Every finding on record at Granite Creek Health & Rehabilitation Center

Based on interviews, review of clinical record, and review of facility policy and procedure, the facility failed to ensure medications were administered according to physician orders for one of four sampled residents (#2). The deficient practice could result in residents not receiving medications as ordered by the physician, which could lead to worsening of the resident's medical condition.-Findings include:Resident #2 re-admitted to the facility on [DATE], with diagnoses that included acquired absence of the right leg above the knee, primary osteoarthritis of the left hip, presence of left artificial hip joint, rheumatoid arthritis, other chronic pain, difficulty in walking, and need for assistance with personal care.A discharge physician order list dated July 11, 2026, included medication orders from the discharging hospital. The orders were uploaded into the resident's clinical record on July 11, 2026, at 9:52 a.m.A nursing note dated July 11, 2026, revealed Resident #2 admitted to the facility at approximately 5:35 p.m.Physician orders dated July 11, 2026, scheduled to start on July 11, 2026, included:-Clonazepam oral tablet 0.5 mg, to give 0.5 mg orally at bedtime for anxiety as evidenced by restlessness-Famotidine oral tablet 20 mg, to give 20 mg tablet orally at bedtime for gastrointestinal discomfort-Simvastatin oral tablet 20 mg, to give 20 mg orally at bedtime for hypercholesteremia-Clonidine HCl oral tablet, to give 0.5 mg orally two times a day for hypertension-Doxycycline monohydrate oral capsule, to give 100 mg orally two times a day for infection-Flovent HFA inhalation aerosol 220 mcg/act, to administer 1 inhalation orally two times a day for wheezing-Fluticasone propionate nasal suspension 50 MCG/ACT, for 2 inhalations in both nostrils two times a day-Modafinil oral tablet 200 mg, to give 1 tablet orally two times a day for wakefulness-Gabapentin 300 mg capsule, to give 1 capsule by mouth three times a day for neuropathy-Sucralfate oral tablet 1 gm, to give 1 tablet orally three times a day for ulcer prevention-Oxycodone HCl oral tablet 10 mg, to give 10 mg orally every 4 hours as needed for pain management for pain level 1-10.The Medication Administration Record (MAR) for July 2026 revealed that the clonazepam, famotidine, simvastatin, clonidine, doxycycline, flovent, fluticasone, modafinil, gabapentin, and sucralfate were marked as not administered on the MAR for July 11, 2026; however, the nurse (Staff #66) documented 7 on the MAR, indicating other / see nurse notes.The clinical record revealed no evidence on July 11, 2026, indicating why the medications were not administered. Additionally, there was no evidence that the pharmacy was contacted, the provider was contacted, or that the medications were attempted to be administered from the emergency kit (e-kit).An admission assessment dated [DATE], revealed that Resident #2 had vocal complaints of pain, and was documented to have a pain level of 4 on July 12, 2026, at 2:26 a.m.The clinical record revealed no evidence that the resident was administered oxycodone for pain during the night shift of July 11-12, 2026.Physician orders dated July 11, 2026, to start on July 12, 2026, included:-Bifidobacterium bifidum oral capsule, to give 1 unit orally one time a day for bowel health-Enoxaparin sodium injection solution prefilled syringe 30 mg/0.3ml, to inject 30 mg subcutaneously one time a day for clot prevention-Estrace oral tablet 0.5 mg, to give 1 tablet orally one time a day for hormones-Lidoderm patch 5%, to apply per additional directions topically in the morning for pain level 1-10-Suzetrigine oral tablet 50 mg, to give 50 mg orally one time a day for non-opioid oral pain reliefThe MAR for July 2026 revealed that the Bifidobacterium bifidum, enoxaparin sodium injection, estrace, Lidoderm patch, and suzetrigine were marked as not administered on the MAR for July 12, 2026; however, the nurse (Staff #66) documented 7 on the MAR, indicating other / see nurse notes.The clinical record revealed no evidence that the resident was administered medication to address her pain until July 12, 2026, at 12:02 p.m. when the resident was administered an oxycodone tablet for a pain level of 9.eMAR- Medication Administration Notes dated July 12, 2026, revealed n/a for the clonazepam, simvastatin, sucralfate, clonidine, doxycycline monohydrate, flovent inhaler, gabapentin, famotidine, and modafinil.Additionally, further eMAR notes dated July 12, 2026, revealed on order for the Bifidobacterium bifidu, Flovent inhaler, estrace, and modafinil.The clinical record revealed no evidence that the pharmacy was contacted, the provider was contacted, or that the medications were attempted to be administered from the e-kit on July 12, 2026.A Brief Interview for Mental Status (BIMS) assessment dated [DATE], revealed the resident had a BIMS score of 13, indicating Resident #2 had intact cognition.Care plan reviews initiated July 13, 2026, revealed Resident #2 was receiving antibiotic therapy for an infection, antihypertensive medication for hypertension, opioid medication, anticoagulant therapy, and anti-anxiety medication for an anxiety disorder. Interventions included administering medications as ordered by the physician.The care plan also identified acute and chronic pain related to a right above-knee amputation, anxiety disorder, chronic back pain, and osteoarthritis of the left hip. Interventions included assessing pain every shift and administering pain medication according to the pain scale and physician orders.A facility e-kit inventory log revealed a list of medications stored in the e-kit, including: -Clonazepam 0.5 mg tablet -Enoxaparin 30mg/0.3 ml syringe -Doxycycline monohydrate 100 mg capsule -Oxycodone 10 mg oral tabletAn interview was conducted on July 21, 2026, at 7:19 a.m. with Resident #2 who stated that she arrived to the facility on July 11, 2026, and that she did not receive any of her bedtime medications, and when she asked for them, she was informed by nursing staff that the facility did not have her physician orders for the medications yet. The resident also stated that she did not get her medications the next morning, and again was told that the orders had not been received yet. The resident stated that she was in pain waiting for her medications.A telephone interview was conducted with a Registered Nurse (RN, Staff #66) on July 21, 2026, at 1:04 p.m. Staff #66 stated that, upon a resident's admission, the nurse transcribed physician orders from the transferring hospital or facility into the facility's electronic medical record (EMR), after which the contracted pharmacy dispensed and delivered the medications. She stated that if the pharmacy did not receive the orders in time, the medications would not be delivered and the resident might not receive them on the first night of admission. Staff #66 stated the facility maintained an emergency medication kit (e-kit) from which nurses could obtain ordered narcotic medications, if needed.Staff #66 stated she did not believe there was a risk if residents missed their medications because she reviewed the medication orders and believed none would cause problems if not administered. She further stated the contracted pharmacy made overnight medication deliveries between 10:00 p.m. and 11:00 p.m. and again between 1:00 a.m. and 2:00 a.m.An interview was conducted with the Admissions Assistant (Staff #18) on July 21, 2026, at 2:10 p.m. Staff #18 stated she receives residents' medical records, including hospital discharge physician orders, before approving transportation to the facility and stated residents are never admitted before those orders are received. She explained that admissions are scheduled with a minimum one- to two-hour interval between receipt of the discharge orders and the resident's arrival to allow the admitting nurse time to transcribe and clarify physician orders in the facility's electronic medical record (EMR).Staff #18 reviewed Resident #2's clinical record and stated the weekend admissions assistant uploaded the resident's hospital records and discharge physician orders into the EMR on July 11, 2026, at 9:52 a.m. She stated the resident was scheduled for hospital pickup between 4:30 p.m. and 5:00 p.m., arrived at the facility at approximately 5:30 p.m., and that sufficient time was available for nursing staff to transcribe and clarify the physician orders before admission. Staff #18 further stated nurses were instructed to seek assistance from another nurse or the Assistant Director of Nursing (ADON) if needed to complete the transcription and clarification process.An interview was conducted with the Charge Nurse/Licensed Practical Nurse (LPN, Staff #22) on July 21, 2026, at 2:25 p.m. Staff #22 stated she receives text notification from the admissions department when a resident is scheduled for admission. She stated she reviews the resident's uploaded medical records and hospital discharge physician orders, transcribes and clarifies the orders in the facility's electronic medical record (EMR), and obtains verbal report from the transferring hospital. She stated nursing staff rotate responsibility for admissions to distribute the workload.Staff #22 stated the contracted pharmacy makes multiple medication deliveries each day, including overnight, and nurses may request additional deliveries as needed. She stated there should not be an instance in which a resident admitted in the evening does not receive prescribed medications that night. She further stated that if ordered medications were unavailable, the nurse should contact both the pharmacy and the provider for further direction.After reviewing Resident #2's medication administration record (MAR) and clinical record, Staff #22 stated the resident did not receive scheduled medications on July 11, 2026, and missed most scheduled morning medications on July 12, 2026. She further stated there was no documentation the nurse notified the physician or pharmacy on either date. After reviewing the electronic MAR notation of n/a, Staff #22 stated it most likely indicated the medications were not available. Staff #22 stated failure to administer ordered medications could place a resident at risk for mental, physical, and psychosocial harm.An interview was conducted with the Director of Nursing (DON, Staff #5) on July 21, 2026, at 2:54 p.m. The DON stated that, before a resident is admitted from a hospital, the admissions department notifies nursing staff when the resident's medical records are uploaded into the facility's electronic medical record (EMR) and when the resident is scheduled to arrive. She stated nurses transcribe the hospital discharge physician orders into the EMR, and the orders are activated upon the resident's admission. Once activated, the orders are automatically transmitted to the contracted pharmacy for delivery on the next scheduled pharmacy run, which occurs three to four times daily, including weekends. The DON stated the pharmacy also provides an overnight delivery between approximately 12:00 a.m. and 2:00 a.m. and can make additional stat deliveries when needed.The DON stated newly admitted residents should receive their scheduled bedtime medications because nurses have access to the emergency medication kit (e-kit), may request a stat pharmacy delivery, and are expected to notify the provider if ordered medications are unavailable. She stated nurses are expected to document provider notification and any instructions received. The DON stated it would not meet her expectations for a nurse to withhold medications because they were unavailable without first checking the e-kit and notifying the provider. She further stated the potential risk of missed medications depends on the medication, the resident's condition, and any alternative instructions provided by the physician.After reviewing Resident #2's clinical record, the DON stated the hospital discharge physician orders were uploaded on July 11, 2026, at 9:52 a.m. and activated at 5:44 p.m. She reviewed the medication administration record (MAR) and confirmed Resident #2 did not receive any scheduled medications on July 11, 2026, and missed some scheduled medications on July 12, 2026. The DON stated the electronic MAR notation of n/a indicated the medications were unavailable. She further stated there was no documentation on July 11 or July 12, 2026, that the provider had been notified or the pharmacy contacted, and acknowledged the medication administration for Resident #2 did not meet her expectations.Review of the facility policy titled Physician Orders, dated June 2025, revealed it is the policy of the facility to accurately implement orders in addition to medication orders (treatment, procedures) only upon the order of a person duly licensed and authorized to do so in accordance with the resident's plan of care.Review of the facility policy titled Pharmaceutical Services, revised August 2018, revealed it is the policy of the facility to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biological) to meet the needs of each resident.

