Every finding on record at Grandview Post Acute

Based on facility policy review, medical record review, facility documentation review, and interview the facility failed to ensure a medication was available from the pharmacy within 24 hours of ordering the medication for 1 resident (Resident #3) of 9 residents reviewed.Review of facility policy titled, Choice of Pharmacy and Medicare (Part D) Drug Plans revised 4/2007, revealed .The pharmacy service provider must deliver routinely prescribed medications within twenty-four hours (24) hours of the order, or sooner if needed .Medical record review revealed Resident #3 was admitted to the facility on [DATE] with diagnoses including Osteomyelitis of Vertebra Thoracic Region, and Management of Vascular Access. Review of a quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #3 scored a 14 on the Brief Interview of Mental Status (BIMS) assessment which indicated was cognitively intact. Review of Physician's Orders for Resident #3 dated 3/19/2026 at 5:10 AM, revealed the resident was ordered Oxycodone (a medication used to treat pain) 10/325 milligrams (mg) every 4 hours as needed for Osteomyelitis (infection of the bone).Review of the Pain Assessment for Resident #3 dated 3/19/2026-3/20/2026, revealed no increase in pain. Review of pharmacy workflow and delivery details documentation revealed Oxycodone 10/325 mg was delivered to the facility on 3/20/2026 at 5:30 PM (approximately 36 hours after the medication was ordered). Review of an email from the Director of Nursing (DON) to the Pharmacy General Manager on 3/20/2026 at 4:09 PM, revealed .Just wondering why it is taking so long for this [medication Oxycodone 10/325mg] to be delivered? It was ordered more than 24 hours ago . continued review of an email from the Pharmacy General Manager to the DON on 3/23/2026 at 1:21 PM, revealed .I have completed a review of the order in question. Your team submitted the request at 5:10 a.m. on the 19th, and it should have been included on the delivery run that same day. Unfortunately, the pharmacy staff member who entered the order incorrectly placed it on the following days run .I do not have an excuse for the error, but I can assure you it is being taken seriously .During an interview on 3/30/2026 at 10:30 AM, the DON stated .the medicine was ordered on 3/19 at 5:00 AM and it got here on 3/20 [3/20/2026] at 5:30 PM . The DON confirmed the facility failed to acquire Resident #3's Oxycodone 10/325 mg within 24 hours of the order.

Based on facility policy review, medical record review, and interview, the facility failed to execute an orderly discharge for one resident (Resident #1) of 4 residents sampled for admission, transfers, or discharges. The facility failure occurred when it referred the discharged resident to out of network providers for follow-up home health care, failed to schedule follow up appointments with the primary care physician of record, and failed to send prescriptions to the pharmacy of record at the time of discharge.The findings include:Review of the facility policy, Transfer or Discharge, copyright date 2001, revealed, .When the facility transfers or discharges a resident, the following information is communicated to the receiving healthcare institution or provider .Disposition of Medications .receiving facility's services that are available to meet .needs .Review of the medical record revealed Resident #1 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included Aphasia Following Cerebral Infarction, Type 2 Diabetes with Neuropathy, Unspecified Dementia, Depression, Duodenal Ulcer Unspecified, and Fibromyalgia.Review of the discharge Minimum Data Set (MDS), dated [DATE], revealed Resident #1 scored 15/15 on the brief interview of mental status examination which indicated Resident #1 was cognitively intact. Resident #1 was free of behaviors or cognitive impairment and required minimal to moderate assistance of one person for activities of daily living.Review of discharge summary for Resident #1, dated 12/23/2025, revealed the name of the pharmacy where prescriptions were to have been sent at the time of discharge. The line for the pharmacy provider's fax number was blank. The document stated the prescription orders were conveyed to the pharmacy by fax. Continued review showed Resident #1 was referred by the facility to home health services with a local agency for follow-up physical therapy and nursing care with the provider named. Continued review revealed no follow-up care with Resident #1's primary physician was scheduled at the time of discharge. The document was signed by the discharging nurse and Resident #1.Review of pharmacy orders electronically transferred to the pharmacy provider by the facility revealed the facility did not transfer orders for discharge medications until 12/30/2025. (7 days after Resident #1 discharged from the facility). There was no evidence in records reviewed that pharmacy orders were transmitted to the pharmacy at the time of discharge as documented on the discharge summary.During a telephone interview on 01/14/2026 at 11:21 AM, the home health service director (HSD) reported she did receive a referral for Resident #1 for PT (Physical Therapy), OT (Occupational Therapy) and nursing services on 12/23/2025, but Resident #1 was not eligible due to the company was out of network for Resident #1's insurance. HSD reported she called the facility on 12/23/2025 and reported to staff that Resident #1 would not be admitted but never received a return call from the facility. During an interview on 1/20/2026 at 2:30 PM, the Director of Nursing, (DON) confirmed the facility failed to refer Resident #1 to an in-network home care provider at discharge. The DON confirmed, for unknown reasons, calls from the home care provider to that effect had not been conveyed up the chain of command to the social worker or facility leadership by floor staff and as a result, the facility failed to provide an effective discharge plan for post discharge wound care and therapy services ordered to Resident #1. The DON confirmed multiple personnel responsible for discharge planning and care coordination were all off duty on 12/24/2025 and 12/25/2025 or on vacations over the holidays until the end of the year, and no designated person to fulfill their responsibilities was in place during their absence. The DON further confirmed the facility could not provide any information indicative it had faxed prescriptions to Resident #1's pharmacy at the time of discharge (as documented on the discharge summary). The DON confirmed prescriptions were electronically transferred to the pharmacy on 12/30/2025 (7 days after Resident #1's discharge) and that occurred after Resident #1's family member called the facility to complain that no prescriptions were provided for the Resident on 12/23/2025, which she was not made aware of until 1/3/26 upon her return to work.During an interview on 1/20/2026 at 4:30 PM in the conference room, the Social Service Director (SSD) confirmed she coordinated the discharge for Resident #1. SSD confirmed Resident #1 was referred to the home care provider with no follow-up. SSD stated she did not set up any follow up appointments with the primary care provider because Resident #1 informed her at discharge she would do it herself. SSD stated she did not coordinate discharge prescription transfers, which were managed by the unit manager who was a nurse. The SSD further stated she was unaware that the home care service to which Resident #1 was referred on 12/23/2025, was out of network for the resident. The SSD also confirmed she had previously reported she had not received telephone messages left to the facility from the homecare provider to inform her it was out of network and wouldn't admit Resident #1 on 12/23/2025 because by that time, she was off work for Christmas break and staff who received messages from the home care provider had not relayed them to her.During an interview on 1/21/2026 at 3:50 PM, the facility Administrator confirmed Resident #1's discharge was not executed in accordance with facility expectations as outlined in policies and procedures. The Administrator confirmed the facility failed to ensure the home health services referred were available to Resident #1 and failed to ensure that medication orders were received by the pharmacy timely. The facility failed to ensure follow-up appointments with the primary care provider were verified prior to Resident #1's discharge. The Administrator confirmed due to absences of facility personnel over the holiday, who were responsible for discharge planning and follow-up care with no backup persons available, communications with the home care service to whom Resident #1 was referred were interrupted, and because the facility failed to ensure alternate personnel were in place to maintain lines of communication with outpatient providers and to coordinate discharge care at time of Resident #1's discharge, the facility failed to provide a safe or effective discharge for Resident #1.

Based on facility policy review, observations, and interviews, the facility failed to ensure kitchen equipment of 1 gas cook top oven and 1 deep fryer was maintained in good working condition. The findings include: Review of the facility's Nutritional Services policy titled, Cleaning & Sanitization, dated 9/2/2020, revealed .The Director of Food and Nutrition Services will develop, implement, and monitor schedules for cleaning, sanitizing and maintenance . Review of facility documentation titled, Instructions .Facility Inspection: Inspect kitchen small appliances, undated, revealed .Conduct safety and operation inspections .Visually inspect all appliances for damage .Test functionality of appliances and proper operation of all controls .Inspect all tethered gas fed appliances . During an observation and interview of the kitchen during the initial tour on 5/4/2025 at 10:45 AM, with the Certified Dietary Manager (CDM) and [NAME] revealed on inspection of the cook top stove, the debris pan located under the gas burners was extremely hot to the touch as well as the handle of the stove. All of the stove burners had been off for hours according to the Cook. All control knobs for the cook top stove and oven were in the OFF position, yet the debris pan, and stove handle remained extremely hot. The deep fryer was located next to the cook top stove, and the cook stated the deep fryer's pilot light and stove top burners pilot lights will not stay lit at times and were not functioning properly. During an interview on 5/4/2025 at 11:53 AM, the CDM confirmed the cook top oven and deep fryer were in need of professional repair. The CDM acknowledged the temperatures of the debris pan and oven door handle had the potential to burn users hands while the burners and stove were not in operation. During an interview on 5/6/2025 at 12:22 PM, the Administrator stated he was made aware of the observations of the gas cook top stove and the deep fryer after the initial tour of the kitchen on 5/4/2025. The Administrator confirmed both pieces of equipment were in need of repair.

Based on facility policy review, medical record review, observations and interview the facility failed to offer hand hygiene assistance prior to meals for 5 residents (Residents #9, #33, #56, #58, and #5) of 18 residents observed on 1 of 3 hallways, the facility failed to wear adequate Personal Protective Equipment (PPE) when delivering meal trays to 3 residents (Residents #25, #35, and #64), and the facility failed to perform appropriate hand hygiene during medication administration for 1 resident (Resident #283) of 18 residents observed for infection control. The facility also failed to ensure staff wore adequate PPE when sorting soiled linens. The findings include: Review of the facility's policy titled, Handwashing/Hand Hygiene, dated 2001, revealed .personnel are trained .in serviced .importance of hand hygiene .preventing the transmission of healthcare-associated infections .residents .are encouraged to practice hand hygiene . 1. The facility failed to offer or assist with hand hygiene prior to a meal for Residents @9, #33, #56, #58, and #5. 1a. Review of the medical record revealed Resident #9 was admitted to the facility on [DATE] with diagnoses including Hemiplegia and Hemiparesis, Heart Failure, and Dementia. Review of the comprehensive care plan for Resident #9 revised 3/7/2025, revealed .ADL [activities of daily living]/Mobility .resident is at risk for ADL/mobility decline and requires assistance related to H/O [history of] CVA [Cerebrovascular Accident] [stroke] with right hemiplegia . Review of a quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #9 scored an 8 on the Brief Interview for Mental Status (BIMS) assessment which indicated moderate cognitive impairment. Further review revealed the resident was dependent upon staff for assistance with personal hygiene. During an observation on 5/4/2025 at 12:25 PM, on the 600 hall, revealed Certified Nursing Assistant (CNA) B placed the meal tray in front of Resident #9, setup the meal tray for the resident to eat, and failed to offer or assist the resident with hand hygiene before the meal tray was delivered or before the resident began eating the meal. 1b. Review of the medical record revealed Resident #33 was admitted to the facility on [DATE] with diagnoses including Hemiplegia and Hemiparesis, Chronic Kidney Disease, Heart Failure, and Diabetes. Review of the comprehensive care plan for Resident #33 revised 1/7/2025, revealed .ADL/mobility decline and requires assistance related to H/O CVA with right hemiplegia . Review of an annual MDS assessment dated [DATE], revealed Resident #33 scored a 10 on the BIMS assessment which indicated moderate cognitive impairment. Further review revealed the resident was dependent upon staff assistance for personal hygiene. During an observation on 5/4/2025 at 12:27 PM, revealed CNA C placed the lunch meal tray in front of Resident #33, setup the meal tray for the resident to eat, and failed to offer or assist Resident #33 with hand hygiene before the meal tray was delivered or before the resident began eating the meal. 1c. Review of the medical record revealed Resident #56 was admitted to the facility on [DATE] with diagnoses including Heart Failure, Diabetes, and Chronic Pain. Review of the comprehensive care plan for Resident #56 revised 1/17/2025, revealed .ADL/Mobility .requires assistance related to non-ambulatory . Review of a quarterly MDS assessment dated [DATE], revealed Resident #56 scored a 12 on the BIMS assessment which indicated moderate cognitive impairment. Further review revealed the resident required substantial/maximal assistance by staff with personal hygiene. During an observation on 5/4/2025 at 12:30 PM, CNA C placed the lunch meal tray in front of Resident #56, setup the meal tray for the resident to eat, and failed to offer or assist Resident #56 with hand hygiene before the meal tray was delivered or before the resident began eating the meal. 1d. Review of the medical record revealed Resident #58 was admitted to the facility on [DATE] with diagnoses including Atrial Fibrillation, Dementia, and Chronic Pain. Review of the comprehensive care plan for Resident #58 revised 1/16/2025, revealed .ADL/Mobility .self-care deficit R/T [related to] .dressing .hygiene . Review of a quarterly MDS assessment dated [DATE], revealed Resident #58 scored a 3 on the BIMS assessment which indicated severe cognitive impairment. Further review revealed the resident was dependent upon staff assistance for personal hygiene. During an observation on 5/4/2025 at 12:35 PM, CNA B placed the lunch meal tray in front of Resident #58, setup the meal tray for the resident to eat, and failed to offer or assist Resident #58 with hand hygiene before the meal tray was delivered or before the resident began eating the meal. 1e. Review of the medical record revealed Resident #5 was admitted to the facility on [DATE] with diagnoses including Hemiplegia and Hemiparesis, Chronic Kidney Disease, and Diabetes. Review of an admission MDS assessment dated [DATE], revealed Resident #5 scored a 14 on the BIMS assessment which indicated the resident was cognitively intact. Further review revealed the resident required substantial/maximal assistance with personal hygiene. Review of the comprehensive care plan for Resident #5 revised 5/6/2025, revealed .ADL/mobility .requires assistance related to CVA . During an observation on 5/4/2025 at 12:37 PM, CNA C placed the lunch meal tray in front of Resident #5, setup the meal tray for the resident to eat, and failed to offer or assist Resident #5 with hand hygiene before the meal tray was delivered or before the resident began eating the meal. During an interview on 5/4/2025 at 12:40 PM, CNA B confirmed hand hygiene was not offered or provided to Resident #9 and Resident #58 before the lunch meal was served or before the residents began eating their meal. During an interview on 5/4/2025 at 12:45 PM, CNA C confirmed hand hygiene was not offered or provided to Resident #33, Resident #56, and Resident #5 before the lunch meal was served or before the residents began eating their meal. During an interview on 5/6/2025 at 10:35 AM, the Director of Nursing (DON) confirmed it was the facility's expectation for the staff to offer hand hygiene assistance to all residents prior to meal service. 2. The facility failed to wear adequate PPE while delivering meal trays to Residents #25, #35, and #64. Review of the facility's policy titled, Infection Prevention and Control Program, dated 2001, revealed An infection Prevention and Control Program (IPCP) is established and maintained to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections .The program is based on accepted national infection prevention and control standards .management is a process that consists of .managing the affected residents .preventing the spread to other residents .educating the staff .Prevention of infection .implementing appropriate .transmission-based precautions . Review of the facility's policy titled, Personal Protective Equipment, dated 2001, revealed .Personnel who perform tasks that may involve exposure to blood/body fluids are provided appropriate personal protective equipment (PPE) .includes but is not necessarily limited to .Gowns/aprons/lab coats .eye wear (goggles and/or face shields) .PPE required for transmission-based precautions is maintained outside .the resident's room . 2a Review of the medical record revealed Resident #25 was admitted to the facility on [DATE] with diagnoses including Chronic Kidney Disease, Cirrhosis, Atrial Fibrillation, and Difficulty Walking. Review of a quarterly MDS assessment dated [DATE], revealed Resident #25 scored a 15 on the BIMS assessment which indicated the resident was cognitively intact. Review of a Physician's Order dated 4/28/2025, revealed Resident #25 was on droplet transmission-based precautions related to a COVID-19 infection with an end date of 5/9/2025. Review of a comprehensive care plan revised 5/5/2025, revealed Resident #25 was on droplet transmission-based precautions related to a COVID-19 infection. During an observation on 5/4/2025 at 11:30 AM, revealed Resident #25's door was closed with an 8.5 x 11 inch laminated sign attached to the door which read .STOP .DROPLET PRECAUTIONS .EVERYONE MUST .make sure their eyes .are fully covered before room entry . The sign also displayed an image of a face shield and eye goggles. Further observation revealed a yellow cloth isolation supply bin hanging from the door. The isolation bin contained multiple isolation gowns, multiple boxes of various sized gloves, and a disposable stethoscope. The isolation storage bin did not contain goggles or face shields. During an observation and interview on 5/4/2025 at 12:22 PM, Licensed Practical Nurse (LPN) S was observed removing PPE from Resident #25's isolation bin, donned (put on) gloves, and an isolation gown. Further observation revealed LPN S entered Resident #25's room and set up the meal tray without wearing a face shield or eye goggles. LPN S stated an isolation gown and gloves were applied because Resident #25 had an active COVID-19 infection and confirmed a face shield or eye goggles were not donned. 2b Review of the medical record revealed Resident #35 was admitted to the facility on [DATE] with diagnoses including Type 2 Diabetes, Chronic Obstructive Pulmonary Disease, Peripheral Vascular Disease, and History of Blood Clots. Review of an admission MDS assessment dated [DATE], revealed Resident #35 scored a 15 on the BIMS assessment which indicated the resident was cognitively intact. Review of a Physician's Order dated 4/28/2025, revealed Resident #35 was on droplet transmission-based precautions related to a COVID-19 infection with an end date of 5/9/2025. Review of a comprehensive care plan revised 4/29/2025, revealed Resident #35 was on droplet transmission-based precautions related to a COVID-19 infection. During an observation on 5/4/2025 at 11:35 AM, Resident #35's door was closed with an 8.5 x 11 inch laminated sign attached to the door which read .STOP .DROPLET PRECAUTIONS .EVERYONE MUST .make sure their eyes .are fully covered before room entry . The sign also displayed an image of a face shield and eye goggles. Further observation revealed a yellow cloth isolation supply bin hanging from the door. The isolation bin contained multiple isolation gowns, multiple boxes of various sized gloves, and a disposable stethoscope. The isolation storage bin did not contain goggles and contained 1 face shield which had a broken elastic strap. During an observation and interview on 5/4/2025 at 12:28 PM, LPN U was observed removing PPE from Resident #35's isolation bin, donned gloves, and an isolation gown. Further observation revealed LPN U entered Resident #35's room without a face shield or eye goggles. LPN U stated an isolation gown and gloves were applied because Resident #35 had an active COVID-19 infection and confirmed a face shield and goggles were not donned. 2c Review of the medical record revealed Resident #64 was admitted to the facility on [DATE], with diagnoses including Chronic Obstructive Pulmonary Disease, Obesity, Lack of Coordination, Cough, and Wheezing. Review of an admission MDS assessment dated [DATE], revealed Resident #64 scored a 14 on the BIMS assessment which indicated the resident was cognitively intact. Review of a Physician's Order dated 4/30/2025, revealed Resident #64 was on droplet transmission-based precautions related to a COVID-19 infection with an end date of 5/11/2025. Review of a comprehensive care plan revised 5/1/2025, revealed Resident #64 had an active COVID-19 infection. During an observation on 5/4/2025 at 11:25 AM, Resident #64's door was closed with an 8.5 x 11 inch laminated sign attached to the door which read .STOP .DROPLET PRECAUTIONS .EVERYONE MUST .make sure their eyes .are fully covered before room entry . The sign also displayed an image of a face shield and eye goggles. Further observation revealed a yellow cloth isolation supply bin hanging from the door. The isolation bin contained multiple isolation gowns, multiple boxes of various sized gloves, and a disposable stethoscope. The isolation storage bin did not contain eye goggles or face shields. During an observation and interview on 5/4/2025 at 12:14 PM, CNA V was observed removing PPE from Resident #64's isolation bin, donned gloves, and an isolation gown. Further observation revealed CNA V entered Resident #64's room without a face shield or eye goggles. CNA V stated an isolation gown and gloves were applied because Resident #64 had an active COVID-19 infection and confirmed a face shield or goggles were not donned. During an interview on 5/5/2025 at 3:00 PM, the Infection Preventionist stated there was additional PPE available in the central supply area, and also stated the staff members were expected to don eye goggles or a face shield prior to entering rooms with droplet precautions signage. The Infection Preventionist confirmed the facility failed to wear the appropriate PPE of goggles or a face shield when entering the isolation rooms for Residents #25, #35, and #64. During an interview on 5/6/2025 at 1:25 PM, the Director of Nursing (DON) stated staff members were expected to wear eye goggles or a face shield prior to entering rooms with droplet precautions for all resident tasks. The DON also stated the facility failed to have adequate PPE of face shields or goggles available outside the resident rooms in the PPE bins. During further interview the DON confirmed the facility failed to wear the appropriate PPE for Residents #25, #35, and #64. 3. The facility staff failed to perform hand hygiene during medication administration for Resident #283. 3a Review of the medical record revealed Resident #283 was admitted to the facility on [DATE] with diagnoses including Metabolic Encephalopathy, Urinary Tract Infection, Sepsis, Alerted Mental Status, and Respiratory Failure. During an observation on 5/6/2025 at 7:55 AM, revealed LPN T prepared multiple and various oral tablet medications for Resident #283 into a clear 30 milliliter (mL) medication cup which was placed on the medication cart. LPN T dropped a Calcium-Vitamin D pill bottle onto the floor, picked the bottle up out of the floor, and then placed the pill bottle back into the medication cart. Continued observation revealed LPN T did not disinfect or clean the medication bottle after the bottle touched the floor and did not clean the hands after retrieving the bottle from the floor. Further observation revealed LPN T retrieved the prepared medications and administered the medications to Resident #283. During an interview on 5/5/2025 at 8:00 AM, LPN T confirmed hand hygiene was not performed after picking up a soiled item from the floor, the soiled medication bottle was not cleaned after touching the floor, was placed back into the clean medication cart, and the medications were administered to Resident #283 with soiled hands. During further interview LPN T confirmed infection control guidelines were not followed during the medication administration. During an interview on 5/5/2025 at 3:00 PM, the Infection Preventionist stated staff were expected to wash their hands or use hand sanitizer after picking up soiled items from the floor and prior to medication administration. During further interview the Infection Preventionist confirmed the facility failed to ensure infection control guidelines were followed during medication administration for Resident #283. During an interview on 5/6/2025 at 1:25 PM, the DON confirmed the facility failed to ensure infection control guidelines were followed during medication administration for Resident #283. 4. The facility staff failed to ensure staff wore appropriate PPE when sorting soiled linens. During an observation on 5/5/2025 at 4:00 PM, revealed the facility had 2 washers in use which contained facility linen, and multiple empty soiled linen containers of various sizes. Further observation of the soiled linen room revealed no gowns or aprons available for staff use. During an interview on 5/5/2025 at 4:02 PM, Laundry Aide W stated 2 loads of laundry were recently sorted and actively washing. During further interview the Laundry Aide stated she wore gloves when handling soiled linens and stated she has never worn a gown or apron when handling or sorting soiled linens. During an interview on 5/5/2025 at 4:05 PM, Laundry Aide X stated she wore gloves when handling soiled linens and stated she has never worn a gown or apron when handling or sorting soiled linens. During an interview on 5/5/2025 at 4:07 PM, the Housekeeping Laundry Supervisor stated gowns were available for staff use in the soiled linen room and stated the gowns were stored next to the washers. The Housekeeping Laundry Supervisor stated Laundry Aides were expected to wear a gown or apron when handling or sorting soiled linens. During an observation and interview on 5/5/2025 at 4:08 PM, the Housekeeping Laundry Supervisor observed the soiled linen room and washer area which revealed no gowns or aprons available for use. The Housekeeping Laundry Supervisor confirmed gowns and aprons were not available for use and also confirmed the facility failed to follow infection control guidelines when handling soiled linens. During an interview on 5/5/2025 at 4:10 PM, the Infection Preventionist confirmed the facility failed to follow infection control guidelines when handling soiled linens. During an interview on 5/6/2025 at 1:25 PM, the DON stated she expected the Laundry Aides to wear a gown or apron when handling soiled linens related to potential exposure to infectious organisms. During further interview the DON confirmed the facility failed to follow infection control guidelines when handling soiled linens.

