DATE] with a written date to be discarded on [DATE]. Licensed Practical Nurse (LPN) C said she did not know why the pen was in the medication cart because the medication had been discontinued and should have been removed from the medication cart. The physician's order for the insulin pen was confirmed to be discontinued on [DATE]. LPN C said the medication should have been discarded when it was discontinued. Registered Nurse (RN) G was observed administering medications on the Cherry Hall on [DATE] at 7:17 AM. When RN G opened the medication cart, an undated plastic medication cup containing several medications was identified in the cart. RN G immediately picked up the cup and dumped the medications into the standard refuse receptacle on the side of the medication cart. When asked what the medications were or who they were for, RN G said, I don't know what those pills are, and I didn't put them in that cup. When asked about disposing of medications in the standard waste container, RN G said, Is that not right? That's how I always waste medications. The Nurse Manager on the Cherry Hall (RN L) was interviewed on [DATE] at 8:13 AM. RN L said it was not permissible for nurses to pre-set medications. The expectation was for nurses to prepare medications at the time of medication administration. The Assistant Director of Nursing (ADON) said nurses were expected to dispose of unwanted medication using Drug Buster® (a medication disposal system that breaks down medications and renders them inactive). The Director of Nursing (DON) was interviewed on [DATE] at 12:09 PM. The DON reiterated the facility utilized Drug Buster® and said medications should not be thrown into the garbage can. The DON said nurses were to prepare medications when medications were passed, and nurses were to refrain from preparing medications prior to medication pass. The policy titled Medication and Treatment Administration, dated [DATE] read, in part: . Medication and/or treatments will be prepared, administered, and documented by the same licensed individual only . The undated policy titled Storing Medications, read, in part: . Medications and biologicals will be stored in a safe, secure and orderly manner .and accessible only to licensed nursing and pharmacy personnel or others authorized by law to administer medications .

Based on interview and record review the facility failed to make prompt efforts to resolve grievances for three Residents (C3, C7, & #66) of nine residents reviewed for the facility's grievance and resolution process. Findings include: On 6/11/25 at 11:05 AM, a confidential group meeting was held with eight interested residents. The residents in attendance stated they were not happy with the grievance process. One confidential resident (C3) said, You voice concerns, but it seems to take a while until they let you know an answer. Another confidential resident (C7) stated, Most of the time we don't hear any solutions or any report back on our concerns. Two residents in this meeting stated they had concerns with missing items. Both residents stated they had told staff and never had resolution. A review of the previous Resident Council minutes revealed many concerns had been brought up without resolution. Examples include: 1/16/25 RESIDENT COUNCIL MEETING The minutes included: The floor was opened for residents to make comments, suggestions, concerns, and or ask questions. The minutes reflected many concerns and comments voiced by the residents, however the meeting minutes of 2/20/25 included the following: Old business: There was not any old business from the previous meeting that needed to be brought up for discussion or to follow-up on. 2/20/25 RESIDENT COUNCIL MEETING The minutes included: The floor was opened for residents to make comments, suggestions, concerns, and or ask questions. The minutes reflected many concerns and comments voiced by the residents, however the meeting minutes of 3/20/25 included the following: Old business: There was not any old business from the previous meeting that needed to be brought up for discussion or to follow-up on. 3/20/25 RESIDENT COUNCIL MEETING The minutes included: The floor was opened for residents to make comments, suggestions, concerns, and or ask questions. The minutes reflected many concerns and comments voiced by the residents, however the meeting minutes of 4/17/25 included the following: Old business: There was not any old business from the previous meeting that needed to be brought up for discussion or to follow-up on. 4/17/25 RESIDENT COUNCIL MEETING The minutes included: The floor was opened for residents to make comments, suggestions, concerns, and or ask questions. The minutes reflected many concerns and comments voiced by the residents, however the meeting minutes of 5/22/25 included the following: Old business: There was not any old business from the previous meeting that needed to be brought up for discussion or to follow-up on. During an interview on 6/10/25 at 11:33 AM, Resident #66 (R66) stated she was missing a few personal items including a purple shirt with an iris that was bedazzled and a queen-sized blanket. During an interview on 6/11/25 at 2:51 PM, Registered Nurse (RN) EE reviewed a log of grievances but the three residents with missing items were not recorded. RN EE stated there were forms that were filled out to track grievances including missing items and a procedure to alert other staff to resolve these concerns. RN EE said, I did not find any reports for the residents you mentioned (who were missing items). During a second interview on 6/11/25 at 5:00 PM, R66 again stated, Yes, I told someone about my missing purple shirt and my blanket. During an interview on 6/11/25 at 5:03 PM, Certified Nurse Aide (CNA) FF was asked about the procedure for missing items. CNA FF said if a resident reported a piece of clothing missing, she would call laundry. CNA FF said, I do not know about a form to fill out. During an interview on 6/11/25 at 5:05 PM, CNA GG also stated she would look in the room and the neighbors room and even take the resident to the laundry to find it, but CNA GG did not know about a form to fill out or to report it to other staff. During an interview on 6/11/25 at approximately 5:15 PM, RN HH stated, I could not find documentation on reporting of either missing item. RN HH agreed there needed to be more education on reporting concerns. During an interview on 6/12/25 at 8:09 AM, CNA II said she was familiar with R66 but did not work with her regularly. When asked if CNA II was aware of R66 missing things, she replied, Do you mean clothes? and then continued by stating, I believe she was missing a purple shirt. During an interview on 6/12/25 at 8:13 AM, Social Worker D said she had visited R66 and there was nothing missing. Social Worker D and this Surveyor visited R66 together and R66 confirmed she was missing a purple shirt and a blanket which she had told staff about. Social Worker D stated the facility had known about the blanket from a while back and she indicated she would pursue the other missing items. The facility presented a policy dated 7/5/2019 titled Missing Items on 6/11/25. The procedure for this policy read in full, PROCEDURE 1. When an item is reported missing, immediately search the surrounding area and initiate process. 2. If the item is missing and theft is suspected, notify the Administrator/designee. The administrator/designee will begin the investigation. 3. If it is determined to be a potential misappropriation of property and/or if the resident/family member states they suspect theft, the guidelines for reporting abuse will be implemented. There was no mention of a tracking tool or a reporting mechanism to keep the resident informed and promptly resolve grievances. .

On 6/11/25, the following observations were made of the dining rooms: Elm Dining Hall: At 12:25 p.m., 25 Residents were observed sitting in the dining room without drinks. Three staff members were observed at 12:30 p.m. when the meal cart was delivered attempting to pass out meals to residents. Dogwood Dining Hall: At 12:20 p.m., six residents were observed in the dining room without drinks. At 12:30 p.m., 10 residents were observed in the dining hall without drinks. The meal cart was delivered at 12:44 p.m. with one staff member assisting residents with their meals. Cherry Dining Hall: At 12:40 p.m., six residents were observed in the dining room without drinks. At 12:45 p.m. nine residents were observed in the dining room without drinks. At 12:50 p.m., 14 residents were observed in the dining room without drinks. At 12:58 p.m., the meal cart was delivered with one staff member assisting residents with their meals. Birch Dining Hall: At 12:32 p.m., one resident was observed in the dining room without a drink. At 12:45 p.m., six residents were observed in the dining room without drinks. At 1:00 p.m., eight residents were observed in the dining room without drinks. At 1:15 p.m. the meal cart was delivered with one staff member assisting residents with their meals. On 6/12/25 at 12:58 p.m., an interview was conducted with General Manager/Staff T regarding the expectation of meal service. Staff T stated, The expectation is that staff would provide drinks as they are bringing residents into the dining hall. I am unsure why nursing brings residents down so early and then leaves them. We have had issues in the past, and believe we need more universal workers. Based on observation, interview, and record review, the facility failed to provide a dignified dining experience for those residents choosing to eat their meals in the congregate facility dining rooms and 6 of 8 residents attending the confidential group meeting. This deficient practice resulted in frustration and helplessness regarding wait times for meal arrival. Findings include: On 6/11/25 at 11:05 AM, a confidential group meeting was held with eight interested residents. Resident C1 stated, We wait in the dining room for a long time when the cart with the meals is sitting right there. Residents C2, C3 and C4 agreed on the long wait times in the dining room. C1 and C5 said there usually was only one woman passing out the trays. It takes more than that. The food cart comes, and it can sit for a half an hour while we wait. We just sit. C6 said usually there are no beverages served and we just sit and wait. A review of the previous Resident Council minutes revealed late service of trays had been brought up without resolution: 1/16/25 RESIDENT COUNCIL MEETING 1. Discussion regarding food . The floor was opened for residents to make comments, suggestions, concerns, and or ask questions: One resident asked why are meal (SIC) getting later and later? . 3/20/25 RESIDENT COUNCIL MEETING 1. Discussion regarding food . The floor was opened for residents to make comments, suggestions, concerns, and or ask questions: .Timeliness of residents receiving trays was discussed - (Staff) to follow up with nursing to make sure trays are being passed efficiently on all floors . 4/17/25 RESIDENT COUNCIL MEETING 1. Discussion regarding food . The floor was opened for residents to make comments, suggestions, concerns, and or ask questions: Dinners are cold . (Staff) to follow up with (staff) to discuss timeliness of trays being passed. 5/22/25 RESIDENT COUNCIL MEETING 1. Discussion regarding food . The floor was opened for residents to make comments, suggestions, concerns, and or ask questions: . Food is slow getting to the Dogwood dining area. (Staff name) to follow up with kitchen.

Based on observation, interview, and record review, the facility failed to provide supervision to prevent resident to resident physical abuse resulting in harm from the reasonable person perspective, for three Residents (R149, R155, and R158) of three residents reviewed for abuse prevention. Findings include: A review of R158's Electronic Medical Record (EMR) revealed admission to the facility on 3/11/25 and diagnoses including dementia with psychotic disturbance. R158's Minimum Data Set (MDS) assessment, dated 3/17/25, showed severe cognitive impairment, was rarely understood, showed signs of physical and verbal behaviors 1-3 days, ambulated independently and resided in the secure (locked) memory care unit. An observation on 6/10/25 at 12:32 p.m. revealed R158 in the main dining hall of the memory care unit. R158 was observed becoming confrontational with other residents while waiting for the lunch meal service to arrive. R158 was observed getting very close to residents sitting at the table, attempting to take various drinks from them and then becoming upset. One staff member was observed attempting to redirect R158 away from other residents. R158 would then pace up and down the hallway and come back to the main dining room to repeat the process. A request for R158's Incident and Accident Reports from May 15th, 2025, through June 10th, 2025, were reviewed with the following incidents noted: 5/19/25: Staff heard resident yell in the common area. This nurse looked up at the camera and another resident (R149) had ahold of this resident's arms and was pushing her backwards into a chair. Resident was visibly upset and telling the other resident to 'let me go or I'm gonna knock you out.' Staff intervened and led both residents in different directions .Resident does not remember what happened but continued to be agitated . 6/4/25: This nurse received witness statement on 6/6/25 in ADON (Assistant Director of Nursing) mailbox from CNA (Certified Nurse Aide) reading '(R158) wandered into (R155's) room and (R155) grabbed her arm and squeezed it and was yelling at her.' This nurse notified nursing administration and contacted nurse assigned to resident that day. Nurse's witness statement obtained and stated, 'CNA informed me that a resident, (R158) was wandering the halls and entered another resident's room (R155). CNA stated (R155) confronted (R158) when entering and squeezed (R158's) arms. (R155) was visibly agitated and yelled at (R158). (R158) was escorted out of the room to separate resident's . A review of R158's care plan on 6/12/25, revealed the following: The resident has the potential to be physically aggressive r/t (related to) dementia; date initiated: 3/12/25; Interventions: Date initiated: 3/12/25 The resident's triggers for physical aggression are multiple people around her/walking with her. The resident's behaviors are de-escalated by 1:1. Snack if able, likes to carry something that resembles a cigarette . The resident was involved in (2) resident-to-resident altercations and the resident was the (aggresse); date initiated: 6/4/25 revision on 6/6/25; Interventions: Date Initiated: 6/6/25 Immediately separate residents and secure their safety . A review of the [States] Facility Reported Incident portal revealed the facility had reported four incidents of Resident-to-Resident Abuse for R158. Three reported incidents involving R158 as the aggressor and R149 the victim. As stated in the above observation, R158 did not receive any of these interventions as directed per the care plan. On 6/12/25 at 12:36 p.m., an interview with the Director of Nursing (DON) revealed the facility had already identified behavioral issues with R158. We have too many issues going on with (R158) and (R149) and now with (R148). We continue to have issues with scheduling with [third party behavioral agency]. One to One's don't work because it just makes (R158) more upset. We've thought about doing a sleep study on (R158). We are also trying to get the facility an in-house psychologist to help residents who have mental health services, but that has not happened yet. Just short of sending (R158) out to the hospital, we are unsure what to do. Review of the facility's Abuse Prohibition and Prevention Program Policy) dated 7/12/23, revealed the following, in part: Our organization will not condone any form of resident abuse and will continually monitor our policies, procedures, training programs, systems, etc., to assist in preventing resident abuse .Resident-to-Resident Altercations 1) Facility staff will monitor residents for aggressive/inappropriate behavior towards other residents .occurrences of such incidents shall be promptly reported to the Director of Nursing/designee 2) If two (2) residents are involved in an altercation, staff will: . f) Make any necessary changes in the care plan approaches to any or all of the involved individuals; g) Document in the resident's clinical record all interventions and their effectiveness; h) Consult psychiatric services as needed for assistance in assessing the resident, identifying causes, and developing a care plan for intervention and management as necessary or as may be recommended by the Attending Physician or Interdisciplinary Care Planning Team; j) If, after carefully evaluating the situation, it is determined that care cannot be readily given within the facility, transfer the resident .