Based on interview, review of clinical record, and review of facility policy and procedure, the facility failed to ensure one of three sampled residents (#25) was provided quality of care regarding prevention, assessment, and treatment of moisture associated skin damage (MASD), according to professional standards. The deficient practice could lead to worsening of a skin issues, increased pain, and physical harm of a resident.-Findings include:Resident #25 was admitted [DATE], with diagnoses that included periprosthetic fracture around internal prosthetic left knee, unspecified fracture of left femur, chronic obstructive pulmonary disease, pneumonia, paroxysmal atrial fibrillation, malignant neoplasm of female breast, and need for assistance with personal care.An Initial admission assessment dated [DATE], revealed Resident #25 had no skin problems on admission.A care plan focus dated March 5, 2026, included that Resident #25 had a pressure ulcer or the potential for pressure ulcer development, due to her comorbidities, and that interventions included to administer treatments as ordered and monitor for effectiveness, to monitor/document/report to the physician as needed any changes in skin status: appearance, color, wound healing, signs and symptoms of infection, wound size and stage, and to notify the nurse immediately of any new areas of skin breakdown: redness, blisters, bruises, discoloration noted during bath or daily care, and to complete weekly head to toe skin assessment.Physician orders dated March 5, 2026, included: -Encourage and assist resident with repositioning frequently, every shift. -Barrier cream to perineal area for incontinence, every shift. -Weekly skin evaluation every Thursday, day shift, with a start date of March 12, 2026. -Weekly Braden Scale for four weeks, every 7 days, with a start date of March 6, 2026.A daily skilled note dated March 6, 2026, revealed Resident #25 had no skin issues noted, and no active symptoms affecting the integumentary system, and no active skin conditions or treatments observed.A Braden Scale for Predicting Pressure Sore Risk assessment dated [DATE], revealed Resident #25 was scored at 16, indicating low risk for developing pressure-related skin impairment.A nursing note dated March 6, 2026, included that Resident #25 was resting in bed, alert and oriented x 1, and unable to let her needs known to staff.A shower sheet dated March 7, 2026, revealed Resident #25 had redness on the sacral/coccyx area. The shower sheet was signed by a certified nursing assistant (CNA) and a nurse.A daily skilled note dated March 7, 2026, included Resident #25 had a left femur fracture with an immobilizer. The note included the resident had redness to the lower back and coccyx area, and active symptoms included abnormalities in skin color.The clinical record revealed no evidence that the redness/abnormal skin color of the lower back and coccyx area was communicated to the physician.A Late Entry provider progress note dated March 7, 2026, revealed Resident #25's skin was warm and dry without rashes, lesions, or wounds noted.A Late Entry daily skilled note dated March 8, 2026 revealed the resident had a left femur fracture with a leg immobilizer, and the resident had redness to the lower back and coccyx area.The clinical record revealed no evidence that the physician was notified of the redness to the lower back and coccyx area.A provider progress note dated March 8, 2026, revealed Resident #25's skin was warm and dry without rashes, lesions, or wounds noted.A shower sheet dated March 9, 2026, revealed Resident #25 had refused the shower, and included that the resident had a shower the night before last, and did not feel like taking one. The shower sheet was signed by Resident #25, a CNA, and a nurse.Daily skilled notes dated March 9 and March 10, 2026, revealed Resident #25 had no skin issues noted, and no active symptoms affecting the integumentary system, and no active skin conditions or treatments observed.Provider progress notes dated March 10, 11, and 12, 2026, revealed Resident #25's skin was warm and dry without rashes, lesions, or wounds noted.There was no evidence of any daily skilled nursing notes completed on March 11, 2026.An admission minimum data set (MDS) assessment dated [DATE], revealed Resident #25 had a brief interview for mental status (BIMS) assessment score of 10, indicating moderately impaired cognition. Section M - Skin Conditions revealed Resident #25 was at risk for developing pressure ulcers / injuries. The assessment revealed the resident had no moisture associated skin damage (MASD), no unhealed pressure ulcers / injuries, no open lesions other than ulcers, rashes, cuts, and no cuts. The documentation included that the resident had surgical wounds.An Occupational Therapy Treatment Encounter Note, dated March 12, 2026, revealed Resident #25 was dependent on staff for toileting hygiene, and required minimum assistance from staff for rolling left and right in the bed. The note also revealed that decubitus ulcers were observed by the Occupational Therapist on bilateral inner thighs, vagina, buttocks, and right heel. Additionally, improper healing of incision on the left anterior pelvis was observed. The note included that nursing, and wound care nurse were immediately notified of all wounds.There was no evidence of any daily skilled nursing notes or any other nurse progress notes completed on March 12, 2026.A shower sheet dated March 12, 2026, revealed Resident #25 had redness, rashes, and open areas in the genital region, an incision in the left groin area, and redness, skin tears, and rashes on the sacral/coccyx area. The shower sheet was signed by a CNA and a nurse.The clinical record revealed no evidence that a detailed skin assessment was completed for the documented redness, rashes, open areas, and skin tears on March 12, 2026.A physician order dated March 12, 2026, included to wash with soap and water at each brief change and cover reddened areas with Zinc cream, and powder perineal area after each brief change.There was no evidence of a change of condition monitoring order for the skin condition on March 12, 2026.Review of the Medication and Treatment Administration Record (MAR / TAR) for March 2026, revealed a scheduled weekly skin evaluation was not marked as competed on March 12, 2026. Additionally, a scheduled Braden scale assessment was not marked as completed on March 13, 2026.The clinical record revealed no evidence that a Braden scale assessment was completed as ordered on March 13, 2026.A Weekly Skin Evaluation created and signed on March 13, 2026 by the wound nurse (Staff #66) however dated March 12, 2026, revealed that Resident #25 had surgical incisions with staples on the abdomen and left knee. There was no evidence of documentation regarding a skin issue on the resident's sacrum/coccyx.A Skin Ulcer Non-Pressure Weekly assessment created and signed March 13, 2026 by Staff #66, however dated March 12, 2026, revealed the resident had multiple surgical wounds to the left knee and left side of abdomen under pannus, with an onset date of February 24, 2026. There was no evidence of documentation regarding a skin issue on the resident's sacrum/coccyx.There was no evidence of any daily skilled nursing notes completed on March 13, or 14, 2026.Review of the MAR / TAR for March 2026, revealed that the record was not marked as completed for the physician orders to apply barrier cream to peri-area for incontinence every shift and to encourage and assist resident with repositioning frequently every shift for the day shifts on March 6, 7, 10, 12, 13, and 14.A daily skilled note dated March 15, 2026, revealed the resident had a left femur fracture with leg immobilizer, and that the resident's skin was clean, dry, intact, and warm to touch. Additionally, that there were no active symptoms affecting the integumentary system observed, and no active skin conditions or treatments observed.A shower sheet dated March 16, 2026, revealed Resident #25 had open and red areas in the genital region, staples in the left groin area, bruises and a cast on the left leg, and open and red areas on the sacral / coccyx area. Additional comments included that the resident's bottom and area in between legs were painful and the open areas were bleeding. The shower sheet was signed by a CNA and a nurse.The clinical record revealed no evidence that the resident's skin issues including red, painful, open, and bleeding areas were communicated to the provider on March 16, 2026.A Late Entry provider progress note dated March 16, 2026, revealed Resident #25 presented for follow-up with confusion about location and sleepiness, and had multiple wounds being redressed per orders. The note revealed assessment included altered mental status, wound care adherence, and oxygen therapy compliance, and the plan was to ensure proper wound care. Despite the documentation of unspecified wounds, the integumentary assessment revealed skin is warm and dry without rashes, lesions, or wounds noted. There was no evidence of documentation regarding the resident's skin issue on the sacrum / coccyx.A Late Entry daily skilled note dated March 16, 2026, revealed the resident required 2 staff for assistance with transfers and activities of daily living (ADLs). Additionally, that the resident's skin was clean, dry, and intact, and there were no active symptoms affecting the integumentary system observed, and no active skin conditions or treatments observed.A daily skilled note dated March 17, 2026, revealed the resident had a left femur fracture with immobilizer, and required 2 staff for assistance with transfers and ADLs. The note included that the resident had a skin injury / ulcer on the coccyx, and a surgical wound on the left femur, and that the skin condition was not a new onset. Additionally, the note revealed no further description or measurements of the skin injury / ulcer on the coccyx.A physician order dated March 17, 2026, included to wash with soap and water at each brief change and cover sacro-coccyx area with foam dressing, and change if soiled or dislodged, and to powder perineal area after each brief change, as needed for skin protection. The order was discontinued on March 18, 2026.A provider progress note dated March 18, 2026, revealed no evidence of documentation regarding wounds, or a skin injury / ulcer on the resident's coccyx. The note revealed the resident's skin is warm and dry without rashes, lesions, or wounds noted.A physician order dated March 18, 2026, included to wash with soap and water at each brief change and cover sacro-coccyx area with foam dressing, to change if soiled or dislodged, and to powder perineal area after each brief change, as needed for skin protection.Daily skilled notes dated March 18 and March 19, 2026, revealed the resident required 2 staff for assistance with transfers and ADLs. The note revealed the resident's skin was warm and dry, and that the resident had a skin injury / ulcer located on the coccyx, and a surgical wound located on the left femur.A physician order dated March 19, 2026, included for sacro-coccyx wound: to wash with wound wash and cover with foam pad dressing, and to change if soiled or dislodged, two times a day for wound treatment.A Weekly Skin Assessment created and signed on March 20, 2026 by a licensed practical nurse (LPN / Staff #43) however dated March 19, 2026, revealed that the resident had moisture associated skin damage (MASD) to the coccyx and upper rear thighs, with treatment in place, and staples in the left femur. The assessment revealed no evidence of further descriptors, including measurements of the MASD.Review of the MAR / TAR for March 2026, revealed a Braden Scale Assessment was marked as completed on March 20, 2026. Despite the physician order for weekly Braden Scale Assessments, review of the clinical record conducted on March 25, 2026, revealed no evidence that any other Braden Scale Assessments were completed after the initial one on March 6, 2026.A daily skilled note dated March 20, 2026, revealed Resident #25 required 2 staff for assistance with transfers and ADLs. The note included that the resident's skin was warm and dry, and that the resident had MASD located on the buttocks, and that the skin condition was not a new onset.A physician order dated March 20, 2026, included for sacro-coccyx wound: to wash with soap and water and apply A&D ointment liberally, every shift, and to cleanse and reapply A&D ointment if soiled.After an interview with the wound nurse (Staff #66) that was conducted on March 25, 2026, there was evidence of an assessment added to the clinical record. A Skin Ulcer Non-Pressure Weekly assessment created March 25, 2026, however dated March 19, 2026 and signed by Staff #66, revealed that Resident #25 had multiple left lower extremity surgical incisions, a surgical incision on abdomen under left pannus. The documentation revealed no evidence of a skin issue on the resident's sacral / coccyx region.Additionally, after the interview with the wound nurse (Staff #66) conducted on March 25, 2026, another assessment was added to the clinical record. A Skin Ulcer Non-Pressure Weekly assessment created March 26, 2026, however dated March 19, 2026 and signed by Staff #66 revealed the resident had a sacro-coccyx wound described as MASD, with an onset date on March 19, 2026. The assessment revealed the partial thickness sacro-coccyx wound measured 6 centimeters (cm) x 5 cm, and 0 cm deep. The wound had serous exudate and undefined wound edges. Surrounding tissue had peripheral tissue edema. Interventions included to wash with wound wash and cover with foam pad dressing, and to change if soiled or dislodged. There was no evidence of any daily skilled nursing notes completed on March 21, 22, or 23, 2026.A daily skilled note dated March 24, 2026, revealed the resident had a left femur fracture with a leg immobilizer, and required 2 staff for assistance for transfers and ADLs. The note included the resident's skin was warm and dry, and that the resident had MASD located on the buttocks, and a surgical wound located on the left femur.A CNA task log for turning and repositioning the resident every shift revealed for the question Did you turn and reposition?:March 6, 2026: no entries logged for day shiftMarch 21 - March 22, 2026: no entries logged for night shift.An interview was conducted with a CNA (Staff #3) on March 25, 2026, at 11:43 a.m. who stated that when she showers or bathes a resident, that a shower sheet with a body diagram is completed and that any new or existing skin issues are documented on the body diagram by the CNA, and that both the CNA and nurse sign the shower sheet. Regarding Resident #25, Staff #3 stated that the resident was easy to work with, was motivated to get up out of bed, and did not typically refuse treatments. Staff #3 stated that she recalled changing Resident #25 when the resident was on the 100 hall unit, and that the resident's sacral area was pretty bad. She stated that there was an open area with what appeared to be many small skin tears that were bleeding. Staff #3 stated that the nurse was aware of the skin issue and provided cream to put on the area.An interview was conducted with an Occupational Therapist (OT / Staff #49) on March 25, 2026, at 12:07 p.m. who stated that she had worked with Resident #25 in therapy and recalled the resident was always motivated to participate, and that there was an issue that the resident had frequent bouts of incontinence that required changing often. Staff #49 stated that she had been notified by Resident #25 that the resident had developed some skin breakdown on her bottom and had a sore there, and that therapy started providing pillows to help offload her bottom, as well as repositioning the resident.An interview was conducted with the wound nurse / registered nurse (RN / Staff #66) on March 25, 2025, at 12:59 p.m. Staff #66 stated that floor nurses perform initial skin assessments on residents when they first admit to the facility, and also weekly. Staff # 66 stated that he is notified by the floor nurses if there is a skin issue that needs to be assessed further by the wound nurse. Staff #66 stated that his expectation for a newly identified or worsened skin condition would be for the floor nurse to notify himself or the provider. Staff #66 stated that he was familiar with Resident #25 and that he had been notified by a floor nurse to assess the skin issue on her sacral area, and that he had noted skin degradation and breakdown in that area, but stated he could not recall when he was first notified. Staff #66 stated that he believed the area had worsened before it got better, but could not provide a timeframe. Staff #66 stated his assessment of the area was that it had an open area, peeling skin, redness, and some bleeding, and that it was caused by moisture. The clinical record was reviewed, and Staff #66 stated that after reviewing the skin assessments in the resident's medical record at that time, he could not tell what size the wound was, or further descriptors. Regarding the daily skilled treatment note on March 17, 2026, Staff #66 stated that the note referenced a skin injury / ulcer on the resident's sacrum / coccyx area, however no evidence that a skin assessment was conducted or any further descriptors. Staff #66 stated he did not know when he first looked at the resident's skin issue. Additionally, Staff #66 stated that based on review of the documentation, he could not tell if the resident's wound was getting better, worse, or remained the same, and that this would not meet his expectations.An interview was conducted on March 26, 2026, at 8:21 a.m. with a CNA (Staff #12) who stated that the CNAs offer showers or baths to residents twice per week, and complete documentation on a shower sheet that includes any skin issues or wounds, and that the CNA and the nurse both sign the document. Staff #12 stated that they (Staff #12) was familiar with Resident #25, and that they (Staff #12) were aware that the resident's skin was really raw and red on her perineal area and tailbone area. Staff #12 stated the resident was having excruciating pain when Staff #12 provided pericare and changing. Staff #12 stated that the facility definitely did not have enough staff to change and/or reposition Resident #12 every 2 hours, and that there were some times it would be over 3 hours before Staff #12 could assist her. Staff #12 stated they (Staff #12) had been begging management for additional staff, and today was the first day that there were enough staff on the floor to meet the residents' needs.An interview was conducted with a licensed practical nurse (LPN / Staff #28) on March 26, 2026, at 10:30 a.m. who stated that the CNA staff will provide the floor nurse a shower sheet to sign off on after a resident is showered or bathed. Staff #28 stated that the importance of CNAs including new and existing skin issues on the shower sheet body diagram is to notify nurses so that the correct treatment orders can be placed timely. Staff #28 stated that they (Staff #28) were familiar with Resident #25 and that the resident had excoriation on her backside toward the middle to top of her sacrum and coccyx. Staff #28 stated they (Staff #28) believed the area was getting better, and that the current treatment was to wash the area and cover with barrier cream.Another interview was conducted on March 26, 2026, at 11:25 a.m. with an LPN (Staff #30), who stated that if a new or worsened skin issue was noted, then an LPN would notify an RN, because LPNs are not supposed to perform assessments. Staff #30 stated that he noticed the resident had some redness on her sacral area and could not specify when, and notified the wound nurse (Staff #66) to assess the resident's skin, and that Staff #30 believed that the cause of the redness was both pressure-related and moisture-associated skin damage. Staff #30 stated that the CNAs are in charge of turning and repositioning the resident when providing care, and also when there is a physician order for turning and repositioning, that the nurses will remind the CNAs to do so. Staff #30 stated that some days, there were enough staff to turn and reposition residents who required repositioning and changing every 2 hours, however some days there were not enough staff, and that management had been notified of the need for more staff multiple times.An interview was conducted with a charge nurse / LPN (Staff #50) on March 26, 2026, at 11:50 a.m. who stated that the facility's process for preventing moisture associated skin breakdown was that the staff implemented skin checks and repositioning every 2 hours for residents who are incontinent, and the nurses perform weekly skin checks, and as needed. Staff #50 stated that she did not remember if she had ever seen Resident #25's skin condition on her sacral area and was not aware if there was a wound or not. The clinical record was reviewed, and Staff #50 stated that on the resident's initial skin assessment dated [DATE], the documentation revealed there was no skin condition present. Staff #50 stated that the skin assessments dated March 12, 2026, included no evidence of a skin condition on the resident's backside. Staff #50 stated that a skin assessment dated [DATE], signed by Staff #66 (created on March 26, 2026), revealed the resident had MASD that was described as a partial thickness wound, measuring 6 cm x 5 cm.An interview was conducted with the Assistant Director of Nursing (ADON / Staff #99) on March 26, 2026, at 12:13 p.m. who stated that the importance of having a complete and accurate medical record was so that care team members know what is going on with a resident and how to care for them. Regarding MASD, Staff #99 stated that the condition develops from moisture on the skin from incontinence, and can worsen if not addressed, and that facility staff prevent MASD by rotating and repositioning residents, providing peri-care so that incontinent residents are clean and dry, treating the affected skin with barrier cream, and providing showers. Staff #99 stated that CNA staff are expected to check incontinent residents at least every 2 hours. Staff #99 also stated that nurses perform weekly skin checks, and as needed, and that the if something is noted that requires the assessment of the wound nurse, that staff will notify the wound nurse who will then perform his own assessment. Staff #99 stated that if a CNA noted a new or worsened skin condition during the resident's shower, that the CNA would inform the nurse who would look at it, and include the documentation in the medical record. Regarding Resident #25, Staff #99 stated that she believed the resident had redness on her sacral area, and that she could not recall if she had notified the wound nurse or not. The clinical record was reviewed and regarding the MAR / TAR for March 2026, Staff #99 stated that the record showed no evidence that the barrier cream treatment was applied or that the resident was encouraged and assisted with repositioning frequently on March 6, 7, 10, 12, 13, and 14. Additionally, the clinical record was reviewed, and Staff #99 stated that it appeared the resident's sacral/coccyx skin issue was first noticed on March 17, 2026, and documented in the daily skilled assessment, and based on the limited documentation, there was no further assessment or descriptors of the skin issue, no measurements, no evidence that the provider or wound nurse were notified of the issue, and no evidence of what action was taken by the nurse that date. Staff #99 stated that it would not meet her expectation of identifying, assessing, and treating a skin condition, and that the risk to residents could be worsening skin conditions.A telephonic interview was conducted on March 26, 2026, at 13:00 p.m. with an LPN (Staff #5) who stated that she recalled working with Resident #25, and that Staff #5 had been notified by other staff that the resident had redness on her sacrum, but could not specify further details of how the skin appeared or when she was notified.An additional telephonic interview was conducted with an LPN (Staff #17) on March 26, 2026, at 5:42 p.m. who stated that she was familiar with Resident #25 and had cared for the resident when the resident was moved to the 400 hall, and that the resident had a skin issue on her sacrum that was already present from before the resident transferred to the 400 hall. Staff #17 stated that she was notified by a CNA that the resident was bleeding from the skin on her sacrum. Staff #17 stated that she then looked at the skin area on the resident's sacrum and noted that there was a large amount of blood from the skin on her sacrum, and that the area was caused by MASD from urine. Staff #17 declined to state whether she had notified either the provider or wound nurse regarding the bleeding skin issue, however did state that she knew the wound nurse was already aware of the issue.Review of the facility policy titled Wound Management, dated July 2025, revealed the nurse responsible for assessing and evaluating the resident's condition on admission are expected to take the following actions: complete comprehensive admission assessment/ evaluation and Braden Scale to identify risk and to identify any alterations in skin integrity noted at that time, develop comprehensive care plan if indicated following the evaluation/assessment, care plans must be individualized and designed to meet the needs of the particular resident for whom they are being developed, and complete weekly head to toe skin assessment with follow up as applicable. Once a wound has been identified, assessed, and documented, nursing shall administer treatment to each affected area as per the Physician's order. All wound or skin treatments should be documented in the resident's clinical record at the time they are administered. To prevent the development of skin breakdown or prevent existing pressure ulcers from worsening, nursing staff shall implement the following approaches as appropriate and consistent with the resident's care plan: Monitor impact of interventions and modify interventions as appropriate based on any identified changes in condition, reposition the resident as tolerated, and if the resident is incontinent, make sure that his/her skin remains clean and dry with regular peri-care and toileting when appropriate. Review and/or re-evaluate existing treatment regimen in connection with the resident's clinical presentation, to include current interventions and care plan considerations, if any wound is non-healing or not showing signs of improvement after a given time or any time a wound is worsening.Review of facility policy titled Physician Orders, dated June 2025, revealed it is the policy of this facility to accurately implement orders in addition to medication orders (treatment, procedures) only upon the order of a person duly licensed and authorized to do so in accordance with the resident's plan of care. Medication, treatment or related procedure orders are transcribed in the MAR / TAR accordingly.Review of the facility policy titled Documentation and Charting, revised July 2022, revealed it is the policy of the facility to provide a complete account of the resident's care, treatment, response to care, signs, symptoms, etc., as well as the progress of the resident's care, guidance to the physician in prescribing appropriate medications and treatments, as well as nursing services personnel with a record of the physical and mental status of the resident.Review of the facility policy titled Change of Condition Reporting revised July 2025, revealed it is the policy of the facility that all changes in resident condition will be communicated to the physician. Unusual signs and symptoms will be communicated to the physician promptly, and the nurse in charge is responsible for notification of physician prior to the end of assigned shift when a significant change in resident's condition is noted. Document resident change of condition and response in progress notes and update resident care plan as indicated. All attempts to reach the physician and responsible parties will be documented in the nursing progress notes, and documentation will include time and response.

Based on observation, resident and staff interviews, facility documentation, and policy review, the facility failed to ensure that food items were palatable, and at a safe and appetizing temperature. The deficient practice could decrease residents' desire to eat which could impact their nutrition status and lead to slower recovery from illnesses or injury. Findings include:Review of the facility's 2025 Grievance log revealed the following food related grievances for the following months:January: general dietary/food concernsAugust: dietary concerns regarding temperatureOctober: food preference issues (2 different residents)November: general dietary/food concernReview of the 2025 Resident Council Meeting Minutes documented the following food related issues brought up by attendees during the indicated month's meeting:January: concerns regarding menu varietyFebruary: concerns regarding food portionsMarch: concerns regarding food portionsApril: concerns regarding food portionsJune: concerns with dietary restrictionsJuly: indicated that residents were educated regarding proper food serving temperaturesDuring screening interviews conducted with residents on January 4, 2026, multiple residents expressed to various surveyors that food was not appetizing because of temperature and taste. The following were resident comments regarding food: Resident #23 stated on January 4, 2026 at 9:21 a.m. that the food is shit and cold;Resident #20 said on January 4, 2026 at 9:40 a.m. that food is repetitive and not appealing;Resident #18 indicated on January 4, 2026 at 10:02 a.m. that her main concern is food because it does not look appealing. Additionally, the resident noted that food looks edible but most of the time, it is not;Resident #72 stated on January 4, 2026 at 10:18 a.m. that food sucks-not appealing;Resident #48 noted on January 4, 2026 at 12:25 p.m. that food is always cold and that he had constantly complained to staff about food;Resident #123 commented on January 4, 2026 at 2:02 p.m. that food is kind of yucky; and, Resident #73 said on January 4, 2026 at 3:51 p.m. that food is not good and always coldA lunch test tray was ordered on January 5, 2026 and arrived in the conference room at 12:46 p.m. The test tray sample consisted of fettucine alfredo with chicken, steamed broccoli, garlic breadstick, mashed potatoes and gravy. The items were temperature checked and the readings were as follows:Fettucine alfredo with chicken: 148.2 FahrenheitSteamed broccoli: 152.3 FahrenheitMashed potatoes: 138.9 FahrenheitGravy: 158.8 FahrenheitThe portion size was adequate. However, the steamed broccoli was grayish-green in color, was bland, overcooked and mushy. The fettucine alfredo with chicken had the chicken pieces looked like tuna flakes. The garlic breadstick tasted stale. A group interview with residents which included resident council members was conducted on January 5, 2026 at 2:37 p.m. There were approximately 12 attendees; and, the following issues were voiced out the attendees:Food is unappealing and tasteless;Food is mushy and tasteless;When you ask for more they are told that the kitchen is out of that item; and, Double portions look the same as regular portionAn interview with the Social Services Manager (staff #108) was conducted on January 6, 2026 at 12:15 p.m. Staff #108 stated that previously food concerns were trending during resident council meetings. However, the complaints pertaining to food had gone down.During an interview with the Dietary Supervisor (staff #39) conducted on January 6, 2026 at 3:02 p.m., staff #39 stated that dietary staff attends resident council meetings. Per staff #39 food concerns were normally brought up during resident council or via nursing staff from the resident; and that, whenever a food temperature issue comes up, she goes and temps the food served in the dining room and resident room. Staff #39 said that they had no complaint/s regarding the food not being appealing or appetizing. However, if she was to receive such a complaint, she would offer a substitute meal to the resident. Further, staff #39 said that it was important to provide food that is nutritious, appealing, and appetizing since it is what helps residents; and that, the impact of not having nutritious, appealing, and appetizing meals is that residents would lose weight, wounds would not heal, and residents could get sick.An interview with a Certified Nursing Assistant (CNA/staff #91) was conducted on January 6, 2026 at 4:17 p.m. The CNA stated that residents have complained about food being cold; and, this was because there was not enough staff so food is not delivered on time. Additionally, she stated that residents had complained to her about food not being appetizing or appealing.During an interview with the Director of Nursing (DON/staff #48) conducted on January 6, 2026 at 5:59 p.m., the DON stated that her expectation was that food served to residents were edible, meet nutritional guidelines and portion, hot, and appropriate temperature. The DON stated that this was important so residents would eat and are provided nutritional intake; and, the impact of food not being nutritious, appealing and appetizing is that residents could lose weight, could suffer from adverse reaction if they have condition such as diabetes, and wounds could be created. In an interview with another CNA (staff #12) conducted on January 7, 2026 at 7:15 a.m., the CNA stated that residents have told her that food was not appealing or appetizing. The CNA indicated that when this occurs, then residents are asked if they want an alternative. Further, the CNA the potential impact of residents not being provided meals that are appealing/appetizing is that the residents would not get enough nutrients if they do not eat. This could lead to residents getting sick and their health declining.During an interview with a Licensed Practical Nurse (LPN/staff #69) conducted on January 7, 2026 at 7:50 a.m., staff #69 stated that residents have approached her with food concerns pertaining to the food not being appealing or appetizing. Per the LPN if the resident does not like the menu, she offers them an alternative as a substitute. According to the LPN if the resident is not provided appealing/appetizing meals then the resident might not receive the appropriate nutrition needed which could lead to deficiency. This could cause healing to be affected.Review of the undated facility policy titled Food Temperatures revealed that foods should be transported as quickly as possible to maintain temperatures for delivery and service. The facility policy titled Menus revised May 2022 indicated that it is the policy of the facility to assure that menus are developed and prepared to meet the nutritional needs of the residents and resident choices while using established national guidelines. Further review of the facility's policies pertaining to dietary/kitchen services did not reveal that it addressed food items being appetizing or appealing.