Based on facility contract review, facility policy review, medical record review, and interview, the facility failed to ensure a coordinated plan of care with the hospice provider was available in the medical record for 1 resident (Resident #4) of 2 residents reviewed for hospice services. The findings include: Review of the facility policy titled, Hospice Program, dated 2001, revealed .Director of Nursing or Designee will coordinate care provided to the resident by our facility staff and the hospice staff .responsible for the following .obtaining the following information from the hospice .most recent hospice plan of care specific to each resident . Review of the medical record revealed Resident #4 was admitted to the facility on [DATE] with diagnoses including Alzheimer's Disease, Anxiety Disorder, and Encounter for Palliative Care. Review of the Physician's Order for Resident #4 dated 12/17/2024, revealed .admit to [Hospice Name] hospice continuous . Review of the facility document titled, Hospice IDG Comprehensive Assessment and Plan of Care Update Report, for Resident #4 dated 1/7/2025, revealed, .Benefit Period Dates .1/6/2025 to 4/5/2025 . Continued review revealed no further documentation of a new recertification period for hospice services or a revised care plan after 4/5/2025. Review of a comprehensive care plan dated 1/30/2025, revealed Resident #4 .End of Life .Resident requires HOSPICE SERVICES R/T [related to] ALZHEIMERS DISEASE .notify hospice of change of condition . Review of a quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #4 scored a 3 on the Brief Interview for Mental Status (BIMS) assessment which indicated severe cognitive impairment. Further review revealed the resident received hospice services. During an interview on 5/6/2025 at 9:20 AM, the Social Services Director (SSD) stated she was the hospice coordinator for the facility. The SSD stated there were hospice plan of care binders located at each nurse station for each resident that received hospice services. The SSD confirmed Resident #4 remained on hospice services and the hospice plan of care had not been updated for Resident #4. During an interview on 5/6/2025 at 10:35 AM, the Director of Nursing (DON) confirmed that Resident #4 remained on hospice services and the hospice plan of care had not been updated for Resident #4.

Review of the medical record revealed Resident #19 was admitted to the facility on [DATE] with diagnoses including Insomnia, Adjustment Disorder with Depressed Mood, Dementia with Psychotic Disturbance, and Schizophrenia. Review of a PASRR Level 2 Outcome (completed prior to admission) dated 11/4/2023, revealed Resident #19 had a PASRR level 2 Outcome related to severe mental illness. Review of an admission MDS assessment revealed Resident #19 scored a 12 on the BIMS assessment which indicated moderate cognitive impairment. Review of a comprehensive care plan revised 4/2/2025, revealed Resident #19's PASRR Level 2 Outcome recommendations were not addressed on the care plan. Review of the medical record revealed Resident #32 was admitted to the facility on [DATE] with diagnoses including Parkinsonism, Anxiety, Depression, Bipolar Disorder, Insomnia, and Tobacco use. Review of a quarterly MDS assessment dated [DATE], revealed Resident #32 scored a 7 on the BIMS assessment which indicated severe cognitive impairment. Review of a PASRR Level 2 Outcome dated 12/28/2024, revealed Resident #32 had a PASRR Level 2 Outcome related to severe mental illness. Review of a comprehensive care plan revised 5/5/2025, revealed Resident #32's PASRR Level 2 Outcome recommendations were not addressed on the care plan. Review of the medical record revealed Resident #35 was admitted to the facility on [DATE] with diagnoses including Bipolar, Anxiety, Seizures, Restless Leg Syndrome, and Nicotine Dependence. Review of a PASRR dated 3/27/2025, revealed Resident #35 had a PASRR Level 2 Outcome related to severe mental illness. Review of an admission MDS assessment dated [DATE], revealed Resident #35 scored a 15 on the BIMS assessment which indicated the resident was cognitively intact. Review of a comprehensive care plan revised 4/23/2025, revealed Resident #35's PASRR Level 2 Outcome recommendations were not addressed on the care plan. Review of the medical record revealed Resident #25 was admitted to the facility on [DATE] with diagnoses including Chronic Kidney Disease, Cirrhosis, Atrial Fibrillation, and Difficulty Walking. Review of a quarterly MDS assessment dated [DATE], revealed Resident #25 scored a 15 on the BIMS assessment which indicated the resident was cognitively intact. Review of a Physician's Order dated 4/28/2025, revealed Resident #25 was on droplet transmission-based precautions related to a COVID-19 infection with an end date of 5/9/2025. Review of a comprehensive care plan revised 5/5/2025, revealed Resident #25 was on droplet transmission-based precautions related to a COVID-19 infection. The care plan was not revised until 7 days after the positive result. During a record review and interview on 5/6/2025 at 12:47 PM, Registered Nurse (RN) MDS K reviewed the PASRR Level 2 outcomes and the comprehensive care plans for Residents #41, #19, #32, and #35 and confirmed the comprehensive care plans were not revised to include PASRR Level 2 Outcomes and specialized services provided by the facility. RN MDS K reviewed the COVID-19 positive result and the comprehensive care plan for Resident #25 and confirmed the comprehensive care plan was not revised timely for Resident #25. During an interview on 5/6/2025 at 1:25 PM, the Director of Nursing (DON) stated it was her expectation for care plans to be updated with PASRR level 2 outcomes, updated with specialized services which were provided by the facility, and also stated she expected care plans to be revised timely. During further interview the DON confirmed the facility failed to revise the comprehensive care plans for Residents #41, #19, #32 and #35. The DON also confirmed the facility failed to revise the comprehensive care plan for Resident #25 timely. Based on facility policy review, medical record review, and interview, the facility failed to revise the comprehensive care plans for 4 residents (Residents #41, #19, #32, and #35), the facility also failed to revise a comprehensive care plan timely for 1 resident (Resident #25) of 18 residents reviewed for care planning. The findings include: Review of the facility's policy titled, Care Plans, Comprehensive Person Centered, revised 3/2022, revealed .A comprehensive, person-centered care plan .meet the resident's physical, psychosocial, and functional needs .describes the services that are to be furnished to attain or maintain the resident's highest practical physical, mental, and psychosocial well-being, including .any specialized services to be provided as a result of PASARR [Preadmission Assessment and Resident Review] recommendations and .which professional services are responsible for each element of care .and .reflects currently recognized standards of practice .care plans are revised as information about the residents and the residents' condition change . Review of the medical record revealed Resident #41 admitted to the facility on [DATE] with diagnoses including Dementia, Bipolar Disorder, and Anxiety. Review of a PASRR dated 1/17/2024, revealed Resident #41 had a PASRR Level 2 Outcome related to serious mental illness. Review of an annual Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #41 scored an 8 on the Brief Interview for Mental Status (BIMS) which indicated moderate cognitive impairment. Review of the comprehensive care plan revised 3/10/2025, revealed Resident #41's Level 2 PASRR and recommended specialized services were not addressed on the care plan.

Review of the medical record revealed Resident #19 was admitted to the facility on [DATE] with diagnoses including Insomnia, Adjustment Disorder with Depressed Mood, Dementia with Psychotic Disturbance, and Schizophrenia. Review of a PASRR Level 2 Outcome (completed prior to admission) dated 11/4/2023, revealed Resident #19 had a PASRR level 2 Outcome related to severe mental illness. Review of an admission MDS assessment dated [DATE], revealed Resident #19 was not coded for a PASRR Level 2 Outcome. Further review of the admission MDS assessment revealed Resident #19 scored a 12 on the BIMS assessment which indicated moderate cognitive impairment. Review of the medical record revealed Resident #35 was admitted to the facility on [DATE] with diagnoses including Bipolar, Anxiety, Seizures, Restless Leg Syndrome, and Nicotine Dependence. Review of a PASRR Level 2 Outcome dated 3/27/2025, revealed Resident #35 had a PASRR Level 2 Outcome related to severe mental illness. Review of an admission MDS assessment dated [DATE], revealed the resident was not coded for a PASRR Level 2 Outcome. Further review of the admission MDS assessment revealed the resident scored a 15 on the BIMS assessment which indicated Resident #35 was cognitively intact. During an interview on 5/6/2025 at 12:13 PM, RN (Registered Nurse) MDS K stated a fall with minor injury should be coded if the resident experienced bruising and swelling as a result from the fall. During further interview RN MDS K stated Resident #69's fall occurred on 1/16/2025 and the resident developed bruising on 1/17/2025 as a result from the fall. RN MDS K confirmed the discharge MDS assessment for Resident #69 was not coded accurately. During a record review and interview on 5/6/2025 at 12:47 PM, RN MDS K reviewed the annual MDS assessment for Residents #41, the admission MDS assessments for Residents #19 and #35. RN MDS K confirmed the MDS assessments for Residents #41, #19, and #35 were not coded accurately. During an interview on 5/6/2025 at 1:25 PM, the Director of Nursing (DON) stated it was her expectation for MDS assessments to be coded accurately. The DON confirmed the facility failed to ensure the accuracy of the MDS assessments for Residents #41, #19, and #35. Based on Minimum Data Set (MDS) 3.0 Resident Assessment Instrument (RAI) Manual Version 1.19.1 review, medical record review, and interview, the facility failed to ensure MDS assessments were accurate for 4 residents (Resident #19, #35, #41, and #69) of 18 residents reviewed for MDS assessments. The findings include: Review of the MDS 3.0 RAI Manual, dated 10/2024, revealed .Health-related Quality of Life .residents covered by Level II PASRR [Pre-admission Screening and Resident Review] process may require certain care and services provided by the nursing home .Steps for Assessment .Code .yes .if PASRR Level II screening determined that the resident has a serious mental illness .Falls Since Admission/Entry or Reentry or Prior Assessment .whichever is more recent .Code .one [yes] .if the resident had one injurious fall . [superficial bruises] since admission/entry or reentry or prior assessment . Review of the medical record revealed Resident #41 admitted to the facility on [DATE] with diagnoses including Dementia, Bipolar Disorder, and Anxiety. Review of a Preadmission Evaluation Screening Resident Review (PASRR) dated 1/17/2024, revealed Resident #41 had a PASRR Level 2 Outcome related to a serious mental illness. Review of an annual MDS assessment dated [DATE], revealed Resident #41 was not coded for a PASRR Level 2 Outcome. Further review of the annual MDS assessment revealed Resident #41 scored an 8 on the Brief Interview for Mental Status (BIMS) assessment which indicated moderate cognitive impairment. Review of the medical record revealed Resident #69 admitted to the facility on [DATE] with diagnoses including Cerebral Infarction, Lack of Coordination, and Dementia. Review of the facility's communication tool titled SBAR [Situation, Background, Assessment, and Recommendation], dated 1/16/2025, revealed Resident #69 had an unobserved fall from the bed. Further review of the SBAR revealed Resident #69 had no bruising or other injuries. Review of a Weekly Summary Note dated 1/17/2025, revealed .Face- Bruising .Red Purple Black .Residents [Resident #69] left eyes swelling has decreased but the eye lid is discolored with bruising . Review of a Nurse Practitioner Progress Note dated 1/17/2025, revealed .[Resident #69] . seen for follow up on fall yesterday .Patient's left eye bruised this am . Review of a Nurse Progress Note dated 1/19/2025, revealed .[Resident #69] Continues to have purple colored bruising to left eye due to fall . Review of a discharge MDS assessment dated [DATE], revealed Resident #69 was severely impaired for cognitive skills for daily decision making. Further review of the discharge MDS assessment revealed Resident #69 was not coded for the 1/16/2025 fall with minor injury.