Based on observation, interview, and record review, the facility failed to revise care plan interventions for one Resident (R155) of five residents reviewed for behavior care planning. Findings include: Review of R155's Electronic Medical Record (EMR) revealed admission to the facility on 9/16/24 with diagnosis including Alzheimer's Disease. R155 was not responsible for her medical and financial decisions. R155 had a recent resident to resident altercation on 6/6/25. Review of R155's Care Plans read, in part, .Modify environment: (redirect others away from my room. If I allow it, place [Name Brand] stop/gate on my room door when I am not in it. I often remove this, but at times it can reassure me) date initiated: 4/2/25 . On 6/10/25 at approximately 11:50 a.m., R155's room was observed by this Surveyor. R155 was not located in her room, and a stop sign appeared to be placed on a fire exit door adjacent to R155's room. The Director of Nursing provided an incident report for R155 on 6/12/25. There was one incident which was provided which occurred on 6/4/24 at approximately 3:40 p.m. between R155 and R158 where R158 wandered into 155's room. R155 then subsequently grabbed and squeezed R158's arm. There was no documentation to show the facility had addressed this incident with any updated intervention as a result of this altercation. The current intervention of the stop sign on the door when R155 is not in their room was observed ineffective during the survey. An interview was conducted with Assistant Director of Nursing (ADON) W on 6/11/25 regarding R155's care plan interventions. ADON W stated, The intervention of a stop sign was added to (R155's) care plan to deter other residents from coming in her room. (R155) frequently removes the stop sign and places it around the unit. On 6/12/25 at 10:07 a.m., R155 was observed to be walking down the hallway returning her breakfast tray to the dining hall. R155 was noted to be anxious and stating she wanted to, Get out of here. After returning her tray, R155 sat in a recliner chair near the nurses' room and continued to show signs of restlessness in wanting to leave the facility. R155's room was observed at this time with no stop sign placed on her door. On 6/12/25 at approximately 2:40 p.m., R155's room was observed to not have a stop sign placed on the front of her door. R155 was not in her room at the time of this observation. Review of the facility's Care Plan policy dated 10/9/23 read, in part, .The care plan is periodically reviewed and revised by the interdisciplinary team after each assessment but at least once quarterly. Interventions no longer applicable should be removed .

Based on interview and record review, the facility failed to administer medication per physician order for one resident (Resident #2) of 35 residents reviewed for quality of care. Findings include: Resident #2 (R2) Review of R2's electronic medical record (EMR) revealed initial admission to the facility on 6/13/16 with diagnoses including anemia, depression, diabetes mellitus, nausea, and hypertension. Review of R2's progress note, dated 3/10/25 at 11:19 PM, read in part, Resident received wrong dose of medication .Resident aware of medication error. Review of facility incident and accident report, dated 3/10/25, read in part, .Incident description .Floor nurse gave resident wrong dose of medication. Resident is ordered 0.5mg (milligrams) of (name brand for lorazepam, a controlled substance commonly used to treat anxiety) and was given 3.0mg .Level of consciousness: Lethargic (drowsy) .Mental status: Resident drowsy due to (name brand for lorazepam) being administered 30 minutes prior . Review of R2's physician order, dated 3/5/25, revealed the following: Lorazepam 0.5 mg, give one tablet by mouth every 4 hours as needed for anxiety/EOL (end-of-life) care. On 6/12/25 at 10:00 AM, an interview was conducted with Assistant Director of Nursing (ADON) L who was asked about R2 receiving the wrong dose of lorazepam on 3/10/25 and replied, I would guess that the nurse gave R55's lorazepam dose and not R2's. The ADON was asked if they could investigate the incident and provide more information. Review of R2's Medication Administration Record (MAR), dated March 2025, revealed one administration of lorazepam date 3/8/25 at 9:01 PM. Review of R2's controlled substance administration record, dated March 2025, revealed two administrations for lorazepam on 3/8/25 at 8:58 PM and 3/9/25 at 11:56 PM. Resident #55 (R55) Review of R55's EMR revealed initial admission to the facility on [DATE] with diagnoses including anxiety, depression, bipolar disorder, and restless leg syndrome. Review of R55's physician order, dated 11/4/24, revealed the following: Lorazepam 1 mg, give three tablets by mouth one time a day (bedtime) for bipolar disorder. Review of R55's controlled substance administration record, dated March 2025, revealed two administrations for lorazepam on 3/10/25 at 10:00 PM with one being marked as a wasted dose. On 6/12/25 at 10:30 AM, an interview was conducted with the Director of Nursing (DON) who was asked if Registered Nurse (RN) M was disciplined for the medication error and educated and replied, I would have to check with human resources. Review of R2's physician order, dated 3/10/25 at 10:56 PM, read in part, Medication incident - Monitor vitals. Medication error monitor vitals one time a day for anxiety for three days BID (two times a day) VS (vital signs) r/t (related to) medication incident. PM (evening) nurse: review vitals and add to vitals board AND one time a day for anxiety for 3 days BID VS r/t medication incident. AM (morning) nurse: review vital signs . Review of R2's vital signs, dated 3/10/25 through 3/14/25, revealed the following: A,) No vital signs recorded for PM shift on 3/11/25. B.) No vital signs recorded for PM shift on 3/12/25. C.) No vital signs recorded for PM shift on 3/13/25. Review of R2's progress notes, dated 3/10/25 through 3/14/25, revealed: No nursing progress notes following up the medication administration error of R2 receiving 3 mg or lorazepam instead of 0.5 mg. On 6/12/25 at 1:00 PM, an interview was conducted with the DON who was asked if medication rights should be followed with each medication pass and replied, Yes, that is the expectation for all nursing staff. The DON was then asked if the MAR and the controlled substance log should reflect the same administration of medications and replied, Yes, absolutely. On 6/12/25 at 1:05 PM, an interview was conducted with RN L who explained that RN N wrote the incident and accident report for the medication error involving R2 and RN M. RN L confirmed that RN M was not disciplined but should have been and that RN L was on vacation that week. RN L stated that RN M should not have written wasted on the controlled substance sheet and should have instead recorded an error, and a second dose was pulled for R55.

Based on observation, interview, and record review the facility failed to properly supervise one Resident (#121) of two residents reviewed for Activities of Daily Living during (ADL) care. This deficient practice resulted in a fall with injury. Resident #121 (R121) On 6/10/25 at 12:24 p.m., R121 was observed sitting in the main dining hall waiting for her meal tray. R121 was noted to have a large purple bruise under her left eye and a dark red/purple bruise under her left nostril. An attempted interview was conducted with R121 who was not able to respond appropriately. Review of R121's Progress Notes read, in part, 6/6/25: (R121) is being seen today to follow up on a witnessed fall that occurred this morning at 6:06 a.m. in the member's room while CNA (Certified Nursing Aide) was dressing her for the day. She (CNA) had turned her back for a moment and the resident fell forward from a seated position on her bed and struck the left side of her head on the floor She is lying in her bed at this time and a large hematoma to the left forehead with ecchymosis to the left eye is noted. She also sustained a skin tear to her right elbow and an abrasion to the left knee .DPOA/husband (Designated Power of Attorney) was notified and informed about recommendations to send to [Hospital Name] for a CT [computed tomography scan] of the head. He refused and reports that he wishes to maintain comfort care at this time. He was also informed that she threw up all her breakfast and that it is a sign of brain injury .pupils are equal and sluggish to react to light. She awakens and looks at you before falling back asleep .staff reports some groaning earlier in shift . An interview was conducted with CNA X on 6/12/25 at 8:25 a.m. CNA X confirmed she was the staff member assisting R121 the morning of 6/6/25 and stated, I just remember trying to get her up and dressed. I had changed her shirt and brief and knelt while she (R121) was sitting at the edge of the bed. I was down by her feet trying to put her pants on when she bent over, and I couldn't stop her. Once she was on the floor, I moved her around and then went to get the nurse. A written statement from Registered Nurse (RN) Y read, in part, .CNA staff alerted this nurse that the resident had fallen in her room. Upon arrival to her room, she was observed in between her bed and her recliner chair laying on her right side with her right arm slightly underneath her with her legs extended outward. CNA staff stated that they rolled her onto her side from a prone position prior to this writer's arrival. Resident unable to give description. Resident assisted off of her side and onto her back. She was assisted up to a standing position via three staff assist and then she sat down in her wheelchair . On 6/12/25 at 9:16 a.m. an interview was conducted with the DPOA for R121 who stated that the facility did call him on the morning of 6/6/25 and informed him that R121 had fallen while trying to get dressed for the morning. He stated that he wanted to the facility to continue to monitor R121, and if she continued to get worse then he would consider sending her to the local hospital. The DPOA for R121 then stated, She easily forgets that she is doing something, and staff know that. An interview was conducted with the Director of Nursing (DON) on 6/12/25 at 10:03 a.m. The DON stated that R121 will become impulsive, and that staff should know and recognize that about her. The DON stated that CNA X should not have moved R121 before notifying RN Y.

Based on observation, interview, and record review, the facility failed to ensure the sanitary storage and cleaning of respiratory equipment for two Residents (#430 and #433) of two residents reviewed for respiratory services. Findings include: Resident #430 (R430) Review of R430's electronic medical record (EMR) revealed initial admission to the facility on 5/27/25 with diagnoses including chronic obstructive pulmonary disease (COPD), moderate persistent asthma, and chronic respiratory failure. Review of R430's Minimum Data Set (MDS) assessment, dated 6/2/25, revealed a Brief Interview for Mental Status (BIMS) score of 13, indicative of intact cognition. On 6/10/25 at 11:42 AM, oxygen tubing was observed connected to a concentrator next to R430's bed and coiled up on the floor. No storage bag was noted. R430 verified she required supplemental oxygen at night and did not recall ever having a storage bag for the tubing. Review of R430's EMR revealed a physician's order, initiated 5/30/25, which read: Continuous Oxygen 2 L (liters)/min (minute) via NC [nasal cannula] at night and PRN [as needed], Maintain sats [saturations] >90%, two times a day for HX [history of] Asthma. On 6/11/25 at 11:53 AM, oxygen tubing was observed connected to a concentrator next to R430's bed and coiled up on the floor with no protective covering. The nasal prongs were observed in direct contact with the floor which was covered with various debris. On 6/11/25 at 4:04 PM, oxygen tubing was again observed connected to a concentrator next to R430's and coiled up on the floor with no protective covering. Resident #433 (R433) Review of R433's EMR revealed initial admission to the facility on 5/23/25 with diagnoses including acute respiratory failure with hypoxia, pneumonitis, asthma, and obstructive sleep apnea. On 6/10/25 at 12:29 PM, R433's undated nebulizer was observed lying on top of their bedside table in one piece with visible condensation in the medication cup. A CPAP [Continuous positive airway pressure] mask was observed in direct contact with bedside chair. Two sets of oxygen tubing were observed connected to a concentrator and portable oxygen tank at the end of R433's bed without protective covering. Review of R433's EMR revealed the following physician's orders: 1. Oxygen 2 lpm [liters per minute] via NC as needed for O2 (oxygen) sat <90% or SOB [shortness of breath], initiated 5/27/25. 2. CPAP/BiPAP (Bilevel Positive Airway Pressure) on at HS [nighttime], initiated 5/23/25. 3. Budesonide (inhaled steroidal medication) Suspension 0.5 MG (milligrams)/2 ML (milliliters) 2 ml inhale orally [via nebulizer] every 12 hours for COPD [chronic obstructive pulmonary disease], initiated 6/2/24. 4. Ipratropium-Albuterol Solution 0.5-2.5 (3) MG/3 ML 1 vial inhale orally four times a day [via nebulizer] for COPD, initiated 6/5/25. On 6/11/25 at 9:03 AM, R433's undated nebulizer was again observed lying on top of their bedside table in one piece with visible condensation in the medication cup. Two sets of oxygen tubing were observed connected to a concentrator and portable oxygen tank at the end of R433's bed without protective covering. On 6/11/25 at 4:39 PM, two sets of oxygen tubing were again observed connected to a concentrator and portable oxygen tank at the end of R433's bed without protective covering. On 6/12/25 at 11:55 AM, an interview with conducted with Assistant Director of Nursing (ADON) O regarding oxygen storage expectations. ADON O stated oxygen tubing and CPAP masks should be stored in bag when not in use. ADON O stated nebulizers should be cleaned and allowed to dry after every use. On 6/12/25 at 1:06 PM, an interview was conducted with the Director of Nursing (DON) regarding oxygen storage expectations. The DON verified oxygen tubing should be stored in a labeled and dated bag when not in use. The DON stated nebulizers were to be disassembled and cleaned after each use. Review of the facility policy titled, Oxygen Therapy, dated 2/2/23, read, in part: .PRN oxygen -temporarily discontinued: clean prongs with exterior tubing with alcohol swab and store in Ziploc bag . Review of the facility policy titled, Medication Administration: Nebulizer Treatment, dated 11/9/09, read, in part: .When treatment is complete, turn off nebulizer and disconnect T-piece, mouthpiece, and medication cup . rinse and disinfect the nebulizer equipment according to facility protocol: a. Wash pieces with warm, soapy water, b. Rinse with hot water, c. Allow to air dry on a paper towel .

Based on interview and record review, the facility failed to provide applicable bed hold policy information and/or written transfer notifications to two Residents (#154 and #68) of four residents reviewed for transfer and discharge process. Findings include: Resident #154 (R154) The medical record for R154 revealed a census record on 2/24/25 stating R154 was sent out to the hospital. The medical record did not have a record that a written notification of discharge or explanation of the bed hold policy was sent to the resident or the responsible party. On 6/11/25 at approximately 12:00 PM, a request was made to the Director of Nursing (DON) for documentation of any written notification of hospital transfers and bed hold policy notifications for R154 for all hospitalizations over the past six months. At 2:36 PM that same day, an email follow up was sent to the DON for the transfer documents for R154. While a written notification of transfer was presented for a December transfer, the 2/24/25 documents were not presented. It was noted that R154 was on the Ombudsman hospital transfer list for February confirming this transfer, but no evidence of notices sent, or bed hold policy was provided. The facility undated document titled Discharge and Transfer Procedure Policy was presented on 6/12/25 at 10:37 AM. It read in part, Notify Campus Manager to facilitate bed hold policy and document in nurses notes . The signed or not signed Bed Hold Authorization or Decline Form will be maintained . This policy did not reference the Ombudsman log or the Written Notification of Transfer. Resident #68 (R68) During an interview on 6/10/25 at 2:00 PM, R68 indicated they had been sent out to the local hospital during their stay at the facility but were unsure of the exact date. The medical record for R68 revealed a transfer to the hospital on 2/4/25 with a readmission on [DATE]. Review of the facility ombudsman transfer notification log, dated February 2025, revealed that R68 was not listed on the log to notify the ombudsman of their transfer out of the facility.