Based on closed record review, staff interviews, and review of facility documentation and policy, the facility failed to ensure that the Ombudsman was notified of the transfer/discharge for 3 of 4 sampled residents (#115, #118, & 110). The deficient practice could lead to notifications and pertinent information regarding the discharge/transfer not being provided. Findings include: -Resident #110 was admitted to the facility on [DATE] with diagnoses that included encounter for other orthopedic aftercare of right hip fracture, hemiplegia of the right dominant hand, failure to thrive, dementia, and type 2 diabetes mellitus. The care plan initiated on October 4, 2025, revealed a focus on failure to thrive, diabetes, high blood pressure, seizure, urinary tract infection, dementia, and anorexia. The goal would be for the resident to be free from complications related to infection. The interventions included to administer medications as ordered and to monitor and document for side effects and effectiveness; dietary consult for nutritional regimen and ongoing monitoring; monitor, document and report to medical doctor as needed any signs and symptoms: headache, visual problems, confusion, disorientation, lethargy, nausea, vomiting, irritability, seizure activity, decreased appetite, and difficulty breathing; and keep routine consistent and try to provide consistent care givers as much as possible in order to decrease confusion. Review of the clinical record revealed that a nurse practitioner was updated on Resident #110's status, the resident had a decreased by mouth intake at breakfast, lunch and with med pass; had a facial and eye twitching; the Resident was unable to follow commands; and the Resident's vital signs were, blood pressure of 118/57, heart rate of 112, and respiratory rate of 24. Resident #110's family member was at bedside, and the family member requested Resident #110 to be transported to the emergency room. Resident #110 was sent out to the hospital on October 11, 2025. There was no evidence found in the clinical record and facility documentation that the Ombudsman was notified of the resident's transfer to the hospital. -Resident #115 was admitted to the facility on [DATE] with diagnoses of dysphagia, dysarthria, cerebral edema chronic ischemic heart disease, atrial septal defect, type 2 diabetes mellitus, atherosclerotic heart disease, parkinsonism, gout, and spinal stenosis. Review of the Order Summary Report revealed a physician order dated June 30, 2025 indicating that the resident may discharge home with remaining narcotics. A Discharge Summary and Post-Discharge Plan of Care dated June 30, 2025 documented a planned discharge scheduled for July 1, 2025. A Discharge Summary – Nursing note dated June 30, 2025 documented that the resident was given instructions for ongoing care, information on community resources, and patient advocacy. Furthermore, review of the resident's signed Transfer/Discharge Report dated July 1, 2025 revealed that it included an inventory of resident's personal effects, list of medications, and medication prescriptions. Review of the resident's face sheet revealed that he is his own financial responsible party. Additionally, the face sheet indicated the resident's wife as his emergency contact and listed her contact information. Additionally, the face sheet noted that the resident was discharged home on July 1, 2025. A discharge Minimum Data Set (MDS) assessment dated [DATE] revealed the reason for the assessment as discharge – return not anticipated. The MDS indicated that the resident was discharged to home/community. Per the assessment the resident had a Brief Interview for Mental Status (BIMS) score of 15 indicating that he was cognitively intact. Further review of the resident's clinical record did not reveal any documentation of ombudsman notification regarding the discharge. Additionally, there was no facility documentation available regarding ombudsman notification. -Resident #118 was admitted to the facility on [DATE] with diagnoses that included paroxysmal atrial fibrillation, neuropathy, and morbid obesity. A Discharge Summary – Nursing note dated December 22, 2025 documented that the resident was given instructions for ongoing care, information on community resources, and patient advocacy. The Order Summary Report revealed a physician order dated December 23, 2025 for the resident to discharge home on December 24, 2025. Review of the resident's face sheet revealed that the resident was her own financial responsible party. The face sheet indicated the resident's friend was her emergency contact and listed the friend's contact information. Additionally, the face sheet noted that the resident was discharged to home on December 24, 2025. The discharge Minimum Data Set (MDS) assessment dated [DATE] revealed that the reason for the assessment was discharge – return not anticipated. The MDS indicated that it was a planned discharge to home/community. Additionally, the MDS noted a Brief Interview for Mental Status (BIMS) score of 15 indicating that the resident was cognitively intact. Furthermore, review of the resident's signed Transfer/Discharge Report dated December 24, 2025 revealed that it included an inventory of resident's personal effects, list of medications, and medication prescriptions. Further review of the resident's clinical record did not reveal any documentation of ombudsman notification regarding the discharge. Additionally, there was no facility documentation available regarding ombudsman notification. An email correspondence with the Ombudsman office dated January 5, 2026 stated that they have not received discharge notices since June 2024. An email correspondence with the Director of Nursing (DON/staff #48) dated January 6, 2026 annotated that notification to ombudsman is verbal and occurs during ombudsman visits. An interview with the Social Services Manager (SS Mgr/staff #108) was conducted on January 6, 2026 at 12:15 p.m. Staff #108 admitted that when it came to ombudsman notification, she failed to do it the right way. Staff #108 said that she was in communication with the ombudsman. According to staff #108 she has been made aware that she has to notify the ombudsman if someone discharges from long-term care. Staff #108 stated she assumes that the ombudsman is a resource for resident and might need it as resident discharges as to why it is important to notify the ombudsman of transfer/discharge. Staff #108 noted that she does not know how to answer what the impact of not notifying the ombudsman of transfer/discharge. Staff #108 admitted that she had not started notifying the ombudsman formally. An interview with the Director of Nursing (DON/staff #48) was conducted on January 6, 2026 at 5:59 p.m. The DON stated that her expectation is that Social Services notify the ombudsman of discharges. According to staff #48 the ombudsman participates in resident council and visits with the social worker but was not sure of the extent of their interaction. The DON noted that it is important to notify the ombudsman of transfer/discharge since the ombudsman is the advocate for the residents. Per the DON the impact of failure to notify the ombudsman of transfer/discharge is that the residents might not get the services or additional resource for them. The DON admitted that the facility did not know that the ombudsman notification had to be in writing. Review of the facility policy titled Discharge or Transfer revised June 2023 indicated that it was the facility's policy to provide the resident with a safe, organized, structured transfer and or discharge. Further review of the facility's policy for discharge/transfer did not reveal that it addressed transfer/discharge notification to resident/resident representative. Additionally, the policy did not indicate what the required information are that is to be provided to the resident/resident representative. Furthermore, the policy did not state that the ombudsman would be notified of transfer/discharge. Per the State Operations Manual Appendix PP, revision 232, the facility must notify in writing the resident and the resident's representative of the transfer/discharge which includes the following items: The reason for the transfer or discharge; The effective date of the transfer or discharge; The location to which the resident is transferred or discharged A statement of the resident's appeal rights including the name, address and telephone number of the entity which receives the request, and information on how to obtain an appeal form and assistance I completing the form and submitting the appeal hearing request The name, address and telephone number of the Office of the State Long-Term Care Ombudsman The contact information for the agency responsible for the protection and advocacy of individual with developmental disabilities (if applicable) The contact information for the agency responsible for the protection and advocacy of individual with mental disorder (if applicable) Additionally, the facility must send a copy of the notice to a representative of the Office of the State Long-Term Care Ombudsman.

Based on observations, clinical record review, staff interviews, and facility policy review, the facility failed to ensure that medications were not left at the bedside for two residents (#62 and #121). Census was 100. The deficient practice could result in harm to the residents and/or visitors who have access to medications.-Resident #121 was admitted to the facility on [DATE], with diagnoses that included pneumonia (lung infection), atrial fibrillation (irregular heart rate), hypertension (high blood pressure), and need for assistance with personal care. A review of order summary revealed an order dated December 31, 2025, for Metoprolol Tartrate oral tablet 25 MG (milligram) give half a tablet by mouth two times a day for high blood pressure, and an order for Saccharomyces Boulardii (probiotic) capsule 250 mg give 1 capsule by mouth two times a day for probiotic. The IDT (interdisciplinary team) - BIMS (Brief Interview for Mental Status) dated January 1, 2026 revealed a BIMS score of 14.0, indicating that the resident was cognitively intact. The Functional Performance Observation dated January 1, 2026, revealed that the Resident was independent with eating and oral hygiene, and mostly required supervision or touching assistance. The order for Metoprolol and Saccharomyces boulardii were transcribed onto the January 2026 Medication Administration Record (MAR). There was no evidence in the clinical record that the resident was assessed for self-administration or a physician order that the resident medications can be left at bedside for Resident #121 to self-administer at a later time. Review of the January 2026 MAR revealed that both of the medications were administered on January 4, 2026 at the 8:00 AM schedule. However, during an observation conducted on January 4, 2026, at 11:32 a.m., Resident #121's medications was left at her bedside table. When Resident #121 was about to take her pills, she knocked it over and the medicine cup flipped along with her 2 pills. She said that she was able to hold on to the white capsule which was her probiotic, but she could not find the tiny pill for her irregular heart rate. She said that she was not able to take her pills right away when the nurse gave it to her because she was on the phone with her brother, who was calling her from out of town. On June 4, 2026, at 11:38 AM, a certified nursing assistant (CNA/Staff #30) came into Resident #121's room. Resident #121 informed Staff #30 that the nurse brought her the medications, and she tipped it over. Staff #30 said that he will inform the nurse. At 11:42 AM, a Licensed Nursing Assistant (LNA/Staff #106) entered Resident #121's room. Resident informed Staff #106 that her medication cup flipped. Staff #106 stated to inform the nurse. At 11:48 AM, a Licensed Practical Nurse (LPN/Staff #90) entered Resident #121's room. Resident #121 informed the LPN that she did a bobo, Resident #121 said that she was going to take her pills but the medication cup went flying. The LPN stated that she will give her another pill. At 11:50 AM, the LPN returned in Resident #121's room. The LPN stated that she brought Resident #121's metoprolol 12.5 mg (milligram) pill. Then the LPN also stated that she found the other pill, and it was dropped in the trash can. While the LPN was with Resident #121, Resident #121 stated dropped another one; Resident stated that the medication flipped out of her mouth. At 11:53 AM, the LPN left Resident #121's room and said to get another one. An interview was conducted on January 6, 2026, at 1:36 PM, with LPN (Staff #80) who stated that her role as a charge nurse included to support and oversee nursing staff. Regarding medication administration, she said that she would follow the medication direction to ensure that the right order, right dose, right route, right time, right medication were followed. The LPN said that she would then pull the medication, close her MAR, lock the medication cart, and walk into the resident's room; and, would tell and explain to the the resident what the medication was for. She said that she would then give the medication to the resident; and, observe the resident taking their medications to ensure it is taken appropriately. She said that she would not leave the medications at bedside because it was not their policy, unless there was an order to may leave at bedside. Further, she said that for her to leave a medication at bedside, there has to be an assessment called self-administration of medication. She stated that a potential bad outcome for leaving a medication at the resident's bedside include the resident may not take the medication, and if it was a heart medicine, for instance, their heart rate would not be controlled. The Director of Nursing (DON/Staff #48) was interviewed on January 6, 2026, at 2:12 PM. The DON stated that the process and expectation for medication administration was to have an order from the provider; and that, nurses administers the medication as ordered including the right time, right medication, right route, and right resident. The DON said that during a medication pass, the nurse introduces herself; informs the resident what medication they are getting and what it was for; and observe the resident swallow the medication. The DON stated that she would not leave the medication at the bedside. The DON said that the only time she would leave medications at bedside was when there is an order for it and the resident was alert and oriented. She also said that she would not leave the medication at bedside because it would place the resident and other residents at risk, and the risk depends on the type of medication. Further, the DON stated that the medications, Metoprolol and probiotic, for Resident #121 should not have been left at bedside because there was no order to leave at the bedside. -Resident #62 was admitted on [DATE], with diagnoses of acute posthemorrhagic anemia, atrial fibrillation, gastro-esophageal reflux disease (GERD) without esophagitis, and alcohol dependence. The care plan dated July 21, 2025, had a focused care area for Gastroesophageal Reflux Disease (GERD) related to medication use. Interventions included giving medications as ordered, monitoring/documenting side effects and effectiveness, and vital signs as ordered. The Quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 15, indicating that the resident was cognitively intact. The physician's order dated December 24, 2025, revealed orders for Calcium Carbonate (antacid) chewable 500 MG (milligram), give one tablet by mouth before meals for GERD without Esophagitis. Review of the medication administration record (MAR) for December 24, 2025, through December 31, 2025, revealed that Calcium Carbonate was administered to Resident #62 as ordered. Review of the physician orders from December 24, 2025, through January 4, 2026 revealed no physician order for resident #62 to self-administer Tums medications. The MAR for January 1, 2026, through January 4, 2026, revealed that Calcium Carbonate was documented as administered as ordered. There was no evidence found in the clinical record that the resident was assessed for self-administration of prescribed medications from July 20, 2025 through January 4, 2026 at 9:36 a.m. An observation was conducted on January 04, 2026, at 9:36 a.m., Resident #62 was awake in her room, lying in her bed and watching television. There was a glass of water, a white, clear cup containing 3 pink circular pills. Resident #62 stated that the pills in the cup were her tums that she takes for her stomach issues; and that, the nurses leave them here for her to take when she needs them. In an interview with the Licensed Practical Nurse (LPN/staff #93) conducted on January 4, 2026, at 9:56 a.m., the LPN identified the medication as Tums and stated that these medications were usually left on the bedside table of Resident #62 for the resident to take by herself. She stated that she left the Tums at the resident's bedside today. She stated that the nurse would give the Tums to Resident #62 who usually took them right away; but that, today, the resident did not. She further stated that Resident #62 does not have a self-administration assessment and that medications should not be left at the bedside for Resident #62. However, the LPN stated that there was no risk associated with leaving Tums at the bedside. Shortly after the observation, the initial evaluation for Self-Administration of Medication was conducted and dated January 4, 2026, revealed that Resident #62 received the approval for self-administration. Assessment included that resident #62 can correctly state the name of the medication, what the medication is used for, state common side effects, state the time when it is supposed to be taken, was the medication is used for, proper dosage; and that, resident #62 was fully capable. The assessment also included that Resident #62 can be assisted with proper handwashing technique before and following medication administration, can correctly measure the appropriate amount of medication from the container, correctly document self-administration The physician's order dated January 4, 2026, included the resident may have Tums at the bedside. An interview was conducted on January 04, 2026, at 9:52 a.m. with a Certified Nurse Assistant (CNA/staff #95), who identified the medication as Tums and stated that no medication should be left at the bedside. She further stated that, as she was not a nurse and was unsure whether there was any risk associated with leaving the Tums at the bedside. An interview was conducted on January 5, 2026, at 2:19 p.m. with the Registered Nurse (RN/staff #76) who stated that no medication including Tums should be left at a resident's bedside unless there was a physician's order to do so. She further stated that if a resident has a physician order to self-administer Tums, the medication should be stored in an appropriate container. Further, the RN stated that leaving Tums at the bedside could pose a risk of medication interactions and electrolyte imbalance. During an interview with the Director of Nursing (DON/ Staff #48) conducted on January 6, 2026, at 2:13 p.m., the DON stated that no medication should be left at a resident's bedside unless the resident has a physician's order for medication self-administration. She stated that Tums may be left at the bedside if the resident was alert and oriented, understands the medication being taken and the reason for it, and has a physician's order to self-administer. She further stated that if there were multiple pills in a medication cup, they should be stored in an appropriate container. The DON stated that leaving medications such as Tums at the bedside could pose a risk to the resident and/or other residents, as another individual could take the medication and potentially experience an allergic reaction. She further stated that leaving medication at the bedside without a physician's order would not meet the expectations of the facility or her own. Review of the facility policy titled Medication Access and Storage, E kit access last revised in June 2025 revealed that it is their policy to store all drugs and biologicals in locked compartments under proper temperature controls. The medication supply is accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications. Only licensed nurses, the consultant pharmacist and those lawfully authorized to administer medications (e.g., medication aides) are allowed access to medications. Medication rooms, carts, and medication supplies are locked or attended by persons with authorized access. The facility policy titled Self Administration of Medications, last revised June 2023, revealed that it is their policy to respect the wishes of alert, competent residents to self-administer prescribed medications as allowable under state regulations. The purpose was to determine the ability of alert residents to participate in self-administration of medication and to maintain the safety and accuracy of medication administration. If a resident desires to participate in self-administration, the interdisciplinary team will assess and periodically re-evaluate the resident based on change in the resident's status. The residents cognitive, communication, visual, and physical ability to carry out this responsibility will be evaluated. If the interdisciplinary team determines that this resident is unable to carry out this responsibility the interdisciplinary team may withdraw this right. If the resident is a candidate for self-administration of medications, this will be indicated in the chart. Resident will be instructed regarding proper administration of medication by the nurse. Nursing will be responsible for monitoring self-administered doses in the resident's medication administration record (eMAR). Storage and location of drug administration (e.g. resident's room, nurses' station, med cart, or activities room) will comply with state and federal requirements for medication storage.

Based on observations, staff interviews, facility documentation, review of facility policies and procedures, the facility failed to ensure infection control standards/protocols related to Transmission Based Precautions (TBP) and hand hygiene were followed by staff. Census was 100. The deficient practice could result in the spread of infection to residents and staff.Findings include: -Regarding Hand Hygiene An observation of hall 100 was conducted on January 05, 2026, at 8:09 a.m. a certified nursing assistant (CNA/staff #55) went into a resident room [ROOM NUMBER] and took the Resident's breakfast tray and exited the room. The CNA then entered the another resident room [ROOM NUMBER] and touched the resident's bed and call light of the resident. The CNA exited room [ROOM NUMBER] and went directly into resident room [ROOM NUMBER]. The CNA did not perform hand hygiene before and after entering resident rooms and touching items found in the rooms. An interview was conducted on January 05, 2026, at 8:36 AM with the CNA (staff #55) who stated that hand hygiene should be performed before assisting with feeding, changing the resident's brief, performing catheter care, or going in and out of the resident room. She stated that she always washes her hands before she leaves any resident's room; and will perform hand hygiene after putting the resident's tray on the cart. She stated that it is important to perform hand hygiene because it will protect her and others from any sickness; and, if hand hygiene was not performed, it can pose a risk of cross-contamination and spreading sickness. Another observation in hall 200 was conducted on January 05, 2026 at 10:39 a.m. a staff entered a resident room, turned off the call light and exited the room without performing hand hygiene or used a hand sanitizer before and after entering the resident room. In another observation in hall 400 was conducted on January 05, 2026 at 10:43 a.m a staff entered and exited a resident room without performing hand hygiene or used a hand sanitizer. On January 5, 2026, at 1:51 p.m. an interview was conducted with a CNA (staff #13) who stated that staff must perform hand hygiene before entering and after leaving a resident's room. She said she uses hand sanitizer each time she goes in and out. She said that hand hygiene was important to prevent the spread of germs between staff and residents; and, not performing hand hygiene can lead to infections, such as flu or COVID-19, by spreading germs. An interview was conducted with a a Registered Nurse (RN/staff #76) on January 5, 2026, at 2:19 p.m. The RN stated that staff should clean their hands when entering and leaving a resident's room and use hand sanitizer each time. She said staff should wash their hands with soap and water if they are visibly dirty, such as when there is debris or body fluids on them. Further, she said that failing to perform hand hygiene can spread germs to residents and make others sick, so standard precautions must always be followed. During and interview with the Director of Nursing (DON/staff #48) conducted on January 6, 2026 at 2:13 p.m. the DON stated that staff were expected to wash their hands before and after providing patient care; and, if there was no direct patient contact, staff may use hand sanitizer. She said that staff must sanitize their hands after touching surfaces or resident belongings and before entering a resident's room; and, not performing hand hygiene increases the risk of infection transmission. -Regarding Following Transmission Based Precaution (TBP) Signage/Protocols During an observation conducted on January 4, 2026 at 9:45 a.m., there were two signs posted on the door of a resident room in the 100 hall: one sign indicated Enhanced Barrier Protection (EBP) and another sign indicated Contact Precaution. This room was occupied by 2 female residents. The sign posted for Contact Precaution included that staff must put gloves on and gown must be worn before entering the room and discarding the gown and gloves before exiting the room. Immediately following the observation, an interview with a Registered Nurse (RN/staff #58) was conducted on January 4, 2026 at 9:51 a.m. The RN stated that he does not know which precaution or TBP posting was to be followed for which resident in the room. The RN also said to ask Management for this information. On January 4, 2026 at 10:00 a.m., a staff member entered the same resident room in the 100 hall and provided the two female residents in the room hygiene supplies. Shortly after, another staff entered the room. Both staff did not have any PPE (Personal Protective Equipment) on and did not perform hand hygiene prior to entering the room. An interview with a Certified Nursing Assistant (CNA/staff #30) was conducted on January 4, 2026 at 10:04 a.m. The CNA stated the sign on the door which was on the left was intended for the resident in bed A; and, the sign on the right was for the resident in bed B. He said that the precaution signs posted on the door were meant to guide for staff; however, he did not know why the two residents in the room on the 100 hall were on precautions and did not believe the precautions applied to them. Therefore, he stated that the posted precaution signs for that room did not need to be followed. On January 4, 2026 at 10:08 a.m., the RN (staff #58) was removed both the EBP and Contact Precautions signs posted in the resident room in the 100 hall and placed both signs on top of the isolation cart located across the resident room in the 100 hall. An interview with the Infection Preventionist (IP/staff #103) was conducted on January 5, 2026 at 11:05 a.m. The IP stated that two residents with different TBP were not usually placed in the same room due to the risk of cross-contamination; however, if this occurs, the stricter TBP must be followed. The IP said that precaution signs were posted on resident doors to inform staff of the correct TBP to follow and that these precautions must be followed. She stated that signs were removed when they no longer apply or when a resident is discharged . She also said that staff, especially the nurse assigned to the resident, should know why a TBP sign was posted; and if they are unsure, they should contact her. She stated it is not appropriate to remove a sign without contacting her, as staff may miss important information about the resident's condition. The IP stated that the two residents in the room on the 100 hall were not supposed to be on TBP, and the signs should not have been posted. However, she said that since the signs were posted, staff should have followed the instructions until it was confirmed that they were not needed. She further stated that following TBP signage was important because a resident may have an infection; and, staff should be aware of the infections and TBP status of each assigned resident so they know what to monitor. The IP said that failure to follow TBP precautions could result in the spread of infection. During an interview with the Director of Nursing (DON/staff #48) conducted on January 6, 2026 at 5:59 p.m., the DON stated that her expectation was for staff to follow TBP signs posted in the resident room signage unless told otherwise; and that, she expected the nurse to know enough about infections and TBP related to the resident/s assigned to them. The DON also said that it was inappropriate for staff to be unfamiliar with resident assigned to them; and that, if staff were not familiar with TBP for their resident, the expectation was for staff to follow the precaution signs posted and to look into what was going on with that resident. She stated that it was important for staff to be familiar with residents in their care so that staff can monitor for adverse reaction. Further, the DON stated that she expected staff to follow standard precautions, hand hygiene and to follow the most stringent of the TBP if there were conflicting information. The DON said that following/implementing infection control standards was important to prevent infection and to protect not only the residents but the staff themselves; and, there is an increased potential for infection to spread if infection control protocols such as hand hygiene and TBP were not followed. Review of the facility policy titled Infection Prevention and Control Program revised/reviewed October 2024 stated that elements of the infection control prevention and control program included coordination/oversight, surveillance, outbreak management, prevention of infection, and employee health and safety. Additionally, the policy noted that the facility will decide what measures/interventions should be applied in individual circumstances. The facility policy titled IPCP (Infection Prevention and Control Program) Standard and Transmission-Based Precautions revised/reviewed October 2024 stated that it is their policy to implement infection control measures to prevent the spread of communicable diseases and conditions. The policy noted that they use and type of PPE (Personal Protective Equipment) is based on the predicted staff interaction with residents and the potential for exposure to blood, body fluids, or pathogens. Transmission-Based Precautions are the second tier of basic infection control and used in addition to Standard Precuations for patients who are or may be infected or colonized with certain infectious agents for which additional precautions are needed to prevent infection transmission.