Based on facility policy, medical record review, observation and interview, the facility failed to provide effective housekeeping and maintenance services to maintain a clean, safe, and homelike environment as evidenced by dirty walls with black vertical marks, vertical scrapes that resulted in damaged sheet rock and holes in the walls in 15 resident rooms (Rooms 204, 205, 208, 506, 508, 509, 511, 600, 601,604, 605, 606,607,608, and 609) of 48 observed rooms throughout the facility. In addition, 1 hole was observed in the drywall in 1 nutrition room (400 Hall nutrition room) of 2 nutrition rooms observed in the facility. The findings include: Review of facility policy titled, Resident Rights and Resident Responsibilities, effective date 11/20/2023, revealed, .The resident has a right to a safe, clean, comfortable and Homelike environment . Review of the medical record revealed Resident #8 was admitted to the facility on [DATE], with diagnoses which included Paraplegia, Pressure Ulcer of Right Buttock, Stage 4, Pressure Ulcer of Sacral Region, Stage 4, Essential (Primary) Hypertension, Lack of Coordination, Unspecified Cirrhosis, and Other Specified Interstitial Pulmonary Diseases. Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] for Resident #8 revealed, a Brief Interview for Mental Status (BIMS) score of 9 which indicated moderate cognitive impairment. Observation and interview in Resident #8's room on 5/14/2024 at 5:25 PM observed the wall behind the headboard Resident 8's bed with a golf ball sized hole through the sheet rock, black vertical marks, and vertical scrapes into the wall that resulted in sheet rock damage with sheet rock dust noted on headboard. Resident #8 was lying in the bed on his back. Resident #8 was asked about the wall behind the headboard. Resident #8 stated the wall was like that on admission. Resident #8 stated if a wall at his home had a hole in it Resident #8 would repair it. Review of the medical record revealed Resident #10 was admitted to the facility on [DATE] and readmitted to the facility on [DATE] with diagnoses which included Atherosclerotic Heart Disease, Chronic Obstructive Pulmonary Disease, Chronic Respiratory Failure, Presence of Urogenital Implants, Sepsis, and altered Mental Status. Review of the Quarterly MDS assessment dated [DATE] for Resident #10 revealed, a BIMS score of 14 which indicated cognitively intact. Observation and interview in Resident #10's room on 5/14/2024 at 5:35 PM, observed vertical scrapes into the wall that resulted in damaged sheet rock behind Resident #10's headboard. Resident #10 was asked about the wall behind the head of his bed. Resident #10 stated it should be fixed. Review of the medical record revealed Resident #22 was admitted to the facility on [DATE] and readmitted to the facility on [DATE] with diagnoses which included Chronic Obstructive Pulmonary Disease, Metabolic Encephalopathy, Parkinson's Disease without Dyskinesia, Transient Cerebral Ischemia, and Hypotension. Review of the Quarterly MDS assessment dated [DATE] for Resident #22 revealed, a BIMS score of 11 which indicated moderate cognitive impairment. Observation and interview in Resident #22's room (606 A) on 5/15/2024 at 5:50 PM, observed black vertical marks and deep vertical scrapes into the wall with damaged sheet rock behind Resident #22's headboard. Resident #22 was asked about the wall behind the head of his bed. Resident #22 stated It was on there when I moved in. It needs to be repaired. I would expect them to repair it. Review of the medical record revealed Resident #23 was admitted to the facility on [DATE] with diagnoses which included Hypertensive Heart Disease, Chronic Obstructive Pulmonary, Morbid (Severe) Obesity, Personal History of Traumatic Brain Injury, and Type 2 Diabetes Mellitus. Review of the Quarterly MDS assessment dated [DATE] for Resident #23 revealed, a BIMS score of 12 which indicated moderate cognitive impairment. Observation and interview in Resident #23's room on 5/15/2024 at 5:55 PM, observed black vertical marks and vertical scrapes into the wall that resulted in sheet rock damage behind the Resident #23's headboard. Resident #23 was asked about the wall behind the headboard. Resident #23 stated, It makes me feel awful. It needs to be fixed. It would never get that way at my house. I would repair it, paint it, and get the wall back to normal or better. Observation in room [ROOM NUMBER] on 5/15/2024 beginning at 10:00 AM, observed vertical black marks and scrapes into the wall that resulted in damaged sheet rock behind the headboard of bed A. During an interview in room [ROOM NUMBER] on 5/15/2024 beginning at 3:00 PM, the Administrator confirmed the black vertical marks on the wall with scrapes into the wall that resulted in damaged sheet rock behind the headboard of bed A. The Administrator stated the wall needed to be repaired. During an interview in room [ROOM NUMBER] on 5/15/2024 beginning at 5:20 PM, the Maintenance Director confirmed behind the headboard of bed A black vertical marks on the wall with scrapes into the wall that resulted in damaged sheet rock. The Maintenance Director stated the wall needed to be repaired. Observation in room [ROOM NUMBER] on 5/15/2024 beginning at 10:00 AM, observed vertical black marks and scrapes into the wall that resulted in damaged sheet rock behind the headboard of bed B. During an interview in room [ROOM NUMBER] on 5/15/2024 beginning at 3:00 PM, the Administrator confirmed the black vertical marks on the wall with scrapes into the wall that resulted in damaged sheet rock behind the headboard of bed B. The Administrator stated the wall needed to be repaired. During an interview in room [ROOM NUMBER] on 5/15/2024 beginning at 5:20 PM, the Maintenance Director confirmed behind the headboard of bed B there were black vertical marks on the wall with scrapes into the wall that resulted in damaged sheet rock. The Maintenance Director stated the wall needed to be repaired. Observation in room [ROOM NUMBER] on 5/15/2024 beginning at 10:00 AM, observed vertical black marks on the wall with scrapes into the wall that resulted in damaged sheet rock behind the headboard of bed A. During an interview in room [ROOM NUMBER] on 5/15/2024 beginning at 3:00 PM, the Administrator confirmed the black vertical marks on the wall with scrapes into the wall that resulted in damaged sheet rock behind the headboard of bed A. The Administrator stated the wall needed to be repaired. During an interview in room [ROOM NUMBER] on 5/15/2024 beginning at 5:20 PM, the Maintenance Director confirmed behind the headboard of bed A there were black vertical marks on the wall with scrapes into the wall that resulted in damaged sheet rock. The Maintenance Director stated the wall needed to be repaired. Observation in the 400 Hall Nutrition Room on 5/15/2024 beginning at 10:00 AM, observed a hole in the wall behind the door through the sheet rock the size of the door handle noted. During an interview in the 400 Hall Nutrition Room on 5/15/2024 beginning at 3:00 PM, the Administrator confirmed the hole in the wall behind the door through the sheet rock the size of the door handle. The Administrator stated the wall needed to be repaired. During an interview in the 400 Hall Nutrition Room on 5/15/2024 beginning at 5:20 PM, the Maintenance Director confirmed the hole in the wall behind the door through the sheet rock the size of the door handle. The Maintenance Director stated the wall needed to be repaired. Observation in room [ROOM NUMBER] on 5/15/2024 beginning at 10:00 AM, observed vertical black marks on the wall with scrapes and dents into the wall that resulted in damaged sheet rock behind the headboard of bed A. During an interview in room [ROOM NUMBER] on 5/15/2024 beginning at 3:00 PM, the Administrator confirmed the black vertical marks on the wall with scrapes and dents into the wall that resulted in damaged sheet rock behind the headboard of bed A. The Administrator stated the wall needed to be repaired. During an interview in room [ROOM NUMBER] on 5/15/2024 beginning at 5:20 PM, the Maintenance Director confirmed behind the headboard of bed A there were black vertical marks on the wall with scrapes and dents into the wall that resulted in damaged sheet rock. The Maintenance Director stated the wall needed to be repaired. Observation in room [ROOM NUMBER] on 5/15/2024 beginning at 10:00 AM, observed vertical black marks on the wall with scrapes into the wall that resulted in damaged sheet rock behind the headboard of bed A. During an interview in room [ROOM NUMBER] on 5/15/2024 beginning at 3:00 PM, the Administrator confirmed the black vertical marks on the wall with scrapes into the wall that resulted in damaged sheet rock behind the headboard of bed A. The Administrator stated the wall needed to be repaired. During an interview in room [ROOM NUMBER] on 5/15/2024 beginning at 5:20 PM, the Maintenance Director confirmed behind the headboard of bed A there were black vertical marks on the wall with scrapes into the wall that resulted in damaged sheet rock. The Maintenance Director stated the wall needed to be repaired. Observation in room [ROOM NUMBER] on 5/15/2024 beginning at 10:00 AM, observed deep vertical scrapes into the wall that resulted in damaged sheet rock behind the headboard of bed B. During an interview in room [ROOM NUMBER] on 5/15/2024 beginning at 3:00 PM, the Administrator confirmed the deep vertical scrapes into the wall that resulted in damaged sheet rock behind the headboard of bed B. The Administrator stated the wall needed to be repaired. During an interview in room [ROOM NUMBER] on 5/15/2024 beginning at 5:20 PM, the Maintenance Director confirmed behind the headboard of bed B there were deep vertical scrapes into the wall that resulted in damaged sheet rock. The Maintenance Director stated the wall needed to be repaired. Observation in room [ROOM NUMBER] on 5/15/2024 beginning at 10:00 AM, observed on the wall to the right of the window peeling paint noted in an area approximately one-and-a-half-inch square, vertical scrapes into the wall that resulted in sheet rock damage behind the headboard of bed B. During an interview in room [ROOM NUMBER] on 5/15/2024 beginning at 3:00 PM, the Administrator confirmed small area of peeling paint to the right of the window, vertical scrapes into the wall that resulted in damaged sheet rock behind the headboard of bed B. The Administrator stated the walls needed to be repaired. During an interview in room [ROOM NUMBER] on 5/15/2024 beginning at 5:20 PM, the Maintenance Director confirmed behind the headboard of bed B there were vertical scrapes into the wall that resulted in damaged sheet rock, and a small area of peeling paint to right of the window. The Maintenance Director stated the walls needed to be repaired. Observation in room [ROOM NUMBER] on 5/15/2024 beginning at 10:00 AM, observed vertical black marks and deep vertical scrapes into the wall that resulted in sheet rock damage behind the headboards of bed A and bed B. During an interview in room [ROOM NUMBER] on 5/15/2024 beginning at 3:00 PM, the Administrator confirmed vertical black marks and deep vertical scrapes into the wall that resulted in sheet rock damage behind the headboards of bed A and bed B. The Administrator stated the walls needed to be repaired. During an interview in room [ROOM NUMBER] on 5/15/2024 beginning at 5:20 PM, the Maintenance Director confirmed behind the headboards of bed A and bed B there were vertical black marks and deep vertical scrapes into the wall that resulted in sheet rock damage. The Maintenance Director stated the walls needed to be repaired. Observation in room [ROOM NUMBER] on 5/15/2024 beginning at 10:00 AM, holes approximately the size of screws noted in the wall at the foot of bed A near the wardrobe and on the wall next to bed A's TV. During an interview in room [ROOM NUMBER] on 5/15/2024 beginning at 3:00 PM, the Administrator confirmed holes in the wall at the foot of bed A near the wardrobe and on the wall next to bed A's TV. The Administrator stated the holes needed to be repaired. During an interview in room [ROOM NUMBER] on 5/15/2024 beginning at 5:20 PM, the Maintenance Director confirmed there were holes in the wall at the foot of bed A near the wardrobe and on the wall next to bed A's TV. The Maintenance Director stated the holes needed to be repaired. Observation in room [ROOM NUMBER] on 5/15/2024 beginning at 10:00 AM, observed black vertical marks and vertical scrapes into the wall that resulted in sheet rock damage behind the headboards of bed A and bed B. During an interview in room [ROOM NUMBER] on 5/15/2024 beginning at 3:00 PM, the Administrator confirmed vertical black marks and vertical scrapes into the wall that resulted in sheet rock damage behind the headboards of bed A and bed B. The Administrator stated the wall needed to be repaired. During an interview in room [ROOM NUMBER] on 5/15/2024 beginning at 5:20 PM, the Maintenance Director confirmed behind the headboards of bed A & bed B there were vertical black marks and vertical scrapes into the wall that resulted in sheet rock damage. The Maintenance Director stated the wall needed to be repaired. Observation in room [ROOM NUMBER] on 5/15/2024 beginning at 10:00 AM, observed black vertical marks on the wall behind the headboard of bed A. During an interview in room [ROOM NUMBER] on 5/15/2024 beginning at 3:00 PM, the Administrator confirmed vertical black marks on the wall behind the headboard of bed A. The Administrator stated the wall needed to be painted. During an interview in room [ROOM NUMBER] on 5/15/2024 beginning at 5:20 PM, the Maintenance Director confirmed behind the headboard of bed A there were vertical black marks. The Maintenance Director stated the wall needed to be painted. Observation in room [ROOM NUMBER] on 5/15/2024 beginning at 10:00 AM, observed black vertical marks and deep vertical scrapes into the wall that resulted in sheet rock damage to the wall behind the headboard of Bed A. During an interview in room [ROOM NUMBER] on 5/15/2024 beginning at 3:00 PM, the Administrator confirmed vertical black marks and deep vertical scrapes into the wall that resulted in sheet rock damage behind the headboard of bed A. The Administrator stated the wall needed to be repaired. During an interview in room [ROOM NUMBER] on 5/15/2024 beginning at 5:20 PM, the Maintenance Director confirmed behind the headboard of bed A there were vertical black marks and deep vertical scrapes into the wall that resulted in sheet rock damage. The Maintenance Director stated the walls needed to be repaired. Observation in room [ROOM NUMBER] on 5/15/2024 beginning at 10:00 AM, observed vertical scrapes into the wall that resulted in damaged sheet rock behind the headboard of bed B. During an interview in room [ROOM NUMBER] on 5/15/2024 beginning at 3:00 PM, the Administrator confirmed vertical scrapes into the wall that resulted in sheet rock damage behind the headboard of bed B. The Administrator stated the wall needed to be repaired. During an interview in room [ROOM NUMBER] on 5/15/2024 beginning at 5:20 PM, the Maintenance Director confirmed behind the headboard of bed B there were vertical scrapes into the wall that resulted in sheet rock damage. The Maintenance Director stated the walls needed to be repaired. Observation in room [ROOM NUMBER] on 5/15/2024 beginning at 10:00 AM, observed the wall behind the headboard of bed A with a golf ball size hole through the sheet rock, black vertical marks, and vertical scrapes into the wall that resulted in sheet rock damage. Sheet rock dust noted on the headboard of bed A. Observed the wall behind the headboard of bed B with vertical scrapes into the wall that resulted in damaged sheet rock. During an interview in room [ROOM NUMBER] on 5/15/2024 beginning at 3:00 PM, the Administrator confirmed a golf ball size hole through the sheet rock, with black vertical marks, and vertical scrapes into the wall that resulted in sheet rock damage behind the headboard of bed A. Sheet rock dust noted on headboard of bed A. Vertical scrapes into the wall that resulted in damaged sheet rock behind bed B. The Administrator stated the wall needed to be repaired. During an interview in room [ROOM NUMBER] on 5/15/2024 beginning at 5:20 PM, the Maintenance Director confirmed behind the headboard of bed A golf ball size hole through the sheet rock, black vertical marks, and vertical scrapes into the wall that resulted in sheet rock damage. Sheet rock dust noted on headboard of bed A. Vertical scrapes into the wall that resulted in damaged sheet rock behind the headboard of bed B. The Maintenance Director stated the walls needed to be repaired. Observation in room [ROOM NUMBER] on 5/15/2024 beginning at 10:00 AM, observed holes approximately the size of screws in the wall above the headboard of bed A near the Auxiliary Drain box. During an interview in room [ROOM NUMBER] on 5/15/2024 beginning at 3:00 PM, the Administrator confirmed holes in the wall above the headboard of bed A near the Auxiliary Drain box. The Administrator stated the holes needed to be repaired. During an interview in room [ROOM NUMBER] on 5/15/2024 beginning at 5:20 PM, the Maintenance Director confirmed there were holes in the wall above the headboard of bed A near the Auxiliary Drain box The Maintenance Director stated the holes needed to be repaired. Observations were made of 48 resident rooms and 2 Nutritional Rooms with 15 resident rooms in need of wall repairs and painting. Observation of 1 nutritional room with a hole in the wall needing repaired and painted.