This deficiency pertains to Intake MI00147134. Based on interview and record review, the facility failed to provide timely notification to the physician for one Resident (#4) of three residents reviewed for a change in condition. This deficient practice resulted in a delay in medical treatment and subsequent death for Resident #4. Findings include: Resident #4 (R4): Review of R4's electronic medical record (EMR) revealed admission to the facility on [DATE] with diagnoses including stroke, anemia (a condition in which the blood doesn't have enough healthy red blood cells), and gastro-esophageal reflux disease (a condition in which the stomach contents move up into the esophagus). Review of R4's most recent Minimum Data Set (MDS) assessment dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 14, indicative of intact cognition. Review of a progress note written by Licensed Practical Nurse (LPN) G on [DATE] at 4:01 AM read, in part: CNA [certified nursing assistant] staff alerted this writer that resident [was] SOB [short of breath] this evening . Another alert by CNA staff stated that resident has had 4 med-large [medium-to-large] black tarry stools that have resulted in two bed changes this evening. This writer went into bathroom while resident was on toilet, and resident nodded off two times .Vitals at ,d+[DATE], 93% RA [oxygen saturation on room air], resp [respirations] from ,d+[DATE], HR [heart rate] 98 [beats per minute] .Resident stated she was dizzy while in [mechanical lift transfer aid] heading back to bed .Resident states that she has not had bowel movements like that before . Review of R4's five blood pressure recordings prior to the event revealed the following: 1. [DATE] 13:45 [1:45 PM] - 144 / 69 mmHg [millimeters of mercury] 2. [DATE] 7:36 AM - 155 / 76 mmHg 3. [DATE] 8:37 AM - 145 / 72 mmHg 4. [DATE] 6:47 AM - 153 / 89 mmHg 5. [DATE] 18:16 [6:16 PM] - 168 / 70 mmHg Review of R4's five pulse recordings prior to the event revealed the following: 1. [DATE] 13:45 [1:45 PM] - 59 bpm [beats per minute] 2. [DATE] 7:36 AM- 68 bpm 3. [DATE] 8:37 AM - 67 bpm 4. [DATE] 6:47 AM - 78 bpm 5. [DATE] 18:16 [6:16 PM] - 70 bpm On [DATE] at 12:03 PM, a phone interview was conducted with LPN G who verified she was the nurse who provided direct care to R4 on the midnight shift from [DATE] - [DATE]. LPN G recalled visiting R4's room several times during her shift due to CNA reports of shortness of breath and abnormal stools. When LPN G was asked about her assessments/conclusions, she replied, I asked for help because I was unsure what to do . I am a newer nurse. I had my manager in the room with me that night, [Registered Nurse (RN) H], who told me to write in the provider book that she [R4] should be seen . LPN G verified she wrote her concerns in the provider book to be reviewed at the next provider round and did not contact the on-call physician. LPN G recollected R4's vitals were, normal but could not remember if her vital assessments were compared relative to R4's baseline vital sets. LPN G acknowledged R4's respiration rate was, above normal. On [DATE] at 3:51 PM, a phone interview was conducted with RN H who verified he was Campus Coordinator on the midnight shift from [DATE] - [DATE]. RN H recalled receiving a phone call from LPN G during his shift who relayed R4 was unable to catch her breath. RN H stated, During the course of the phone call, I was never told she [R4] had black tarry stools . Had I had more information, I would have sought immediate medical evaluation by the provider . The provider book is helpful for non-immediate needs, but it sounds like for this patient there was immediate need to call the provider. Review of a progress note written by RN F on [DATE] at 4:27 PM read, in part: This nurse was doing rounds and observed this resident [R4] with head slumped forward and unresponsive. I was unable to arouse her and she had no pulse and no breathing observed at 3:26 PM a code nurse [was] called and CPR [cardiopulmonary resuscitation] started immediately and 911 called for EMS [Emergency Medical Services] and they arrived at 3:42 [PM] .The EMS team took over at 3:42 [PM] providing CPR with a machine, iv [intravenous] fluids and 2 rounds of epi [epinephrine] was given. EMS stopped CPR at 3:58 [PM] pronouncing her death . On [DATE] at 11:39 AM, an interview was conducted with RN F who confirmed she found R4 unresponsive on [DATE]. RN F stated she was notified during shift change that R4 experienced, a lot of bowel movements in the middle of the night but was unaware of any other symptoms. After review of the progress note written by LPN G on [DATE] at 4:01 AM, RN F stated, I would have called the provider right away. On [DATE] at 10:21 AM, an interview was conducted with Medical Director (MD) K regarding her clinical expectations for a resident who experienced multiple instances of black tarry stools. MD K stated black tarry stools combined with hemodynamic symptoms (symptoms that indicate an issue with blood flow in the body) would be indicative of an emergent situation. When asked for examples of hemodynamic symptoms, MD K stated, Things like hypotension [low blood pressure], tachycardia [accelerated heart rate], shortness of breath, abdominal discomfort, and/or dizziness. After record review of R4's symptoms which accompanied abnormal stools, MD K stated, A phone call to the on-call provider was warranted. Review of R4's death certificate read, in part: Cause of death: Acute End Organ Failure . GI [gastrointestinal] bleed . Approximate interval between onset and death: hours . Review of the facility policy titled, Change in Condition dated [DATE], read, in part: PURPOSE: To assist facility staff with identifying individuals at risk for acute changes in condition .describing and documenting symptoms and /or condition changes, and establishing a process of reporting findings .PROCEDURE: Assess the resident's symptoms, mental status and physical function .Use SBAR [A communication technique meaning Situation, Background, Assessment, Recommendation] to notify the physician and proceed as instructed . Vital Signs: Blood pressure 20 mm Hg lower or higher than normal . Respirations fewer than 12 or greater than 20 breaths per minute .Acute changes in any of the following: .Shortness of breath and/or change in breath sounds .Dizziness .

This deficiency pertains to Intake MI00147235. Based on interview and record review, the facility failed to ensure timely laboratory services were provided per physician's orders for one Resident #1 (R1) of 3 residents reviewed for laboratory services. This deficient practice resulted in extreme elevation of blood glucose levels requiring R1 to be hospitalized . Findings include: Resident #1 (R1) Review of R1's electronic medical record (EMR) revealed initial admission to the facility on [DATE] with diagnoses including dementia, type two diabetes with hyperglycemia (high blood glucose levels), and cognitive communication deficit. Review of R1's most recent Minimum Data Set (MDS) assessment dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 9, indicative of moderate cognitive impairment. Review of Intake MI00147235 read, in part: .On or about [DATE], the facility's doctor [Medical Director (MD) K] discontinued [R1]'s diabetes medication. [R1] had been taking diabetes medication(s) for at least the prior ,d+[DATE] years. [Durable Power of Attorney (DPOA) M] of [R1] had durable power of attorney, was not informed of this change at the time it was made . [DPOA M] was given a few reasons why they might have done . [DPOA M] was told that [R1]'s A1c [a blood test which measures blood sugar levels as a means to diagnose of manage diabetes], which was supposedly checked every 3 months, had gone down .However, [acute care hospital] records showed her [R1] last A1c had been about 7.5 [%] in [DATE], and it hadn't been taken since . On [DATE] at 11:00 AM, a telephone interview was conducted with Family Member A of R1 who confirmed R1 was supposed to have an A1c test every 3 months to assist in diabetic management. Review of R1's laboratory records in the facility EMR revealed the most recent A1c lab test occurred on [DATE]. Review of a physician order dated [DATE] read, HgbA1c [hemoglobin A1c] one time a day every 90 day(s) for diabetes. On [DATE] at 12:14 PM, an interview was conducted with Director of Nursing (DON) who verified R1 had physician orders for an A1c laboratory test every 3 months. The DON confirmed R1's last A1c result was on [DATE]. The DON did not know why an A1c test was not conducted in June per physician orders. Review of R1's EMR revealed the following progress notes by Registered Nurse (RN) B: 1. [DATE] at 5:14 PM: Resident lethargic this shift, unable to communicate at her baseline, unable to complete a sentence. Resident refusing food & drink . 2. [DATE] at 10:50 AM: Resident lethargic this AM [morning] attended breakfast but would only drink sips of fluid, refused to eat making gestures as if she was going to throw-up, unable to communicate. Blood sugar tested reading of HI obtained at 09:00 [AM]. Blood sugar re-checked at 09:45 [AM] reading of HI obtained again. On-call provider notified . ordered resident to be sent to ER for treatment due to extreme hyperglycemia [an excess of glucose in the bloodstream] . On [DATE] at 1:07 PM, a telephone interview was conducted with RN B who verified she checked R1's blood glucose level on [DATE] due to confusion, nausea, and changes in ability to communicate. RN B confirmed the glucometer read HI both times she tested R1's blood sugar, meaning the level was over 600 [milligrams per deciliter (mg/dL)] per glucose meter manufacturer's guide. RN B stated she notified the physician who gave orders to send R1 due to severe hyperglycemia. Review of R1's Emergency Department summary, dated [DATE], read, in part: Chief complaint: .Recently taken off diabetic meds per [DPOA M] unbenknowst [sic] to her. x2 weeks of mental status changes, lethargy, and nausea without vomiting . Based on patient's [R1]'s history and physical examination there is concern for hyperglycemia, DKA [diabetic ketoacidosis], electrolyte abnormality, dehydration . Review of R1's Hospital summary, dated [DATE], read, in part: [R1] is a .female with untreated DM2 [type II diabetes mellitus] . who presented to the ED [emergency department] . for altered mental status . Her [DPOA] states that she has been concerned about elevated blood glucose for a while, as her diabetic regimen was discontinued . Per review of records, her last A1c was checked ,d+[DATE] and came back at 7.6%, compared to 10.9% today . Laboratory studies demonstrated a hyperglycemia at 834 [mg/dL] . (Reference fasting range: ,d+[DATE] mg/dL). On [DATE] at 11:00 AM, a telephone interview was conducted with Family Member A of R1 who confirmed R1 was hospitalized from [DATE] - [DATE] as a result of the hyperglycemic episode. Family Member A stated R1 discharged to the facility on [DATE] and expired on [DATE] on hospice services. Review of a Health Status Note on [DATE] read, in part: .Upon revisit to administer comfort medications at 8:15 [AM] resident was noted to be no longer breathing. Upon auscultation residents' death was confirmed by 2 RN's. Time of death 8:18 [AM] . Review of the facility policy titled, Resident Care Policies, dated [DATE], read, in part: In order to meet the physical and psychological needs of the resident, diagnostic services are provided to enhance identification of these needs, and facilitate diagnoses . A diagnostic test or service shall only be provided per written order of the physician .