Based on observation, interview, and review of the facility's policies, the facility failed to ensure that 7 of 7 sampled residents (#65, #344, #38, #13, #19, #58, and #33) were provided a comfortable and homelike environment. The deficient practice could have a negative psychosocial impact on residents. -Regarding Residents #65 and #344: An observation was conducted on September 30, 2024 at 10:43 AM of room [ROOM NUMBER] belonging to Resident #65 who was not in the room at that time. From the doorway, observation of the wall revealed that paint had been scraped off of behind and surrounding the headboards of both A and B beds. An additional observation was conducted of the wall in room [ROOM NUMBER] later that day on September 30, 2024 at 2:25 PM. Per the floor nurse, Resident #65 was still out at an appointment. The area where the paint had been scraped off of the wall had still not been re-painted over. It appeared white where the paint had previously been scraped off, in contrast to the tan color of the wall paint. On October 02, 2024, at 10:48 AM, an additional observation was conducted of room [ROOM NUMBER]. At that time, Resident #65 had discharged , and Resident #344 had admitted into the room. The area where the paint had been scraped off of the wall had still not been repaired. Numerous areas of paint damage were present, with each white area appearing approximately 4-5 inches wide. An interview was conducted on October 02, 2024, at 12:30 PM, with Resident #344 who was in the room at that time. Resident #344 stated that he had noticed that the paint was scraped off of the walls around the headboards of the beds, and that if the room looked messy, that it would bother him. Supplemetal visual evidence of room [ROOM NUMBER] were obtained during observation. -Regarding Residents #38 and #13: An observation was conducted on October 02, 2024, at 10:51 AM, of room [ROOM NUMBER] belonging to Resident #38 and Resident #13. From the doorway, observation revealed that paint had been scraped off of the wall behind and surrounding the headboard of Resident #38's bed. Additionally, there were patches with missing paint on the wall above and to the left side of Resident #13's bed. Further, observation revealed paint scraped off of the wall with broken and damaged drywall visibly on the wall below the resident's window and located approximately 12 inches above the floor. -Regarding Resident #19: An observation was conducted on October 02, 2024, at 10:54 AM of room [ROOM NUMBER] where Resident #19 resided. Observation revealed elongated area of paint, approximately 1-4 inches high by approximately 4 feet long had been scraped off of the wall, easily seen from the doorway of the room. The area was located about 1-2 feet above the floor, and under the window. The drywall was damaged and broken in that area. -Regarding Residents #58 and #33: An observation was conducted on September 30, 2024 at 12:48 PM of room [ROOM NUMBER], belonging to Resident #58 and Resident #33. On the ceiling, directly above Resident #58's bed, was a crack with a liquid residue stain on the ceiling. An additional observation was conducted on October 02, 2024, at 12:35 PM of the ceiling in room [ROOM NUMBER]. The crack on the ceiling was still present. It was approximately 2 feet long, and the brown colored liquid residue mark surrounding the crack was still present as well. In an interview was conducted at that time with Resident #58, who stated that it was important to her how her room looked, and that the crack on the ceiling had been there for as long as she had been there. An interview was also conducted with Resident #33 on October 02, 2024 at 12:38 PM. Resident #33 stated that the ceiling crack had been there longer than she had been there, and further specified that she had been there for over a year. She stated that it looked like there was water dripping because of water marks around it, and that it bothered her because it is unsightly. She stated that she had told facility staff about it when she first moved into the room. On October 02, 2024 at 11:03 AM, an interview was conducted with the Maintenance Director (Staff #55), who stated that he performed daily walk through the building to assess the need for repairs or maintenance tasks. On October 02, 2024 at 1:42 PM an additional interview was conducted with Staff #55, who stated that his daily maintenance walk-throughs include walking through each hallway. He stated that room checks were done weekly. He also stated that, when a new admission is scheduled to come into a room, staff were trained to inspect the room and to look for any needed maintenance repairs, and then notify him. He stated that if a maintenance issue was noticed, then they fix it when the issue is found. At this time, a walk-through was conducted alongside Staff #55 through rooms 104, 402, 404, and 412, where the missing paint areas, damaged drywall areas, and the crack in the ceiling were all observed. Staff #55 stated that the facility ordered new beds with extended bumpers on the headboard side of the bed to help protect the paint from being scraped off the wall. He stated that the paint being scraped off of the walls from the beds won't be an issue in the future. On October 02, 2024 at 1:54 PM, an interview was conducted with the Administrator (Staff #195). The Administrator stated that as far as the building appears, we do our best to keep it a homelike environment, so that residents can enjoy their space. He stated that the importance of timely maintenance work was to ensure that the building looks and feels good. If maintenance issues were not reported timely -- then the building might not appear as attractive as we would want it to be, and this could cause dissatisfaction with the residents. Staff #195 stated that the facility had recently secured a quote from a construction company to provide a facelift for the rooms in order to improve them; and that, there are intensified efforts over the past year to ensure that building appearance is being fixed. Review of the facility's policy titled Homelike Environment, revised May 2022, revealed that the facility will provide a homelike environment. An additional review of the facility's policy titled Maintenance Request/Work Orders, revised September 2023, revealed the facility will maintain a clean, well repaired building, and provide staff to report any issues needing attention. Work requests must be in the form of work orders, not verbal.

Based on observations, staff and resident interviews, clinical record and policy review, the facility failed to protect the rights of three residents (#22, #54, #89) to be free from abuse. The deficient practice may result in further resident to resident abuse. Findings include: -Resident #22 was admitted on [DATE] with diagnoses of a Crohn's disease, acute kidney failure, anxiety disorder, bipolar disorder, and depression. The care plan dated January 6, 2022 revealed that resident was taking antidepressant medication related to depression for episodes of crying. Review of care plan dated October 13, 2022 included the resident was on anti-anxiety medication related to restlessness, racing thoughts, and inability to sleep. The Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) summary score of 15 which indicated the resident had intact cognition. Moreover, the MDS revealed no indication of atypical behavior or presences of psychiatric/mood disorders. Review of an order dated September 23, 2024 revealed that resident had change of condition due to Behavioral/psychosocial episodes and antianxiety medication dose increase every shift for 3 days. -Resident #54 was admitted on [DATE] with diagnoses of a chronic obstructive pulmonary diseases, sepsis, hypertensive heart disease with heart failure and edema. Review of the MDS assessment dated [DATE] revealed BIMS score of 15 indicating the resident had intact cognition. Further review of the MDS reported no indication of atypical behavior or presences of psychiatric/mood disorders. The facility assessment dated [DATE] regarding Social Services Assessment/Evaluation revealed resident had re-traumatization and showed yelling or swearing behavior and was provided a calm and quiet environment. -Resident #60 was admitted on [DATE] with diagnoses of unspecified cataract, hypertension, benign prostatic hyperplasia and chest pain. The MDS assessment dated [DATE] revealed resident active diagnosis including hypertension, Parkinson's disease, and seizure disorder or epilepsy. Review of an order summary revealed that resident had orders for the following medications: anti-Parkinson's, anticonvulsants, antianxiety and antidepressant. The care plan dated September 18, 2024 revealed that resident had a behavior problem related to clothing preferences. Goal was that the resident will have fewer episodes of walking down the hall without any clothing on. Interventions included to intervene as necessary to protect the rights and safety of others and monitor behavior episodes and attempt to determine underlying cause. An interview was conducted on September 30, 2024 at 11:59 a.m. with resident #22 who stated that resident #60 without wearing clothes, had roamed into resident rooms several times; and that, resident #60 should not be inside her room because resident #22 had scared and frightened her. Resident #22 was tearful at both eyes and was crying throughout the interview. Further, resident # 22 stated that in their last resident council meeting, residents discussed the behavior of resident #60 and had notified administrator (staff #195) and director of nursing (staff #62); but nothing had been done about the resident's inappropriate behavior. An interview was conducted on September 30, 2024 at 1:31 p.m. with resident #55 who stated that she saw resident #60 roaming into the lady's room, and going into the room of resident #54; and, walked into the room of another resident (#36) who was unable to hear. She said that two weeks ago, resident #60 walked into their room, grabbed the wheelchair, and pushed it out to the hall; and that, her roommate saw this and made resident #60 bring the wheelchair back. The resident also said that after that incident she called out for a nurse because resident #60 remained inside their room; and that, the nurse had to remove resident #60 out of their room. She further stated that she did not consider telling anyone about these occurrences because she felt that bringing up the situation would be a problem and had known of people being kicked out from the facility for complaining. Another interview with resident #22 was conducted on September 30, 2024 at 1:41 p.m. The resident stated that on a Sunday a week ago she had been scared by resident #60 who was yelling right outside the room. The resident said that two nights ago, resident #60 was nude, entered her room and had placed his hands on her bed and told her that he was going to lay on her bed. She stated that she told him not to and resident #60 stood there for a few minutes processing the response before leaving. The resident said that a certified nursing assistant (CNA/staff #168) asked resident #60 to put his clothes on and resident #60 yelled and told the CNA that the CNA was not his boss. The resident also stated that one and a half weeks ago, resident #60 came into her room and slammed into their wheelchair. Further, the resident stated that her roommate could not sleep due to resident #60 and had wanted to call the police because there were items missing including a jar of lotion from their room. The resident stated that she was scared and frightened by resident #60 since moving into the unit. She stated that she was claustrophobic and unfortunately had to keep her room door open. She stated that she had discussed these concerns with the administrator, the director of nursing (DON) and the charge nurse; and that, this resulted in changes in her medication. She said that she was placed on anti-anxiety medication because they thought she was losing it. During the interview, the resident became tearful, cried and stated that resident #60 had hurt her mind and soul. The resident said that when she reported her feelings to the administrator and the DON about a week ago, they told her that maybe it was time for her to go to a new facility. The resident stated that she told them that she had been at the facility for a long time and she was not leaving. In an interview with resident #54 conducted on October 1, 2024 at 7:54 a.m. the resident stated that resident #60 continued to come into their room, as soon as moving in about 2 months ago. She stated that the first time resident #60 came inside their room, resident #60 drank their water and soda. She stated that she requested for resident #60 to get out, but resident #60 told her that he would be getting in bed with her. She stated that she then started screaming and staff came and got him out of the room. However, she stated that resident #60 continued to come again and again and watched them (resident #54 and her roommate) sleeping. The resident said that last Friday night, resident #60 came into the room with his wheelchair and hit her wheel chair; and that, she yelled at him and even after yelling at him to get out, resident #60 did not leave. She stated that staff had to come into the room to get him out. She stated that she did not feel safe in the facility and had spoken to the administrator and the DON following the first incident. The resident said that their solution was to move her to another room because the administrator told her that it was the law that if one resident had a problem then they had to move. She said that she should not move to another room because she liked her current roommate. The resident said that the administrator later placed a red label ribbon do not enter on their door but this did not stop resident #60 from entering their room. She stated that she had been scared ever since hearing and noticing resident #60 outside their room naked; and that, resident #60 had entered about 8 or 9 resident rooms while naked, including their room a month ago. An interview was conducted on October 1, 2024 at 1:01 p.m. with CNA (staff #156) who stated that abuse incidents were reported to the administrator and DON. The CNA stated that the impact on residents who were subjected to abuse may be change in behavior, become more aggressive, or may avoid eating; however, the staff keep residents safe and happy. The CNA said that she had seen resident #60 roaming around the room of residents #54 trying to use their restroom. The CNA also said that the licensed practical nurse (LPN/staff #71) had pulled resident #60 out of the room of residents #54; and that, she was also aware that resident #22 reported that resident #60 was also in her room. An interview was conducted on October 1, 2024 at 8:14 a.m. with social service director (staff #59) who stated that when grievances are brought by residents, staff were to ensure the resident feel safe. Staff #59 stated that grievances were documented, would talk to relevant departments, find resolution, and ask the resident if they were satisfied with that. An interview was conducted on October 1, 2024 at 1:31 p.m. with the DON who stated that resident subjected to abuse could result to emotional harm manifested as crying, withdrawn and physical harm manifested as getting injured, bruising. The DON stated that no one should suffer from abuse whether emotional or physical. Further, the DON stated that residents #22 and #54 had brought concerns regarding resident #60 roaming into their room; and that, it upset them. An interview was conducted on October 2, 2024 at 10:12 a.m. with administrator who stated that if there were allegations of abuse, his expectation was for staff to notify him immediately, and to ensure that resident was safe. Further, the administrator stated that he would not like it if someone come into his room uninvited and naked. 50887 -Regarding Resident #89 Resident #89 was admitted into the facility on [DATE] with diagnoses that included fracture of unspecified part of neck, bipolar disorder, and post traumatic disorder. A nursing progress note dated June 3, 2024 at 8:20 PM revealed that there was a physical incident that occurred between resident's #89 and his roommate resident #238; and that, after the incident the roommate had been removed from residents #89's room. Moreover, the progress note revealed that the nurse practitioner was notified and ordered resident #89 to go to the emergency room for further evaluation, however once emergency services arrived the resident #89 refused to go. Review of physician progress note dated June 4, 2024 revealed that the resident reported being punched in the face during the altercation. The note revealed that the resident had a chief complaint of visible bruise to his right eye. Review of the order summary revealed a physician order dated June 4, 2024 to monitor abrasion under left eye, left cheek, and scratch under right eye for infection. Review of care plan initiated on June 4, 2024 revealed re-traumatization related to history of trauma PTSD (post traumatic stress disorder) related to disasters, and altercation with roommate on June 3, 2024 indicated interventions which included: administering medications as orders, anticipate and meet needs, and approach in a calm manner. An admission Minimum Data Set (MDS) assessment dated [DATE] revealed a BIMS (brief interview of mental status) score of 3 which indicated resident was severely cognitively impaired. Moreover, MDS revealed that the resident was negative for psychosis and behavioral symptoms during the assessment period. Review of the facility investigation report submitted on June 10, 2024 revealed that on June 3, 2024 at approximately 8:15 pm resident #89 was poked in the face by resident #238. The investigation report included an interview with the alleged victim. According to resident #89, the incident had occurred while he and his roommate were in their room. The resident stated that resident #238 had come up to him and pointed at him. The report revealed that it was during that time that resident #238 cut resident #89's face with his pointer finger. Review of the facility investigation submitted on June 10, 2024 revealed an interview was conducted on June 5, 2024 with a Certified Nursing Assistant (CNA/staff #260) who stated that resident #238 wanted the television off and resident #89 volunteered to mute the television. The investigation revealed that the CNA told the residents that they had to respect each other's rights. The report revealed that staff #260 had returend approximately 10 minutes later and observed resident #238 standing next to resident #89; and that, resident #89 was observed with a scratch under his eye. An interview was conducted on October 1, 2024 at 01:31 PM with the Director of Nursing (DON/Staff #62) who stated that all staff are trained on abuse upon hire, annually and as needed. The DON stated that the process for a resident to resident altercation includes making sure the resident is safe, separate the residents, report the incident within two hours, and to notify the physician, ombudsman, and family. The DON (Staff #62) stated that neither residents had a history of aggressive or physical behavior. The DON further stated that resident #89 is usually withdrawn and quiet but that was his baseline. DON stated that there had not been any behavior changes since the incident occurred. According to the DON, residents that are subjected to abuse can sustain emotional and physical harm which can include bruising and cuts. Additionally, DON stated that residents can experience pain, crying, being emotionally distraught, and become withdrawn. A review of the facility policy titled, Abuse: Prevention of and Prohibition Against, reviewed October 2023 indicated that each resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation. Review of facility policy regarding Abuse: Prevention of and Prohibition Against revealed that the facility will act to protect and prevent abuse and neglect from occurring within the facility by establishing a safe environment that supports, to extent possible.