Based on facility policy review, medical record review, facility investigation review, personnel file review, and interview, the facility failed to protect a resident's right to be free from misappropriation and/or exploitation for 1 (Resident #7) of 7 sampled residents reviewed when Certified Nursing Assistant (CNA) BB transferred money from Resident #7's bank card to her (CNA BB) personal account. The findings include: Review of facility policy titled, Abuse Prohibition Plan, effective date 11/2/2023, revealed, .The facility has a zero-tolerance policy for abuse .The resident shall not be subjected to mistreatment, neglect, exploitation, or misappropriation of property .The Abuse Policy applies to anyone involved with the residents of this facility, including, but not limited to, all facility staff .Misappropriation of Resident Property means the deliberate misplacement, exploitation, or wrongful, temporary or permanent, use of a resident's belongings or money without the resident's consent .The facility shall report to the State Nurse Aide Registry or State Licensing Authority any knowledge it has of actions by a court of law against and employee, which would indicate unfitness for service as a nurse aide or other facility staff .The facility must take steps to ensure that the resident is protected from abuse . Review of facility policy titled, Resident Rights and Resident Responsibilities, effective date 11/20/2023, revealed, .The resident has the right to a dignified existence, self-determination .The resident has the right to exercise his or her rights as a resident and as a citizen or resident of the United States .The resident has a right to be treated with respect and dignity . Review of the police department's Incident/Investigation Report, dated 9/5/2023 at 12:18 PM, revealed the (Named Police Department) responded to a crime incident of Financial Exploitation of Elderly or Vulnerable Person. The victim, Resident #7, alleged money in the amount of $350.00 had been stolen from her bank card. The suspect listed was CNA BB. Review of the facility Investigation Summary, dated 9/8/2023, revealed, .Verified approx. [approximately] 400.00 missing from Pt's [patient's] [Resident #7] bank card. Ongoing police investigation. Received email from Family Member CC with copy of transaction for September . Review of the medical record revealed Resident #7 was admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses which included Chronic Obstructive Pulmonary Disease, Osteomyelitis of Vertebra, Chronic Respiratory Failure with Hypoxia, Chronic Diastolic (Congestive) Heart Failure, Depression, and Anxiety Disorder. Review of the Admission Minimum Data Set (MDS) assessment for Resident #7 dated 8/19/2023, revealed a Brief Interview for Mental Status (BIMS) score of eleven (11) which indicated moderate cognitive impairment. Review of Resident 7's bank statement dated September 2023, revealed a transaction dated 9/1/2023, showing CNA BB withdrew $350.00 from Resident #7's account. Review of the Nurse's Event Note, for Resident #7, dated 9/5/2023, revealed, .type of Occurrence .Misappropriation of Resident Property/Exploitation .Pt. [patient] reported that someone named [First Name of Certified Nursing Assistant (CNA) BB] took 400.00 off her bank card and the bank is the one that told her the name of the person was [Named CNA BB]. Pt. reported that she had given [Named CNA BB] her card to get her a couple of cokes out of the machine . Review of the personnel file for CNA BB revealed the facility terminated CNA BB for .Policy/Conduct Violation . on 9/6/2024. Review of a (Named County) Criminal Court document dated 4/16/2024, revealed CNA BB was charged with 1 count Financial Exploitation Elderly/Vulnerable Person on 10/02/2023. During an interview on 5/15/2024 at 4:10 PM, Resident #7 stated that CNA BB had stolen $350.00 from her bank card. Resident #7 stated, I had to get the police involved . Review of the document titled, Misappropriation Decision Tree, dated 5/16/2024, revealed accused individual CNA BB was an employee of the facility. The accused CNA BB wrongfully used Resident #7's money. The accused CNA BB's act was deliberate, and Resident #7 did not consent. The Decision Tree ended with notice of intent to place CNA BB on Abuse Registry. During a telephone interview on 5/16/2024 at 4:45 PM, Family Member (FM) CC stated a CNA took $350.00 out of Resident #7's bank card. FM CC confirmed that she provided the facility with the September 2023 bank statement showing the transaction on 9/1/2023. During an interview in the conference room on 5/16/2024 at 5:15 PM, the Administrator stated Resident #7 had given CNA BB her bank card to use to get Resident #7 two drinks out of the drink machine. The Administrator stated Resident #7 reported the bank had notified her that CNA BB had taken $350.00 out of her bank account and sent it to a Cash Application. The police came and started an investigation. The Administrator stated, I spoke with [Named Police Detective] two to three months ago. I was told there was enough evidence to proceed, and charges are being filed. During an interview in the conference room on 5/17/2024 at 9:05 AM, the Housekeeping Supervisor confirmed she had reported an allegation of misappropriation to the Administrator that was brought to her attention by Housekeeper DD (noted in a written statement dated 9/5/2023). The Housekeeping Supervisor stated Resident #7 had reported CNA BB had taken money from her account to Housekeeper DD, who then reported it to her (Housekeeping Supervisor). During an interview in the conference room on 5/17/2024 at 9:37 AM, Housekeeper DD confirmed that Resident #7 had told her CNA BB took $400.00 from her bank account and her bank told her it was CNA BB (as noted in a written statement dated 9/5/2024). Housekeeper DD stated, I reported it to my supervisor [Named Housekeeper Supervisor]. During an interview in the conference room on 5/17/2024 at 10:30 AM, the former Director of Nursing (DON) stated the facility substantiated the allegation of misappropriation when FM CC sent the facility a copy of the transaction on 9/1/2023, which verified money had been transferred to CNA BB's Cash Application. The former DON stated, .When the police phoned [Named CNA BB] from the facility, she denied the allegation. I found it odd she offered to refund the resident the money . When asked if the facility reported CNA BB to the Abuse Registry, the former DON stated, No. During an interview in the conference room on 5/17/2024 at 11:50 AM, the Social Worker confirmed during an interview Resident #7 stated she had given her card to CNA BB to purchase a drink from the vending machine for her. The Social Worker stated Resident #7 told her the bank had confirmed CNA BB had transferred almost $400.00 from her (Resident #7) account to an online account belonging to CNA BB (as noted in a written statement dated 9/5/2023). During a phone interview on 5/17/2024 at 1:34 PM, the Police Detective stated Resident #7's missing funds had been investigated and CNA BB was arrested 12/1/2023 and charged with 1 count of Financial Exploitation Elderly/Vulnerable Person. The Police Detective stated the court case had been continued a few times and CNA BB is due back in court on 5/28/2024 at 9:00 AM.

Based on the facility policy review, Incident Reporting System document review, medical record review and Interview, the facility failed to ensure 1 (Resident #6) of 7 residents reviewed were free from sexual abuse. Resident #12 (Perpetrator) was observed with his hand in the shirt of Resident #6. The findings include: Review of the facility policy titled, Abuse Prohibition Plan, dated 4/1/2018, revised 10/24/2022, revealed, .The facility has a zero-tolerance policy for abuse .sexual abuse is prohibited .The facility shall attempt to identify and shall investigate any reported violation or allegation of abuse .The abuse applies to anyone involved with residents of this facility .'Abuse Coordinator' of this facility is the Administrator .'Abuse' means the willful infliction of injury .It includes .sexual abuse .is non-consensual sexual contact of any type with a resident. It includes, but is not limited to, sexual harassment, sexual coercion, or sexual assault .All staff shall monitor residents and shall be educated regarding how to identify signs and symptoms of abuse. This includes staff to resident abuse and certain resident to resident altercations. Resident, staff, or family report of abuse .The alleged offender shall immediately be removed, and the Resident protected .the staff member shall immediately remove the perpetrator from the situation and another staff member shall stay with the alleged offender and wait for further instruction from Administration .Employees must always report any allegations of abuse or suspicion of abuse immediately to their supervisor .any staff member or person affiliated with this facility who has witnessed or who believes that a resident has been a victim of .abuse .shall immediately report, or cause a report to be made of, the mistreatment or offense . Review of the Incident Reporting Systems document revealed, .[Named Dietary Staff M] stated .I was watching from the other door and saw [Resident #12] put his hand down [Named Resident #6's] shirt. I opened the door and coughed to get him to stop then shut the door and watched again. [Named Housekeeping Staff VV] came in to mop dining room floor and after he left [Resident #12] put his hand down .underneath [Named Resident #6]'s shirt again and she tried to stop and shoo [fanning arms around to redirect] him away. [Resident #6] seemed upset and kept trying to get [Resident #12] to leave her alone . Review of the medical record revealed Resident #6 was admitted to the facility on [DATE] with diagnoses which included Insomnia, History of Benign Neoplasm of the Brain and Mild Intellectual Disability. Review of the Quarterly MDS (Minimum Data Set) assessment dated [DATE], for Resident #6, revealed a BIMS (Brief Interview for Mental Status) score of 13 ,which indicated no cognitive impairment. Continued review revealed Resident #6 required the use of a wheelchair. Review of the medical record revealed Resident #12 was admitted to the facility on [DATE] with diagnoses which included Systolic and Diastolic Heart Failure, Hemiplegia (paralysis on one side of the body), and Chronic Obstructive Pulmonary Disease. Review of the Quarterly MDS assessment dated [DATE], for Resident #12, revealed a BIMS score of 12, which indicated moderate cognitive impairment. Continued review revealed Resident #12 required the use of a wheelchair. Review of the Nurse's Event Note dated 3/31/2024 at 10:30 AM, revealed LPN O documented, (Dietary Staff M) reported to multiple nursing staff that Resident #12 had his hand down Resident #6's shirt. LPN O asked Resident #6 if she felt violated or uncomfortable in any way? Resident #6 told LPN O that she was uncomfortable, and she waved her hand to get Resident #12 to go away. LPN O went to speak with the Administrator and when she returned Resident #12 was wheeling towards Resident #6. Resident #12 then turned round and headed back toward the nurses' station. Resident #12 did not receive direct supervision by staff following the incident. During an interview on 5/15/2024 at 3:36 PM, the Dietary Staff N said she looked out of the kitchen door and saw Resident #12 sitting really close to Resident #6. Resident #12 had his hand on the top part of Resident #6's leg. During an interview on 5/15/2024 at 4:07 PM, revealed LPN O said she was made aware of the touching incident between Resident #6 and Resident #12. LPN O stated she pulled Resident #6 out of the dining room. LPN O said when Resident #6 was asked about the incident with Resident #12, Resident #6 stated she felt uncomfortable. During an interview on 5/20/2024 at 4:00 PM, the Director of Nursing (DON) stated expectations were for the staff to intervene when there has been suspected abuse. The DON stated staff would have also been expected to remove the resident from the harmful situation, immediately take the resident to the nurse, and report the incident to the Abuse Coordinator.

Based on facility policy review, medical record review, and interview, the facility failed to provide wound care and administer medications as ordered for 1 of 5 (Resident #1) residents reviewed. The findings include: 1. Review of the facility's policy titled, Admission Orders, dated 11/30/2016 and revised 3/28/2023 revealed, To provide guidance on admission orders needed for the residents immediate care .At the time each resident is admitted , the facility shall have physician or other authorized individual orders for the resident's immediate care in accordance with law and regulation and professional practice acts, before care, treatment, and services are provided . Review of the facility's policy titled, Medication Reconciliation, dated 8/2018 and revised 11/23/2022, revealed, Medication Reconciliation/Drug Regimen Review is an interdisciplinary process between Nursing, Medical Staff and Pharmacy that compares the resident's most current list of home medications against the physician's orders upon admission and discharge, addresses discrepancies/issues, and thereby decreases potential Adverse Drug Events (ADEs) and omissions of medication therapy .Medication Reconciliation is the process of verifying, clarifying and reconciling the resident's most current list of medications against the physician's order on admission to the nursing home. It occurs at time of admission and discharge .Residents shall have all medications reconciled upon admission and at discharge. The nurse shall review the medication list with the resident/representative. The physician/practitioner shall review the resident's medication and any recommendation/order. The final outcome of this process is to generate the most accurate medication list and to identify potential or actual clinically significant medication issues .Procedure: Admission: 1. Upon admission staff shall obtain a list of current medications from the referral source i.e. hospital, resident/representative or another source .2. Upon admission the nurse and resident/representative shall review and clarify the medication list as indicated .3. The Physician/Practitioner shall review the medication orders and recommend recommendations/orders, if indicated, which shall be completed by the next calendar day . Review of the facility's policy titled, Medication Administration, dated 11/2017 and revised 8/4/2023 revealed, .Medications shall be administered by licensed medical or nursing personnel acting within the scope of their practice and per the Physician's Signed Order . Review of the facility's policy titled, Wound Care Guidelines, dated 6/6/2022, revealed, .Accurate and timely wound assessment is important to ensure correct diagnosis and for developing a plan of care to address the resident, the wound, and the skin problems that impact healing .Skin tears are a traumatic break in the skin .Procedure: Identify and evaluate the wound and surrounding area .Initiate the weekly wound assessment form and classify as indicated .Notify physician and/or nurse practitioner to obtain treatment orders as needed .Initiate the treatment on the physician orders and/or treatment administration record .Notify therapy, dietary, and other team members as appropriate related to risk factors that may impede healing, hydration, and nutritional status .Discuss the plan of care with the resident and/or family as indicated .Complete a weekly wound assessment each week .Identify, implement, and/or revise interventions and the plan of care as needed .Monitor for decline and/or worsening .Notify MD [Medical Doctor] and RP [Responsible Party] .Treatment Guidelines/Suggestion .Option 1. Clean with normal saline, apply skin prep, and stay strips, monitor and change as needed .Option 2. Clean with normal saline, apply skin prep, apply stay strips, cover with transparent dressing, change twice a week . 2. Review of the medical record revealed Resident #1 was admitted to the facility on [DATE] with diagnoses of Atherosclerosis Heart Disease, Old Myocardial Infarction, Presence of Cardiac Pacemaker, and Non Pressure Chronic Ulcer of Right Heel and Midfoot. The resident was admitted for a five-day Hospice Respite stay. Resident #1 discharged home on 9/18/2023 with family. Review of the Nursing Admission Form for Resident #1 dated 9/13/2023 revealed 1+ pitting edema (swelling) to right lower extremity, incontinence of bowel and bladder, bed or chair bound, required extensive assistance of two people for transfers, and a vascular wound to the right posterior heel. Review of the Hospice admission Orders for Resident #1 dated 9/13/2023, revealed the following medications were ordered to be given: Polyethylene Glycol 17 grams daily and Docusate Calcium 240 mg daily. Continued review of the Admission Orders revealed the following medications had been discontinued: Furosemide 40 mg 1/2 tablet (20 mg) daily, Furosemide 40 mg daily as needed when feet are swollen, and Lidocaine 4% topical patch daily. Review of the September 2023 Medication Administration Record (MAR) for Resident #1 revealed Resident #1 was given Furosemide 40 mg by mouth at 8:00 AM on 9/14/2023, 9/15/2023, 9/16/2023 and 9/17/2023, Lidocaine 4% topical patch applied on 9/14/2023, 9/15/2023 and 9/17/2023. Continued review revealed Docusate Calcium 240 mg and Polyethylene Glycol 17 grams was not administered. During an interview on 9/22/2023 at 3:00 PM, Family Member (FM) #1 stated Resident #1 had been admitted to the facility for a five-day Hospice Respite stay, 9/13/2023-9/18/2023. FM#1 stated the facility staff banged her leg in the shower causing a wound, and the wound was never treated. Review of the Nurse's Event Note for Resident #1 dated 9/18/2023, revealed on 9/16/2023 at 8:00 PM, Resident #1 received a skin tear to her left shin. The Event Note stated Resident #1 received the skin tear in her room, and no other details were documented as to how the injury occurred. During an interview on 9/26/2023 at 2:49 PM, Registered Nurse (RN) #1, also known as Unit Manager #1, stated when nurses are told a resident has a skin tear, the nurse should assess and measure the wound, and apply a dressing. RN #1 stated she was told about Resident #1's skin tear and asked LPN #1 if she had applied a dressing. RN #1 stated LPN #1 stated she did not apply a dressing to Resident #1's skin tear . During an interview on 9/26/2023 at 3:00 PM, LPN #2, also known as the Treatment Nurse, stated she did not know about Resident #1 having a skin tear until after she was discharged home. LPN #2 stated after Resident #1's family took her home, they called back and complained to the Administrator about a wound on her shin. During an interview on 9/26/2023 at 3:30 PM, CNA #3 stated she provided care to Resident #1 on 9/15/2023, 9/16/2023, and 9/17/2023. CNA#3 stated on Saturday, 9/16/2023, she and another CNA got Resident #1 up to take a shower. CNA #3 stated when they were transferring Resident #1 to the shower chair, Resident #1 went down but did not fall to the ground. CNA #3 stated during this event, Resident #1 bumped her leg and obtained a skin tear that was bleeding. CNA #3 stated she told another CNA that came into the shower room, to go tell the nurse. CNA #3 stated a nurse never came to the shower room. CNA #3 stated she held pressure to the skin tear and it stopped bleeding. CNA #3 stated a dressing was not applied to Resident #1's skin tear. CNA #3 stated she told LPN #1 and RN #1 about the skin tear and they replied, OK. CNA #3 stated Resident #1 didn't want to get up the following day (9/17/2023), so she gave Resident#1 a bed bath. CNA #3 stated the skin tear did not have a dressing on it. During an interview on 9/27/2023 at 9:05 AM, the Hospice Case Manager stated Resident #1 had an order in the past for Furosemide but was only given for 3 days and then discontinued. The Case Manager reviewed Resident #1's medication orders and confirmed the order for Furosemide had been discontinued on 7/9/2023. During an interview on 9/27/2023 at 9:17 AM, the Admissions Coordinator (AC) stated she transcribed Resident #1's orders upon admission on 9/13/2023. While reviewing the orders with surveyor, the AC confirmed the medications Furosemide and Lidocaine patch had been discontinued, but was placed on the active order list in error. The AC also confirmed the medications Polyethylene Glycol 17 grams daily and Docusate Calcium 240 mg were entered into the system in error, to be administered as needed but the medications were ordered to be given daily. The AC stated the usual process for new admissions is the first nurse enters the new orders, the orders are sent to the pharmacy and confirmed, then two other nurses are to review the orders and verify they are accurate. The AC stated each nurse is to initial at the top of the admission order form to ensure accuracy. The AC confirmed only her initials were at the top of the admissions order form. During an interview on 9/27/2023 at 10:42 AM, the Director of Nursing (DON) confirmed the admission orders for Resident #1 were incorrect. The DON stated new admission orders are to be verified by three nurses. The DON stated Resident #1's admission orders were only verified by one nurse.