This citation pertains to intake MI00145621. This citation has two parts: A and B. A. Based on interview and record review, the facility failed to ensure appropriate, timely assessments and physician/provider notification for a change in condition for one Resident (#173) of three residents reviewed for death, resulting in actual harm when R173 became unresponsive and ultimately expiring in the facility. Findings include: Resident #173 (R173) R173 was admitted on [DATE] with diagnoses including congestive heart failure (CHF), atrial fibrillation (abnormal heart rhythm), coronary artery disease (CAD) S/P (status-post) heart catheterization, transient ischemic attack (ministroke) and acute kidney injury. Review of R173's Minimum Data Set (MDS) assessment, dated [DATE], revealed R173 expired in the facility on [DATE]. Review of R173's Medical Certificate of Death, revealed the Resident expired on [DATE] at 1:59 p.m., cause of death was heart failure. Review of R173's electronic medical record (EMR) revealed on [DATE] the resident was hypotensive (blood pressure below ,d+[DATE] mmHg (millimeters of Mercury, a unit of pressure) became unresponsive and expired in the facility. Further review revealed the following: [DATE] at 12:35 [p.m.], [signed by Registered Nurse (RN) V] Behavior Note: low BP [ blood pressure] with a manual this morning, asymptomatic. Noted to run low following hospital discharge and among admission yesterday, [R173] had a shower and was ambulating with no complaints following lunch. Upon laying down this nurse was planning to obtain another set of vitals and other care. Wife requested for blood sugar to be checked before lunch . and requested he get short acting insulin; provider notified and ordered a sliding scale . [DATE], 15:45 [3:45 p.m.], Alert Note: Wife informed CNA [Certified Nurse Assistant] that [R173] became unresponsive. CNA alerted nursing staff . immediately responded and noted [R173] to have irregular, apneic breathing with a weak thready pulse . still assessing patient, pulse stopped and CPR [Cardiopulmonary Resuscitation] was immediately initiated. Fire arrived at 1336 [1:36 p.m.], EMS [Emergency Medical Services] arrived at 1341 [1:41 p.m.]. CPR lasted ,d+[DATE] [1:25 p.m. - 1:59 p.m.]. At that time EMS called time of death [1:59 p.m.] . Further review of R173's EMR revealed the following blood pressure readings: [DATE] at 5:57 p.m. - ,d+[DATE] mmHg (manual, right) [DATE] at 10:19 p.m. - ,d+[DATE] mmHg (machine) [DATE] at 7:24 a.m. - ,d+[DATE] mmHg (machine) [normal blood pressure range is below ,d+[DATE] mmHg and above ,d+[DATE] mmHg] [DATE] at 8:48 a.m. - ,d+[DATE] mmHg (manual, right) [DATE] at 8:49 a.m. - ,d+[DATE] mmHg (manual, left) The following was noted in review of R173's blood pressure readings, the documented reading on [DATE] at 7:24 p.m. was 30 points lower systolic and 21 points lower diastolic than the previous reading on [DATE] at 10:19 p.m. It was also noted there were no blood pressure readings recorded from [DATE] at 7:24 a.m. until [DATE] at 8:48 a.m., a timeframe of one hour and 24 minutes after R173's blood pressure was noted to be low. It was noted in review of R173's EMR, there were no physical assessments documented prior to or in response to the Resident's low blood pressure readings on [DATE]. It was also noted there was no documentation of assessments of R173's heart rate, oxygen saturation, or respiratory rate to accompany the low blood pressure readings at 8:48 a.m. or 8:49 a.m. Review of R173's Medication Administration Record (MAR) revealed RN V withheld administration of the following scheduled morning (8:00 a.m.) medications: Bumex [medication used to remove excess fluid in the body] Oral Tablet 1 MG (milligram). Give 1 tablet by mouth two times a day for CHF. Metoprolol Tartrate [medication used to lower blood pressure and heart rate] Oral Tablet 25 MG. Give 1 tablet by mouth two times a day for HTN [hypertension]. Further review of R173's MAR revealed RN V documented the reason for withholding the medications as Vital outside of parameters for administration. It was noted, the orders for the medications included no vital sign parameters for administering or withholding the medications. Further review of R173's EMR revealed no documentation of physician/provider notification of R173's low blood pressure readings on [DATE] or of RN V withholding administration of the scheduled doses of Bumex 1mg and metoprolol tartrate 25mg. Review of physician/provider notification documentation binder for [DATE], provided by Assistant Director of Nursing (ADON) F, revealed no entry or documentation to alert the physician or advanced practice providers of R173's low blood pressures on [DATE] or of the need to withhold administration of the Resident's scheduled Bumex 1 mg or metoprolol tartrate 25mg. During an interview on [DATE] at 1:50 p.m., RN V confirmed she was assigned to R173's care on [DATE]. RN V reported she was aware of the Resident's low blood pressure readings and verified the blood pressure readings on [DATE] were out of normal range. RN V stated she was not concerned about R173's low blood pressure readings because the Resident was not having any symptoms of hypotension, but the Resident's blood pressure was difficult to measure due to being hard to hear when taken manually. When asked what symptoms she would expect to see a change in condition, RN V stated R173 was not having symptoms because the Resident took a shower and ate lunch without reporting any increased fatigue. RN V did not remember conducting a physical assessment of R173, including listening to R173's lung sounds in response to the low blood pressure. RN V was asked if R173 was having any difficulty with breathing or cough to which she replied he must have at some point, he was wearing oxygen. A query was made regarding withholding administration of R173's scheduled Bumex 1mg and metoprolol tartrate 25mg on the morning of [DATE]. RN V reported she held administration of the medications because she was worried the medications would lower R173's blood pressure further. RN V reported she did not notify the physician of the need to withhold administration of the medications or of R173's low blood pressure readings. When asked why her concern over R173's blood pressure dropping further did not warrant physician notification, RN V stated she did not feel a call was necessary because the resident was asymptomatic and had been running low prior to admission. Review of R173's Hospital Summary, dated [DATE] at 3:04 p.m., revealed a blood pressure reading of ,d+[DATE] mmHg at discharge. During an interview on [DATE] at 4:50 p.m., the Director of Nursing (DON) confirmed R173's low blood pressure readings and RN V withholding scheduled medications on [DATE] warranted physician/provider notification and should have been considered a change in condition. The DON agreed withholding medications for complicated cardiac conditions and heart failure is not always the best option. The DON confirmed transfer to a higher level of care is at times needed for continuous monitoring while providing the necessary medications. During a telephone interview on [DATE] at 10:47 a.m., Physician Assistant (PA) W reported being the provider on-call on [DATE]. PA W reported she was not notified of R173's low blood pressure readings or the withholding of the Resident's scheduled Bumex 1mg or metoprolol tartrate 25mg on [DATE] until after the Resident expired. PA W stated she did remember being called by RN V for R173's insulin order on [DATE] but no mention of the Resident being hypotensive or requiring supplemental oxygen was made. PA W confirmed physician notification should be made for a change in condition to allow for changes in the plan of care or transfer to a higher care setting. Review of the facility policy titled, Change in Condition, dated [DATE], revealed the following, in part: To assist facility staff with identifying individuals at risk for acute changes in condition . Procedure: Assess the resident's symptoms, mental status and physical function . Use SBAR to notify the physician and proceed as instructed, complete clinical note . Vital Signs . Blood pressure 20 mmHg lower or higher than normal. 49302 B. Based on observation, interview, and record review, the facility failed to adhere to physician treatment orders for rehabilitation services and fluid administration for one Resident ( #621) out of 32 residents reviewed for quality of care. This deficient practice resulted in delayed treatment for respiratory illness, hospitalization , sepsis, and death. Findings include: Resident #621 (R621) Review of R621's electronic medical record (EMR) revealed admission to the facility on [DATE] with diagnoses including dementia and fracture of the left femur (leg). Review of R621's MDS, dated [DATE], revealed a score of 3 on the Brief Interview for Mental Status (BIMS) assessment, indicative of severe cognitive impairment. Review of R621's EMR revealed the following progress notes: 1. [DATE] at 17:22 (5:22 PM): Res [resident] continues to be lethargic and refuse[s] to get out of bed or eat meals. Oral intake is poor. output is minimal. Low grade temp [temperature] continues at 99.7 [degrees Fahrenheit]. 2. [DATE] at 12:31 PM: Pt [patient] heard with barky, productive cough. Thick clear mucus noted on tissue. Pt also has thick, clear mucus noted from nose. Lungs clear in upper lobes, clear in right lower, slight crackles heard in left lower lobe . 3. [DATE] at 15:55 (3:55 PM): Writer contacted on-call provider . New orders: Peripheral IV [intravenous] placement; 500 cc [cubic centimeters] NS [normal saline] IV fluid [NAME] [sic] followed by 100 cc/hr [cubic centimeters per hour] x 10 hours . 4. [DATE] at 22:50 (10:50 PM): At approximately 2130 [9:30 PM] resident noted to be in bed shivering. Temperature 100.5 [degrees Fahrenheit] . Resident lethargic, responding minimally .This nurse sat with resident and provided emotional support and comfort for approximately one hour. Temp is now 101.5 [degrees Fahrenheit] . 5. [DATE] at 16:22 (4:22 PM): Positive sepsis screen . send to [acute care hospital] for evaluation . 6. [DATE] at 9:55 AM: Per [acute care documentation], resident passed away [DATE]. On [DATE] at 2:49 PM, an interview was conducted with Licensed Practical Nurse (LPN) O who verified she was the nurse on duty who received orders on [DATE] for IV fluid. LPN O stated she gathered the necessary supplies to hang the prescribed IV fluids and asked Registered Nurse (RN)/Staff Educator P for assistance hanging fluids as it was outside her scope of practice. LPN O stated, She didn't help me . she told me to start the fluids at 8:00 PM so the next shift could deal with it .I think we received orders [from the physician] between 12:00 PM and 4:00 PM. On [DATE] at 3:29 PM, an interview was conducted with LPN Q who verified she worked the night of [DATE] alongside LPN O. LPN Q verified RN/Staff Educator P said to delay hanging the IV fluids until the night shift arrived after LPN O asked for assistance. On [DATE] at 2:19 PM, an interview was conducted with Assistant Director of Nursing (ADON) I who verified she was aware R621 was being monitored for a possible infection. ADON I stated, When I came into work that night, I poked my head in to check on her [R621]. I noticed the fluids weren't hung, so I personally hung them around 11:00 PM. ADON I verified the orders for IV fluids were given around 4:00 PM on [DATE]. When asked the acceptable timeframe between physician orders and administration, ADON I stated, My expectation is it should be done right away. ADON I replied, Yes when asked if this would be considered a delay in treatment. On [DATE] at 3:36 PM, an interview was conducted with the DON regarding the lapse in time between physician orders and administration of IV fluids to R621. The DON stated, That is not an acceptable timeframe and does not meet my expectation. Review of 2023 Update on Sepsis and Septic Shock in Adult Patients, published by the Journal of Clinical Medicine in [DATE] (https://doi.org/10.3390/ jcm12093188), read, in part: .Sepsis is a life-threatening and time-dependent condition that is still accompanied by an overall poor prognosis . Nonetheless, a well-orchestrated treatment based on selected antimicrobics, fluids, oxygen, and, if necessary, vasoactive agents can improve patients' outcomes .