Based on clinical record review, staff interviews, and facility documentation and policy review, the facility failed to ensure adequate supervision for one resident (#60). The deficient practice resulted in resident wandering into other resident rooms uninvited. Finding includes: Resident #60 was admitted on [DATE] with diagnoses of unspecified cataract, hypertension, benign prostatic hyperplasia and chest pain. The initial admission record dated August 12, 2024 included that the resident was alert and oriented to time, place and person, was able to follow simple commands, had no behavior problems, was ambulatory or self-mobile in the wheelchair. The elopement/wandering evaluation dated August 12, 2024 revealed a score of 5 indicating the resident was low risk for elopement/wandering. Per the documentation, the resident had no elopement history. The MDS (Minimum Data Set) note dated August 15, 2024 revealed the resident was alert and oriented x 3-4, had adequate hearing, was able to understand others and had some difficulty expressing words at times. The MDS assessment dated [DATE] revealed resident active diagnosis including hypertension, Parkinson's disease, and seizure disorder or epilepsy. The assessment included that the resident did not have any behavioral symptoms directed towards others; and that, the reside did not have any wandering behaviors. Review of an order summary revealed that resident had orders for the following medications: anti-Parkinson's, anticonvulsants, antianxiety and antidepressant. The care plan dated September 18, 2024 revealed that resident had a behavior problem related to clothing preferences. Goal was that the resident will have fewer episodes of walking down the hall without any clothing on. Interventions included to intervene as necessary to protect the rights and safety of others, monitor behavior episodes and attempt to determine underlying cause, document behavior and potential causes and frequent reminders for privacy related to clothing. Despite being care planned, the clinical record revealed no documentation found in the clinical record of any incident/s that the resident was walking down the hall without any clothing on. The clinical record no documentation that the resident had any behaviors related to wandering behaviors or entering other resident rooms; and, any type of supervision the resident needed or required. The care plan was initiated on September 30, 2024 to include that the resident had a potential to demonstrate behaviors related to dementia. Interventions included 1:1 sitter, review for continued need for an ongoing basis, every 15 minutes checks, and monitor for changes in mood and behavior patterns, psychosocial changes and notify the provider if needed. The care plan was revised on October 1, 2024 to included an alleged incident with a female resident. An interview was conducted on September 30, 2024 at 11:59 a.m. with resident #22 who stated that resident #60 without wearing clothes, had roamed into resident rooms several times; and that, resident #60 should not be inside her room because resident #22 had scared and frightened her. Resident #22 was tearful at both eyes and was crying throughout the interview. Further, resident # 22 stated that in their last resident council meeting, residents discussed the behavior of resident #60 and had notified administrator (staff #195) and director of nursing (staff #62); but, nothing had been done about the resident's inappropriate behavior. An interview was conducted on September 30, 2024 at 1:31 p.m. with resident #55 who stated that she saw resident #60 roaming into the lady's room, and going into the room of resident #54; and, walked into the room of another resident (#36) who was unable to hear. She said that two weeks ago, resident #60 walked into their room, grabbed the wheelchair, and pushed it out to the hall; and that, her roommate saw this and made resident #60 bring the wheelchair back. The resident also said that after that incident she called out for a nurse because resident #60 remained inside their room; and that, the nurse had to remove resident #60 out of their room. She further stated that she did not consider telling anyone about these occurrences because she felt that bringing up the situation would be a problem and had known of people being kicked out from the facility for complaining. Another interview with resident #22 was conducted on September 30, 2024 at 1:41 p.m. The resident stated that on a Sunday a week ago she had been scared by resident #60 who was yelling right outside the room. The resident said that two nights ago, resident #60 was nude, entered her room and had placed his hands on my bed and told her that he was going to lay on her bed. She stated that she told him not to and resident #60 stood there for a few minutes processing the response before leaving. The resident said that a certified nursing assistant (CNA/staff #168) asked resident #60 to put his clothes on and resident #60 yelled and told the CNA that the CNA was not his boss. The resident also stated that one and a half weeks ago, resident #60 came into her room and slammed into their wheelchair. Further, the resident stated that her roommate could not sleep due to resident #60 and had wanted to call the police because there were items missing including a jar of lotion from their room. The resident stated that she was scared and frightened by resident #60 since moving into the unit. She stated that she was claustrophobic and unfortunately had to keep her room door open. She stated that she had discussed these concerns with the administrator, the director of nursing (DON) and the charge nurse; and that, this resulted in changes in her medication. She said that she was placed on anti-anxiety medication because they thought she was losing it. During the interview, the resident became tearful, cried and stated that resident #60 had hurt her mind and soul. The resident said that when she reported her feelings to the administrator and the DON about a week ago, they told her that maybe it was time for her to go to a new facility. The resident stated that she told them that she had been at the facility for a long time and she was not leaving. In an interview with resident #54 conducted on October 1, 2024 at 7:54 a.m. the resident stated that resident #60 continued to come into their room, as soon as moving in about 2 months ago. She stated that the first time resident #60 came inside their room, resident #60 drank their water and soda. She stated that she requested for resident #60 to get out, but resident #60 told her that he would be getting in bed with her. She stated that she then started screaming and staff came and got him out of the room. However, she stated that resident #60 continued to come again and again and watched them (resident #54 and her roommate) sleeping. The resident said that last Friday night, resident #60 came into the room with his wheelchair and hit her wheel chair; and that, she yelled at him and even after yelling at him to get out, resident #60 did not leave. She stated that staff had to come into the room to get him out. She stated that she did not feel safe in the facility and had spoken to the administrator and the DON following the first incident. The resident said that their solution was to move her to another room because the administrator told her that it was the law that if one resident had a problem then they had to move. She said that she should not move to another room because she liked her current roommate. The resident said that the administrator later placed a red label ribbon do not enter on their door but this did not stop resident #60 from entering their room. She stated that she had been scared ever since hearing and noticing resident #60 outside their room naked; and that, resident #60 had entered about 8 or 9 resident rooms while naked, including their room a month ago. An interview was conducted on October 1, 2024 at 1:01 p.m. with CNA (staff #156) who stated that abuse incidents were reported to the administrator and DON. The CNA stated that the impact on residents who were subjected to abuse may be change in behavior, become more aggressive, or may avoid eating; however, the staff keep residents safe and happy. The CNA said that she had seen resident #60 roaming around the room of residents #54 trying to use their restroom. The CNA also said that the licensed practical nurse (LPN/staff #71) had pulled resident #60 out of the room of residents #54; and that, she was also aware that resident #22 reported that resident #60 was also in her room. An interview was conducted on October 1, 2024 at 8:14 a.m. with social service director (staff #59) who stated that when grievances are brought by residents, staff were to ensure the resident feel safe. Staff #59 stated that grievances were documented, would talk to relevant departments, find resolution, and ask the resident if they were satisfied with that. An interview was conducted on October 1, 2024 at 1:31 p.m. with the DON who stated that resident subjected to abuse could result to emotional harm manifested as crying, withdrawn and physical harm manifested as getting injured, bruising. The DON stated that no one should suffer from abuse whether emotional or physical. Further, the DON stated that residents #22 and #54 had brought concerns regarding resident #60 roaming into their room; and that, it upset them. An interview was conducted on October 2, 2024 at 10:12 a.m. with administrator who stated that if there were allegations of abuse, his expectation was for staff to notify him immediately, and to ensure that resident was safe. Further, the administrator stated that he would not like it if someone come into his room uninvited and naked. Review of facility policy regarding Elopement/Unsafe Wandering revealed that the residents with capabilities of ambulation and/or mobility in wheelchair will have an elopement/wandering evaluation completed to determine risks for elopement and unsafe wandering on admission and with observed behaviors of wandering or attempts to elope. It further revealed that the resident's care plan will be updated and include interventions to address the possible need for the increased level of supervision.

Based on observation, staff interviews, and policy review, the facility failed to ensure that a medication cart was locked when unattended and that controlled medications in the medication storage room were properly secured according to facility policy. The deficient practice could result in residents or staff members having unrestricted access to medications and controlled substances. -Regarding the medication cart: An observation was conducted on October 01, 2024, at 7:28 AM in the hallway of the 400 unit. It was observed that a medication cart was unlocked without staff presently attending it or in close proximity. A nurse was observed to be in a room across the hall from the med cart, attending to the resident in the bed furthest from the door, looking opposite and away from the cart. An interview was conducted with this Licensed Practical Nurse (LPN, Staff #49) on the same day at 8:33 AM. Staff #49 acknowledged that she had left the cart unlocked while she was administering medication during med pass. An interview was conducted on October 02, 2024 at 11:28 AM with the Director of Nursing (DON, Staff #62). The DON stated that it was her expectation that a medication cart should be locked if a nurse leaves their assigned medication cart. -Regarding the controlled substance: An observation was conducted on October 02, 2024 at 7:34 AM, of the medication storage room with a Licensed Practical Nurse (LPN, Staff #154). Observation of the medication storage room revealed two brown plastic storage containers stacked upon each other and placed next to the facility's e-kit (automated dispensing cabinet for secure medication management). Staff #154 identified the brown plastic boxes as back-up e-kit boxes. Neither box was locked and the flip-up lids of the boxes were easily opened. The contents of the first box were examined. Inside the first box was another clear plastic storage box with multiple compartments present. The inner plastic box was held shut by a thin red plastic zip tie that could easily be cut or torn. The zip tie did not have a locking mechanism or code. It was observed that multiple pills were present in the separate compartments of the clear plastic box, and the different compartments were labeled with the name of the medication and the quantity of pills. The labels included the following: -tramadol 50 milligram x 5 -hydrocodone 5/325 milligram x 5 -hydromorphine 2 milligram x 5 -methadone 5 milligram x 10 -temazepam 15 milligram x 2 The second brown plastic box was easily opened with no lock securing it. Inside was a clear plastic storage box with a thin red zip tie holding the box shut. This box also contained numerous pills, and was labeled as follows: -morphine sulf IR 15 milligram x 4 -tramadol 50 milligram x 5 -hydrocodone 5/325 milligram x 5 -hydromorphine 2 milligram x 5 -methadone 5 milligram x 10 -temazepam 15 milligram x 2 On October 2nd, 2024, at 8:02 AM, an interview was conducted with the Director of Nursing (DON, Staff #62). The DON stated that the process for storing narcotics was to double-lock the medications. She also stated that in the nurses' carts contain a second locking box within the carts. She further stated the e-kit holds the narcotics in the medication storage room, and the nurses can obtain access to the e-kit by calling the pharmacy for a code to get into the e-kit, and there must be an additional witness at that time. The DON stated that even if the e-kit is not working, it is locked and secured; and that, the pharmacy would send out a technician. The DON stated that approximately 1-2 weeks ago, the e-kit was malfunctioning, and the pharmacy company provided the facility 2 backup e-kit boxes that currently need to be picked up by the pharmacy. Review of the facility's policy titled Medication Access and Storage, E Kit Access, revised July, 2024, revealed that it is the policy of the facility to store all drugs in locked compartments, and that the medication supply is accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications. Medication rooms and carts are locked or attended by persons with authorized access. Further, Schedule III and IV controlled medications are stored separately from other medications in a locked drawer or compartment designed for that purpose. Schedule II medications are stored in a separate area under double lock. Review of the facility's policy titled Controlled Medications - Storage and Reconciliation, revised December, 2023, revealed that controlled medications are substances that have an accepted medical use (medications which fall under US Drug Enforcement Agency Schedules II-V), have a potential for abuse, and may lead to physical or psychological dependence. Medications listed in Schedule II-V are stored under double-lock location in a locked cabinet or safe designed for that purpose, separate from all other medication.

Based on observations, staff interviews and policy review, the facility failed to provide food within safe serving temperature. The deficient practice could result in foodborne illnesses among residents. Findings include: On October 1, 2024 at 12:12PM, the lunch tray line was observed, and the initial temperatures of the food were as follows: meat at 149 degrees Fahrenheit, the starch temped at 178 degrees Fahrenheit, the pasta salad temped at 70 degrees Fahrenheit. During this observation, staff #123 was interviewed and stated that the pasta salad will be put on ice to assist with the cooling of the component as it was not at their desired temperature range. On October 1, 2024 at 1:33PM, a test tray was brought into the conference room after being closely monitored and followed throughout the facility. The final temperatures of the food were as follows: Meat at 96.4 degrees Fahrenheit; Tater tots at 95.7 degrees Fahrenheit; Pasta salad at 75.6 degrees Fahrenheit; While Staff #11 was observed temping each food component, without sanitizing the temperature rod utilized by staff throughout the demonstration process. During this observation, staff #11 was interviewed regarding the palpability of the food, to which staff reported that the temperature of the food were not to professional standards, and, that the expectation of proper sanitization is to sanitize the temperature rod in-between temping food components. An interview on October 2, 2024 at approximately 12:40 PM was conducted with dietary manager (staff #14) who stated that the expectation with food storage, preparation, distributing and serving food is that staff is to complete the labeling and dating food, keeping the areas clean, washing their hands, and maintaining appropriate temperatures. And reported that the risk of improper palpable temperatures can get people sick. Review of the provided kitchen policies, which were policies titled, 'Dietary Policy', 'Code of Dress Code and Personal Appearance', 'Proper Handwashing and Glove Use', 'Nutrition', 'Resident/Personal Food Storage', and 'Sanitization of Dining and Food Service Areas', revealing that there is no policy is in place for maintaining appropriate food temperatures.

Based on observations, staff interviews and policy review, the facility failed to ensure the areas used for preparing, cooking and serving food were cleaned and maintained sanitary in accordance with professional standards for food service safety. The deficient practice could result in foodborne illnesses among residents. Findings include: On September 30, 2024 at 10:51 a.m., an observation was conducted of the facility's kitchen with the dietary supervisor (staff #14). At this time, the stove and stacked oven was observed to have grease build-up and burned debris under and behind the stove and stacked oven. Also, there was burned debris on the metal shelf on the front side of the deep fryer. Crackers and an applesauce cup were observed on the floor in the dry storage room. During this observation, staff #14 stated that cleaning of the kitchen happens daily, reported that the expectation in the kitchen is proper hand hygiene to prevent foodborne illness, that also includes hair and beard covering. Temperature and cleaning logs for the month of September 2024 were requested for further review. The review revealed that temperature logs were completed with specific temperatures. The review also revealed that daily cleaning of the kitchen did not include initials of the completion of the task. On October 1, 2024 at 10:33AM, an observation was conducted of the facility's kitchen with the dietary supervisor (staff #14), cook (staff #123), and dietary aide (staff #11). At that time, yellow square slices were observed near a preparing sink, unattended, unwrapped, and undated appropriately. The preparation sink had darkened objects directly under the sink, near these [NAME] burnt like objects was a silver container that appeared to contain towels with darkened corners and spots present. On the floor near that sink, red circular was observed. When asked, staff #123 stated that hamburgers with tomatoes and cheese, french fries and a pasta salad will be prepared for lunch. What appeared to be already prepared food and observed without dates on them. When asked, staff #11 reported that the observed food were individually wrapped peanut butter and jelly sandwiches, that they will be put in the nutrition fridges on the unit for overnight, and that they do not require a date on them. Collected hardened ice was observed running down the side of the wall in the kitchen refrigerator, as well as additional hardened ice collecting on the floor of the refrigerator, directly under a pipe. Moreover, cooking and baking sheet pans stacked on top of each other were observed with a wet like substance in between the stacked pans and deep baking sheets. The wall directly behind the stacked cooking and baking pens appeared to be exposed, as evidenced by chipped wall paint, directly behind the stacked and stored pans and deep sheets. An opened brown bag filled with a powder substance was also observed near the preparation station. A brown powdery substance was observed in the dry storage directly under containers that contained what appeared to be brown. [NAME] string like substances were observed on the corner of the metal stand holding items in the dry storage. Later that day at 12:12PM, the tray line was observed. Six residents out of the 19 (Resident #17 with a mechanical diet was given a regular diet, resident #65 with a mechanical diet was given a regular diet, resident #394 with a mechanical soft diet was provided regular diet, resident #7 was provided an item that was stated as a dislike, resident #62 with a mechanical soft diet was provided a regular diet, and resident #49 was provided an item that they stated a dislike) were provided items that were not listed on their meal tickets and/or provided meal items that are not in accordance to the diet provided on the meal ticket. Staff #123 also reported that in the event of a non-gluten diet, resident's receive items such as non-gluten pasta and non-gluten bread. In regards to diet type, Staff #123 reported that in the event of a mechanical soft diet, a resident will be provided grounded up meat, grounded up pasta, and grounded up tater tots, to assist with eating. Staff #11 reported that diabetic diets will then receive fresh fruits for a regular diet or zero sugar jello for a mechanical soft diet in replacement of the desert on the menu. An interview on October 2, 2024 at approximately 12:40PM was completed with dietary manager (staff #14) to which they stated what their expectation with food storage, preparation, distributing and serving food is that staff is expected to complete the labeling and dating food, keeping the areas clean, washing their hands, and maintaining appropriate temperatures. Staff #14 stated that the risk of improper palpable temperatures can get people sick. Staff #14 also stated that for individuals with dietary restrictions, ie. Gluten or fish, providing residents with those dietary restrictions are not within professional standards and that they will attempt to provide non-gluten and try to substitute it with another protein for there is restrictions with fish. Staff stated forgetting to provide a gluten free option for the burgers and pasta salad on October 1, 2024; and that, forgetting the preferences of the resident's upsets their mood and their time here. Review of the kitchen policy titled, 'Sanitization of Dining and Food Service Areas', revealed that staff is responsible for all cleaning tasks and that staff will initial the tasks as they are completed. Review of the provided kitchen policies, which were policies titled, 'Dietary Policy', 'Code of Dress Code and Personal Appearance', 'Proper Handwashing and Glove Use', 'Nutrition', 'Resident/Personal Food Storage', and 'Sanitization of Dining and Food Service Areas', revealed no policy addressing personal preference of food options and diets, and as well as no policy addressing the execution of following established diets as stated on a resident's meal ticket.

Based on observations, staff interviews and policy review, the facility failed to adhere to infection control policies while serving, preparing, and distributing food to residents, and while providing care to one resident (#65). The deficient practices could result in foodborne illnesses among residents and the transmission of infection. -Regarding food preparation and distribution to residents: On September 30, 2024 at 10:51 a.m., an observation was conducted inside the facility's kitchen with the dietary supervisor (staff #14) who did not have a beard covering. At that time, staff #14 reported that the expectation in the kitchen is proper hand hygiene to prevent foodborne illness, that also includes hair and beard covering. On October 1, 2024 at 10:33AM, an observation was conducted of the facility's kitchen with the dietary supervisor (staff #14), cook (staff #123), and dietary aide (staff #11). At that time, staff #14 was observed without a beard covering. Staff #123 was observed at the sink rinsing their hands in prior to preparation of lunch, however soap was not used. During this observation, staff #14 reported that the expectation in the kitchen was proper hand hygiene to prevent foodborne illness; and that, includes hair and beard covering. Later, staff had put on a beard covering. On October 1, 2024 at 1:33PM, a test tray was brought into the conference room after being closely monitored and followed throughout the facility. The final temperatures of the food were as follows: Meat at 96.4 degrees Fahrenheit; Tater tots at 95.7 degrees Fahrenheit; Pasta salad at 75.6 degrees Fahrenheit; While Staff #11 was observed temping each food component, without sanitizing the temperature rod utilized by staff throughout the demonstration process. During this observation, staff #11 was interviewed regarding the palpability of the food, to which staff reported that the temperature of the food were not to professional standards, and, that the expectation of proper sanitization is to sanitize the temperature rod in-between temping food components. An interview on October 2, 2024 at approximately 12:40PM was conducted with dietary manager (staff #14) who stated that the expectation with food storage, preparation, distributing and serving food is that staff complete the labeling and dating food, keeping the areas clean, washing their hands, and maintaining clean hygiene, hair net, beard nets, gloves are used, masks are used when needed, typically when something is under the weather. 51124 -Regarding Resident #65 Resident #65 was admitted into the facility on [DATE], with diagnoses that included metabolic encephalopathy, acute respiratory failure, end stage renal disease, cirrhosis of liver, hemiplegia and hemiparesis following cerebral infarction, and dysphagia. The admission minimum data set (MDS) assessment dated [DATE], revealed that the resident had a brief interview for mental status (BIMS) score of 3, which indicated was severely cognitively impaired. Moreover, assessment revealed that the resident had the presence of a feeding tube on admission and while a resident. Review of Resident #65's physician orders revealed an order dated July 10, 2024, for Enhanced Barrier Precautions (EBP): personal protective equipment required for high resident contact care activities, with an indication of indwelling medical device. Review of Resident #65's care plan initiated July 23, 2024, revealed the resident requires tube feeding due to a swallowing problem, with an intervention to use Enhanced Barrier Precautions (EBP). An observation conducted on October 01, 2024, at 9:48 AM, revealed a registered nurse, (RN/Staff #72) performed hand hygiene and donned gloves, but did not wear a gown, when entering the resident's room. The RN administered the resident's medications with a syringe into the resident's feeding tube. The feeding tube was flushed with water and cleaned with a sanitizing wipe. Staff #72 performed hand hygiene when leaving the resident's room. Directly after the observation of medication administration, an interview was conducted with Staff #72. When asked if Resident #65 is on any precautions, Staff #72 initially stated I don't think he is, then stated he is on Enhanced Barrier Precautions. When asked what EBP entails, Staff #72 stated I have to look it up, and was able to walk over to the resident's room to read the precautions sign posted on the resident's door. Staff #72 stated that EBP entails using hand sanitizer and wearing a gown and gloves when providing all hands-on resident care. Staff #72 then stated, I forgot to put my gown on. In an interview conducted on October 02, 2024 at 11:21 AM, the Director of Nursing (DON/ Staff #62) stated that for Enhanced Barrier Precautions, there is a sign posted outside the resident's door and posted above the resident's bed as well; and that, entails wearing a gown and gloves when providing direct care to residents. The DON stated that EBP is indicated for residents with catheters, indwelling medical devices, certain wounds, and residents with a history of multi-drug resistant organism infections. The DON stated that the importance of adhering to EBP is to prevent the spread of infections; and that, the risk when EBP is not followed would be that a resident could get an infection. Review of the facility's policy titled Infection Prevention and Control Program, revised July, 2023, revealed that the infection prevention and control program involved all disciplines and individuals and that facility personnel will conduct themselves in a way that minimizes the spread of infection. The facility will decide what measures and interventions should be applied in individual circumstances. Review of the kitchen policy titled, 'Dietary Policy', 'Code of Dress Code and Personal Appearance' revealed the employees will be enforced to use effective hair restraints, such as hair nets, hair bonnets, and beard guards to prevent contamination of food or food contact services.