Based on facility policy review, medical record review, and interview, the facility failed to provide mouth care for 1 of 5 (Resident #1) residents reviewed. The findings include: 1. Review of the facility's policy titled, Activities of Daily Living (ADL), dated 3/9/2022 and revised 3/9/2023 revealed, .The facility shall, based on the resident's comprehensive assessment and consistent with the resident's needs and choices, ensure a resident's abilities in ADLs do not deteriorate unless deterioration is unavoidable .Care and services shall be provided for the following activities of daily living: 1.oral care .A resident who is unable to carry out activities of daily living shall receive the necessary services to maintain good nutrition, grooming, and personal and oral hygiene . 2. Review of the medical record revealed Resident #1 was admitted to the facility on [DATE] with diagnoses of Atherosclerosis Heart Disease, Old Myocardial Infarction, Presence of Cardiac Pacemaker, and Non Pressure Chronic Ulcer of Right Heel and Midfoot. The resident was admitted for a five-day Hospice Respite stay. Resident #1 discharged home on 9/18/2023 with family. Resident #1 did not have an Minimum Data Set assessment completed. Review of the Nursing Admission Form for Resident #1 dated 9/13/2023 revealed 1+ pitting edema (swelling) to right lower extremity, incontinence of bowel and bladder, bed or chair bound, required extensive assistance of two people for transfers, required assistance with Activities of Daily Living, and a vascular wound to the right posterior heel. Review of the Baseline Care Plan for Resident #1 dated 9/13/2023, revealed Problems for Bathing/Hygiene Dependent, Dressing/Grooming Extensive Assistance, Toileting Dependent, Eating Tray Preparation, Ambulation/Transfer Extensive Assistance, Assistive Devise/Aide Wheelchair, Mouth Care Dentures Upper Dentures Lower, Bladder/Bowel Incontinence, Respiratory Compromise, Terminal Care, Cardiac Diagnosis, Diabetes, Skin Integrity, At Risk for Falls, Advanced Directives, Cognitive Behavior, At Risk for Elopement, and Use of Psychotropic Medications. 3. During an interview on 9/22/2023 at 3:00 PM, Family Member (FM) #1 stated Resident #1 had been admitted to the facility for a five-day Hospice Respite stay, 9/13/2023-9/18/2023. FM #1 stated the staff did not remove and clean Resident #1's dentures. FM#1 stated she had to scrub the grime from her dentures when Resident #1 discharged home on 9/18/2023. During an interview on 9/26/2023 at 3:30 PM, CNA #3 stated she provided care to Resident #1 on 9/15/2023, 9/16/2023, and 9/17/2023. CNA #3 stated she did not clean Resident #1's dentures or do mouth care on 9/15/2023, 9/16/2023, or 9/17/2023. CNA#3 was asked why mouth care was not provided to Resident #1. CNA #3 stated, I guess it just slipped my mind. CNA#3 was asked if mouth care should be provided to residents who are unable to perform their own mouth care, CNA #3 replied, yes. During an interview on 9/27/2023 at 11:30 AM, the Regional Nurse Consultant stated mouth care should be provided daily and as needed.

Based on facility policy review, medical record review, and interview, the facility failed to revise the care plan for 1 of 5 (Resident #1) residents reviewed. The findings include: 1. Review of the facility's policy titled, Baseline Careplan, dated 11/2016 and revised 10/21/2022, revealed, The facility shall develop and implement a baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care .In the event that the comprehensive assessment and comprehensive care plan identified a change in the resident's goals, or physical, mental, or psychosocial functioning, which was otherwise not identified in the baseline care plan, those changes shall be incorporated into an updated summary provided to the resident and his or her representative . 2. Review of the medical record revealed Resident #1 was admitted to the facility on [DATE] with diagnoses of Atherosclerosis Heart Disease, Old Myocardial Infarction, Presence of Cardiac Pacemaker, and Non Pressure Chronic Ulcer of Right Heel and Midfoot. The resident was admitted for a five-day Hospice Respite stay. Resident #1 discharged home on 9/18/2023 with family. Review of the Nursing Admission Form for Resident #1 dated 9/13/2023 revealed 1+ pitting edema (swelling) to right lower extremity, incontinence of bowel and bladder, was bed or chair bound, required extensive assistance of two people for transfers, and a vascular wound to the right posterior heel. Review of the Baseline Care Plan for Resident #1 dated 9/13/2023, revealed Problems for Bathing/Hygiene Dependent, Dressing/Grooming Extensive Assistance, Toileting Dependent, Eating Tray Preparation, Ambulation/Transfer Extensive Assistance, Assistive Devise/Aide Wheelchair, Mouth Care Dentures Upper Dentures Lower, Bladder/Bowel Incontinence, Respiratory Compromise, Terminal Care, Cardiac Diagnosis, Diabetes, Skin Integrity, At Risk for Falls, Advanced Directives, Cognitive Behavior, At Risk for Elopement, and Use of Psychotropic Medications. Appropriate goals and interventions were implemented. The Care Plan did not address a fall which resulted in a skin tear on 9/16/2023. Review of the Nurse's Event Note for Resident #1 dated 9/18/2023, revealed on 9/16/2023 at 8:00 PM, Resident #1 received a skin tear to her left shin. The Event Note stated the resident received the skin tear in her room, and no other details were documented as to how the injury occurred. During an interview on 9/27/2023 at 8:43 AM, the DON reviewed Resident #1's care plan with surveyor. The DON confirmed Resident #1's care plan had not been updated to reflect a fall resulting in a skin tear on 9/16/2023, and should have been.

Based on facility policy review, medical record review, and interview, the facility failed to notify the Physician/Nurse Practitioner and family for 1 of 5 (Resident #1) residents reviewed for falls with injury. The findings include: 1. Review of the facility's policy titled, Notification of Change, dated 11/30/2017 and revised 3/28/2023 revealed, The purpose of this policy is to ensure the facility informs the resident, consistent with his or her authority, when there is a change requiring notification .The facility shall inform the resident, consult with the resident's physician, and/or notify the resident's family member .when there is a change requiring such notification .Circumstances requiring notification include: 1. Accidents a. resulting in injury . Review of the facility's policy titled, Accidents and Supervision, dated 11/1/2017 and revised 10/21/2021 revealed, .the resident environment remains as free of accident hazards as is possible: and each resident receives adequate supervision and assistive devices to prevent accidents .'Accident' refers to any unexpected or unintentional incident, which results in injury or illness to a resident . Review of the facility's policy titled, Wound Care Guidelines, dated 6/6/2022, revealed, .Accurate and timely wound assessment is important to ensure correct diagnosis and for developing a plan of care to address the resident, the wound, and the skin problems that impact healing .Skin tears are a traumatic break in the skin .Procedure: Identify and evaluate the wound and surrounding area .Initiate the weekly wound assessment form and classify as indicated .Notify physician and/or nurse practitioner to obtain treatment orders as needed .Discuss the plan of care with the resident and/or family as indicated . 2. Review of the medical record revealed Resident #1 was admitted to the facility on [DATE] with diagnoses of Atherosclerosis Heart Disease, Old Myocardial Infarction, Presence of Cardiac Pacemaker, and Non Pressure Chronic Ulcer of Right Heel and Midfoot. The resident was admitted to the facility for a five-day Hospice Respite stay. Resident #1 discharged home on 9/18/2023 with family. Review of the Nurse's Event Note for Resident #1 dated 9/18/2023, revealed on 9/16/2023 at 8:00 PM, Resident #1 received a skin tear to her left shin. The Event Note stated the resident received the skin tear in her room and no other details were documented of how the injury occurred. The Event Note stated the Nurse Practitioner was notified of the injury on 9/20/2023, five days after the injury occurred, and the Responsible Party, listed as Resident #1, was notified on 9/18/2023. 3. During an interview on 9/22/2023 at 3:00 PM, Family Member (FM) #1 stated Resident #1 had been admitted to the facility for a five-day Hospice Respite stay 9/13/2023-9/18/2023. FM #1 stated the staff banged her leg in the shower causing a wound, and the wound was never treated. During an interview on 9/2/2023 at 2:28 PM, Licensed Practical Nurse (LPN) #1 stated the resident had a skin tear on her leg that she obtained at the facility. During an interview on 9/26/2023 at 2:49 PM, Registered Nurse (RN) #1, also known as Unit Manager #1, stated when nurses are told a resident has a skin tear, the nurse should assess and measure the wound, and apply a dressing. They also fill out the paperwork required, and notify the provider and the family. During an interview on 9/26/2023 at 3:00 PM, LPN #2, also known as the Treatment Nurse, stated she did not know about Resident #1 having a skin tear until after Resident #1 was discharged home. LPN #2 stated after Resident #1's family took her home, they called back and complained to the Administrator about a wound on her shin. During an interview on 9/26/2023 at 3:30 PM, CNA #3 stated she provided care to Resident #1 on 9/15/2023, 9/16/2023, and 9/17/2023. CNA#3 stated on Saturday, 9/16/2023, she and another CNA got Resident #1 up to take a shower. CNA #3 stated when they were transferring Resident #1 to the shower chair, Resident #1 went down but did not fall to the ground. CNA #3 stated during this event, Resident #1 bumped her leg and obtained a skin tear that was bleeding. During an interview on 9/26/2023 at 4:02 PM, RN #1 stated the skin tear Resident #1 obtained in the shower, should have been reported to the physician or Nurse Practitioner (NP) and the family when it happened.

Based on facility policy review, observation, and interview, the facility failed to provide a clean, safe, and sanitary environment in 2 of 4 resident rooms (room [ROOM NUMBER] and room [ROOM NUMBER]) observed. The findings include: Review of the facility's policy titled, Infection Prevention and Control Program, dated 10/24/2022, revealed, .It is the policy of this facility to establish and maintain an infection prevention and control program (IPCP) designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections per accepted national standards and guidelines . Review of the facility's policy titled, Housekeeping-Cleaning and Disinfecting, revised 7/12/2021, revealed, .Bathroom cleaning and disinfection to include, but not limited to: a. Remove soiled linen and trash . Review of the facility's policy titled, Resident Rights and Responsibilities, .The resident has the right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility .The resident has a right to a safe, clean, comfortable and Homelike environment, including but not limited to receiving treatment and supports for daily living safely . Observation in room [ROOM NUMBER] on 11/8/2022 at 11:20 AM, revealed the bathroom had dirty linens in the floor, feces in the commode, and black debris around the base of the commode. Observation in room [ROOM NUMBER] on 11/8/2022 at 11:44 AM, revealed a bath pan in the floor with a moderate amount of dark brown debris in it, and disposable wipes with a moderate amount of dark brown debris on it in the floor. Observation in room [ROOM NUMBER] on 11/8/2022 at 11:50 AM, revealed the bathroom had dirty linens in the floor, feces in the commode, and black debris around the base of the commode. Observation and interview in room [ROOM NUMBER]'s bathroom on 11//8/2022 at 11:58 AM, revealed the bathroom had dirty linens in the floor, feces in the commode, and black debris around the base of the commode. The Director of Nursing (DON) confirmed the dirty linens in the floor, feces in the commode and black debris around the base of the commode. She confirmed the bathroom was dirty. Observation and interview in room [ROOM NUMBER]'s bathroom on 11/8/2022 at 12:00 PM, revealed the bathroom had a bath pan in the floor with a moderate amount of dark brown debris in it, and disposable wipes with a moderate amount of dark brown debris on it in the floor. The DON confirmed the bathroom was dirty, had a bath pan in the floor with a moderate amount of dark brown debris and disposable wipes with moderate amount of dark brown debris in the floor. She stated nursing staff were responsible to dispose of dirty linens and trash in the appropriate containers and she expected the dirty linens and trash to be disposed of appropriately.