Based on observation, interview and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety as evidenced by not sanitizing food contact surfaces, including plates, glasses, cups and flatware used among the entire resident population, and other food preparation equipment/utensils when using the high temperature mechanical dish washer and three compartment sink. This failure included: 1. Staff failing to identify the mechanical dish washer was not reaching a proper water temperature during the sanitizing cycle 2. F\ailing to demonstrate the dish machine had been tested and was properly sanitizing dishes for over a three month period. 3. Failing to operate the three compartment sink in a manner which sanitized food contact surfaces. 4. Failing to provide knowledgeable and competent staff conducting oversight and management of the kitchen functions. 5. Observation of expired and spoiled food was found in refrigerators. 6. Failing to ensure cooling processes were followed for potentially hazardous foods which had been cooked, cooled and stored to be re-heated at a later date. 7. Observations of floors, wall, ceilings and equipment soiled with grease, dust and grime. This deficient practice resulted in a high likelihood of a food borne illness among any or all the 132 highly susceptible resident population. Immediate Jeopardy (IJ) was identified on [DATE] at 11:11 AM, when the mechanical dish machine failed to demonstrate proper sanitizing of food contact surfaces and the facility having failed to show the machine had been properly sanitizing for over three months. The Immediate Jeopardy was identified to have begun on [DATE], being the initiation of the contract with the current kitchen vendor, when monitoring of the mechanical dish machine ceased to occur and demonstrate proper sanitizing of food contact surfaces which were used among the entire resident population. The Nursing Home Administrator was notified of the Immediate Jeopardy on [DATE] at 2:30 PM, with an abatement plan requested at that same time. The abatement plan was submitted and received by the State Agency (SA) on [DATE] at 3:49 PM via email from the NHA and accepted at this time. The following observations, interviews and review of records are evidence of the immediate jeopardy: On [DATE] at 10:57 AM observations of the mechanical dish machine were made. The digital final rinse temperature gauge, on the top of the machine was observed during the placement of 10 racks being pushed through. On the tenth rack through, using this surveyor ' s tools, including a self-adhesive 160 F Thermolable, heat sensitive irreversible strip was attached to a ceramic plate, and a Dish Temp irreversible maximum registering thermometer were placed on a rack and allowed to go through the wash, rinse and sanitize cycle of the machine. When the rack exited the conveyor of the machine, the strip had not turned black, indicating the plate surface had not reached the minimum temperature of 160 F and the maximum registering thermometer read 154 F. this temperature corresponded to the temperature read out on the top of the dish machine. When the temperature on the machine read out was pointed out to CDM B , she responded by stating Oh, I think the thermostat isn't working. When CDM B was shown the irreversible thermometer matched the read out on the machine, CDM B stated Oh. CDM B was then requested to conduct a test of the dish machine using the facility procedure. CDM B brought out a box of T-sticks , removed one, and placed it on a plastic cafe tray and placed the tray on a dish machine rack. (T-Sticks are irreversible temperature monitors used to measure the internal temperature of food, and can be used to confirm water temperature. They are not approved as a device to demonstrate temperature compliance for a food contact surface.) CDM B stated It ' s probably going to just get washed off. On the same rack, another plate with an irreversible thermolable and the maximum registering thermometer were placed to go through the machine cycle concurrently. The maximum temperature the final rinse gauge read was 158 F during the cycle. When the rack exited the machine, the T-Stick was not present, the maximum registering thermometer read 158 F and the thermolable had not turned black, indicating the food contact surface had not reached the minimum 160 F. CDM B opened the dish machine and retrieved the T-stick and showed it had also not reached 160 F. The container of T-sticks was then retrieved and the directions shown to CDM B for testing the water temperature of the machine. The container directions were clear as to place the cardboard part of the device within the tines of a fork to hold it in place. (this prevents it from being washed away). Further, the T-sticks are not approved for the demonstration of the food contact surface temperature compliance, rather, only indicates if the water temperature reached the temperature for which the T-stick is engineered to measure. CDM B stated, following the reading of the directions, I didn ' t know that. What do we do now? CDM B was then asked to produce documentation the dish machine had been properly sanitizing food contact surfaces prior to this time. CDM B stated We don ' t have any documentation for that. When asked when the dish machine was last documented properly sanitizing dishes, CDM B stated That was before me. When asked how long that was, CDM B stated over three months. On [DATE] at approximately 10:45 AM, it was observed that the three compartment sink was being used to wash, rinse and sanitize cooking equipment, including pans, pots, and utensils. The facility test strips were utilized to test the concentration of quaternary sanitizer in the sink, and determined it was between 100 and 150 ppm (parts per million). At 1:26 PM an observation of the three compartment sink was again made, with CDM B in attendance. The concentration of of quaternary sanitizer was again measured using the facility strips and found to be 100 ppm. An interview with CDM B was conducted at this time and asked what the concentration of the sanitizer should be, to which she answered 50? 100? I'm not sure, then stated that has probably been there all day. CDM B confirmed with Food service worker D that the sanitizing solution had not been changed all day. When asked if she knew what chemical was being used for sanitizing, she stated I am not sure. A review of the sanitizing chemical bottle was conducted with CDM B and was noted it was a quaternary chemical and required a minimum concentration of 200 ppm. CDM B was asked if there was documentation of testing of the sanitizing solution, to which she replied We don't keep that. On [DATE] at approximately 3:30 PM, dishwasher (DW) E was observed to take a pan from the middle rinse sink, of the three compartment sink, dip it into the third compartment containing the sanitizing solution, for less than two seconds, then place it on the drain board. CDM B was present during this observation and did not correct DW E . CDM B was then asked how long a food contact surface was supposed to be immersed in the sanitizing solution to be properly sanitized. CDM B stated 30 seconds? A minute? A review of the container of sanitizing chemical revealed that a minimum of 60 seconds was required for proper sanitizing of food contact surfaces. A review of the policies provided by the dietary vendor included: Policy #F019 Subject: Dishmachine temperatures; Date Issued ,d+[DATE]; Date Revised: ,d+[DATE] This policy stated the following regarding the monitoring of the high temperature dish machine: POLICIES: Dishmachine wash and rinse water should be maintained at temperatures that meet the guidelines established by the Food and Drug Administration.* state or local regulations will apply if more strict. PROCEDURES: Director Confirms the wash and rinse temperatures listed on the manufacturer's data plate on the dishmachine. Write these temperatures on the Dishmachine Temperature Record. Supervisor/Food and Nutrition Associate as assigned High Temperature Dishmachine - record on Dishmachine Temperature Record form: Wash and final rinse temperatures during each period of use. Once a day,run a test strip (160F strip) through the dishmachine to verify, the surface temperature of a dish. (The machine readings are the temperatures at the manifold of the machine, and not on the surface of the plate). Attach the used test strip to the Test Strips Results form. The test strip must verify that the surface temperature of the plate reached l60 F. An alternative is to use an irreversible maximum registering thermometer. Write the sanitizing rinse temperature on the Irreversible Max Temperature form. Immediately brings any substandard temperatures to the attention of management. If documentation of the temperatures and test strips/max temps results has been assigned to a Food and Nutrition Associate, confirms that it is completed at each meal period. Director (In the event of inappropriate temperature) * Determines if reading is due to malfunctioning temperature gauge or inappropriate temperature. * Makes management decision concerning adequacy of sanitation of service ware. If due to inappropriate water temperature (high temperature machine), or inappropriate concentration of sanitizer solution (low temperature machine), implements disposable service ware. Contacts sources of repairs. . Documents action taken on back of form. Director/Designee Verifies completion of logs; initials form weekly. Retains Dishmachine Temperature Records for one ( 1) year A review of Policy #F018: Sanitizing Food Contact Surfaces; Date Issued ,d+[DATE]; Date revised: ,d+[DATE], was conducted and stated the following: Immerse items in sanitizing solution (third sink) for a minimum of 60 seconds. complete pot-sink Sanitizer Concentration Log daily at each meal period. the facility submitted the following abatement plan following the issuance of notice of Immediate Jeopardy: Abatement Plan 1. Immediately transitioned to disposable products for meal service and food preparation. 2. Reeducation being provided to dietary staff regarding maintaining temperature logs of the dishwasher, proper procedures for testing, and temperature requirements for food surfaces. 3. [NAME] (Dishwasher Maintenance Company) contacted and service call scheduled for [DATE]. 4. Non-disposable cookware will be cleaned utilizing the three-compartment sink where sanitizer is used. 5. Reeducation will be provided to staff regarding use of the three-compartment sink and sanitization. 6. All residents have the potential to be affected however there have been no residents affected. Reeducation started on [DATE] and will be conducted daily until all dietary staff have attended. Disposable products will be utilized until the dish machine meets the required temperatures and has been serviced by [NAME]. Once the dish machine is working properly the temperature log will be completed daily. The three compartment sink is being utilized and a sanitization (parts per million) log is being completed before use. The Immediate Jeopardy was removed on [DATE] at 11:11 AM following demonstration the mechanical dishwasher was operating correctly. Although the immediate jeopardy was removed on [DATE], the facility remained out of compliance at a scope and severity of no actual harm with potential for more than minimal harm that has the potential to affect a large portion of the facility's residents due to the inability to verify staff education, all policy updates, system changes, and sustained compliance. The FDA Food Code 2013 states: ,d+[DATE].11 Hot Water and Chemical. After being cleaned, EQUIPMENT FOOD-CONTACT SURFACES and UTENSILS shall be SANITIZED in: (A) Hot water manual operations by immersion for at least 30 seconds and as specified under S ,d+[DATE].111; (B) Hot water mechanical operations by being cycled through EQUIPMENT that is set up as specified under SS ,d+[DATE].15, ,d+[DATE].112, and ,d+[DATE].113 and achieving a UTENSIL surface temperature of 71 C (160 F) as measured by an irreversible registering temperature indicator; On [DATE] at 10:30 AM, the initial tour of the kitchen was initiated. Observations of the walk in cooler included: 1. A large uncovered stainless steel pan containing scrambled eggs. The temperature was measured using a metal stem digital Thermapen, and found to have an internal temperature ranging between 95 F and 105 F. An interview with Chef A was conducted at this time. Chef A was asked when the pan of cooked eggs had been placed in the refrigerator, to which he responded Is there a problem? Right after breakfast, about a half hour ago. When questioned further about the time Chef A revised the time to maybe an hour or hour and a half . When asked if an initial temperature had been taken to track the cooling process, Chef A stated No. I'll throw them out. 2. Six stainless steel pans containing a total of 24 beef roasts, covered with plastic wrap. There was no label indicating when the meat was cooked and placed in the refrigerator. The internal temperature of the whole intact roasts was measured using a metal stem digital Thermapen and found the temperatures to range between 41 F and 44 F. The ambient air temperature of the walk in cooler was 37 F. An interview was conducted with Chef A concerning the cooking and cooling process of the meat. Chef A stated They were probably cooked last night. When asked about the cooling process and evidence of cooling logs, Chef A stated I don ' t know anything about cooling logs. 3. Four boxes of cucumbers with multiple rotting cucumbers in each box. 4. A tray containing 8 clear boxes of strawberries with 3 containers having multiple berries covered with mold. 5. A bag of cut Romaine lettuce with an expiration date of [DATE]. Portions of the cut lettuce were turning brown and liquifying 6. One bag of carrot matchsticks with an expiration date of [DATE]. 7. One open bag of chopped carrots, looking brown and withered and without a date indicating when it had been opened. 8. One bag of chopped celery with an expiration date of [DATE]. Some pieces having turned brown. 9. Four stainless steel hotel pans with what appeared to be whole cooked turkey breasts, covered with plastic wrap. There was no label indicating when the turkey had been cooked and or placed in the refrigerator. At 1:45 PM it was observed a label had been attached to the plastic wrap which indicated the turkey had been cooked on [DATE], then had an expiration date of [DATE] for total of 14 days. The floors of the walk in cooler were dirty, covered with food debris with the junction of the walls and floor filled with dirt and grime. The wall/floor junction was not coved (rounded) to allow for proper cleaning. 10. The wall between the walk in refrigerator compartment and the freezer compartment, at the floor level, on the refrigerator side, had a build up of ice, on the right side of the door between the compartments. This indicates the wall and floor are not sealed and there was a constant leaking of air from the freezer compartment into the refrigerator compartment. 11. Four sealed packages of sliced cooked corn beef were observed in the walk in freezer. The package stated Use by or freeze by [DATE]. There was no date written on the package indicating when it had been placed in the freezer to allow for proper usage following future thawing. On [DATE] at approximately 1:45 PM, an interview with CDM B was conducted concerning the contents of the walk in refrigerator and freezer. When asked what the holding time for cooked food was, CDM B replied Three Days. CDM B was shown the cooked turkey breasts with the 14 day time frame, to which she responded I ' ll change that. When shown the beef roasts and turkey breasts, CDM B was asked about documentation for the cooling process, CDM B stated We don ' t have any cooling logs. At this same time CDM B was shown the rotting cucumbers and containers with moldy strawberries. The following day on [DATE] at 8:48 AM the rotting cucumbers and strawberries were still on the shelves in the walk in cooler. During the initial tour a large plastic bin, labeled Thickener was observed to be uncovered and located partially under the food prep table near the three compartment sink No cover for the bin was observed in the vicinity or on the container, leading to potential contamination of the food inside. During the initial tour the only hand sink in the food preparation/three compartment sink area was observed to have a sign posted above stating: NOT A HANDWASHING SINK. PLEASE DO NOT STORE ANYTHING IN THIS SINK. This was observed throughout the survey during each visit to the kitchen. On [DATE] at 1:58 PM, an interview was conducted with CDM B and asked about the sink. CDM B replied I don ' t know. We don ' t use it. No other hand sink was readily available in the immediate area of the food preparation area. During all observations of the kitchen the plastic cover for the fluorescent light fixture in the cooking and serving area was observed to be covered with a layer of dust. During all observations of the kitchen the grease filters for the exhaust hood above the cooking equipment were observed to be covered and caked with excessive grease. Non food contact surfaces, including the stand up mixer, the exterior of the ice machine, floors, walls, table legs and ceilings were observed to have excessive coverings of dirt, dust and grease. On [DATE] at approximately 8:45 AM CDM B was asked when the last deep cleaning of the kitchen had occurred. CDM B responded Probably before I got here three months ago. On [DATE] at approximately 8:30 AM, an open plastic garbage can, one third filled with rotten fruit was observed near the above mentioned hand sink and at the soiled end of the three compartment sink. Fruit flies were observed flying and landing throughout the kitchen, in the food preparation area, dish washing area and serving area. At this same time dirty pots, pans and cooking utensils were piled over three feet high, above the drain boards of the three compartment sink. The contents of the pans were not breakfast food, rather, dried on food from the previous day. During all observation opportunities on [DATE] and [DATE] in the kitchen, the floors under equipment were observed to be filled with days old debris, trash, food remnants and dust. Kitchen policies and procedures were requested from the Registered Dietitian F . The following policies were provided and reviewed and are sourced from the contracted Vendor providing dietary services to the Facility: FOOD HANDLING GUIDELINES (HACCP) Policy #B007; Date Issued ,d+[DATE]; Date Revised ,d+[DATE] CLEANING OF FOOD AND NONFOOD CONTACT SURFACES; Policy #F013; Date Issued ,d+[DATE]; Date Revised ,d+[DATE]. SANITIZING FOOD CONTACT SURFACES; Policy #F018; Date Issued ,d+[DATE]; Date Revised ,d+[DATE]. Included in the above policies were requirements for proper cooling of cooked food to be reheated later for service and included Cooling Log to track requirements for proper cooling of food. Hot Holding Box and Cold Holding Log were also included with policy #B007. Policy #F018 included forms for documenting the concentration and temperature of sanitizing solutions in the three compartment sink as well as buckets containing sanitizing solution for wiping cloths. These forms were identified as: SANITIZER SOLUTION FROM DISPENSER ; POT SINK TEMPERATURE & SANITIZER CONCENTRATION LOG (requiring documentation for each meal and a manager weekly review); RED BUCKET LOG (requiring two hour monitoring intervals and a manager review). On [DATE] between 12:00 PM and 12:30 PM, ice dispensers were observed to have black bio film accumulation in the discharge spouts in the following locations: Birch Unit Dining and pantry Cherry unit Dining and pantry Dogwood unit pantry Elm unit pantry On [DATE] between 12:00 PM and 12:30 PM juice dispensers in the individual unit pantries were observed to have coagulated juice residue in the discharge nozzles. This was observed in the Birch, Cherry and Dogwood unit pantries. During this time, a box of take out pizza and chicken bites were observed in the Dogwood pantry refrigerator. No identification indicating the date it was placed in the refrigerator or to whom it belonged was on the boxes. The refrigerator walls and fan grates, in the Dogwood pantry, were observed to be covered with food debris and dust. On [DATE] at 10:05 AM the refrigerator in the Maple unit pantry was observed. The interior panel for the door was observed to have a black mold-like covering and the gasket was torn at the bottom of the door allowing air and moisture to escape On [DATE] at approximately 11:30 AM, an interview was conducted with Sr. Culinary Director (SCD) G, representing the kitchen vendor company hired by the Facility. SCD G confirmed the conditions of the kitchen when he arrived the previous evening were unacceptable, and acknowledged there was still rotten food in the walk in cooler, unlabeled food, and an unclean environment to be serving food from. REFERENCES TO THE FDA FOOD CODE 2013 INCLUDE: ,d+[DATE].11 Safe, Unadulterated, and Honestly Presented. FOOD shall be safe, unADULTERATED, and, as specified under S ,d+[DATE].12, honestly presented. ,d+[DATE].14 Cooling. (A) Cooked TIME/TEMPERATURE CONTROL FOR SAFETY FOOD shall be cooled: (1) Within 2 hours from 57 C (135 F) to 21 C (70 F); and (2) Within a total of 6 hours from 57 C (135 F) to 5 C (41 F) or less. ,d+[DATE].11 Discarding or Reconditioning Unsafe, Adulterated, or Contaminated Food. (A) A FOOD that is unsafe, ADULTERATED, or not honestly presented as specified under S ,d+[DATE].11 shall be discarded or reconditioned according to an APPROVED procedure. ,d+[DATE].11 Equipment, Food-Contact Surfaces, NonfoodContact Surfaces, and Utensils. (A) EQUIPMENT FOOD-CONTACT SURFACES and UTENSILS shall be clean to sight and touch. (B) The FOOD-CONTACT SURFACES of cooking EQUIPMENT and pans shall be kept free of encrusted grease deposits and other soil accumulations. (C) NonFOOD-CONTACT SURFACES of EQUIPMENT shall be kept free of an accumulation of dust, dirt, FOOD residue, and other debris ,d+[DATE].11 Equipment Food-Contact Surfaces and Utensils. (A) EQUIPMENT FOOD-CONTACT SURFACES and UTENSILS shall be cleaned: (1) Except as specified in (B) of this section, before each use with a different type of raw animal FOOD such as beef, FISH, lamb, pork, or POULTRY; (2) Each time there is a change from working with raw FOODS to working with READY-TO-EAT FOODS; (3) Between uses with raw fruits and vegetables and with TIME/TEMPERATURE CONTROL FOR SAFETY FOOD; (4) Before using or storing a FOOD TEMPERATURE MEASURING DEVICE; and (5) At any time during the operation when contamination may have occurred ,d+[DATE].13 Nonfood-Contact Surfaces. NonFOOD-CONTACT SURFACES of EQUIPMENT shall be cleaned at a frequency necessary to preclude accumulation of soil residues ,d+[DATE].13 Floor and Wall Junctures, Coved, and Enclosed or Sealed. (A) In FOOD ESTABLISHMENTS in which cleaning methods other than water flushing are used for cleaning floors, the floor and wall junctures shall be coved and closed to no larger than 1 mm (one thirty-second inch). (B) The floors in FOOD ESTABLISHMENTS in which water flush cleaning methods are used shall be provided with drains and be graded to drain, and the floor and wall junctures shall be coved and SEALED. ,d+[DATE].111 Controlling Pests. The PREMISES shall be maintained free of insects, rodents, and other pests. The presence of insects, rodents, and other pests shall be controlled to eliminate their presence on the PREMISES by: (A) Routinely inspecting incoming shipments of FOOD and supplies; (B) Routinely inspecting the PREMISES for evidence of pests; (C) Using methods, if pests are found, such as trapping devices or other means of pest control as specified under SS ,d+[DATE].12, ,d+[DATE].12, and ,d+[DATE].13; and (D) Eliminating harborage conditions. On [DATE] at approximately 1:30 p.m., an observation was made of Certified Nurse Aide (CNA) S in the Dogwood main dining room using the microwave to reheat sausage and sauerkraut. When asked why CNA S was reheating the food, she stated, The food has been sitting out so long and it got cold. CNA S was observed taking the temperature of the sausage and while removing the thermometer, used her bare hands to touch the sausage in order to remove the thermometer. When asked what temperature the food needed to be reheated, CNA S stated, It's either 145 (degrees Fahrenheit) or 165. I'm not sure so I try to get the food in between there. When asked if staff have to consistently reheat foods for residents because it gets cold, CNA S stated, It depends on the day and who is in the kitchen.

Based on interview and record review, the facility failed to monitor for and recognize signs of [CONDITION(S)] for one Resident (#92) out of two reviewed for urinary tract infections ([CONDITION(S)]'s). This deficient practice resulted in a change of condition for Resident #92 where he went unresponsive and received two round of cardiopulmonary resuscitation (CPR) prior to being hospitalized for [CONDITION(S)]. Findings include: A review of Resident #92's medical record revealed he admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of his [DATE] Minimum Data Set (MDS) assessment revealed he scored ,d+[DATE] on the Brief Interview for Mental Status (BIMS) assessment, indicating intact cognition and assessed to be continually incontinent of urine. A review of a progress note for Resident #92 (R2) dated [DATE] revealed, This nurse was called at approx (approximately) 0500 (5:00 a.m.) to assess resident post possible [CONDITION(S)]. Upon entering room, resident's eyes are opened and breathing is unlabored. Very soon after, resident's eyes rolled back in head and resident began a snore-like breathing which lasted ,d+[DATE] breaths. Resident then became completely unresponsive, color turned gray. Resident's code status checked and it was noted that resident is full-code. Code nurse initiated. Resident not breathing at this time. Resident immediately moved to floor to begin CPR. Mottling noted on legs. RN (Registered Nurse) x3 unable to palpate pulse in carotid artery. Chest compressions begin at this time. After two rounds of CPR, resident observed trying to open eyes. Resident was reassessed and noted to be breathing on own. Oxygen 74-percent on room air, pulse 150's. Oxygen applied at 20 lpm (liters per minute). Oxygen saturation eventually maintained at 94-percent on 8 lpm. Pulse remained ,d+[DATE] for duration of code. Resident became alert and responsive. Denies pain. BS (blood sugar) checked and is within acceptable range. EMTs (Emergency Medical Technicians) arrive and take over. Resident to (name of Hospital). A review of a progress note dated [DATE] (four days prior to the event) revealed, New order for [MEDICATION(S)] to low back for pain. Resident is aware. Provider will f/u (follow up) in 1 week. A review of the hospital notes for R92 dated [DATE] revealed, .acutely ill in appearance, much more alert on the afternoon of the 14th after fluids and IV antibiotics initiated the [CONDITION(S)] seems to be the ultimate trigger here. Potentially infectious/[CONDITION(S)] etiology as etiology to arrhythmia Assessment/plan: 1. [CONDITION(S)]. Pt (patient) presents with fevers/chills, questionable rigors with fevers, [CONDITION(S)] and [CONDITION(S)] . 2. Shock due to systemic infection and cardiogenic. Pt with pyuria (white blood cells or pus in the urine) - recent left [CONDITION(S)] stent removal ,d+[DATE] in urology office for obstructive kidney stones . had subsequent c/o (complaints of) LBP (lower back pain) on ,d+[DATE] per progress notes at (name of facility) . A review of the labs drawn on [DATE] at the hospital revealed, .Appearance, urine: Hazy (A- abnormal) . Protein, urine: 30 mg/dl (milligrams per deciliter) (A - Abnormal) . Bacteria, urine: Many (A- abnormal) A review of R92's vitals page revealed the last pulse documented on [DATE] at 7:32 p.m. was 104 beats per minute (bpm), but was normally between ,d+[DATE] bpm. The last blood pressure on the vitals page was documented as [DATE] at 8:26 p.m. of ,d+[DATE] (low). On [DATE] at approximately 5:00 p.m., the Director of Nursing (DON) was asked to provide documentation as to why R92 was not monitored closely for signs and symptoms of infection post a urology procedure or why the low back pain was not considered a sign of potential urinary tract infection ([CONDITION(S)]). Documentation was provided as follows: back pain was addressed [DATE] and a physician note was provided which revealed, Resident is seen as requested by nursing staff to evaluate the above (back pain). Resident has never reported back pain to staff before and often has little to no physical complaints upon assessment . A transfer/consult form was provided dated [DATE] which revealed a pulse of 157 (high) and a blood pressure of ,d+[DATE] (low). A print out of a medication administration showed that the blood pressure was ,d+[DATE] when the blood pressure medication was given on [DATE] at 9:15 a.m. but was not documented in the vitals log. A review of the facility policy titled, [CONDITION(S)] Screening Policy (noted as a Draft) with no date revealed, . Symptoms of [CONDITION(S)] include fever, difficulty breathing, low blood pressure, fast heart rate, and mental confusion. [CONDITION(S)] can progress very quickly. Purpose and Procedure: to aide in the prevention of [CONDITION(S)], a [CONDITION(S)] screen will be completed by licensed nursing staff every 8 hours . A [CONDITION(S)] screen will be completed every 8 hours for the duration of antibiotic use, duration of infection, change in condition or at any time nursing staff suspects infection of [CONDITION(S)] .