Based on clinical record review, staff interviews, facility documentation and review of facility policy and procedure, the facility failed to ensure dental needs were met for one sampled resident (#58). The deficient practice could result in residents not receiving necessary services for oral and dental care. Findings include: Resident #58 was admitted to the facility on [DATE] with diagnoses that included subluxation of the right shoulder joint, sequelae of cerebral infarction, hypertension, major depressive disorder, hyperlipidemia, and acute kidney failure. The quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15 indicating that the resident was cognitively intact. Further review of the MDS did revealed that Section L - Oral/Dental Status was blank. Review of a physician order dated December 20, 2023 revealed dental consultation and treatment as needed. Review of the quarterly Nutrition evaluation dated March 19, 2024 revealed that the dentition section for both upper and lower was left blank. A physician progress note dated April 10, 2024 revealed that Patient A presents with reports of teeth pain. The patient note with really bad oral hygiene with reports of extreme pain in her mouth, new order in place to change patient pain regimen. Moreover, revealed that Will also have patient follow up with the dentist. A physician's order dated April 11, 2024 prescribed a dental consult regarding the resident's teeth pain. Review of the resident's clinical record revealed an e-MAR (electronic Medication Administration Record) note dated April 11, 2024 revealed a dental consult related to teeth pain, one time a day for dental pain for 3-days. However, further review of the resident's clinical records did not reveal any dental referral notes. Furthermore, it did not reveal any documentation regarding a dental visit, or that a visit occurred. A progress note dated April 16, 2024 revealed that during the nurse practitioner visit the resident reported experiencing teeth pain. The note revealed that the resident actively participated in assessments and discussions, expressing discomfort and requesting attention for her dental issue. The note indicated that arrangements were being made for the resident to be seen by a dentist to address her teeth pain directly. An e-MAR note dated April 21, 2024 revealed a change of condition for oral antibiotics for teeth infection. The note indicated that the resident started the first dose during that shift. Another e-MAR note dated April 22, 2024 indicated a change of condition for oral antibiotics for teeth infection. Review of note revealed that the resident started her antibiotics last evening, the resident continued with pain, and that the Case Management was notified to set up a dental appointment for patient for dental care. However, further review of the clinical record did not reveal any documentation that an appointment was scheduled around that time. Review of the resident's clinical records revealed an e-MAR note dated April 23, 2024 documented a change of condition for oral antibiotics for teeth infection. The note revealed that PRN (as needed) medication were given for complaint of toothache. Another e-MAR note dated April 24, 2024 regarding change of condition for oral antibiotics for teeth infection documented that resident was doing well. However, resident had reported pain throughout the day. The note stated that PRN (as needed) pain medications were given and were effective. A care plan pertaining to the resident's tooth infection was initiated on April 22, 2024 revealed that the resident was on antibiotics until April 28, 2024. Interventions included to follow-up dentist appointment when antibiotics were completed. A physician order dated May 31, 2024 revealed to send resident to a dental facility on June 5, 2024 at 8:15 a.m. However, further review of the resident's clinical record did not reveal any dental referral/encounter notes. Additionally, it did not reveal any documentation of the dental visit or if that visit had occurred. Review of a quarterly Nutrition evaluation dated June 18, 2024 revealed that the resident had her own upper and lower teeth. However, the assessment indicated additional information to document whether the resident's teeth had carious or if resident had some missing teeth. A physician progress note dated June 27, 2024 marked late entry, revealed that the resident needs to follow-up with a dentist for resident's dental caries. A comprehensive visit progress note dated July 29, 2024 revealed that resident was positive for poor dentition. According to the review of systems portion of the note, the resident had to be seen by a dentist soon to have all of her teeth pulled and get dentures. The physical exam portion of the note indicated that the resident was partially edentulous and did not have dentures. Additionally, the note revealed a diagnosis of dysphagia, orpharyngeal phase with a [NAME] that stated dysphagia related to chewing issues from missing teeth. The note further revealed that resident had a follow-up appointment with facility dentist to pull all of her teeth and then supply dentures and to monitor. Review of a Dental Appointment Note dated August 8, 2024 revealed that the resident was seen for full-mouth radiographs, caries risk assessment, fluoride treatment, full-mouth debridement, and periodontal and restorative charting. The note did not indicate if resident had further dental treatment needs. A physician note dated August 23, 2024 stated Dysphagia related to chewing issues from missing teeth. The note revealed that resident had follow-up appointment with facility dentist to pull all of her teeth, supply dentures, and monitor. However, further review of the resident's clinical record did not reveal any documentation of a dental appointment or mention of resident's dental status. Review of the September 19, 2024 quarterly Nutrition evaluation indicated that the resident had her own upper and lower teeth for dentition. However, the assessment did not indicate additional information to document whether the resident's teeth was carious or if resident had some missing teeth. On October 2, 2024, a physician order dated October 2, 2024 reviewed revealed follow-up appointment with the facility's contracted dental provider on October 10, 2024 pending POA (Power of Attorney) approval. Additionally, on October 2, 2024 the facility provided a faxed treatment plan from the contracted dental provider dated October 2, 2024 was provided by the facility. The dental treatment plan indicated that the resident required multiple tooth extractions and interim mandibular dentures. The cover sheet of the faxed treatment plan noted that the POA will be contacted once the dental provider knows when the next date is that they will be in the facility. A nursing note dated October 2, 2024 revealed that the facility attempted to contact the POA three times that day to confirm dental acceptance of dental appointment for resident on October 10, 2024. Lastly, another faxed note from the facility's contracted provider dated October 2, 2024 listed the names of the residents seen on August 8, 2024 and services rendered. According to the note, the resident was only seen for an exam. The cover sheet revealed that the referral for the resident was received by the contracted dental provider on July 22, 2024 which indicated was months after the resident's dental issues were first identified. During an interview with resident #58 conducted on September 30, 2024 at 12:46 p.m., the resident stated that her teeth need to be pulled. Resident #58 stated that dentist had looked at them but had not seen anyone for her teeth since. An interview with the Director of Social Services (staff #205) was conducted on October 2, 2024 at 10:44 a.m. who stated that her job mainly consists of grievances and assessments. However, was unsure if those were her only duties based on her job description. The Director of Social Services noted that no one passed on any tracker for resident care follow-up. Staff #205 also indicated had not received any communication with nursing services regarding resident's care. Staff #205 stated that as far as she knows, it would be Case Management that would know about care of residents' follow-up care. However, she is unsure if Case Management does this for both skilled and long term care residents. During an interview with the Case Manager (staff #210) conducted on October 2, 2024 at 11:50 a.m., staff #210 stated that they are covering for Social Services regarding dental services. The Case Manager said that depending on the need for referral for dental care, the contract company and unit secretary coordinate. Staff #210 said that normally the doctor will put in a referral for care, then transport is set-up. The Unit Secretary (staff #134) tracks who needs follow-up appointments and schedules them. Another coordinates to see if dental services could be approved through the resident's insurance. In an interview with the Unit Secretary (staff #134) conducted on October 2, 2024 at 12:04 p.m., staff #134 noted that usually nursing puts in the order and notify case management then she is notified after. The Unit Secretary said that she schedules the needed appointment and arranges transportation for the resident to attend their appointment. She indicated that in regards to dental services, the contract company normally comes to the facility on ce a month. Staff #134 noted that resident #58 was last seen for dental in August 2024; and that, was the only information she had and it did not reveal whether the resident need further dental treatment. She noted that she would reach out to the dental provider and get the information to determine the residents need and provide it to the survey team. A follow-up interview with resident #58 was conducted on October 2, 2024 at 1:38 p.m. Resident #58 stated that she is unsure of when she last saw the dentist. She confirmed that she had pain while eating. However, she noted that she does not remember if she had told anyone about the pain. During an interview with a Certified Nursing Assistant (CNA/staff #156) conducted on October 2, 2024 at 1:53 p.m., staff #156 stated that if a resident complains of dental pain or pain in general that they would report it to the nurse. Staff #156 stated that it is important to get dental issues taken care of since it can lead to something more serious. Additionally, the CNA said that dental pain/issues can impact the resident's ability to eat since a resident will not eat if they are in pain. Staff #156 noted that resident #58 had not mentioned anything about dental or oral pain. An interview with a Licensed Practical Nurse (LPN/staff #61) was conducted on October 2, 2024 at 3:02 p.m. Staff #61 said that if they received a report that a resident is having pain, they assess for what is causing the pain. If it is something simple, they try things such as positioning for starters to see if resident can get comfortable. The LPN noted that they will check to see if there is an order for PRN (as needed) or scheduled pain medication to see about managing the pain. If the medication and distraction are not working, then they notify the doctor to see what needs to be done. Staff #61 stated that If the issue is dental related, they ask the resident to: describe the pain, when it started, and what makes it worse. The LPN said that they ensure there was no trauma then forward the information to the provider to see what needs to be done or if a dental appointment has to be scheduled. Staff #61 stated that the impact on residents that do not get their dental needs taken care of is that it can lead to infection so it is important to get it resolved. Additionally, the LPN noted that it can cause the resident discomfort. In the case of resident #58, since the dental issue was previously identified, it should have been followed-up. Moreoever, staff #61 stated that it was 100% inappropriate for the dental issue to go unresolved if it was already previously identified based on standing orders and progress notes. It should have been followed-up and scheduled for treatment. During an interview with the Director of Nursing (DON/staff #62) conducted on October 2, 2024 at 4:03 p.m., staff #62 stated that her expectation was that staff alert the provider if a resident is having dental issues or concerns. The DON indicated that she expected nursing to follow-up and ensure there are no outstanding appointments for the residents' dental needs. Staff #62 noted that this is important because oral health is part of a resident's overall health. If dental needs are not taken care of it can cause the resident pain, infection, and even weight loss. The facility policy titled Dental Services revised January 2024 indicated that it is the facility's policy to ensure that its residents who require dental services on a routine or emergency basis have access to such services without barrier.

Based on observations, resident and staff interviews, and record review, the facility failed to ensure one resident's (#58) dietary needs were met. The deficient practice could place residents at risk of malnutrition and dissatisfaction with their meals. Findings include: Resident #58 was admitted to the facility on [DATE] with diagnoses that included subluxation of the right shoulder joint, sequelae of cerebral infarction, hypertension, major depressive disorder, hyperlipidemia, and acute kidney failure. Review of the nutrition care plan initiated on December 21, 2023 indicated a goal in which resident will maintain adequate nutritional status by maintaining weight with no signs and symptoms of malnutrition. Interventions included: provide, serve diet as ordered and registered dietitian to evaluate and make diet change recommendations PRN (as needed). Further review of the care plan did not indicate or address the resident's gluten allergy. A quarterly Nutrition evaluation dated March 19, 2024 revealed that the resident needed a gluten free diet order. The top portion of the evaluation which contains pertinent resident information noted that the resident had a gluten allergy. Review of the resident's order summary revealed a physician order dated April 10, 2024. The order prescribed a regular diet, mechanical soft texture, thin liquid consistency, upright for meals, gluten free, and sandwiches cut in quarters. A quarterly Nutrition evaluation dated June 18, 2024 documented that the resident had a gluten allergy. The diet order indicated regular, gluten free diet that is mechanical soft in texture/consistency. The quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15 indicating that the resident was cognitively intact. Review of the quarterly Nutrition evaluation dated September 19, 2024 indicated that the resident had a gluten allergy documented under the Identified Dietary Needs for Dietary Interventions section that resident had gluten allergy. However, the diet order did not indicate that the resident needed a gluten free diet which was previously identified in the resident's previous nutrition evaluations. Review of the resident's electronic record on the dashboard under allergies section revealed that the resident had a gluten allergy. Furthermore, review of the resident's clinical record revealed that the allergies portion of the progress notes identified that the resident had a gluten allergy. The facility's Week 4 (September 29, 2024 through October 5, 2024) had not indicated if any of the items served were gluten free. Review of the facility's Always Available alternative menu listed the following items: Grilled Cheese, Turkey & Cheese Sandwich, PB & J (Peanut Butter & Jelly), Side Salad, Fruit Cup, Gelatin, Yogurt, Applesauce, Cottage Cheese, and Pudding. The menu had not indicated whether the items were gluten free. During the tray line observation conducted on October 1, 2024 at 12:30 p.m. The [NAME] (staff #123) tater tots and mashed potatoes were seen on the plate for resident #58's lunch. An interview with resident #58 was conducted on September 30, 2024 at 2:07 p.m. who stated was not not happy with the food. According to resident #58 she was not offered substitutions other than sandwiches which are not gluten free. The resident indicated that there were no actual substitutes for her dietary needs. The resident stated that she had a gluten allergy ; and that, the food in the facility did not accommodate for her gluten allergy. In an interview with the [NAME] (staff #123) conducted on October 1, 2024 at 11:33 a.m., staff #123 stated that for today's menu consisted of hamburgers, French fries and pasta salad, however those that have gluten allergy will receive a patty with toppings on top - no bread. During an interview with the Dietary Supervisor (staff #70) conducted on October 2, 2024 at approximately 12:35 p.m., staff #70 stated that for residents with gluten allergy, they do have gluten free bread, hot dog buns, and pasta. Staff #70 admitted that they forgot to do that yesterday with the menu. The Dietary Supervisor stated it definitely upsets them if they do receive items that they are not supposed to. The CNA (Certified Nursing Assistant) informed the kitchen staff when such incidents happen. Staff #70 stated that he then talks to the residents individually to make sure they are being accommodated. An interview with a Certified Nursing Assistant (CNA/staff #156) was conducted on October 2, 2024 at 1:53 p.m. Staff #156 stated that reports or meal ticket indicate a resident's dietary restrictions and allergies. According to the CNA information is also availiable on PCC (Point Click Care). Staff #156 stated that during meal pass, they check or verify if there is anything on the tray that the resident is allergic to. The CNA stated that residents have a sheet of the alternative meals and some of the residents can call in and they can assist in submitting their request. Staff #156 stated that it is up to the resident to call and ask for the alternative. The CNA stated that the menu is posted on the wall or given to residents upon request. Staff #156 stated that the alternate menu consisted of grilled cheese sandwich, PBJ (Peanut Butter & Jelly sandwich), soup, fruit, cottage cheese, and quesadilla. The CNA stated that the impact of residents not getting a menu that meets dietary restrictions or needs is refusing to eat which can affect the resident's health and weight loss. Staff #156 stated that to her knowledge she did not know of a resident that had a gluten allergy. The CNA stated being familiar with resident #58. Staff #156 stated that resident #58 did not like the food in the facility and usually asks for Jell-O or pudding. The CNA stated that resident #58 would say how she does not like the food but believes that the resident does not eat it for a reason. Staff #156 stated not remembering if resident #58 had any dietary restrictions/allergies. During an interview with a Licensed Practical Nurse (LPN/staff #61) conducted on October 2, 2024 at 3:02 p.m., staff #61 stated that staff make effort to ensure that residents' dietary restriction or allergies are updated on the chart and notify the kitchen. The LPN stated that they communicate and report specific diet needs. Staff #61 stated that they are unaware of any resident that had a gluten restriction. The LPN stated that the staff should be familiar with residents' dietary restrictions or allergies since it could turn into something severe if a resident has an allergy or precaution. This can cause the resident to choke or aspirate. Staff #61 admitted that they are not familiar with the dietary alternate for residents with gluten allergy. According to the LPN an alternate menu that mainly consists of sandwiches would not meet dietary restriction or nutrition for someone that had a gluten allergy because a resident cannot eat sandwiches every day all day. Staff #61 stated that if there is not a good alternative meal for a resident with gluten allergy, they can have a decline in weight which can lead to malaise and fatigue. The LPN also stated that this would make the resident feel like they are being deprived. Lastly, staff #61 stated that a resident's gluten allergy should be indicated on the resident's nutrition assessment since that is a vital information pertaining to the resident's nutrition needs/restrictions. With regards to resident #58, the LPN stated that they were not aware of special diet or restrictions. An interview with the Director of Nursing (DON/staff #62) was conducted on October 2, 2024 at 4:03 p.m. Staff #62 stated that her expectation is that staff members would put in the dietary restriction in the system and obtain an order from the provider. The DON stated that nutrition assessment was a question more appropriate for the dietitian/nutritionist. Staff #62 stated that it is her expectation that residents' dietary needs will be bet. Additionally, the DON stated that she expected that there would be food options for different diet need; and that, if sandwiches were the only option then it is not a viable one. Staff #62 stated that she was not sure if they were meeting resident #58's dietary needs. However, if the nutritional needs are not being met then the doctor should be contacted. DON stated that if she had a gluten allergy and sandwiches was her only option, she would not enjoy eating sandwiches all the time. Review of the facility policy titled Menus indicated that it is the policy of the facility to assure that menus are developed and prepared to meet the nutritional, religious, cultural, and ethnic needs while using established national guidelines. The facility policy titled Nutrition reviewed July 2024 noted that clinical evaluation for nutritional assessment may include relevant conditions and diagnoses. The policy further notes that care plan will be updated or revised as needed.