Based on facility policy review, medical record review, observation, and interview, the facility failed to provide a safe, sanitary, and comfortable environment to help prevent the spread of infection related to: staff failed to provide [CONDITION(S)] care in a sterile technique for 1 of 3 sampled residents (Resident #61); provide catheter care in a sanitary manner for 1 of 10 sampled residents (Resident #37) who required an urinary catheter; ensure oxygen tubing was not on the floor for 5 of 36 sampled residents (Resident #18, Resident #30, Resident #32, Resident #61, and Resident #72), and clean nebulizer mask for 1 of 36 sampled residents (Resident #32) who received respiratory treatments, and ensure urinary drainage bag was not laying in the floor for 2 of 10 sampled residents (Resident #64 and Resident #274) who required an urinary catheter. The facility also failed to prevent the spread of infection related to: staff not sanitizing hands between resident contact while passing meal trays during the supper meal on 3/27/2022; dirty linen carts, and a trash barrel were on the hall during the meal cart delivery and meal pass. staff place a dirty tray on a clean tray cart with clean trays; staff sitting on a residents bed; no Transmission Based Precaution (TBP) sign posted on a TBP room; TBP rooms doors not closed; staff did not apply appropriate Personal Protective Equipment (PPE) prior to entering an TBP room. The findings include: Review of the facility policy titled, Infection Prevention and Control Program, dated 6/9/2021, revealed .it is the policy of this facility to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections .a resident with an infection or communicable disease shall be placed on isolation precautions as recommended by current CDC [Centers of Disease Control] Guidelines .isolation signs are used to alert staff, family members and visitors of isolation precautions . Review of the medical record revealed Resident #61 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #61 had [CONDITION(S)] care. Review of current Physician's Orders for Resident #61 revealed, .[CONDITION(S)] cannula care: Clean inner cannula with [MEDICATION(S)] [antiseptic liquid to kill germs] every one day .Change [CONDITION(S)] [[CONDITION(S)]] ties every one day .Clean with Normal Saline (NACL) every one day .Tracheobronchial suctioning for signs and symptoms of increased secretions [secretions] .Monitor tolerance of [CONDITION(S)] Care one time daily .[CONDITION(S)] cannula care Two times Daily . Observation in Resident #61's room on 3/28/2022 at 10:05 AM, during tracheotomy care, revealed the Certified Respiratory Therapist (CRT) dipped a cotton tipped applicator into the peroxide/sterile water solution, then cleaned around the tracheotomy site, and dipped the cotton tipped applicator back into the peroxide/sterile water solution and cleaned around the [CONDITION(S)] site again. Further observation revealed the CRT removed the inner cannula and placed into the peroxide/sterile water solution, then placed it back into the tracheotomy site. During an interview on 3/28/2022 at 10:08 AM, the CRT confirmed she dipped the cotton tipped applicator into the peroxide/sterile water solution after she cleaned the tracheotomy site, cleaned around the tracheotomy site again, and placed the inner cannula into the peroxide/sterile water solution. She replaced the inner cannula into the tracheotomy site. She stated she should have used a sterile cotton tipped applicator each time she cleaned around the tracheotomy site, but she didn't have enough cotton tipped applicators in the tracheotomy kit. Review of the medical record revealed Resident #37 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Admission MDS assessment dated [DATE] revealed Resident #37 required an urinary catheter. Observation in Resident #37's room on 3/29/2022 at 3:26 PM, during catheter care, revealed Licensed Practical Nurse (LPN) #7 did not clean the catheter lumen. During an interview on 3/29/2022 at 3:30 PM, LPN #7 confirmed she did not clean Resident #37's catheter lumen during catheter care. Review of the medical record revealed Resident #18 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the 5-Day MDS assessment dated [DATE], revealed Resident #18 received oxygen therapy. Review of the current Physician's Orders for Resident #18 revealed, .Oxygen (O2) at 2 L [Liter]/min [minute] per nasal cannula . Observation in Resident #18's room on 3/27/2022 at 4:41 PM, revealed the oxygen cannula and tubing was draped over the arm of the chair, and the nebulizer mask was laying on the bedside table uncovered. During an interview on 3/27/2022 at 5:37 PM, the Director of Nursing (DON) confirmed Resident #18's oxygen tubing was draped across the arm of the chair, and the nebulizer mask was not stored properly. Review of the medical record revealed Resident #30 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Quarterly MDS assessment dated [DATE], revealed Resident #30 received oxygen therapy. Observation in Resident #30's room on 3/27/2022 at 5:04 PM, revealed the oxygen tubing was touching the floor. During an interview on 3/27/2022 at 5:34 PM, the DON confirmed Resident #30's oxygen tubing was touching the floor. Review of the medical record revealed Resident #32 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Quarterly MDS assessment dated [DATE], revealed Resident #32 received oxygen therapy. Review of the current Physician's Orders for Resident #32 revealed, .Oxygen at 3Lpm (liters per minute) continuous . Observation in Resident #32's room on 3/27/2022 at 3:40 PM, revealed the oxygen tubing was touching the floor, and the nebulizer mask was laying on the bedside table with dried debris on the inside of the mask, and was not properly stored. Observation and interview in Resident #32's room on 3/27/2022 at 5:32 PM, the DON confirmed Resident #32's oxygen tubing was touching the floor, and the nebulizer mask had dried debris on the inside of the mask and was not properly stored. The DON confirmed oxygen tubing should not touch the floor, and the nebulizer mask should be clean and stored in a plastic bag. Review of the medical record revealed Resident #61 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Quarterly MDS assessment dated [DATE], revealed Resident #61 received oxygen therapy. Review of the current Physician's Orders for Resident #61 revealed an order for [MEDICAL RECORD OR PHYSICIAN ORDER] Observation in Resident #61's room on 3/27/2022 at 3:53 PM, revealed the oxygen tubing was touching the floor. Observation and interview in Resident #61's room on 3/27/2022 at 5:27 PM, the DON confirmed Resident #61's oxygen tubing was touching the floor. Review of the medical record revealed Resident #72 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] Review of the current Physician's Orders for Resident #72 revealed an order for [MEDICAL RECORD OR PHYSICIAN ORDER] Review of the Quarterly MDS assessment dated [DATE], revealed Resident #72 received oxygen therapy. Observation in Resident #72's room on 3/27/2022 at 3:55 PM, revealed the oxygen tubing was touching the floor. Observation and interview in Resident #72's room on 3/27/2022 at 5:36 PM, the DON confirmed Resident #72's oxygen tubing was touching the floor. Review of the medical record revealed Resident #64 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] Review of the Significant Change In Status (SCIS) MDS assessment dated [DATE], revealed Resident #64 had an indwelling catheter. Observation in Resident #64's room on 3/27/2022 at 3:47 PM, revealed his urinary drainage bag was laying on the floor. Observation and interview in Resident #64's room on 3/27/2022 at 3:53 PM, LPN #2 confirmed Resident #64's urinary drainage bag was on the floor. She stated the catheter bag should not be on the floor because of infection. Review of the medical record revealed Resident #274 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Quarterly MDS assessment dated [DATE], revealed Resident #274 had an indwelling catheter. Observation in Resident #274's room on 3/28/2022 at 8:05 AM, revealed her urinary drainage bag was laying on the floor. Observation and interview in Resident #274's room on 3/28/2022 at 8:06 AM, Occupational Therapist (OT) #1 confirmed Resident #274's urinary drainage bag was laying in the floor. Observation on 3/27/2022 at 5:55 PM to 6:10 PM, during the supper meal, revealed LPN #8 passed meal trays into 4 residents rooms and did not sanitize or wash his hands. During an interview on 3/27/2022 at 6:12 PM, LPN #8 confirmed he did not sanitize his hands after each resident contact while passing the meal tray. He stated, I wash my hands after passing 2 to 3 trays. Observation on 3/28/2022 at 7:32 AM, during the breakfast meal, revealed Registered Nurse (RN) #1 placed a dirty meal tray on the clean meal cart with clean trays. During an interview on 3/28/2022 at 7:33 AM, RN #1 confirmed she placed a dirty tray on the clean cart with clean trays. She stated, This is the first time I have passed trays. Observation on the 300 Hall on 3/28/2022 at 7:44 AM, revealed Dietary staff called for 300 Hall cart to be delivered to the hall. Further observation revealed a soiled linen cart, and a trash barrel on the hall way with the meal trays. Observation on the 300 Hall on 3/28/2022 at 7:52 AM, revealed a second meal cart delivered to the hall, staff passed trays, and the soiled linen and trash barrel remained on hall way with meal trays. During an interview on 3/28/2022 at 8:38 AM the Risk Management LPN confirmed the dirty linen cart and trash barrel was on the hall with the meal trays and should not be on the hall when meals are delivered. Observation on 3/28/2022 at 8:03 AM, revealed staff delivered a meal tray and placed the tray in front of a resident on the overbed table. The staff member then sat down on the resident's bed to assist the resident with the meal. Observation and interview outside a resident's room on 3/28/2022 at 8:05 AM, the DON confirmed staff was sitting on the resident's bed while she assisted the resident with the breakfast meal. The DON stated, She should not be sitting on the bed to assist the resident because of infection control. The DON stated, I would correct her and get linens to change the bed. The DON then left the hall and didn't do anything to correct the situation. Observation on the 200 Hall on 3/28/2022 at 8:10 AM, revealed a TBP cart outside of room [ROOM NUMBER] and no TBP sign on the door. Observation and interview outside of room [ROOM NUMBER] on 3/28/2022 at 8:30 AM, the DON confirmed the resident in room [ROOM NUMBER] was on TBP and there wasn't a TBP sign on the door. Observation on 200 hall on 3/28/2022 at 8:11 AM, revealed 3 TBP rooms with doors open. During an interview on 3/8/2022 at 8:15 AM, Certified Nurse Aide (CNA) #3 confirmed the 3 residents were on TBP and the doors were open. Observation on the 200 Hall on 3/28/2022 at 10:30 AM, revealed CNA #3 went into a TBP room without donning appropriate PPE (she did not don a gown or gloves). During an interview on 3/28/2022 at 10:32 AM, CNA #3 confirmed she did not don a gown or gloves prior to entering a TBP room.

Based on facility policy review, medical record review, observation, and interview, the facility failed to maintain patient confidentiality related to 3 computer screens open with resident health information visualized with no staff attendance. The findings include: Review of the facility policy titled, Patient Confidentiality, dated 2/2021, revealed, .Confidentiality is defined as safeguarding the content of information .or other computer stored information from unauthorized disclosure without the consent of the resident and/or representative .all efforts will be made to protect the confidentiality/privacy of the resident and their health information .this includes medical records .the electronic record is equipped with security features that allow only those with a password to retrieve and review records . Review of the medical record revealed Resident #18 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Observation of the 300 Hall medication cart on 3/27/2022 at 5:37 PM, revealed a computer screen with Resident #18's heath information displayed on the computer screen on the medication cart and no staff in attendance. During an interview on 3/27/2022 at 5:38 PM, the Director of Nursing (DON) confirmed Resident #18's health information was displayed on the computer screen on the medication cart. She stated, The computer screen should be closed for privacy because of HIPPA (Health Insurance Portability and Accountability Act). Observation at the 100 Hall nurse station on 3/28/2022 at 7:35 AM, revealed one computer screen on the nurses desk and one on the medication cart opened with resident health information visible and no staff in attendance. During an interview on 3/28/2022 at 7:38 AM, Registered Nurse (RN) #1 confirmed the 2 computer screens with resident health information were visible to everyone that could visualize the computer screens and there weren't any staff at the desk or at the medication cart.

Based on facility policy review, observation, and interview, the facility failed to maintain water temperatures for a dish machine at or above 120 F [Fahrenheit] degrees and failed to clean and sanitize 1 of 3 refrigerators located in the nourishment rooms. The facility also failed to deliver food that was covered to residents for 2 of 2 meal observations. The findings include: Review of the facility's policy titled, Dietary: Cleaning dated 7/13/2022, revealed, .Cleaning surfaces, equipment or utensils involve the use of hot water and detergent which removes soil grease, food, and odors .Turn on machine, checking temperatures to assure proper wash and rinse temperature for your machine and cleaning chemicals .Wash and rinse temperatures will be observed and recorded at each meal service. This will be achieved while the dish machine is in operations .Low temperature machines should be between 120 F-140 F. With the low temperature machines, the sanitizer will also be checked and recorded using a PH [Potential of Hydrogen] strip. Any temperatures recorded outside the acceptable levels should be reported to the supervisor immediately. Maintenance should be notified . Review of the facility's policy titled, Dietary: Dining Services, revised 1/30/2021, revealed, .Meals must be delivered to the resident in a timely fashion. Meals are delivered in an enclosed or covered cart . Observation in the kitchen on 3/28/2022 at 2:18 PM, revealed the dish machine was a low temperature machine. Observation on 3/28/2022 at 2:24 PM, revealed Cook #1 had already ran a rack of dishes through the dish machine. Continued observation revealed when another rack of dishes were placed in the dish machine, the temperature on the thermometer did not reach 120 degrees F during the wash cycle. Observation and interview on 3/28/2022 at 2:26 PM, the Director of Nutrition Services confirmed the thermometer did not reach to 120 degrees F, but to 110 degrees F, during the wash cycle and the facility would use disposable dining ware for the residents. Continued observation revealed the sanitation for the dish machine was above 50 ppm [parts per million]. Observation in the kitchen on 3/28/2022 at 3:52 PM, the 3 compartment sink sanitation was between 200 and 400 ppm, which was within normal limits. Observation on 3/29/2022 at 12:52 PM, with the Director of Nutrition Services revealed the manual temperature of the water to the dish machine was 90 degrees F. During an interview on 3/28/2022 at 2:30 PM, Cook #2 stated, it took 5 to 10 dish cycles before the water temperature reached 120 degrees F. During an interview on 3/28/2022 at 3:29 PM, Cook #1 stated, Staff had been filling up the tank as a faster way to fill up the machine. The motor had been changed recently. They have to fill up the tank because the water would run out. We have to run the dish machine 4 to 5 times before the temperature gets to the appropriate temperature of 120 degrees F. We explained the issue about the machine and we spoke to the CDM (Certified Dietary Manager). During an interview on 3/28/2022 at 5:00 PM, the Maintenance Director stated, The staff was pouring water into the tank of the dish machine because it was a faster way than waiting for it to fill up with water. The facility had a tankless water heater which was set at 140 degrees F. Continued interview confirmed the tankless water heater could not circulate enough water to reach a water temperature of at least 120 degrees F. During an interview on 3/29/2022 at 2:42 PM, the Maintenance Director confirmed he knew there were issues with the tankless water heater that it needed to be fixed. During an interview on 3/30/2022 at 11:15 AM, the Director of Nutrition Services confirmed the water temperatures on 3/28/2022 and 3/29/2022 were too low to clean the dishes effectively in the dish machine and they had been washing all dishes in the 3 compartment sink. Observation on the North hall nourishment room on 3/30/2022 at 3:07 PM, revealed the North Hall refrigerator had dead flies on the inside bottom of the refrigerator and on the side door bottom shelf. Continued observation revealed all three shelves in the body of the refrigerator had dried substance on them. Observation and interview on the North Hall nourishment room on 3/30/2022 at 3:10 PM with Licensed Practical Nurse (LPN) #3 confirmed there were dead flies on the refrigerator inside bottom and the shelves were dirty. Observation and interview on 3/30/2022 at 3:23 PM, the Housekeeping Director confirmed there were dead flies inside the refrigerator and there was dried debris on the inside shelves. Continued interview revealed the refrigerator was to be cleaned once a day by housekeeping staff. Observation in the kitchen on 3/27/2022 at 2:42 PM, revealed 49 yellow cake desserts plated and uncovered inside 7 tray carts. Observation on the 600 Hall during supper meal pass on 3/27/2022 at 6:03 PM, revealed staff delivered uncovered dessert cakes from the meal cart to the resident's rooms. Observation and interview in the kitchen on 3/27/2022 at 5:31 PM, with the Cook #1 revealed the kitchen had completed the 1st 100 Hall cart and began to deliver the cart outside of the kitchen for delivery of the dinner trays. Continued observation revealed the cakes on the cart were not covered. The cook confirmed the dietary staff did not apply a covering to the cake because the cake was already covered by the trays, and no one had ever told them to cover all of the food for distribution. Observation during the breakfast meal on 3/28/2022 at 7:24 AM, revealed 25 residents had uncovered oatmeal plated on the meal carts. Observation during the breakfast meal on 3/28/2022 at 7:55 AM, 8:01 AM, 8:18 AM, and 8:34 AM, revealed staff delivered uncovered oatmeal from the meal cart to the resident's rooms. During an interview on 3/28/2022 at 7:52 AM, the Director of Nutrition Services stated, Food should be covered when staff are walking the tray to the residents' rooms.