Based on observation, interview, and record review, the facility failed to ensure nutritional asessment, monitoring, and interventions were in place for wound healing and to prevent significant weight loss for three Residents (#40, #76, and #82) out of eight reviewed for nutrition. This deficient practice resulted in significant weight loss, and the potential for further skin breakdown and functional decline. Findings include: Resident #40 A review of Resident #40 (R40's) medical record revealed she admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of her 5/17/22 MDS assessment she was assessed by staff to be severely impaired in cognition, and was at risk for pressure ulcer development. A review of R40's progress note dated 7/5/22 revealed, Family was updated on medication change. Resident was observed with a 2.0 cm x 2.5 cm DTI (deep tissue injury) on the rt (right) heel. DTI is observed with a white center and reddish brown in color surrounding. Family updated. There were no further progress notes in her medical record regarding the status of the wound. The only documentation of the wound was found on the Treatment Administration Record (TAR). A review of a physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . continue nutritional supplementation. Staff to report any worsening in condition. A review of a physician order for [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the July MAR for this order revealed it was not given as ordered 15 times out of 32 possible administrations. A review of R40's weight log revealed the following: 2/1/22 139.6 pounds 5/1/22 142.0 pounds 7/2/22 136.2 pounds 8/1/22 127.6 pounds (-14.4 pounds or 10% in 3 months, and -8.6 pounds or -6.3% in month - significant). On 8/3/22 at 8:55 a.m., R40 was observed sitting in a wheelchair at the dining table. Her meal tray was covered and pushed approximately 1 foot inward to the center of the table, out of R40's reach. Licensed Practical Nurse (LPN) AA came and sat next to R40 to start mixing a packet of Carnation Instant Breafast powder into her milk. At 9:10 a.m., the surveyor approached R40, who had still not received any food, only sips of milk. R50 was asked how her breakfast was and stated, I want food. LPN AA stated to R40 that she would need to heat the breakfast food up. LPN AA continued to give R40 sips of chocolate milk instead of trying to feed her the breakfast meal. A review of R40's nutrition care plan initiated on 9/23/17 revealed, . My diet order is: Puree solids/level 4 with nectar liquids/ level 2. Encourage small sips/bites at a slow rate, upright after meals . Provide resource 2.0 BID with med pass. Offer me fortified foods with meals. Offer carnation instant breakfast as the breakfast meal. On 8/3/22 a review of R40's medical record revealed the last nutrition note was dated 5/18/22 by RD EE, indicating the significant weight loss and new pressure ulcer development were not reviewed by any qualified nutrition professionals. On 8/4/22 a review of the R40's record revealed a nutrition note had been written on 8/3/22. It did not reveal any new nutritional interventions and did not document any observations of the assistance that R40 was receiving at meals. Resident #76 On 8/1/22 at 12:05 p.m., Resident #76 (R76) was observed up in a gerichair in the common area. RN FF was asked if R76 had any areas of breakdown and reported that they had just found a stage II pressure ulcer that same morning. A review of a progress note dated 8/1/22 for R76 revealed, Resident has a new stage 2 PI (pressure injury) to Coccyx measuring 1.1x0.3x0.1cm . A review of Resident R76's medical record revealed she admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of her 6/15/22 MDS assessment revealed she was assessed by staff to be severely cognitively impaired and was at risk for developing pressure ulcers. This assessment did not answer the questions of whether or not she had experienced significant weight loss and listed her weight as 187 pounds. Per weight records R76 weighed 136.2 pounds on 6/12/22 and has not weighed anywhere near 187 in the past year. A review of R76's weight log revealed the following: 2/2/22 143.4 pounds 5/1/22 134.2 pounds 7/3/22 131.0 pounds 8/1/22 129.0 pounds (-14.4 pounds or 10% in 6 months) A review of the most recent note regarding R76's nutrition was written by Registered Nurse (RN) II on 7/21/22 indicating a significant weight loss of 10% in 180 days. The most recent note provided from a qualified nutrition professional was dated 3/22/22. A review of R76' meal ticket revealed, . Diet: General. Texture: Liquid Puree. Fluid: thin .mugs with lids and straws . CIB (carnation instant breakfast) with whole milk . A review of a progress note for R76 dated 7/8/22 revealed, Resident was noted by staff to be letting her liquid pureed diet run out of her mouth during feeding/has been difficult to feed lately; ST (speech therapy) screen sent in to re-evaluate. On 8/2/22 at 9:16 a.m., R76 was observed at a table in the dining area and was sucking on her hand. At 9:18 a.m. CNA CC put clothing protector on R76 and proceeded to start opening and setting up her tray. Each time CNA CC picked up a cup, R76 would open her mouth very wide and glare at CNA CC. At approximately 9:24 a.m., CNA CC finally gave R76 a sip of juice which took approximately 12-15 seconds for her to swallow before opening her mouth wide again. CNA CC used a spoon to give R76 small bites of food. On 8/3/22 at 8:55 a.m., CNA CC was observed standing near R76 at the dining table. R76's meal was pushed toward the center of the table and R76 was starting at the cups. The meal was noted to be untouched. At 8:59 CNA CC sat down beside R76 and proceeded to scoop the brown sugar off the top of the oatmeal. R76 was observed staring at CNA CC opening her mouth very wide to signal she wanted to eat/drink. CNA CC then left the table to retrieve a packet of thickener and then went to the opposite side of the table to assist another resident in eating. R76 watched as the other Resident was fed and continued to open her mouth wide for a bite. CNA CC finally returned to R76 at approximately 9:07 a.m. and gave her a sip of cranberry juice. CNA CC then started to feed the resident next to R76 who was sleeping with her eyes closed. CNA CC proceeded to give R76 a small bite of food on a plastic spoon. On 8/4/22 at 9:26 a.m., CNA BB was observed assisting R76. CNA BB was observed using a squished paper cup to dump milk into R76's mouth. R76 appeared to be struggling to clear the amount of food that was being given to her and food was dribbling out of the corners of her mouth and onto her clothing protector. CNA BB repeated Swallow it., over and over to R76 in rapid succession. The Carnation Instant Breakfast packet was uponed on the tray and had not been mixed into the milk that R76 was being given. A review of R40's nutrition care plan initiated on 9/23/17 revealed, . My diet order is: Puree solids/level 4 with nectar liquids/ level 2. Encourage small sips/bites at a slow rate, upright after meals . Provide resource 2.0 BID with med pass. Offer me fortified foods with meals. Offer carnation instant breakfast as the breakfast meal. On 8/4/22 at 1:55 p.m., an interview was conducted with Speech Therapist (ST) OO and the Director of Rehab PP. When asked about the observations of how CNA BB, CNA CC, and LPN AA were feeding residents, the Director of Rehab reported that their department had done many educations on proper feeding techniques as well as the Nursing Education department. Neither ST OO or the Director of Rehab could answer as to why the staff were not feeding the residents per the care plan, but indicated that residents who are awake and alert should be fed, especially if showing signs of hunger, before residents who are sleeping. On 8/4/22 at 11:38 a.m., a phone interview was conducted with Registered Dietitian (RD) F. When asked about food preferences, RD F reported that the facility didn't have them documented prior to her starting in June of 2022 and that she was in the process of getting them updated. When asked how often residents with significant weight loss should be reviewed, RD F stated, It should be monthly. When asked when Residents with new pressure ulcer should be assessed, RD F stated, Right away. When asked about the intake monitoring of the supplements, RD F reported that when she started in June 2022 she had requested that nursing start to document how much of the supplements were accepted. A review of the facility policy titled, Monitoring monthly weights and vital signs dated 11/3/21 revealed, . 2. The nurse will complete the (Name of Facility) Weight loss-gain process, which alerts the designated group (including the dietician) of the weight change . the process includes, but is not limited to, documenting potential contributing factors, notification to the provider and responsible party, as well as appropriate care planning . A review of the facility policy titled, Sunroom dining room service dated 6/29/10 revealed, .12. Assigned CNAs will observe residents' food preferences/dislikes, changes in eating habits, increase/decrease in food intake, chewing/swallowing difficulties, problems with or need for adaptive devices, and will report observations to the (name of Facility) ADON (assistant director of nursing) or designee accordingly . Resident #82 Review of Resident #82's Electronic Medical Record (EMR) revealed an admitted [DATE] and diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Her 6/22/22 Quarterly Minimum Data Set (MDS) assessment revealed she was unable to complete the Brief Interview for Mental Status (BIMS) score and was marked with severely impaired cognition. She was also noted to need extensive one person assist for eating, and was not marked for a significant weight loss. On 8/1/22 at 1:15 p.m., Resident #82 was observed in the small dining room located in the Dogwood hallway. Resident #82 was asleep in her high-back wheelchair at a dining room table. On 8/2/22 at 9:06 a.m., Resident #82 was observed in the small dining room waiting for her breakfast meal. Resident #82 appeared to be asleep in the small dining room. A review of Resident #82's weights included the following: 1/2/22 130.6 lbs 2/2/22 124 lbs (significant weight loss 5% times one month) 3/2/22 123 lbs 4/2/22 121.2 lbs 5/2/22 120.0 lbs 5/22/22 116.8 lbs 5/29/22 117.6 lbs 6/2/22 118 lbs 7/2/22 116.6 lbs (significant weight loss 10% times six months) 7/31/22 114.8 lbs 8/1/22 114.4 lbs A review of Resident #82's Nutritional Quarterly assessment dated [DATE] and written by RD Z read, in part, No significant weight change x (times) 30, 90, or 180 days however weigh is down -5# (pounds) over the past 180 days . A review of Resident #82's Nutritional Quarterly assessment dated [DATE] and written by RD EE read, in part, .No significant weight changes but has continued to gradually lose weight over the past 6 months of which approximately 50% occurred over the past 3 months . A review of the most recent note regarding Resident #82's nutrition was written by Registered Nurse (RN) II on 7/18/22 indicating a significant weight loss of 10% in 180 days. A review of Resident #82's nutritional care plan read, in part, I am at risk for alterations in my nutritional and hydration status r/t (related to) dx (diagnoses) of [CONDITION(S)] and dementia. I need assistance at meals. My intake is usually good though my weight has been gradually trending downward . An active date of 1/26/22 read, Offer me fortified foods with meals and instant Breakfast TID for an additional 1400 kcals and 54 gms protein daily. There were no additional interventions noted or attempted to prevent Resident #82's weight loss.