Based on observation, record review, interviews, and facility policy review, the facility failed to ensure respiratory services were provided according to professional standards, specifically that an order was obtained for the use of oxygen, for one resident (#339). The deficient practice could result in residents receiving unnecessary supplemental oxygen, and the provider not being aware of the resident's status. -Findings include: Resident #339 was admitted into the facility on [DATE], with diagnoses that included congestive heart failure, hypertension, and coronary artery disease. A review of the resident's hospital discharge orders dated September 27, 2024 revealed no orders for oxygen use. The admission minimum data set assessment (MDS) had not yet been completed due to the resident's newly admitted status. Review of the facility's physician orders conducted on September 30, 2024 at 1:19 PM, revealed no evidence of orders for oxygen administration. On October 01, 2024 at 10:44 AM an additional review of resident #339 physician orders revealed no evidence of orders for oxygen administration. On October 02, 2024 at 7:22 AM a follow-up review of the facility's physician orders was conducted which revealed evidence of a new physician order placed on October 1, 2024, for oxygen at 1-5 liters per minute via nasal cannula continuously for shortness of breath, may titrate to maintain oxygen saturation greater than 90%. Review of Resident #339's care plan initiated September 28, 2024, revealed no care plan regarding oxygen administration. Upon review of the resident's progress notes, there was no evidence of provider notes including the initiation or administration of oxygen. There was no evidence of nurse-to-provider or provider-to-nurse communication regarding a change of respiratory status or the initiation of oxygen. A Daily Skilled nursing note dated September 28, 2024, revealed the resident was on room air. A Daily Skilled nursing notes dated September 29, 30, and October 1, 2024, revealed the resident was on, Oxygen via Nasal Cannula. A review of the O2 Summary log revealed that Resident #339 was documented to be on Room Air on September 28, 2024, however the log revealed that the resident was on Oxygen via Nasal Cannula on September 29, 2024 and September 30, 2024. An observation conducted on September 30, 2024, at 10:50 AM, revealed Resident #339 was lying in bed in his room, receiving oxygen through a nasal cannula, with the concentrator at bedside set at 1 liter per minute. An additional observation conducted on October 01, 2024, at 9:08 AM, revealed the resident receiving oxygen via nasal cannula, with the concentrator set at 1 liter per minute. An interview was conducted with Resident #339 on September 30, 2024, at 10:50 AM. The resident stated that he was not sure what oxygen dose he was supposed to be on, and that he was not sure why he was supposed to be here. In an interview conducted on October 01, 2024, at 11:08 AM, an admissions nurse/registered nurse (RN/Staff #144) stated that when a resident admits to the facility from the hospital and has orders for oxygen administration, that Staff #144 transcribes those orders into the facility's physician orders. An interview was conducted on October 01, 2024, at 11:12 AM with a licensed practical nurse, (LPN/Staff #71) who stated that if a resident was experiencing a change of condition in which the nurse believed a resident required oxygen, that she would notify the provider, obtain an order for oxygen, and apply oxygen as per the physician order. Moreover, Staff #71 stated she would notify family or the responsible party, and would put the resident on a change of condition status, which is specific monitoring for three days. In an interview conducted on October 01, 2024, at 11:28 AM, an Assistant Director of Nursing/licensed practical nurse (ADON/Staff #159) stated that if a resident was experiencing a change of condition in which a nurse believed the resident may require oxygen, that the nurse would then contact the provider, follow the provider's orders, and transcribe those orders into the facility's physician orders. Staff #159 also stated that when oxygen is used as a treatment intervention, that a care plan is put into place. When Resident #339's discharge orders from the hospital were reviewed together, the ADON stated that no orders for oxygen could be found. When the facility's physician orders were reviewed together, the ADON also stated that no orders for oxygen use could be found. Finally, Resident #339 was visited alongside ADON at his room, and Staff #159 confirmed that oxygen was in use. An interview was conducted on October 01, 2024 at 12:09 PM with the Director of Nursing (DON, Staff #62). The DON stated that if a resident was noted to experience a respiratory change of condition or a deviation from baseline, that a nurse would complete an assessment of the resident, initiate a change of condition status, notify the provider, and would document in a progress note or assessment in the medical record. When reviewing the medical record together for Resident #339, the DON stated that there were no notes with evidence of a respiratory change of condition or initiation of oxygen use. The DON stated that it was her expectation that nursing documentation be completed timely; and that, any new oxygen orders should be in place for the next shift. Additionally, the DON stated that the importance of timely nursing documentation is what allows the nurses on the following shifts to know what was implemented for a resident. Review of the facility's policy titled Oxygen Administration, revised July 2013, revealed that oxygen therapy is administered as ordered by the physician or as an emergency measure until the order can be obtained. The purpose of oxygen therapy is to provide sufficient oxygen to the blood stream and tissues. Further, the resident's medical record will include that oxygen is to be administered, when and how the oxygen is to be administered, and the type of oxygen device to use. Review of the facility's policy titled Documentation and Charting, revised July 2022, revealed that the facility is to provide a complete account of the resident's care, treatment, response to care, signs, symptoms, as well as progress of the resident's care.

Based on observations, clinical record reviews, staff interviews and facility policy review, the facility failed to provide resident (#1) with physician ordered necessary wound care services. The deficient practice can put resident at risk for wound infection. Findings include: Resident #1 was admitted on [DATE], with diagnoses that included acute kidney failure, chronic obstructive pulmonary disease, type 2 diabetes mellitus with diabetic chronic kidney disease, end stage renal disease, and recent surgical history of resection of the perforated bowel and placement of an ostomy. The Care plan initiated on July 21, 2024 stated the resident has actual impairment to skin integrity related to abdominal surgery present on admission. The goal stated that the resident will not have rehospitalization within 30 days. The interventions included to float heals, monitor/document location, size and treatment of skin injury, report abnormalities, failure to heal, signs and symptoms of infection, maceration etc. to medical director, and use enhanced barrier precaution. However, the care plan failed to include wound care instructions and wound vac as indicated in the hospital discharge orders. An admission Minimum Data Set (MDS) assessment dated [DATE] included a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident cognition is intact. The MDS also included dialysis for special treatments. Review of clinical records revealed an order for routine colostomy care, monitor abdominal surgical site for signs and symptoms of infection every shift, enhanced barrier precautions indication wound, hemodialysis, and regular diet. Further review of the clinical record, titled Hospital Records Discharge Orders revealed the resident had a discharge wound care and wound care instructions for wound vac. However, review of Resident's clinical Order Summary Report on August 6, 2024 at 11:27 am revealed no order for wound care instructions and wound vac placed in Point Click Care (PCC) system. A review of resident's medication administration record (MAR) for the month of July 2024 revealed no abdominal surgical site wound care/wound vac task. An interview was conducted with Resident #1 on August 6, 2024 at 11:39 am. Resident #1 stated that care seems to be okay. Resident #1 was observed to have a wound vac at bedside. He stated that it needed to be changed that day and it needs to be changed every other day. He stated that Staff #22 is the nurse that worked and changed the wound vac. Resident #1 stated that he did not remember when the wound vac was placed since he first got there but resident #1 stated the facility did not have one at first. An interview was conducted on August 6, 2024 at 12:43 pm with licensed practical nurse (LPN)/Staff #32. Staff #32 stated that when someone is on a wound vac, she will read the orders, then assembles the supplies, get everything set up, then take everything off, clean the area, then follow the directions reapplying the fresh new supplies. She stated that they have an admission nurse that places the orders in for new admission. Their central supply person is responsible for ordering wound supplies and if the wound order supplies are not available, she stated that she would call the nurse practitioner and ask what would be use in place of the current orders. An interview was conducted with an admission nurse/Staff #33 on August 6, 2024 at 1:32 pm. Staff #33 stated that his role is to put all doctor's discharge order from the hospital in the PCC. In addition, he welcomes the new resident, perform a skin assessment, get consents in regards to their stay in the facility such as advance directives, and document initial assessment and care plans. For example, for a wound, he will put in the instructions of wound care in the PCC. Staff #33 stated that the process of admission involves getting discharge orders from the admission team. The admission team gets the orders from the hospital from the hospital's case management. Staff #33 was looking at PCC for the hospital discharge orders of Resident #1. Staff #33 pointed out that on page 19 of the hospital discharge orders, there's the discharge wound care and wound vac. Staff #33 looked at the PCC order tab and he stated that there is no wound vac order placed just the colostomy order. Staff #33 stated that he was not the admission nurse when Resident #1 arrived at the facility that day/weekend. Staff #33 stated that it was LPN/Staff #34 was the admission nurse that day. He stated that he does not know what happened and why the wound vac order was not in PCC. An phone interview was conducted with LPN/Staff #34 on August 6, 2024 at 2:02 pm. Staff #34 stated that she works on the cart and during the weekend she does admission. Staff #34 stated that as an admission nurse, she put all orders in, and have the consents signed. She stated that she worked that day on July 21, 2024 and she did not remember an order for wound vac on top of her head. An interview was conducted on August 6, 2024 at 2:36 pm with the director of nursing (DON)/Staff #21. The DON stated that they have an admission nurse that takes admission and they take care of the consents and evaluations. The admission orders come from the hospital, they review the physician orders by calling their in-house physician for the new admit. Then, the hospital orders are placed in the PCC. Staff #21 was looking into the PCC to see a wound vac order for resident #1. Staff #21 stated that she does not see an order for wound vac in PCC. Staff #21 stated that she remembered the resident having a wet to dry dressing on Monday and the wound vac was placed later on that week. A phone interview was conducted with wound nurse/LPN/Staff #22 on August 6, 2024 at 3:05pm. Staff #22 stated that the wound vac on Resident #1 was started 2 weeks ago when he was told that the resident has a wound vac. He stated that he went to get a wound vac supply but did not have a cannister, so he placed a wet to dry dressing until the cannister arrived on Thursday, July 25. He stated that the assistant director of nursing (ADON) told him to place a wet to dry dressing and apply the wound vac on Friday because they change the wound vac on Mondays/Wednesdays/Fridays. Staff #22 stated that the wound vac was placed on July 26 but it was not him that placed the wound vac. Staff #22 stated that he found out about the order for a wound vac for resident #1 when the resident was asking about the wound vac and from the resident's hospital discharge orders. Review of facility policy titled Nursing Clinical reviewed on June 2024 revealed that it is the policy of the facility to accurately implement orders in addition to medication orders (treatment, procedures) only upon the order of a person duly licensed and authorized to do so in accordance with the resident's plan of care. Furthermore, number 3 of the procedure states Admission orders are reviewed with the physician upon admission based on the discharge instructions from the discharging facility and are transcribed accordingly. Review of facility policy titled Nursing Services, section: Care and Treatment, subject: Wound management last revised February 2021 and last reviewed July 2024 revealed once a wound has been identified, assessed, and documented, nursing shall administer treatment to each affected area as per the Physician's order.

Based on clinical record review, resident and staff interviews, review of facility documentation and policy, the facility failed to ensure that infection control guidelines related to oxygen use was followed for one resident (#2). The deficient practice could result in the spread of spread of disease to residents. Findings include: Resident #2 was admitted to the facility on [DATE] with diagnoses of primary pulmonary adenocarcinoma (lung cancer) and dyspnea. A physician order dated 6/19/2024 included for 1-5 liters of oxygen as needed via nasal cannula to keep oxygen saturation greater than 90% for shortness of breath related to ineffective gas exchange. Another physician order dated 6/19/2024 included to change oxygen tubing every night shift and as needed. The daily skilled note dated 6/20/2024 revealed that the resident was alert and oriented x3; and that, the resident had no respiratory treatments. The physician admission progress note dated 6/20/2024 included that the resident was alert, ill-appearing, had clear breath sounds and unlabored breathing. Assessments included primary pulmonary adenocarcinoma, dyspnea with exertion and chronic cough. The care plan dated 6/20/2024 revealed the resident had oxygen therapy related to ineffective gas exchange and lung cancer. Interventions included to give medications as ordered by physician, monitor/document side effects and effectiveness, and oxygen 1-5 liters continuously via NC (nasal cannula)/mask. The brief interview for mental status (BIMS) dated 6/21/2024, the resident had a BIMS score of 14 indicating the resident had intact cognition. The MDS (minimum data set) note dated 6/21/2024 included the resident was alert and oriented x3 and had shortness of breath. The daily skilled note dated 6/23/2024 revealed the resident was alert and oriented x3 and had no active respiratory symptoms. The documentation included that respiratory treatments included use of continuous oxygen set at 2 LPM (liters per minute) via nasal cannula. An observation was conducted on 6/24/2024 at approximately 3:30 p.m., the oxygen tubing including the nasal cannula for resident #2 was on the floor by her bed. Resident #24 stated that she had dropped it when she got up to go to the bathroom. Multiple nursing staff were observed walking past the room and entering the resident room to talk with resident #2 while the resident's oxygen tubing was on the floor. At 4:00 p.m., the resident had her nasal cannula on; and, the resident stated that staff picked the oxygen tubing for her but did not sanitize it. The resident further stated that the staff did not provide her new oxygen tubing. In an interview with Licensed Practical Nurse (LPN/Staff #45) conducted on 6/24/2024 at 4:15 p.m., the LPN stated that if the resident's oxygen tubing, mask or nasal cannula fell on the floor, then the resident would get a new tubing or a mask. Regarding resident #2, the LPN said that she did not notice that the oxygen tubing of resident #2 was on the floor. During an interview with the Assistant Director of Nursing (ADON/staff #61) conducted on 6/24/2024 at 4:22 p.m., the ADON stated that her expectation was for staff to use hand sanitizer gel when they enter and exit the resident room even if they were just talking to the resident. Further, the ADON stated that if the resident's mask or oxygen tubing or nasal cannula fell on the ground, she would expect staff to replace these before putting it back on the resident. A facility policy titled, Oxygen Administration, revealed that staff may replace oxygen tubing as needed. The facility policy on Infection Prevention and Control Program included that it is the facility's goal to decrease the risk of infection to residents, recognize infection control practices while providing care, and identify and correct problems relating to infection control practices.

Based on clinical record review, resident and staff interviews, and review of facility documentation and policy, the facility failed to ensure that medication was available for administration as ordered by the physician for one resident (#1). The deficient practice could result in the resident not receiving the needed medication. Findings include: Resident #1 was admitted on [DATE] with diagnoses of other seizures, hypertension, and neuropathy. A hospital progress note dated 5/21/2024 revealed that the resident had a history of myoclonic seizures; and, had tried Keppra (anti-seizure) in the past but could not tolerate this. The hospital clinical summary dated 5/23/2024 included that the resident had a diagnosis of seizure disorder. It also included to continue clonazepam 1 mg by mouth once a day at bedtime. A physician order dated 5/23/2024 included for clonazepam 1 mg at bedtime for anxiety AEB (as evidenced by) restlessness. The facility medication administration record (MAR) for 5/23/2024 revealed that clonazepam was marked as 7 which indicated to see Other/see nurse notes. The electronic MAR progress note timestamped 5/24/2024 at 1:38 a.m. indicated that clonazepam was not available. It also included that the pharmacy was contacted and the expected delivery date was 05/24/2024. The MDS (Minimum Data Set) note dated 5/24/2024 revealed that the resident was alert and oriented x4, had clear speech and was able to make self-understood. The Leaving the Facility Against Medical Advice form was signed by resident #1 and dated 5/24/2024. In an interview with resident #1 conducted on 6/24/2024, the resident stated that she did not get her medications at 10:30 p.m. on 5/23/2024 during medication pass; and that, she had to wait. The resident stated that when she received her medications on 5/23/2024, her seizure medication, clonazepam, was missing and she ended up having a seizure. She stated that she ultimately left the facility AMA on 5/24/2024 after staying less than 24 hours. In an interview with a licensed practical nurse (LPN/staff #45) conducted on 6/24/2024 at 4:15 p.m., the LPN stated that she will document in the electronic record that the resident's medication was not available and whether the facility was waiting delivery from pharmacy. She stated that the facility has e-kits (emergency kits) for medications; but, the e-kit have more generic medications and does not have all the medications. The LPN said that if there was a delay in the delivery of the medications resulted in the resident missing a dose, she will not notify the provider. She said that if the medication that was delayed in the delivery will medically impact the resident, for example, blood pressure medications, this needed to be reported to the provider. The LPN stated that if a resident has a seizure disorder, it would not be appropriate for that resident to miss even one dose of the seizure medication. She stated that she had seen clonazepam used to treat seizures and a missed dose of clonazepam would require talking to the doctor. The LPN said that the Assistant Director of Nursing (ADON) have the keys to the e-kit or pyxis; and, she would ask the ADON if clonazepam was available in the facility's e-kit or pyxis. In an interview with the ADON (staff #61) conducted on 6/24/2024 at 4:22 p.m., the ADON accessed the inventory for the facility's pyxis machine and stated that that clonazepam was available in the facility's pyxis. However, the ADON stated that the clonazepam in the facility's pyxis had a different dose than what was ordered for resident #1. The ADON said that resident #1 was ordered for clonazepam 1 mg tablet. She stated that if the resident was just admitted at the facility like resident #1, staff could get a one-time order from the doctor to get the medication from the pyxis and administered to the resident until the pharmacy delivered the medications. During an interview with the Director of Nursing (DON/staff #33) conducted on 6/24/2024, the DON stated that she agreed that if the resident really wanted the medication, then the staff would have to get a new order to pull the new dose of medication from the pyxis. The facility policy on Medication Administration- Administration of Drugs, it included that it is their policy that medications shall be administered as prescribed by the attending physician.

Based on clinical record review and staff interviews, the facility failed to ensure one resident (#3) was received written notification of changes in charges to services during stay at the facility. The deficient practice could result in residents not being informed of their potential liability for payment. Findings include: Resident #3 was admitted on [DATE] with diagnoses of infection and inflammatory reaction due to internal left knee prosthesis and wedge compression fracture of T11-T12 vertebra. A review of the Admission Agreement signed by resident on November 1, 2023 revealed that changes in any charges based on a change in the Resident's condition shall be communicated prior to the effective date of the revised charges. It also included that if notice of changes in charges based on a change in the Residents condition was given orally, written notice shall be given within one (1) week following the effective date of the revised charges. The care plan initiated on November 3, 2023 included a discharge plan to return home. Goal was for the resident to verbalize/communicate understanding of the discharge plan and describe the desired outcome by the review date. Interventions included establishing a pre-discharge plan with the resident, family, or caregivers and evaluate progress and revise plan as needed. The Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview of Mental Status (BIMS) score of 15 indicating the resident had intact cognition. Review of the clinical record revealed that the resident was on IV (intravenous) Vancomycin antibiotic therapy for an infected prosthetic knee joint for 6 weeks (order date November 2, 2023); and, IV daptomycin (antibiotic-order date November 9, 2023) for infection. The November 2023 Medication Administration Record (MAR) revealed that IV Vancomycin was last administered and was discontinued on November 9, 2023. A review of the resident's census documentation since admission (November 2, 2023) revealed that there was a liability change on November 22, 2023. However, the clinical record revealed no evidence that resident #3 received a written notice regarding the change in liability for payment. There was also no documentation that the resident was notified of change liability for payment. Review of the SA intake information received on March 20, 2024 revealed that the resident was not informed that the resident received a bill of $2,800.00 two weeks after he was discharged from the facility; and that, the resident was not informed that his insurance ran out prior to his discharge from the facility. The December 2023 MAR included that daptomycin was last administered and discontinued on December 5, 2023. Further review of the clinical record revealed that the resident was discharged from the facility on December 7, 2023. In an interview with assistant business office managers (ABOMs/staffs #11 and #22) was conducted on April 26, 2024 at 1:50 p.m. Staff #22 stated that the insurance for resident #3 was Medicare Advantage which meant that on the 21st day at in the facility, the resident became responsible for the copay; and this was the liability change. Staff #22 also said that the resident did not have a secondary insurance; and, he became responsible for his stay on day 22. Staff #22 further stated that it would not be appropriate to issue resident #3 a NOMNC (Notice of Medicare Non-Coverage) because Medicare coverage was just dropping to 70%; and the resident was not out of days. Staff #22 said that resident #3 would still have his 100 covered Medicare days allotted to him and can stay as long as he had a skilled need. Staff #22 said that the 21st day of the resident stay was when it got kicked to 70% which resident #3 had. Staff #11 stated she was newer to the position, and was unsure how payor changes were communicated to the resident back in November 2023. Staff #11 said the current process was to give the resident a written notice about the liability change and notify the resident about the liability change it is due. Staff #11 said that if a resident does not have the ability to pay they will try to have the resident discharged . During an interview with the Business Office Manager (BOM/staff #440 conducted on 4/26/2024 at 2:31 p.m., the BOM stated that when there was going to be a payor change, a letter will be given to the resident. The BOM stated that there was no letter completed for resident #3. The BOM said that the resident was on IV antibiotic and the facility did not want him to discharge until it was complete. The BOM also said that the resident was informed there would be a $200 copay for each day; and that, the resident wanted to go home when he was told this. Further, the BOM said that the conversations with resident #3 regarding payor changes were not documented; however, resident #3 was in the business office almost daily because he was worried about the payment. The BOM said that the resident was told that the priority was to get him better and he needed to finish his IV antibiotic for his knee. She stated the resident was notified well before discharge that he would need to pay. The BOM said resident #3 should have been given an Advance Beneficiary Notice of Non-Coverage (ABN) or NOMNC which was issued by insurance; and that, when an insurance emails the facility a notice of non-coverage, the facility will then this to the resident who then signs it. The BOM said that the signed copy would be uploaded into the Electronic Health Record (EHR). Further, the BOM said that an ABN and NOMNC were given at the same time and the resident is told of how much it would be if they stayed; and that, if a resident discharged before completing their care, it would be noted in the discharge summary that the resident left early, or there would be an order from the physician saying patient discharged sooner than planned. During the interview, a review of the clinical record was conducted with the ABOM who stated that the ABN/NOMNC was not issued to resident #3. Immediately after the interview with the ABOM, the facility provided a note from the business office with a date and time of December 18, 2023 11:40 a.m. (9 days after the resident's discharge date ) and was written by the BOM. The documentation included that the resident was in the business office multiple times during his stay and reported that he did not have the money to pay coinsurance at $200.00 per day. It also included that the resident was not able to leave due the facility due to his diagnosis and IV therapy; and that, the resident discharged when the IVs were discontinued.