Based on facility policy review, facility documentation review, medical record review, observations, and interviews, the facility failed to maintain adequate staffing levels to meet the care needs of 5 of 44 sampled residents (Resident #19, #27, #31, #34, #37, and #51) residing on 3 of 5 hallways having the potential to affect the entire facility related to receiving showers/baths, passing meal trays, and turning and repositioning residents every 2 hours. The findings include: Review of the facility's policy titled, Nurse Staffing Posting Information, dated 11/2017 and revised 11/2018, revealed, .It is the policy of this facility to have sufficient staff to provide nursing services to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident . Review of the facility's Full Time Equivalent Staffing sheet revealed there was only 1.9 nursing hours per patient per day (PPD) on 3/6/2022 and 3/16/2022, and the facility did not meet the state required nursing hours per PPD of 2.0. Review of the facility Daily Nurse Staffing sheet dated 3/27/2022, revealed the resident census was 79 (100 Hall contained 19 residents; 200 Hall contained 10 residents; 300 Hall contained 21 residents; 400 Hall contained 10 residents; and 600 Hall contained 19 residents), Continued review revealed 1 Medicare Registered Nurse (responsible for medicare charting), 6 Licensed Practical Nurses (LPN) (charge nurses), and 8 Certified Nurse Aides (CNA) for 5 halls for the 24 hour period. Review of the facility Daily Nurse Staffing sheet dated 3/28/2022, revealed the resident census was 79. Continued review revealed 1 Medicare Registered Nurse (responsible for medicare charting), 7 LPNs (charge nurses), and 7 CNAs scheduled for 12 hour shift and 1 CNA scheduled for 8 hour shift, for 5 halls for the 24 hour period. Review of the facility Daily Nurse Staffing sheet dated 3/29/2022, revealed the resident census was 79. Continued review revealed 1 Medicare Registered Nurse (responsible for medicare charting), 6 LPNs (charge nurses), and 8 CNAs scheduled for 12 hour shifts, 1 of these CNAs was on light duty, and 1 CNA scheduled for a 4 hour shift from 8 PM to 12 AM, for 5 halls for the 24 hour period. Review of the facility Daily Nurse Staffing sheet dated 3/30/2022, revealed the resident census was 79. Continued review revealed 1 Medicare Registered Nurse (responsible for medicare charting), 6 LPNs (charge nurses), and 9 CNAs for 5 halls for the 24 hour period. Review of facility documentation dated 5/28/2014, titled, CNA (Certified Nursing Aide) Assignment Sheet, revealed, .Routine patient care - nail care .Full Bath/Shower - follow facility schedule, patient's preference, or Even numbered rooms on Monday, Wednesday, Friday .Odd numbered rooms on Tuesday, Thursday, Saturday .Sponge bath offered on non-bath days or as requested . Review of an undated facility documentation titled, Shower Days For Facility, revealed, .A [Resident in bed A] bed showers are scheduled/offered on Monday, Wednesday, and Friday. B [Resident in bed B] bed showers are scheduled/offered on Tuesday, Thursday, and Saturday . Review of the undated facility documentation revealed there was 26 residents who required a lift for transfers. Review of the medical record revealed Resident #19 was admitted to the facility on [DATE] with readmission on 3/23/2022, with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] Review of the Activities of Daily Living (ADL) Verification Worksheet revealed there was no bathing documented for Resident #19 on 3/26/2022 and 3/27/2022. Observation on 3/27/2022 at 2:45 PM, revealed the 300 Hall smelled strongly of urine. Observation in Resident #19's room on 3/27/2022 at 3:38 PM, revealed the resident had dried brown debris under his fingernails on both hands. Observation and interview in Resident #19's room on 3/27/2022 at 3:40 PM, CNA #1 stated, Residents' fingernails are to be cleaned with bathing and when needed. Continued interview he confirmed Resident #19 had brown dried debris under his fingernails on both hands. Observation and interview in Resident #19's room on 3/27/2022 at 3:53 PM, Licensed Practical Nurse (LPN) #2 stated, residents' nails are cleaned with bathing and as needed. LPN #2 looked at Resident #19's hands and confirmed he had brown dried debris under his fingernails on both hands. Review of the medical record revealed Resident #27 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the ADL Verification Worksheet revealed Resident #27 received 4 showers from 1/3/2022-1/31/2022, 5 showers from 2/2/2022-2/27/2022, and 4 showers from 3/1/2022 -3/28/2022. Continued review revealed there was no bathing documented on 33 days from 1/1/2022 through 3/28/2022. Observation in Resident #27's room on 3/28/2022 at 7:58 AM, revealed the resident's hair was matted and oily. Observation on 3/28/2022 at 6:30 PM, revealed the 300 Hall smelled strongly of urine. Observation and interview in Resident #27's room on 3/28/2022 at 8:42 PM, CNA #6 held the residents head up so surveyor could visualize her hair. Continued observation revealed a crusty, scaly area to the top of the resident's head. The back of the resident's hair was matted in knots, and she had hair loss to the top of her head. CNA #6 stated, Her hair is a wreck; it is pitiful. She has scabs on her head with bald spots. The last time I was able to give her a shower, her hair came out in chunks. I am usually on this hall by myself, [referring to 400 and 600 hall which currently consists of 29 residents]. There is no way I can give all the showers when I have both the halls. Observation and interview in Resident #27's room on 3/28/2022 at 8:42 PM, LPN #6 confirmed the resident's hair was matted and the resident had crusty and scaly areas on her head. During an interview on 3/30/2022 at 4:25 PM, the Director of Nursing (DON) stated, Residents should receive showers three times per week. The DON reviewed the ADL Verification Worksheet for Resident #27 and confirmed the resident did not receive her showers three times per week as scheduled. Review of the medical record revealed Resident #31 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] Review of the Quarterly Minimum Data Set assessment dated [DATE], revealed Resident #31 had a Brief Interview for Mental Status Score of 14, which indicated the resident had no cognitive impairment. Review of the medical record revealed Resident #34 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the ADL Verification Worksheet revealed Resident #34 received no showers from 1/3/2022-1/31/2022, 3 showers from 2/2/2022-2/27/2022, and 3 showers from 3/1/2022 -3/28/2022. Continued review revealed there was no bathing documented on 25 days from 1/3/2022 through 3/28/2022. Observation in Resident #34's room on 3/27/2022 at 4:00 PM, Resident #34 had a disheveled appearance and oily hair. During an interview in Resident #34's room on 3/30/2022 at 9:38 AM, Family Member #1 stated Resident #34 is not receiving her showers regularly. Family Member #1 stated her hair was oily and smelly. Resident #34 stated, All the CNAs do is wash my face. During an interview on 3/31/2022 at 12:23 PM, the DON reviewed the ADL Verification Worksheet and confirmed Resident #34 did not receive her showers as scheduled three times per week. Review of the medical record revealed Resident #37 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] Review of the ADL Verification Worksheet revealed Resident #37 received 1 shower from 1/12/2022-1/31/2022, 3 showers from 2/1/2022-2/27/2022, and 1 shower from 3/1/2022 -3/27/2022. Continued review revealed there was no bathing documented on 23 days from 1/12/2022 through 3/27/2022. Observation in Resident #37's room on 3/27/2022 at 3:34 PM, revealed the resident's feet were exposed and his skin appeared very dry. Observation in Resident #37's room on 3/29/2022 at 11:07 AM, revealed the resident's feet were exposed and his skin still appeared very dry. During an interview on 3/28/2022 at 9:46 AM, CNA #7 stated, We have 13 to 14 residents each. Showers are scheduled for residents in A bed on Mondays, Wednesdays, and Fridays and B bed on Tuesdays, Thursdays, and Saturdays. During an interview on 3/30/2022 at 7:06 PM, the DON confirmed CNAs were to administer scheduled and by choice showers per the facility schedule and she expected the nurses to monitor that showers were completed. Review of the medical record revealed Resident #51 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Quarterly MDS assessment dated [DATE], revealed Resident #51 had a BIMS score of 14, which indicated no cognitive impairment. Continued review revealed the resident required extensive assist of 2 staff for bathing. Review of the ADL Verification Worksheet revealed Resident #51 received 3 showers from 2/1/2022-2/25/2022 and 1 shower from 3/1/2022-3/26/2022. Continued review revealed there was no bathing documented on 23 days from 2/1/2022 through 3/26/2022. Review of Resident #51's current Care Plan revealed, .bathing: bath/shower 3 x [times] week prn [as needed] as tolerated alternating days with bed baths . Observation and interview in Resident #51's room on 3/27/2022 at 4:55 PM, revealed she was wearing a hospital gown. She stated, I haven't had a shower in three weeks, this upcoming Tuesday. My hair hasn't been washed either. She put her hand on her head and stated, See how greasy it is. It needs washed. She stated, If there's only 1 CNA on this hall, I won't get up to get a shower because they have to use a lift to get me up and that takes 2 people. During observation of supper meal on 3/27/2022 at 6:23 PM, revealed a meal cart was delivered to the 300-hall containing 11 trays with 1 staff member passing trays. Continued observation revealed the last tray was delivered to a resident on 3/27/2022 at 7:29 PM; total time for tray delivery was 1 hour and 6 minutes. Observation on the 400/600 hall on 3/28/2022 at 6:55 PM, revealed CNA #5 doing rounds on the 400 hall with three call lights going off on the 600 hall for over 5 minutes. During an interview on 3/28/2022 at 7:33 AM, RN #1 stated, I am the Medicare Nurse; I only do charting. This is my first time passing trays. During observation of the breakfast meal on 3/28/2022 at 7:52 AM, revealed a meal cart was delivered to the 300-hall containing 11 trays with 1 staff member passing trays. Continued observation revealed the last meal tray was delivered to a resident on 3/28/2022 at 8:44 AM; total time for tray delivery was 52 minutes. During an interview on 3/28/2022 at 7:39 AM with CNA #2, when asked about showers given to Resident #51, she stated, I'm the only aide on this hall [referring to 300 and part of 200 hall]. I have 23 residents with 6 residents who needs assisted dining. Continued interview she stated, if there's 1 aide on this hall, then residents don't get showers whether it's their shower day or not. During an interview on 3/28/2022 at 6:45 PM, CNA #5 stated she was the only CNA on the 400/600 hall for the 6 PM-6 AM shift. CNA #5 stated she was currently responsible for 29 residents, and she reports this is not uncommon for her to be the only CNA for this whole hall. CNA #5 stated 19 residents on this hall required incontinence care and repositioning. She stated she was unable to turn and dry the residents every two hours. She stated there was only one nurse on the hall, and she is limited on how much she can help. She reports she has residents with behaviors on the halls, 4 residents that wander, 4 residents are high risk for falls, 2 residents that require assistance with their meal, and several have to be followed up on to ensure adequate intake. During an interview on 3/29/2022 at 11:41 AM, Resident #31 stated, We have monthly resident meetings. We have complained about staffing in the meetings and there have been times that there have not been enough staff here to take care of us. They will schedule enough staff but sometimes staff calls in and then they are not enough people here; the administrative staff have had to come in and work in place of people who call in; here lately it has happened quite often that there's not enough staff in the building. During an interview on 3/29/2022 at 12:19 PM, LPN #3 stated, When we have only 1 CNA on this hall [referring to the 300 and part of the 200 hall] the residents don't always get their showers. There's no way 1 CNA can get them all done. During an interview on 3/30/2022 at 9:05 AM with the Assistant Director of Nursing, she confirmed the nursing hours PPD on 3/6/2022 and 3/16/2022 was 1.9 hours per patient, and not the required amount of 2.0 hours per PPD. During an interview on 3/30/2022 at 3:09 PM, the Assistant Director of Nursing (who is currently in charge of staffing), stated, We are budgeted for 7 CNAs for day shift and 5 for night shift. The majority of the days have 4 CNAs on day shift and 3 CNAs on night shift. We do not use any agency staff; we have 13 or 14 CNA positions open; we have no CNA applications; we don't have any CNAs to be hired.

Based on facility policy review, observation, and interview, the facility failed to promote a homelike environment for 5 of 5 residents observed, in the dining room, during the breakfast meal on 3/28/2022. The findings include: Review of the facility's policy titled, Resident Rights and Resident Responsibilities, dated 1/2022, revealed, .The resident has a right to a safe, clean, comfortable and Homelike environment, including but not limited to receiving treatment and supports for daily living safely . Observation in the 100 Hall dining room on 3/28/2022 at 7:30 AM, revealed 3 residents sitting in the dining room eating breakfast. Continued observation revealed the meal plates were on meal trays. Observations in the 100 Hall dining room on 3/28/2022 at 7:56 AM and 7:59 AM, revealed Certified Nurse Aide (CNA) #3 assisted 2 residents to the dining room, set up their meal trays and left the plate on the tray. During an interview on 3/28/2022 at 7:40 AM, Registered Nurse (RN) #1 confirmed meal plates were on the meal trays for the 3 residents sitting in the dining room. During an interview on 3/28/2022 at 8:00 AM, CNA #3 confirmed she did not remove the plate from the tray when she served the breakfast meal to the two residents.

Based on policy review, medical record review, and interview the facility failed to administer treatment and services to restore normal bowel function for 2 Residents (#2 and #7) of 7 Residents reviewed for bowel protocol placing both Residents in Immediate Jeopardy (a situation in which the provider's noncompliance with one or more requirements of participation has caused or is likely to cause serious injury, harm, impairment, or death to a Resident). On [DATE] Resident #2 was diagnosed with severe fecal impaction after being transferred to a local emergency room after vomiting what the facility staff described as black slime. Resident #2 expired shortly after arrival to the hospital. The facility noncompliance had the potential to affect Resident #6 when bowel protocol was not implemented when Resident #6 did not have a bowel movement for 5 days. The Administrator and the Regional Director of Operations were informed of the Immediate Jeopardy (IJ) on [DATE] at 6:26 PM in the Administrator's office. F-600 was cited at scope and severity of J. The facility was cited F-600 at a scope and severity Level of J which is Substandard Quality of Care. An extended survey was conducted from [DATE] to [DATE]. The Immediate Jeopardy was effective from [DATE] through [DATE]. An Immediate Action Removal Plan which removed the Immediacy of the Jeopardy was received on [DATE] at 11:22 PM and corrective actions were validated on site by the surveyor on [DATE]. The facility's noncompliance continues at a scope and severity of D to monitor the effectiveness of the corrective actions. The facility is required to submit a plan of correction. The findings include: Review of the Facility policy titled Constipation, Revised ,d+[DATE] revealed .Based on the resident's comprehensive assessment, residents that have constipation will receive appropriate treatment and services . Review of the Facility policy titled Resident Rights and Resident Responsibilities, Revised ,d+[DATE], revealed .The resident has the right to a dignified existence, self-determination .The right to receive the services and/or items included in the plan of care . Review of the undated, CONSTIPATION AND BOWEL PROTOCOL revealed, .Check for bowel sounds. If no bowel sounds or has vomiting in the last 24 hours, call MD/NP before giving any constipation medication. Symptoms and Interventions: 1. STEP ONE: If No BM (bowel movement) for 2 days (assessed on day 3): give [MEDICATION(S)] 30 cc PO or Per Tube x 1 dose. 2. STEP TWO: If No BM for 3 days (assessed on day 4): a. Listen for bowel sounds; Notify MD if no bowel sounds. b. Give [MEDICATION(S)] suppository rectally X1 AND [MEDICATION(S)] 30 cc PO or Per Tube every 6 hours for 24 hours or until Resident has adequate bowel movement. 3. STEP THREE: If No BM following Step 2, (assessed on day 5) a. Licensed nurse to give Fleets Enema x1 rectally. 4. Notify MD if no results from Enema, for complaints of increased pain and/or abdominal distention, vomiting OR absent bowel sounds . Review of the medical record revealed, Resident #2 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #2's Admission Minimum Data Set (MDA) dated [DATE] revealed Resident #2 had a Brief Interview for Mental Status (BIMS) of 3 indicating severe cognitive impairment and Resident #2 was always incontinent of bowel. Review of the Discharge MDS dated [DATE] revealed Resident #2 was discharged due to death. Review of the February and [DATE] Medication Administration Records (MAR) for Resident #2 showed no PRN (as needed) medications were recorded as given for constipation. Review of Resident #2's Clinical Notes Report entry dated [DATE] at 12:50 PM, revealed LOA (leave of absence) to Hospital (Hosp). Further review revealed entry at 18:41 (6:41 PM) .pt. (patient) sent to [named] hospital via ambulance at 11:11 AM. Therapy alerted nurse to pts condition and LOC (level of consciousness), therapy stated that pt. had regurgitated black slime . Continued review revealed .NP believes the black substance to be old blood . Review of Resident #2's Nurse Practitioner (NP) SOAP (Subjective, Objective, Assessment Plan) Note, dated [DATE], revealed, .Nursing requesting visit due to physical therapy noticed that patient had dark emesis on her and increased respiratory rate. Upon assessment abdomen distended and rigid and patient complained of pain with palpitation. Instructed nurse to send patient to ER (emergency room ) for possible GI (gastrointestinal) bleed. Vital signs stable . Review of Resident #2's [named] hospital Discharge Summary, dated [DATE] confirmed, .She (Resident #2) was transferred because of reports of coffee-ground emesis. She was found to have a massively dilated rectum, which was disimpacted in the emergency room . She had distended abdomen with few bs (bowel sounds) . Continued review showed .[named] antibiotics were added to cover for provability of gastrointestinal [CONDITION(S)] . Further review revealed .[named] pain medication was given IV (intravenously) given the huge girth of her rectum and the fact that I did not think she would absorb it and comfort measures were also initiated. [named] resident (Resident #2) passed shortly after arriving at the floor . Review of Resident #2's medical record confirmed there were no BMs documented, medications for constipation administered, or abdominal assessments completed for 10 consecutive days ([DATE]-[DATE]) and no bowel movements documented [DATE] to [DATE]. Review of Resident #2's Death Certificate revealed .Physician .to the best of my knowledge, Death occurred at that date, time and place and due to the cause(s) and manner stated .Medical examiner .On the bases of examination and/or investigation. In my opinion, death occurred at the date, time and place and due to the cause(s) and manner stated .E. COLI [CONDITION(S)] .SEVERE OBSTIPATION .SEVERE FECAL IMPACTION . Review of Resident #6's medical record revealed Resident #6 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #6's Admission MDS dated [DATE] revealed a BIMS score or 7 indicating severe cognitive impairment. Resident #6 was always incontinent of bowel. Review of Resident #6's Clinical Notes Report and the Activities of Daily Living (ADL) Verification Worksheet, dated [DATE], revealed Day 4 ([DATE]), bowel protocol not implemented: STEP TWO: If No BM for 3 days (assessed on day 4) [[DATE]]: a. Listen for bowel sounds; Notify MD if no bowel sounds. b. Give [MEDICATION(S)] suppository rectally X1 AND [MEDICATION(S)] 30 cc PO or Per Tube every 6 hours for 24 hours or until Resident has adequate bowel movement. Review of Resident #6's Clinical Notes Report and the ADL Verification Worksheet, dated [DATE], revealed Day 3 ([DATE]), bowel protocol not implemented: STEP ONE: If No BM (bowel movement) for 2 days give: (assessed on day 3) a. [MEDICATION(S)] 30 cc PO or Per Tube x 1 dose. Continued review of Resident #6s medical record confirmed there were no BMs documented, medication administered, or abdominal assessments completed for [DATE] and [DATE]. Review of Resident #6's ADL Worksheet and Clinical Notes Report revealed Resident #6 did not have a bowel movement on the following days:[DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE];[DATE], [DATE],[DATE],[DATE], [DATE], [DATE] and [DATE]. Review of Resident #6's MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . During a phone interview on [DATE] at 9:25 PM, with the Nurse Practitioner (NP) she stated, Yes, I remember [named] resident (Resident #2) She was on the 400-hall. The nurse requested me to see the patient (Resident #2) for dark brown emesis. During continued interview when asked, is staff usually on top of the bowel protocol? The NP stated, Yes and no, it depends on the nurse as to whether they are on top of it. I can't fix a problem if the staff does not tell me about. During continued interview, the NP stated, The nursing staff should notify me no later than 3 days. That is why we have a bowel protocol. During further interview she stated, I had spoken to nurses in a nurses meeting about the bowel protocol in the last few months, I think it was in March. During an interview on [DATE] at 5:37 PM, with the Director of Nursing (DON) she confirmed, the facility bowel protocol had not been followed. The surveyor verified the Immediate Action Removal Plan by: 1.The surveyor confirmed through interviews with licensed staff on site Education was conducted as evidence by the knowledge of the bowel protocol and when to implement. 2. The surveyor confirmed through interviews with Certified Nursing Assistants (CNAs) on site, education was conducted as evidenced by the knowledge of the bowel protocol and when to report to nursing. 3. The surveyor confirmed by matching signatures with post- tests that all licensed staff who were in- serviced, took the tests. 4. The surveyor confirmed each identified resident had a care plan with interventions for constipation and dehydration. 5. The surveyor reviewed and verified the facility's Quality Assurance Performance Improvement (QAPI) meeting was held on [DATE] to discuss the Corrective Action Plan for the deficiencies. Noncompliance continues at a scope and severity level of D for monitoring the effectiveness of the corrective actions. The facility is required to submit a plan of correction.