Based on observation, interview and record review, the facility failed to ensure staff administered Cardio-Pulmonary Resuscitation (CPR) timely to one Resident (#101) of 18 residents reviewed who had elected CPR. This deficient practice resulted in the likelihood of delayed CPR contributing to death, and with the potential to affect 32 total residents who resided at the facility and who had elected CPR. The Immediate Jeopardy (IJ) notice was presented to the facility on [DATE] at 1:14 PM, and an abatement plan was requested. The IJ began on [DATE] at approximately 07:14 PM when Registered Nurse (RN) A entered to find Resident #101 unresponsive, without pulse, without breath, and a change in skin color. RN A acknowledged there was a heart picture (a desire to have CPR initiated in the event of sudden [MEDICAL CONDITION]) and corresponding correct name on the door sign for Resident #101. RN A then exited the room to find the nurse responsible for the care of Resident #101 without initiating CPR, or taking steps to initiate the facility CPR policy. to notify them of the condition of Resident #101. A total of approximately five minutes passed from the time Resident #101 was found unresponsive, pulseless, breathless, and had a noted change in skin color until CPR was initiated by RN B. The immediate jeopardy was removed on [DATE] when the following had been completed: 1. Code status for each resident was confirmed correct and accessible to nursing staff 2. Reeducation of nursing staff designated to provide CPR on response to unresponsive resident, when to initiate CPR, and reeducation to both nursing and CNA (Certified Nurse Aide) staff on use of the All Page system had begun, with completion expected prior to next shift. 3. All resident charts were checked for code status sticker and the process for door sign code status was revised. The deficient practice continued at an F level until all aspects of the abatement plan dated [DATE] are confirmed. Findings include: Review of the Hospital Summary dated [DATE], provided by the facility revealed the following: Resident #101 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #101 underwent a surgical repair of the fractures on [DATE] and was discharged from the acute care hospital admitted directly to the facility. On [DATE] at approximately 7:12 PM, Resident #101 was discovered by CNA C and CNA D unresponsive and without pulse, per interview on [DATE] at 10:12 AM with with CNA D. A review of the camera footage shows Resident #101 was discovered in the state discovered by CNA C and as described by CNA D at approximately 7:12 PM. RN A then returns with CNA C and CNA D at approximately 7:14 PM. RN A was observed exiting the room and walking down the hall. Licensed Practical Nurse (LPN) [NAME] was then seen walking to the nurses station in a hurried fashion. LPN [NAME] then enters the room along with RN A and RN F at approximately 7:17 PM. At approximately 7:21 PM, RN B was observed entering the room. On [DATE] at 8:47 AM, an interview with the Director of Nursing (DON) revealed the following: .We could not find (RN A's) CPR certification. (RN G) had been asking for it from him for months to bring it in. So eventually she just told him he would just have to take the class coming up this (MONTH) (2020). A review of the last known CPR certification on file for RN A revealed a certification date of [DATE], and a recommended renewal date of ,[DATE]. On [DATE] at 9:48 AM, during a subsequent interview, the DON stated (RN A) had . verification of completion, but did not have an actual card from the (CPR Education Provider) to show he had completed the practical skills in person. When asked if there was any other staff required to be CPR certified who did not have verification of current CPR certification, the DON stated, Not that I know of. When asked if there was an audit done on required staff having CPR certifications, the DON stated, Yes, and we also did an audit of the CPR status. When asked if there were any discrepancies with the CPR status audit, the DON stated, We found that the rehab unit was not having (CPR) stickers placed on the spine of the charts, and when we asked Medical Records why this was not happening, they said it was because the residents turn over so fast down there. When asked if there were any discrepancies in the desire for residents to receive CPR found, the DON stated, There was one resident (Resident #119) on (400 unit), who had a (CPR) sticker on her door, but was found to be a (No CPR). Only the door sign was wrong. On [DATE] at 10:09 AM with RN G revealed the following: I purchase CPR courses online through (CPR Certification Provider), for the nurses to complete . late (MONTH) of 2019, I was running my list from (facility education system) of those who need renewing for this quarter, which would be January,February and (MONTH) of 2020. There were four people who did not have (proof of certification), RN A, RN H, RN I and Physical Therapist (PT) [NAME] So I sent them a (Internet web link) to get the renewals done right away. RN H expired on [DATE], and the others will not expire until the 26th of (MONTH) (2020). When asked How long the CPR recertification issue went undetected for RN A, RN G stated, From (MONTH) (YEAR) until I ran the report in (MONTH) (2019). When asked how RN A went undetected from the past 8 quarters, RN G stated, I pull the report it doesn't show the cards so it showed as completed, and I didn't notice he didn't have that card. On [DATE] at 11:02 AM an interview with CNA K revealed the following: I was told I left the room at about 6:00 PM by (Chief Operating Officer (COO)). When asked what the condition of Resident #101 was at that time, CNA K stated, (Resident #101) appeared fine. I didn't see anything wrong with (Resident #101). When asked what time CNA G left the floor, CNA G stated, I left the floor at 6:30 PM to go and do in-services but did not punch out until 7:00 PM, and then left the building. CNA stated when she left at 7:00 PM she was not aware of any issues going on with Resident #101. On [DATE] at 9:45 AM, an interview with LPN L revealed the following: When asked if Resident #101 presented with any medical concerns prior to her death, LPN stated, No she was pretty stable. She was sitting in her chair talking on the phone when I last saw her. On [DATE] at 11:30 AM, an interview with Nurse Practitioner (NP) N revealed the following: When asked when NP N had seen Resident #101 last, NP N stated, On that day ([DATE]). She presented totally normal. I was just following up on her pain control. When asked if there was any reason to believe Resident #101 would not be anticipated to have a full recovery from her admitting [DIAGNOSES REDACTED]. On [DATE] at 11:14 AM, an interview with RN F revealed the following: . one of the CNAs asked me came and look up a code status. (Resident #101) was cold, . lips were sunken in, . had changed color and (Resident #101) legs looked purple to me. I called (RN B Campus Manager) and (RN B Campus Manager) came down . I was told she was the one who started CPR . Then EMS arrived, and they weren't aware it was a Code situation. They took over the scene and I left. When asked if Resident #101 was in the bed when entering the room, RN F stated, Yes, and apparently (RNA) and another CNA had entered the room and discovered the resident was unresponsive, cold, and he had checked her all over and said there was no pulse, and no breathing, and no lung sounds . I went and called EMS and the family, and the campus manger. When asked what should have been done per policy upon finding Resident #101 in the condition discovered, RN F stated, 'Code Nurse', I have never worked where a Code Nurse would have been called. All that does is bring everybody down to where the code is, and I thought we had enough help at the time. There were four nurses in the room. It didn't seem to be an emergency situation because we had felt (Resident #101) had been gone too long. I made the decision not to call the Code Nurse. I know I felt like we were following the procedures to the best of our ability . They told me CPR should have been started right away . On [DATE] at 12:00 PM, an interview with RN A, who worked the night of [DATE] revealed the following: .about 7:05 PM . two CNAs came down (CNA C and CNA D) and told me a resident (Resident #101) needed attention. (Resident #101) was slumped over and cold to the touch, and (Resident #101's) head was hard to push back. When asked why CPR was not started then, RN A stated, I thought (Resident #101) was long gone. When asked how RN A knew that, stated, When we transferred (Resident #101) to the bed, I could kind of see . legs were mottled. When asked if there were any other signs, RN A stated (Resident #101's) head was kind of off the pillow. When asked how it could be determined resident was 'long gone', when resident was seen alive only an hour prior, RN A did not reply. On [DATE] at 10:12 AM, an interview with CNA D revealed the following: . (Resident #101) was the third or fourth person we went to that evening. We knocked and entered the room, and (Resident #101) did not respond, so we entered the room and tried to wake (Resident #101) up and noticed . skin was cool and . color was not the same and . had no pulse. We went and got a nurse to get some help. When we got back (RN A) saw the same thing we did. When asked who helped RN A move Resident #101 from the chair to the bed, CNA D stated, I did. When asked if CNA D could recall if Resident #101's body was stiff or loose during the transfer, CNA D stated, (body) was not stiff, (body) was loose. When asked if the neck of Resident #101 was raised or laying flat on the pillow after the transfer to the bed, CNA D stated, The neck laid flat on the pillow. On [DATE] at 3:33 PM, an interview with RN B revealed the following: I received a call from (RN F), (RN F) said (Resident #101) was already gone at 7:19, and at 7:20 I walked into the room. (LPN E) was bagging (providing artificial respirations) to (Resident #101), and (RN A) was just standing at the foot of the bed. There was no carotid pulse, so I started CPR right away . (RN A) said it was not (RN A's) patient, and the (code status) sign on the door is not always correct. When asked about RN Bs assessment of Resident #101, RN B stated, She was non-responsive and warm, no pulse, and no breathing. When asked if there was any mottling or rigor mortis, RN B stated, No mottling, and no rigor mortis. When asked if there was any reason not to initiate CPR on Resident #101, RN B stated No. When asked if RN A ever assisted with CPR, RN B stated, After multiple rounds (RN A) was asked to assist with compressions and (RN A) did. When asked if anyone had announced the 'Code Nurse' as the policy stated, RN B stated, No. A review of the Medical Examiner (ME) Report for Resident #101 dated [DATE] revealed the following: Initial 911 call was placed on [DATE] at 6:20 PM. The ME was notified on [DATE] at 6:32 PM. The ME arrived on scene on [DATE] at 10:15 PM. The ME departed the scene at 11:20 PM. According to the ME report Resident #101 was found deceased at 7:10 PM. The ME report stated Resident #101's death was reported as natural/sudden/unexpected death. The ME report described the body of Resident #101 as .extremities cool to the touch, but her core body was slightly warm. Rigor (mortis) had hardly set in and all joints moved with ease . A review of the facility policy and procedure with a revision date of [DATE] in place at the time of the incident on [DATE] revealed the following: . 1. When a cardio-respiratory arrest is suspected, the witness will call for the nurse who will determine the need for Cardio-Pulmonary Resuscitation (CPR), based on assessment of the following: [NAME] Airway, breathing, and circulation status. B. Resident code status. Identify residents who have requested a 'yes code' identified with a sticker of 'yes code' on the chart cover and spine- no code will be identified on the front cover only. Residents who are a 'yes' code will have a heart sticker placed outside their door. Code status is also indicated in the electronic medical record on the resident ribbon. C. Clinical signs of death (rigor mortis, dependent lividity, decompostion, and obvious mortal wounds, apnea and asystole for five (5) minutes. CPR will NOT be initiated on residents who display obvious signs of clinical death. 2. CPR will be initiated on the following residents: [NAME] Residents who have elected to have CPR initiated. B. Residents who have not formulated an advance directive. C. Residents who do not have a valid DNR (Do Not Resuscitate) order. 3. If determined that basic CPR is appropriate and the resident has a 'Yes' code status, use all page button on phone and announce 'Code Nurse ____ Unit' for help and initiate basic 1 rescuer CPR. . 5. Licensed nurses and licensed therapist will be trained in CPR with recertification every two years. CPR certification will be reviewed upon the hiring process with the licensed staff member. Tracking will be completed through Staff Development .

This citation has two deficient practices, [NAME] and B.: [NAME] Based on observation, interview, and record review, the facility failed to implement infection prevention practices per facility policy and accepted national standards of practice to prevent the spread of infection for two sampled Residents (#64, 161) and 18 supplemental Residents (#9, 14, 30, 39, 57, 74, 105, 112, 113, 121, 140, 169, 174, 175, 183, 208, 434, and 1000), who exhibited signs and symptoms of Gastrointestinal (GI) illness by failing to implement transmission-based precautions to protect all vulnerable residents from the spread of infection. This deficient practice resulted in an Immediate Jeopardy due to the likelihood of infection spreading after 18 of 35 Residents on the Elm unit and 2 additional Residents on the rehab unit of the facility had symptoms of GI illness, and placed all residents, staff, and visitors at risk for serious harm and/or death. Immediate Jeopardy was identified at F880 during the recertification survey on 8/22/19 at 3:27 p.m. The Director of Nursing (DON) was notified of the Immediate Jeopardy on 8/22/19 at 4:05 p.m. (the Administrator was not onsite on 8/22/19), and a plan for Abatement was requested. The immediacy began on 8/14/19 when five Residents (#14, 74, 169, 175, and 183) were documented as having exhibited GI symptoms. The immediacy was removed on 8/22/19 at approximately 5:47 p.m., when initial interventions to prevent the spread of infection were put in place, including: 1. Place signage for Standard Precautions and to notify families entering the facility 2. Immediate creation of tracking log which documents symptoms, start date, and date and interventions to monitor residents with GI symptoms 3. Immediate notification to the local health department 4. Immediate notification to ES (Environmental Services) to sanitize unit twice daily. The deficient practice continued at a widespread level of no actual harm with the potential for more than minimum harm until confirmation of adequate implementation of the facility Infection Control and Prevention program. Findings include: On 8/22/19 at 8:30 a.m. during the breakfast meal observation, an unidentified dietary Staff asked Certified Nurse Aide (CNA) R if Residents on the Elm unit were still sick. CNA R responded, Yes. On 8/22/19 at approximately 12:15 p.m., Social Worker (SW) P was asked about residents on Elm unit being sick. SW P reported a few residents on the unit had been experiencing GI symptoms over the weekend. SW P was asked to provide details as to the symptoms and which residents were involved. On 8/22/19 at 12:17 p.m., the Elm unit doors were observed with no signage or notification to alert residents, staff, or visitors of a GI illness outbreak on the unit. A review of the GI Results report provided by the Director of Nursing (DON) revealed the following data regarding the number of Residents with symptoms: 8/13-8/14- five Residents, 8/15- four additional Residents, 8/16- one additional Resident, 8/17- one additional Resident, 8/19- one Resident, 8/20- two additional Residents, 8/22- three additional residents. This report did not provide the duration of their illnesses or their symptoms. The document also revealed, ES (environmental services - housekeeping) notified and more extensive cleaning done. When active sickness will attempt to keep separated however not all were acting sick and continued to wander about unit. Generally would only last a couple of days. Would offer clear liquids and have them eat meals in common are as able. On 8/22/19 at 1:24 p.m., the DON was asked about the GI illness outbreak on the Elm unit. The DON stated, I don't believe they (nursing staff) called the health department. When asked what the facility was doing to prevent the spread to the rest of the facility, the DON stated, After the first few people got sick we got ES to come more frequently. Most of them only had it 24 hours or so. When asked if staff from the Elm unit were covering and working on other units, the DON stated, They have good staff on that unit, so if they are overstaffed they go to work on the other floors, which has probably happened. On 8/22/19 a review of the facility Infection Control Binder revealed no update to the line listings for individuals with GI illness after 8/16/19. This Binder contained a map of the Elm unit for the month of (MONTH) which revealed the following data for GI illnesses: 8/13- three Residents, 8/14- two Residents, 8/16- seven Residents. This mapping did not correlate with the GI Results document provided earlier by the DON. A review of the employee call in log revealed between 8/12 and 8/22/19, there were seven call-ins involving GI illnesses for staff working on the Elm unit. On 8/22/19 at 3:17 p.m. the DON was asked who was filling in to supervise the Infection Control program while RN L was on vacation. The DON stated, I guess that's me. When asked about when she would become concerned about a GI outbreak and report it to the health department, the DON stated, If the symptoms persist, if the labs show there is an electrolyte imbalance. If there is weight loss. It's hard to tell if its GI symptoms or chronic diarrhea. When asked what the criteria was for reporting a GI outbreak to the local health department, the DON stated, I called (RN L) and she said it's 2 Residents for flu (influenza) and 6 for GI. When asked why then the outbreak wasn't reported since there were 16 Residents as of 8/20 with GI symptoms, the DON stated, They weren't all sick at once. On 8/22/19 at 4:10 p.m., there was no signage or posting on the doors of the Elm unit regarding the GI illness that was occurring. On 8/22/19 at 4:11 p.m., CNA R was asked if any of her assigned residents had experienced any GI symptoms out of the normal. CNA R stated, I assisted with (Resident #161) this morning when he was being cleaned up just before breakfast. A large loose stool. On 8/22/19 at 4:12 p.m., an interview was conducted with CNA Q, who when asked if he was aware of anyone with GI symptoms out of the ordinary stated, (Resident #208) has been having issues the past couple of days, but she seems ok today. When asked what symptom Resident #208 was exhibiting, CNA Q stated, Vomiting. On 8/22/19 at 5:09 p.m., the DON provided a bowel report which confirmed multiple Residents on the Elm unit had experienced multiple loose stools. The DON also confirmed Residents #14 and #39 had been having episodes of vomiting. On 8/22/19 at 5:30 p.m., an interview was conducted with the DON and Infection Control/RN [MI] When asked what the criteria was for having the stool tested during a GI outbreak, RN L stated, If they have vomiting and diarrhea. The providers would order it. We told the Nurse Practitioner (NP M) but she said she wasn't concerned, that it was fast acting and was going around the community and in her other buildings. When asked if the Physician was aware of each case, the DON stated, No, not all of the cases. RN L was asked what her last day at work was before going on vacation and stated, The 16th (of August). RN L provided line listings of GI symptoms up until 8/16/19. On 8/26/19 at 3:35 p.m., an interview was conducted with RN [MI] When asked if she had ever had to report a GI illness outbreak to the local health department, RN L stated, Yes, on (MONTH) 10th (2019). When asked if the current outbreak should have been reported, and whether she would have reported it had she not been on vacation, RN L stated, Yes. When asked who was supposed to be responsible for maintaining the Infection Control program while she was on vacation, RN L stated, (Name of DON) was doing Infection Control. A review of the facility's Infection Control Policies revealed no clear instructions for steps to take in the event of a GI outbreak, nor did the policy include instructions as to when the health department should be notified. A review of the facility policy titled, Identifying and Surveillance of Healthcare-Associated Infections revealed, .3. The purpose of the surveillance of communicable disease and infections is to identify both individual cases and trends in the transmission of epidemiologically significant organisms and HAI (healthcare associated infections) to permit interventions to try to slow or stop the transmission of such infections. 4. The criteria for such infections are based on the current standard definitions of infections for HAI's. 5. Identify predominant organisms or sites of infection among residents in the Organization or on particular pavilions .1. When an infection is identified, the Infection Control Coordinator/designee, with the input of the nursing staff and Attending Physician as needed, will confirm that the situation meets the criteria for an infection and will attempt to identify whether the infection developed in the Organization. This will be based upon standard, published definitions of infections, laboratory results, and surveillance data collected in the Organization . 7. Transmission based precautions or other preventative measures are implemented to slow or stop the spread of infection, the Infection Control Coordinator/designee will collect data to help determine the effectiveness of such measures B. Based on observation, interview, and record review, the facility failed to maintain effective infection control practices related to hand hygiene while providing feeding assistance for three (Residents # 10, 46, and 92) of eight residents reviewed for feeding assistance. This deficient practice resulted in the increased risk of transmission of infections to other individuals. Findings include: Resident #10's face sheet revealed an individual admitted to the facility on [DATE]. Resident #10 had medical [DIAGNOSES REDACTED]. Resident #10's Minimal Data Set (MDS) assessment dated [DATE] revealed a mental status score of three indicating severe cognitive impairment Resident # 46's face sheet revealed an individual admitted to the facility on [DATE]. Resident #46's face sheet had medical [DIAGNOSES REDACTED]. Resident #46's MDS assessment dated [DATE] revealed a mental status score of three indicating severe cognitive impairment. Resident #92's face sheet revealed an individual admitted to the facility on [DATE]. Resident #92 had medical [DIAGNOSES REDACTED]. Resident #92's MDS assessment dated [DATE] revealed a mental status score of three indicating severe cognitive impairment. During dining observation on 08/19/19 at 12:21 p.m., Certified Nurse Aide (CNA) K was observed itching their nose, coughing directly into their hands and then continuing to assist in feeding Residents #10, #46, and #92. Handwashing or hand sanitizing was not observed during this observation. On 08/19/19 at 2:47 p.m., CNA K was asked what the guidelines were in regards to hand washing after touching their nose and coughing into their hand while assisting with feeding residents. CNA K reported they thought they thought they had coughed into their elbow but admitted they should have washed their hands.