Based on Facility policy review, medical record review and interview, the facility failed to provide treatment and services as care planned to prevent constipation and fecal impaction for Resident #2 placing the Resident in Immediate Jeopardy (a situation in which the provider's noncompliance with one or more requirements of participation has caused or is likely to cause serious injury, harm, impairment, or death to a resident). On [DATE] Resident #2 was diagnosed with severe fecal impaction after being transferred to a local emergency room after vomiting what the facility staff described as black slime. Resident #2 expired shortly after admission to the hospital on [DATE]. The facility's noncompliance had the potential to affect 1 additional resident (#6) of 7 Residents reviewed for Abuse/Neglect placing them at risk for Immediate Jeopardy. The Administrator and the Regional Director of Operations were informed of the Immediate Jeopardy (IJ) on [DATE] at 6:26 PM in the Administrator's office. F-600 was cited at scope and severity of J. The facility was cited F-600 at a scope and severity Level of J which is Substandard Quality of Care. An extended survey was conducted from [DATE] to [DATE]. The Immediate Jeopardy was effective from [DATE] through [DATE]. An Immediate Action Removal Plan which removed the Immediacy of the Jeopardy was received on [DATE] at 11:22 PM and corrective actions were validated on site by the surveyor on [DATE]. The facility's noncompliance continues at a scope and severity of D to monitor the effectiveness of the corrective actions. The facility is required to submit a plan of correction. The findings include: Review of the Facility policy titled Constipation, Revised ,d+[DATE] revealed .Based on the resident's comprehensive assessment, residents that have constipation will receive appropriate treatment and services . Review of the Facility policy titled Resident Rights and Resident Responsibilities, Revised ,d+[DATE], revealed .The resident has the right to a dignified existence, self-determination .The right to receive the services and/or items included in the plan of care . Review of the facility policy titled Abuse Prohibition Plan, Revised ,d+[DATE], revealed .The facility has a zero-tolerance policy for abuse. Verbal, mental, sexual, or physical abuse, corporal punishment, or involuntary seclusion is prohibited .he resident will not be subjected to mistreatment, neglect, exploitation, or misappropriation of property. The facility will attempt to identity and will investigate any reported violation or allegation of abuse . Review of the undated, CONSTIPATION AND BOWEL PROTOCOL revealed, .Check for bowel sounds. If no bowel sounds or has vomiting in the last 24 hours, call MD/NP before giving any constipation medication. Symptoms and Interventions: 1. STEP ONE: If No BM (bowel movement) for 2 days (assessed on day 3): give [MEDICATION(S)] 30 cc PO or Per Tube x 1 dose. 2. STEP TWO: If No BM for 3 days (assessed on day 4): a. Listen for bowel sounds; Notify MD if no bowel sounds. b. Give [MEDICATION(S)] suppository rectally X1 AND [MEDICATION(S)] 30 cc PO or Per Tube every 6 hours for 24 hours or until Resident has adequate bowel movement. 3. STEP THREE: If No BM following Step 2, (assessed on day 5) a. Licensed nurse to give Fleets Enema x1 rectally. 4. Notify MD if no results from Enema, for complaints of increased pain and/or abdominal distention, vomiting OR absent bowel sounds . Review of the medical record revealed, Resident #2 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #2's Minimum Data Set (MDS) dated [DATE] revealed Resident #2 had a Brief Interview for Mental Status (BIMS) of 3 indicating severe cognitive impairment and Resident #2 was always incontinent of bowel. Review of the Discharge MDS dated [DATE] revealed Resident #2 was discharged due to death. Review of the February and [DATE] Medication Administration Records (MAR) for Resident #2 showed no PRN (as needed) medications were recorded as given for constipation. Review of Resident #2's Clinical Notes Report entry dated [DATE] at 12:50 PM, revealed .LOA (leave of absence) to Hospital (Hosp) . Further review revealed entry at 18:41 (6:41 PM) .pt. (patient) sent to [named] hospital via ambulance at 11:11 AM. Therapy alerted nurse to pts condition and LOC (level of consciousness), therapy stated that pt. had regurgitated black slime . Continued review revealed .NP believes the black substance to be old blood . Review of Resident #2's Nurse Practitioner (NP) SOAP (Subjective, Objective, Assessment Plan) Note, dated [DATE], revealed, .Nursing requesting visit due to physical therapy noticed that patient had dark emesis on her and increased respiratory rate. Upon assessment abdomen distended and rigid and patient complained of pain with palpitation. Instructed nurse to send patient to ER (emergency room ) for possible GI (gastrointestinal) bleed. Vital signs stable . Review of Resident #2's [named] hospital Discharge Summary, dated [DATE] confirmed, .She (Resident #2) was transferred because of reports of coffee-ground emesis. She was found to have a massively dilated rectum, which was disimpacted in the emergency room . She had distended abdomen with few bs (bowel sounds) . Continued review showed . [named] antibiotics were added to cover for provability of gastrointestinal [CONDITION(S)] . Further review revealed . [named] pain medication was given IV (intravenously) given the huge girth of her rectum and the fact that I did not think she would absorb it and comfort measures were also initiated. [named] resident (Resident #2) passed shortly after arriving at the floor . Review of Resident #2's medical record confirmed there were no BMs documented, medications for constipation administered, or abdominal assessments completed for 10 consecutive days ([DATE]-[DATE]) and no bowel movement documented on [DATE]-[DATE]. Review of Resident #2's Death Certificate revealed .Physician .to the best of my knowledge, Death occurred at that date, time and place and due to the cause(s) and manner stated .Medical examiner .On the bases of examination and/or investigation. In my opinion, death occurred at the date, time and place and due to the cause(s) and manner stated .E. COLI [CONDITION(S)] .SEVERE OBSTIPATION .SEVERE FECAL IMPACTION . Review of Resident #6's medical record revealed Resident #6 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #6's MDS revealed Resident #6 had a BIMS score of 7, indicating severe cognitive impairment. Continued review revealed Resident #6 was always incontinent of bowel. Review of Resident #6's Clinical Notes Report and the Activity of Daily Living (ADL) Verification Worksheet, dated [DATE], revealed Day 4 ([DATE]), bowel protocol not implemented: STEP TWO: If No BM for 3 days (assessed on day 4) [[DATE]]: a. Listen for bowel sounds; Notify MD if no bowel sounds. b. Give [MEDICATION(S)] suppository rectally X1 AND [MEDICATION(S)] 30 cc PO or Per Tube every 6 hours for 24 hours or until Resident has adequate bowel movement. Review of Resident #6's Clinical Notes Report and the ADL Verification Worksheet, dated [DATE], revealed Day 3 ([DATE]), bowel protocol not implemented: STEP ONE: If No BM (bowel movement) for 2 days give: (assessed on day 3) a. [MEDICATION(S)] 30 cc PO or Per Tube x 1 dose. Continued review of Resident #6's medical record confirmed there were no BMs documented, medications administered, or abdominal assessments completed for [DATE], [DATE], [DATE], [DATE], [DATE], [DATE];[DATE], [DATE] and [DATE] and did not have a BM x4 days [DATE], [DATE], [DATE] and [DATE]. Review of Resident #6's MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . During a phone interview on [DATE] at 9:25 PM, with the Nurse Practitioner (NP) she stated, Yes, I remember [named] resident (Resident #2) She was on the 400-hall. The nurse requested me to see the patient (Resident #2) for dark brown emesis. During continued interview when asked, is staff usually on top of the bowel protocol? The NP stated, Yes and no, it depends on the nurse as to whether they are on top of it. I can't fix a problem if the staff does not tell me about. During continued interview, the NP stated, The nursing staff should notify me no later than 3 days. That is why we have a bowel protocol. During further interview she stated, I had spoken to nurses in a nurses meeting about the bowel protocol in the last few months, I think it was in March. During an interview on [DATE] at 5:37 PM, with the Director of Nursing (DON) she confirmed, the facility bowel protocol had not been followed for Resident #2 and confirmed the process is to identify the residents who have not had a bowel movement in 3 days and follow the bowel protocol. The surveyor/s verified the Immediate Action Removal Plan by: 1.The surveyor confirmed through interviews with licensed staff on site Education was conducted as evidence by the knowledge of the bowel protocol and when to implement. 2.The surveyor confirmed through interviews with Certified Nursing Assistants (CNAs) on site, education was conducted as evidenced by the knowledge of the bowel protocol and when to report to nursing. 3.The surveyor confirmed by matching signatures with post- tests that all licensed staff who were in- serviced, took the tests. 4.The surveyor confirmed each identified resident had a care plan with interventions for constipation and dehydration. 5.The surveyor reviewed and verified the facility's Quality Assurance Performance Improvement (QAPI) meeting was held on [DATE] to discuss the Corrective Action Plan for the deficiencies. Noncompliance continues at a scope and severity level of D for monitoring the effectiveness of the corrective actions. The facility is required to submit a plan of correction.

Based on facility policy review, manufacturer's user guide review, medical record review, observation, and interview, the facility failed to provide adequate supervision to prevent an avoidable accident resulting in a fracture for 1 Resident (#91) and the facility failed to ensure a fall intervention was implemented for 1 resident (#36) of 5 residents reviewed for accidents of 22 sampled residents. The facility's failure to provide supervision resulted in actual Harm to Resident #91. The findings include: Review of the DYN-ERGO Scoot Chair (specialty chair for people with limited mobility) Users Guide updated 3/11/16 revealed .Dyn-Ergo Scoot Chair Usage .For safest operation, please familiarize your-self with the following components .Tilt-In-Space lever activator .Available Options .Removable Swing-Away Footrests . Review of the facility policy Post Occurrence Management, last revised 4/2018, revealed .Implement new interventions (that will attempt to prevent a reoccurrence) and complete an in-service as needed .Modify/update the resident's current Care Plan and Resident Care Needs with new intervention(s) . Medical record review revealed Resident #91 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Care Plan Report dated 3/18/19 revealed .COGNITION .Confusion, alteration in thought process related to .DEMENTIA WITH HX (history) OF BEHAVIORS .[MEDICAL CONDITION] END STAGE .Task segmentation as needed .Face resident and make eye contact when communicating with resident .Self-care deficit R/T (related to) .locomotion, and transfers. Continued review of Resident #91's care plan revealed .Locomotion-assist (Resident #91) as needed to desired location in/out of facility with wheelchair/walker as needed. Ambulatory at times .4/16/19 USE OF SCOOT TYPE CHAIR . Further review revealed no instructions for the use of the scoot chair during transport of the resident. Medical record review of a Quarterly Minimum Data Set ((MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 2 indicating the resident had severe cognitive impairment. Further review revealed the resident required extensive assist of 2 staff members for bed mobility, transfers, dressing, and toilet use. Continued review revealed the resident required extensive assist of 1 staff member with walking, locomotion, eating, and personal hygiene. Medical Record Review of a physician progress notes [REDACTED].currently being treated for [REDACTED].She continues to decline .[MEDICAL CONDITION] with end stage characteristics . Medical record review of a facility investigation dated 5/19/19 at 9:15 AM revealed .Resident was returning from the dining room holding her feet up while being rolled in her (scoot chair). She suddenly threw her feet down and rolled right leg underneath the chair .Indicate area of injury .Right lower leg, medial aspect of ankle .Ice applied to swelling of ankle . Xray ordered .STEPS IMPLEMENTED TO PREVENT RECURRENCE .Staff educated to roll slowly .to prevent the leg from rolling underneath . Medical record review of local hospital Emergency Department (ED) Discharge Instructions dated 5/19/19 revealed .Diagnosis .fracture (bone break) of right lower leg . Medical record review of a Physical/Occupational Therapy Screening Form dated 5/20/19 revealed .Is patient able to follow simple commands .NO .Are current devices appropriate .No .Additional, transportation comments .Pt (patient) current WC (wheelchair) does not have leg rests . Medical record review of a History and Physical from Orthopedic Physician dated 5/31/19 revealed .presents for evaluation of a right ankle fracture .x-rays show .left (right) ankle fracture .PLAN .keep in splint for now and see her back again in 4 weeks for re-x-ray out of the splint and a clinical check . Observation of Resident #91 on 6/10/19 at 9:30 AM, in front of the nurse's station off the 500 hallway, revealed the resident sitting in a high back wheelchair with feet elevated and splint on the right lower leg. Observation of Resident #91 on 6/11/19 at 12:17 PM, in the resident's room, revealed the resident lying on the bed with splint to right lower leg. Interview with Certified Nursing Assistant (CNA) #1 on 06/11/19 at 12:45 PM, in the conference room, revealed CNA #1 had assisted Resident #91 back to the resident's room on 5/19/19 in a .scoot chair . Further interview revealed CNA #1 had told the resident several times to .hold your feet up . Continued interview revealed as the CNA pushed Resident #91 back to her room, the resident dropped her feet and the chair rolled over the right foot. Interview with CNA #2 on 6/11/19 at 1:20 PM, on the 500 hallway, revealed Resident #91 had used a .scoot chair . prior to the event on 5/19/19 and could self-propel with the feet. Continued interview revealed the resident was unable to follow commands or directions due to the resident's dementia. Further interview confirmed the resident was unable to consistently hold her feet up during transport in the scoot chair .at times we used a pillow case to hold her legs up .one would hold legs up and the other would push .(Resident #91) could not remember to hold her feet up . Interview with CNA #3 on 6/11/19 at 1:30 PM, at the nurse's station off the 500 hallway, revealed normally Resident #91 is in a .scoot chair .but since her foot got broke she is in a high back wheelchair with legs . Continued interview with CNA #3 revealed Resident #91 .was not able to keep (legs) up all the time . Further interview on 06/12/19 at 7:34 AM, in the 500 hallway, confirmed CNA #3 had reported Resident #91 was dropping her feet in the scoot chair to nursing and was told . they would look into switching chairs . Interview with Licensed Practical Nurse (LPN) #1 on 6/11/19 at 1:35 PM, at the nurse's station off the 500 hallway, confirmed Resident #91 would frequently drop her feet down while being transported in the scoot chair. Further interview on 6/12/19 at 7:34 AM, at the nurse's station on the 500 hallway, revealed .everyone was aware of (Resident #91) dropping her feet . Continued interview revealed therapy was involved in decisions made about any types of chairs used by residents. Further interview revealed LPN #1 was unsure if she had reported Resident #91 dropping her feet during transport to therapy. Interview with CNA #4 on 6/11/19 at 1:46 PM, at the nurse's station off the 500 hallway, revealed Resident #91 had not been able to remember to keep her feet up when asked to hold them up during transport in the scoot chair, and rarely followed directions. Continued interview with CNA #4 revealed Resident #91 frequently put her feet down while being transported. Further interview on 6/12/19 at 7:40 AM, in the 500 hallway, confirmed CNA #4 had reported Resident #91 had been dropping her feet while being transported in the scoot chair to nursing staff. Interview with CNA #5 on 6/12/19 at 8:18 AM, in the conference room, revealed Resident #91 had been unable to consistently hold her feet up while being transported in the scoot chair. Continued interview confirmed she had reported this to the nurses, but was unsure as to which nurse she had reported to. Interview with the Physical Therapist (PT), on 6/12/19 at 9:07 AM, in the conference room, revealed therapy had been involved with the decision to place Resident #91 in the scoot chair after a fall on 4/16/19. Continued interview confirmed the PT had not been made aware of Resident #91 having any issues with holding her feet up during transportation in the scoot chair. Interview with the Physician on 6/12/19 at 10:09 AM, by phone, confirmed if the facility had addressed the issue of the resident dropping her feet during transport prior to the event the fracture could .Probably . have been prevented. Further interview confirmed the resident was difficult . and does not follow commands. Interview with the Director of Nursing (DON) on 6/12/19 at 10:20 AM, in the conference room, revealed staff had not made her aware of problems with Resident #91 dropping her feet down while being transported in the scoot chair. Further interview confirmed the facility failed to prevent an avoidable accident resulting in fracture and caused actual Harm for Resident #91. Medical record review revealed Resident #36 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of an Admission MDS dated [DATE] revealed the resident scored a 7 on the BIMS indicating the resident was moderately cognitively impaired and required the extensive assist of 2 staff for transfers and the extensive assist of 1 staff for locomotion of the unit. Continued review revealed Resident #36 utilized a walker and wheelchair for mobility. Medical record review of a fall investigation dated 3/19/19 revealed Resident #36 had a fall on 3/19/19 in the resident's room and sustained a right humeral fracture (broken bone of the right upper arm). Further review revealed the resident had been sitting up in a wheelchair prior to the fall. Continued review revealed the facility implemented the following intervention .Patient not to be left alone in room while up in wheelchair . Medical record review of a Significant Change of Status MDS assessment dated [DATE] revealed a BIMS score of 5, indicating the resident had severe cognitive impairment. Further review revealed the resident required extensive assist of 2 staff members with bed mobility, transfers, and toileting. Continued review revealed the resident required extensive assist of 1 staff member with locomotion. Medical record review of the Care Plan Report dated 3/25/19 revealed .At Risk For Falls .DO NOT LEAVE RESIDENT ALONE IN ROOM WHEN UP IN W/C (wheel chair) D/T (due to) FALL 3/19/19 . Observation of Resident #36 on 6/11/19 at 7:34 AM, in the resident's room, revealed Resident #36 was sitting up in a wheelchair with no staff member present. Observation of Resident #36 on 6/11/19 at 11:08 AM, in the resident's room, revealed the door to the room was closed. Further observation revealed the resident was sitting up in a wheelchair with no staff member present. Interview and observation of Resident #36 with Certified Nursing Assistant (CNA) #6 on 6/11/19 at 11:10 AM, in the resident's room, confirmed Resident #36 was alone in the resident's room sitting in her wheelchair. Continued observation and interview revealed Resident #36 had attempted to wheel the wheelchair in the resident's bathroom. Continued interview and observation of the Resident Care Summary Assessment (Care plan for CNAs taped to the inside of resident's closet doors) confirmed the resident was not be left alone in the room while sitting in a wheelchair. Interview with the Restorative Nursing Assistant (RNA) on 6/11/19 at 12:54 PM, in the dining room, confirmed the RNA had assisted Resident #36 to the resident's room and had left the resident sitting in a wheelchair with no staff member present. Continued interview confirmed the resident was at risk for falls .when she first got here she fell . Further interview and observation of the Resident Care Summary Assessment confirmed the resident was not to be left alone in the room while sitting in a wheelchair. Interview with the Assistant Director of Nursing (ADON) on 6/12/19 at 9:02 AM, in the ADON's office, confirmed the facility failed to ensure Resident #36 was not left alone in the resident's room while sitting up in a wheelchair.