BASED ON INTERVIEW AND RECORD REVIEW, THE FACILITY FAILED TO PROVIDE APPROPRIATE CARE AND SERVICES, SPECIFICALLY, FAILED TO ANALYZE COLLECTED DATA AND TAKE TIMELY ACTION FOR ONE RESIDENT (#1) WHO fell AND DEVELOPED SYMPTOMS OF AN ACUTE CHANGE OF CONDITION OF ONE RESIDENT REVIEWED FOR FALLS OUT OF A FACILITY RESIDENT POPULATION OF 233. THIS FAILURE RESULTED IN A DELAY IN RESIDENT #1 BEING SENT TO THE EMERGENCY DEPARTMENT FOR [DIAGNOSES REDACTED]. FINDINGS INCLUDE: DURING THE ABBREVIATED SURVEY ON 1/19/12, THE CLINICAL RECORD OF RESIDENT #1 WAS REVIEWED. THE FACE SHEET REVEALED RESIDENT #1 IS AN [AGE] year OLD MALE admitted TO THE FACILITY 10/06/11 AND RE-admitted on [DATE]. HIS [DIAGNOSES REDACTED]. A REVIEW OF THE FACILITY REPORTED INCIDENT DATED 1/07/12, READS "ON 1/07/12 AT 7:40 A.M., RESIDENT #1 WAS OBSERVED ON THE FLOOR NEXT TO THE BATHROOM DOOR PRESENTING ON HIS LEFT SIDE. CERTIFIED NURSE AIDES (CNA'S) "D" AND "G" RESPONDED TO HIS ALARM SOUNDING....LICENSED PRACTICAL NURSE "A" ASSESSED RESIDENT #1 FOR INJURIES AND INITIATED HEAD INJURY PROTOCOL AND NEURO (NEUROLOGICAL) CHECKS....AT 4:30 P.M. RESIDENT #1 HAD AN EMESIS. THE PHYSICIAN AND WIFE WERE NOTIFIED AND ORDER OBTAINED TO SEND RESIDENT TO THE ED. (EMERGENCY DEPARTMENT). ED REPORTS ADMITTING FOR HEAD TRAUMA." A REVIEW OF AN "EMERGENCY DEPARTMENT REPORT" DATED 1/7/12 AT 6:36 P.M. READS, "...NEUROLOGICALLY, THE PATIENT (RESIDENT #1) DOES MOVE THE EXTREMITIES, BUT DOES NOT RESPOND VERBALLY AND STARES STRAIGHT AHEAD. ER COURSE: CT HEAD NONCONTRAST IS CARRIED OUT PER [MEDICATION NAME] REVERSAL PROTOCOL...DX (DIAGNOSES): INTRAPARENCHYMAL CEREBRAL HEMORRHAGE, status [REDACTED]. A REVIEW OF THE DOCUMENT TITLED "HEAD INJURY MONITOR FLOWSHEET" AND DATED 1/07/12, INSTRUCTS STAFF TO "ASSESS RESIDENT EVERY HOUR X6 (SIX HOURS) THEN EVERY SHIFT FOR THE REMAINING 24 HOURS FOR ANY HEAD INJURY. REPORT ABNORMAL FINDINGS TO DOCTOR." THE "HEAD INJURY MONITOR FLOWSHEET" DOCUMENT REVEALS SERIAL BLOOD PRESSURE (B/P) READINGS AND NEURO STATUS CHECKS FOR RESIDENT #1 STARTING AT 7:45 A.M. ON 1/7/12. AT THAT TIME, THE B/P WAS RECORDED AS 175/75 MMHG (MILLIMETERS OF MERCURY). ON 1/7/12 AT 8:45 A.M., THE BP WAS RECORDED AT 150/62 MMHG AND AT 9:45 A.M., RESIDENT #1'S B/P HAD SIGNIFICANTLY REDUCED TO 85/37 MMHG. THERE IS NO DOCUMENTATION TO REFLECT THAT ANY ACTION WAS TAKEN REGARDING THIS ABNORMALLY LOW BLOOD PRESSURE READING. THE NEXT B/P RECORDED ON 1/7/12 WAS AT 12:45 P.M. WITH THE READING OF 93/54 MMHG. ALSO NOTED IS RESIDENT #1'S LOC (LEVEL OF CONSCIOUSNESS) RECORDED ON 1/7/12 AS BEING "ALERT" DURING THE TIME PERIOD OF 7:45 A.M. UNTIL 1:45 P.M., WHEN IT IS CHANGED TO "DROWSY". ADDITIONALLY, THE BEHAVIOR CHANGE CATEGORY IDENTIFIES RESIDENT #1 EXPERIENCED A BEHAVIOR CHANGE OCCURRING AT 12:45 P.M. PER THIS "HEAD INJURY MONITOR FLOWSHEET", RESIDENT #1'S BEHAVIOR CHANGED FROM "QUIET" AT 12:45 P.M. TO "SLEEPY" AT 1:45 P.M. RESIDENT #1, WHO HAD EXPERIENCED A FALL ON 1/7/12 AT 7:40 A.M., AND WAS RECEIVING ANTI-COAGULANT THERAPY DURING THE PERIOD OF TIME ON 1/7/12 AT 9:45 A.M. THRU 1:45 P.M., WAS ASSESSED TO HAVE CHANGES IN HIS BLOOD PRESSURE, LEVEL OF CONSCIOUSNESS AND HIS BEHAVIOR. FACILITY STAFF DID NOT RECOGNIZE THESE EARLY SIGNS OF NEUROLOGICAL STATUS CHANGES UNTIL APPROXIMATELY SEVEN HOURS AFTER THE FIRST SIGNIFICANT CHANGE IN CONDITION. A REVIEW OF THE NURSES NOTES DATED 1/7/12 AT 5:00 P.M. READS, "AROUND 4:30 P., CNA REPORTED TO THIS NURSE RESIDENT (#1) HAD EMESIS WHILE SITTING IN W/C (WHEELCHAIR) IN HALLWAY...RESIDENT NON-VERBAL...RESIDENT WITH 2ND EMESIS..." A TELEPHONE INTERVIEW WAS CONDUCTED WITH LPN "F" ON 1/19/12 AT 3:50 P.M. LPN "F" STATED SHE WAS "NOT THE NURSE ON DUTY WHEN RESIDENT #1 fell , BUT SHE TOOK OVER THE CARE OF HIM LATER". WHEN LPN "F" WAS ASKED ABOUT THE LOW B/P RECORDED AS 85/37 MMHG AT 9:45 A.M., LPN "F" REPLIED "I REMEMBER THE B/P WHEN I WROTE IT DOWN...I QUESTIONED WHETHER TO SEND HIM DOWN TO THE ACTIVITY....HIS CHURCH WAS HERE AND HE WANTED TO GO.... HE (RESIDENT #1) COULDN'T PINPOINT PAIN, HE WAS GIVEN HIS SCHEDULED TYLENOL, HE DIDN'T SEEM TO BE IN PAIN." LPN "F" WAS ASKED IF SHE CONTACTED THE DOCTOR REGARDING THE ABNORMAL B/P FINDINGS AND BEHAVIOR CHANGE AS DIRECTED ON THE FACILITY'S "HEAD INJURY MONITOR FLOWSHEET" AND SHE REPLIED "NO". LPN "F" FURTHER STATED, "I'M NOT CHECKING THE B/P'S MYSELF, THE CNA'S TAKE THE VITAL SIGNS AND THEN GIVE THEM TO US (NURSES)...WE DON'T ALWAYS GET THE RESULTS RIGHT AWAY." A REVIEW OF RESIDENT #1'S "VITAL SIGNS RECORD" REVEALS BLOOD PRESSURE RECORDINGS DATED 1/02/12 THROUGH 1/09/12, WITH THE LOWEST B/P RECORDED AS 120/55 AND AS HIGH AS 176/77; THEREFORE A B/P READING OF 85/37 IS SIGNIFICANT CHANGE FOR RESIDENT #1. AN INTERVIEW WAS CONDUCTED WITH THE DIRECTOR OF NURSING (DON) ON 1/19/12 AT 3:40 P.M. WHEN THE DON WAS ASKED WHAT ABNORMALS WOULD SHE EXPECT HER STAFF TO REPORT TO THE PHYSICIAN FROM THE "HEAD INJURY MONITOR FLOWSHEET?", THE DON REPLIED "I WOULD EXPECT THEM (NURSES) TO REPORT CHANGES IN PUPILS, BLOOD PRESSURES OR CHANGES IN BEHAVIORS. THE DON AND THIS WRITER REVIEWED THE "HEAD INJURY FLOWSHEET" AND FOUND NO AREA FOR THE NURSING STAFF TO RECORD PUPIL CHANGES. RESIDENT #1'S NEUROLOGICAL STATUS WAS NOT ADEQUATELY ASSESSED IN ADDITION TO THE PHYSICIAN NOT BEING NOTIFIED TIMELY RESULTING IN DELAYED treatment of [REDACTED]. A REVIEW OF THE "HISTORY AND PHYSICAL" REPORT DATED 1/8/12 REGARDING RESIDENT #1'S hospitalization , REFLECTS THAT RESIDENT #1'S SPOUSE COMMUNICATED THE WISHES OF RESIDENT #1 (PERTAINING TO A POWER OF ATTORNEY DOCUMENT) "WOULD NOT HAVE SURGERY AND THAT HE WOULD REMAIN "NO CODE". A physician progress notes [REDACTED].#1) IS SEEN IN FOLLOWUP FROM A hospitalization THIS WEEKEND. HE APPARENTLY fell on MONDAY, 1/2/12 AND AGAIN ON SATURDAY, 1/7/12....HE WAS FOUND TO HAVE A 4 CM (CENTIMETER) ACUTE INTRAPARENCHYMAL HEMORRHAGE OF THE LEFT FRONTAL LOBE WITH MASS EFFECT AS WELL AS A SUBDURAL COMPONENT ALONG THE INTERHEMISPHERIC FISSURE....RECOMMENDED MEDICAL TREATMENT...HE WAS ON [MEDICATION NAME], ASPIRIN, AND [MEDICATION NAME] PRIOR TO FALL...IMPRESSION/PLAN: INTRACRANIAL BLEED. status [REDACTED]. MICHIGAN NURSES ASSOCIATION PUBLICATION TITLED "PROFESSIONAL AND LEGAL REGULATION OF NURSING PRACTICE IN MICHIGAN", 3RD EDITION, PAGES 9 AND 10, READS, "...THE REGISTERED NURSE COLLECTS COMPREHENSIVE DATA PERTINENT TO THE PATIENT'S HEALTH OR SITUATION... ANALYZES THE ASSESSMENT DATA TO DETERMINE THE [DIAGNOSES REDACTED]. THE AMERICAN NURSES ASSOCIATION PROVIDES A DOCUMENT TITLED, "CODE OF ETHICS FOR NURSES WITH INTERPRETIVE STATEMENTS" VIA THE INTERNET WEBSITE WWW.NURSINGWORLD.ORG THAT READS ON PAGE 9, "...NURSES ARE REQUIRED TO HAVE KNOWLEDGE RELEVANT TO THE CURRENT SCOPE AND STANDARDS OF NURSING PRACTICE... WHERE THE CARE REQUIRED IS OUTSIDE THE COMPETENCIES OF THE INDIVIDUAL NURSE, CONSULTATION SHOULD BE SOUGHT OR THE PATIENT SHOULD BE REFERRED TO OTHERS FOR APPROPRIATE CARE...". ( )