Based on observations, interviews, facility documentation, review of the Center for Disease Control (CDC) guidelines and policies and procedures, the facility failed to maintain an effective infection control program, by having multiple staff who were either symptomatic and positive for COVID-19 or exhibited symptoms of COVID-19 and provided care to residents. As a result, the Condition of Immediate Jeopardy (IJ) was identified. Findings include: On July 1, 2020 at 1:30 p.m., the Condition of Immediate Jeopardy (IJ) was identified. The Administrator (staff #42) was informed of the facility's failure to implement infection control procedures, as multiple staff (#12, #15, #17, #21, #9, #73 and #70) who were either symptomatic (coughing, sore throat, muscle pain, headache) or who were positive for COVID-19 and symptomatic, and were permitted to work with non COVID and COVID positive residents. The Administrator presented a plan of correction on July 1, 2020 at 3:29 p.m. At 3:46 p.m., the Administrator was informed that the plan of correction needed to address additional processes, in order to correct the identified concerns. A revised plan of correction was presented on July 1, 2020 at 5:30 p.m. and was accepted at 6:13 p.m. The plan of correction included for re-education of staff regarding being sent home immediately if they reported signs or symptoms of COVID-19 at the beginning of their shift, or if they developed symptoms at any time during their shift. Staff would also receive in-service education regarding the up-dated screening process, which included having a designated employee assigned to screen staff at the start of their shift. The plan further included that the facility would continue to monitor and track staff symptoms and testing results on a line listing daily, and that the implementation of staffing mitigation strategies would be put into place to address any staffing shortages. On July 1, 2020 between 6:20-6:45 p.m., multiple staff were interviewed regarding if education had been provided pertaining to whether or not symptomatic staff were permitted to work in the facility, and the updated staff screening process. Only one of six staff members understood that symptomatic staff would not be allowed to work with residents and would be sent home. None of the staff interviewed were aware of any changes to the screening process. The Administrator was informed that the facility was not compliant with implementing their plan of correction and inservice's were initiated. On July 2, 2020 between 9:00-10:00 a.m., additional interviews were conducted with facility staff regarding the implementation of their plan of correction. Staff reported that in-services were conducted on handwashing, and donning and doffing Personal Protective Equipment (PPE), however, they had not been educated regarding the revised screening process, and staff did not have an understanding that they would be sent home if they were symptomatic for COVID-19. In addition, review of the staff screening sheets for July 2, 2020 revealed that ten staff members had documented the presence of symptoms and had been permitted to work. Only one of the ten staff members with symptoms had been sent home. In interviews with staff conducted on July 2, 2020, multiple staff reported there had been no designated individual to provide screening for staff entering the COVID unit that morning. On July 2, 2020 at 12:45 p.m., the Administrator was notified that the plan of correction needed to specifically address staff education to include the following: staff who were symptomatic were to be sent home and would not care for residents; the process for asymptomatic COVID positive staff to return to work, and that staffing mitigation strategies were in place and being implemented in the facility. The plan of correction also needed to include specific details of which staff members would be designated to screen staff during the week and on weekends/holidays, and which staff members would review and follow up on the screening results for staff who documented the presence of symptoms. A revised plan of correction was presented on July 2, 2020 at 1:35 p.m. At 3:26 p.m., The Administrator was informed that the plan of correction needed to address additional areas. On July 2, 2020 at 3:48 p.m., a revised plan of correction was presented. At 4:26 p.m., additional revisions were requested to include who would be responsible for reviewing the employee data collected on the screenings each shift and following up to ensure that symptomatic staff were sent home and removed from caring for residents, and if symptoms were consistent with the employee's baseline, documentation would be completed with detailed information before the employee would be permitted to work. This criterion was to pertain to all staff, whether entering the building through the front door or entering through the COVID unit. A revised plan of correction was presented on July 2, 2020 at 5:10 p.m. and was accepted. Multiple observations were conducted in the afternoon on July 2, 2020, of the facility implementing their plan of correction. Staff in-services were being completed and staff interviewed were knowledgeable of infection control procedures, including that symptomatic staff would not be permitted to work with residents on any unit. In addition, a designated staff member conducted the screenings, as staff arrived for their shifts. As the facility was implementing their plan of correction and staff were knowledgeable about the new processes that had been put into place, and there were no additional concerns identified, the Condition of Immediate Jeopardy was abated at 5:15 p.m. on July 2, 2020. Regarding staff who were symptomatic and/or were symptomatic and had tested positive for COVID-19, and provided care to non-COVID and COVID residents: -An entrance conference was conducted on June 30, 2020 at 9:10 a.m., with the Administrator and the Director of Nursing (DON/staff #1). The DON stated that the current census was 68. The DON also stated there had been a staffing shortage and they were currently in emergency mode for staffing. During the survey, an interview was conducted with direct care staff (staff #12), who stated they had received prior in-services regarding COVID-19 about being screened daily for signs and symptoms of illness. Staff #12 stated they were told that if they had three or more symptoms they would be sent home. Staff #12 stated that symptoms began on June .2020, which included a sore throat, cough, muscle aches, fatigue and a headache, and that he/she was tested for COVID-19. He/she said the staffing coordinator (staff #23) was told on June .2020 that he/she was having symptoms (cough, muscle pain, headache and sore throat) and asked not to work. Staff #12 stated that staff #23 said he/she was on the schedule and needed to come to work. Staff #12 stated that he/she worked that day and was screened by staff #23. Staff #12 said that staff #23 completed the documentation on the log. Staff #12 said that he/she told staff #23 that his/her symptoms were cough, muscle pain, headache and sore throat, but was sent out to work on a non-COVID unit that day. Staff #12 said that after the shift was over, he/she went for the exit screening but no one there to screen, so he/she looked at the screening log (from earlier that day) and there was a circle around the symptom of cough and a small question mark had been written next to it. Staff #12 stated the yes answer to muscle pain had also been scribbled out and the no answer had been checked instead, and there was a circle around the yes answer for headache. Review of the corresponding staff screening log for staff #12 for the day referred to in the above interview revealed the following: a question mark had been written next to the symptom of cough; the answer regarding muscle pain was yes but it had been scribbled out and a no had been marked; for headache the answer was yes but a circle had been drawn around yes and the symptom of sore throat had both the yes and the no boxes checked and both had been scribbled out. In the signature screener section, staff #23 (staffing coordinator) had signed her name. Review of the punch detail record for that date revealed that staff #12 worked a full shift. Continued in the interview staff #12 stated that the next day while being screened, he/she reported symptoms which included a cough, muscle pain, headache and sore throat, but was sent to work on a non-COVID unit again. Staff #12 stated that once on the unit, he/she reported to the nurse about feeling sick, so the nurse called the Assistant Director of Nursing (ADON/staff #33). Staff #12 stated the staffing coordinator (staff #23) texted back and said to stay and work the shift, and text her every two hours to report his/her symptoms, which he/she did. The corresponding staff screening log for staff #12 included yes answers for cough, muscle pain, headache and sore throat. Review of the punch detail record for this same day revealed that staff #12 worked a full shift. Staff #12 further stated that the following day (June .2020) he/she also developed diarrhea and vomiting and called off sick. He/she said the next day, a text was received from staff #23 saying that he/she was on the schedule to work that afternoon/evening. Staff #12 stated that he/she texted staff #23 saying he/she still felt sick and staff #23 texted her back and said to get some rest, because he/she needed to be there. Staff #12 stated that he/she worked that afternoon/evening on a COVID unit. Staff #12 said that during the shift, he/she had another episode of diarrhea and reported it to staff #23 via text and asked to go home, but staff #23 said no, as there was no one to work the hall. Review of the staff screening log for staff #12 on that day revealed that both yes and no were marked for cough, muscle pain and headache and that sore throat was marked no and diarrhea and vomiting was marked yes. In the signature screener section, staff #23 had signed her name. The punch detail report for this date revealed that staff #12 had worked a full shift. In the interview, staff #12 further stated the next day (June .2020) he/she called off sick and went to urgent care. They did another COVID test because the results from the facility were not back yet. He/she said the physician from the urgent care told her to go home and quarantine. Staff #12 stated that he/she texted staff #23 the next day on June .2020 and told her that he/she had no taste or smell, and that urgent care said to self-quarantine. Staff #12 also stated that he/she emailed the doctor's note from urgent care to the Human Resource representative (staff #11). Staff #12 said that same day on June .2020, the Administrator said he/she had tested positive for COVID. Staff #12 said the Administrator asked if he/she was symptomatic and responded yes, and had been for a while. Staff #12 stated the Administrator said that asymptomatic COVID positive staff could work on the COVID positive unit. Staff #12 stated the Administrator also said they could make an exception for staff and to keep them informed of his/her symptoms. Staff #12 said the next day on June .2020, he/she texted staff #23 and told her that he/she had tested positive for COVID. Staff #12 stated that staff #23 said he/she was scheduled to work that day and was expected to come in. Staff #12 said that he/she told staff #23 that he/she was still symptomatic and was not working sick. -During the survey, an interview was conducted with direct care staff (staff #17). Staff #17 stated that multiple symptomatic/COVID positive staff members including his/herself have worked with non COVID residents. A follow-up interview was conducted with staff #17. Staff #17 stated that on June .2020, he/she was tested for COVID-19, along with other staff. Staff #17 said a few days later, he/she developed a fever of 100.2 degrees F, congestion, sore throat, body aches and a cough, and was scheduled to work that day. Staff #17 said that he/she texted the staffing coordinator (staff #23) and told her that he/she did not feel good and she would try to find someone else to cover his/her shift. Staff #17 stated that he/she did not hear back, so he/she went into work that day. Staff #17 stated that after he/she was screened that day, he/she spoke with the staffing coordinator (staff #23) and the DON (staff #1) about being sick. Staff #17 stated that despite his/her symptoms, staff #23 and the DON told him/her to work the floor. Staff #17 stated that he/she was sweating and weak during the shift and texted the staffing coordinator that he/she felt terrible and asked for a replacement. Staff #17 said the staffing coordinator never responded back and he/she worked over an 8 hour shift that day on a non-COVID unit. Review of the corresponding staff screening log for that day when he/she worked over an 8 hour shift, revealed that staff #17 had a fever of 100.2 degrees F, a cough, muscle pain and a headache. The log also included that a temperature greater than or equal to 100.0 degrees F was considered out of the acceptable range. Review of the punch detail record for this same date revealed that staff #17 worked over 8 hours. In the interview, staff #17 further stated after that he/she was sick for a few days and that the test results came back negative. Staff #17 said that he/she was still intermittently symptomatic and had a cough, and had not been retested . Staff #17 stated that today he/she worked on a non-COVID unit. -During the survey, an interview was conducted with a direct care staff member (staff #15). Staff #15 stated he/she started having a cough, sore throat and fever of 101 degrees F a couple of weeks ago and didn't work. Staff #15 said that he/she returned to work a couple of days later on June .2020 and since then, has continued to work with a cough, sore throat and intermittent fever. Staff #15 stated that he/she has not been tested for COVID-19. A follow-up interview was conducted with staff #15, who stated that he/she continues to have a cough, congestion and headaches. Staff #15 said that yesterday, he/she was asked to stay until registry staff arrived, and worked on both the COVID and non-COVID units. Review of the staff screening logs for June 2020 through July 2, 2020 revealed that staff #15 had reported various symptoms on multiple days, which included the following: a cough, fever, muscle pain, headache, sore throat or shortness of breath. On one day in June, staff #15 had reported shortness of breath, cough and a headache, and the original screening temperature was illegible, as it had been scribbled out and replaced with 99. According to the corresponding punch detail reports, staff #15 worked on those days in June and July when exhibiting symptoms. -During the survey, an interview was conducted with direct care staff (staff #21), who stated that on June .2020 he/she began having a headache, body aches, sore throat and chills. Staff #21 stated that he/she texted the staffing coordinator (staff #23), the Administrator and the DON to report his/her symptoms, but no one responded back. The next day, staff #21 said he/she had a fever of 100.3 degrees F, a headache, muscle pains, sore throat, chills and a cough. Staff #21 said he/she was told by staff #23 that he/she was still expected to work his/her shift that day and then worked on the COVID unit. Review of the corresponding staff screening log for that day when he/she had a fever of 100.3 and other symptoms, revealed that staff #21 had reported muscle pain, headache, sore throat and chills, when she reported to work that day. Continued in the interview, staff #21 said that a couple of days later he/she worked on a non COVID unit, but was sent home early, because of not feeling well. Review of the corresponding staff screening log for that day revealed that staff #21 had reported having a cough, fever, muscle pain, headache, sore throat and chills. The punch detail record for that date revealed that staff #21 had worked a short time that day. During the interview, staff #21 further stated that the next day June .2020, he/she worked on a non-COVID unit and still wasn't feeling well. Review of the corresponding staff screening log for that day revealed that staff #21 reported symptoms which included cough, fever, muscle pain, headache and sore throat. The punch detail record for that same day included that staff #21 worked a full shift. Continued in the interview staff #21 stated that a few days later on June .2020, he/she worked on a non-COVID unit again and was short of breath and didn't feel well. Later that afternoon, staff #21 said he/she was told by the Administrator that he/she had tested positive for COVID-19. Staff #21 stated that per the staffing coordinator, the DON and the Administrator, all COVID positive staff still needed to report to work, because that was the facility's policy. Later that same day while working, he/she texted the staffing coordinator (staff #23), the DON and the Administrator that he/she was short of breath and his/her oxygen saturation level was 88% (normal oxygen saturation level is 95-100%). Staff #21 stated that staff #23 said they did not have anyone to replace him/her and that he/she was still on the schedule for the next day June .2020. Review of the corresponding staff screening log for the day that he/she was notified of the positive test results for COVID, revealed that staff #21 had a cough, muscle pain, a sore throat, and for chills it was marked both yes and no. The punch detail record for that same day included that staff #21 worked a full shift. In the interview, staff #21 also stated that the next day he/she had a physician visit who told him/her to immediately go to the emergency room . Staff #21 said he/she texted the staffing coordinator, the DON and the Administrator and told them what the physician said and sent them a copy of the doctor's note. Staff #21 said he/she received a text from staff #23 stating that he/she needed him/her to show up for work that day. Staff #21 stated that he/she went to work as scheduled, so the next shift could be relieved. Staff #21 stated that he/she told them that they needed to find someone to take over in a couple of hours. Staff #21 stated that around noon that day, he/she texted the staffing coordinator, the DON and the Administrator and asked for someone to relieve him/her, because it hurt to breathe. Staff #21 stated the Administrator texted back saying they were trying to get someone in to relieve him/her. Staff #21 stated they never called him/her back and he/she ended up working a 12 hour shift on a non-COVID unit. Review of the corresponding staff screening logs revealed there was no screening documentation for staff #21 for that day. Review of the punch detail record for that same day revealed that staff #21 worked approximately 12 hours. On June 30, 2020 at 11:25 a.m., an interview was conducted with the DON (staff #1). He stated that if staff tested positive for COVID-19 but were well enough to work, they may work on the COVID unit. He said if staff are symptomatic they are asked to leave. However, he further stated that if he had to he would allow someone with a cough and fever to work on the COVID unit. He said when staff have asked him what their policy was for coming to work with symptoms, he referred them to the Human Resources representative (staff #11), because she was more familiar with that policy. An interview was conducted on July 1, 2020 at 1:37 p.m., with the Human Resource representative (staff #11). She stated that her understanding of the facility screening process included that if a staff member triggered 2-3 symptoms, they would need to consult with the DON and the Administrator for further screening. She said she believed that staff were switched to two 12 hour shifts to prevent a staffing shortage. She stated she would not consider the facility to have a staffing shortage. She stated that she knows what the CDC has recommended. She said her understanding is if staff have been exposed to COVID-19 but have no symptoms, they would be screened, and allowed to work if they wore a face mask and all the appropriate PPE. She stated if a symptomatic staff member were referred to her, she would review the CDC guidelines which states that the staff member would need to be tested and to isolate, until the results are received. She said if staff came to her to ask about the facility's policy regarding working, she would direct them to speak to the DON. She stated that as far as she knows, they aren't forcing anyone with symptoms to work. She stated that COVID positive staff are allowed to work as long as they are asymptomatic, and only on the COVID unit. She said no one has been referred to her with any questions about COVID positive symptomatic staff continuing to work. She stated that she has not been made aware that symptomatic staff are working in the facility. Regarding changes to the staff screening logs: -Review of the staff screening logs for June 2020 revealed multiple alterations in the form of scribbling over, marking through, writing on top of and/or crossing out of the screening data that had been provided by facility employees which included the following: June 2 and 3: changes made to one staff's screening June 4: changes made to three staff's screenings June 5 and 7: changes made to one staff's screening June 8: changes made to three staff's screenings June 9 and 10: changes made to two staff's screenings June 11: changes made to four staff's screenings June 12: changes made to four staff's screenings June 16: changes made to one staff's screening June 17: changes made to two staff's screenings June 18 and 19: changes made to three staff's screenings June 20: changes made to one staff's screening June 21, 22 and 23: changes made to two staff's screenings June 24: changes made to six staff's screenings June 25: changes made to eight staff's screenings June 26: changes made to four staff's screenings June 27: changes made to seven staff's screenings June 28: changes made to three staff's screenings June 29: changes made to four staff's screenings June 30: changes made to six staff's screenings July 1: changes made to four staff's screenings July 2: changes made to seven staff's screenings An interview was conducted on June 30, 2020 at 2:19 p.m., with the staffing coordinator (staff #23). She stated that she does all the staffing for the nurses and the CNAs. She stated that she keeps the staff screening logs with her. She stated if an employee screens in with a temperature of 100.4 degrees F or higher or has more than 2-3 symptoms, she screens them further to see if the symptoms are normal for them. She stated that she has never altered the screening documents to make it seem like staff have no symptoms. She stated that staff are screened at the back entrance and that anyone in the facility can be a screener. Another interview was conducted on June 30, 2020 at 2:20 p.m. with staff #23, who stated that she had no idea who may have altered the screening sheets. Staff #23 stated that screeners must initial the logs when completing the screening. Regarding the facility declaration of a staffing emergency: -On June 30, 2020 at 11:25 a.m., an interview was conducted with the DON (staff #1). He said the facility had not reached critical staffing levels until 2 or 3 days ago (June 27 or June 28, 2020). He said the facility was looking into CNA waivers. An interview was conducted on June 30, 2020 at 2:20 p.m. with staff #23, who stated that a staffing emergency began on June 29, 2020, which caused the facility to implement 12 hour shifts for nurses and CNAs. Staff #23 stated that a staffing crisis is when the facility is using 100% registry in their building. She said the core staff have been helpful and pitched in, by taking additional shifts and working extra hours. She stated the staff are grateful for their jobs and the hours. She stated that they had 2 nurses resign, due to concerns for their health and the health of their family. On July 1, 2020 at approximately 12:20 p.m., an interview was completed with the Administrator. The Administrator said that he had not contacted the county himself for information or assistance, but stated that the DON was in contact with a staff member at the county. Another interview was conducted with the DON on July 1, 2020 at 12:30 p.m. The DON stated that he had been in contact with Epidemiology at the county office to report any new cases and to give facility updates. In a later interview at 3:56 p.m., the DON stated that he also talked to the county regarding the need for personal protective equipment (PPE), and had briefly discussed a waiver for CNAs. He said that he briefly mentioned possibly needing staffing assistance at some point, but acknowledged that there was no follow up to that conversation which occurred around June 23 or June 25, 2020. A follow up interview was conducted on July 1, 2020 at 4:01 p.m., with the DON. He stated that he and the Administrator began to have conversations about staffing on June 22, 2020. He stated they were not in crisis mode on that date, but considered what they would do in the event of a staffing shortage. He said during that week, he asked the Administrator about strategies that they would use if things went bad. The DON said that on June 23 and June 24, 2020, they were still not in crisis mode and were still considering their options. He said on June 25, he asked the Administrator that if things went bad, what were they going to do? He said he suggested that they needed to consider transferring residents out to another facility. He said on June 25, he also spoke with the county and briefly discussed the CNA waiver and mentioned the potential need for staffing assistance. The DON said that on June 26, he was more concerned and wondered if they should be reaching out to other facilities. He stated they were not short-staffed that day and they were not in crisis mode. The DON said he had another conversation with the Administrator regarding their crisis staffing plan. He said on June 27, 2020, staff began calling out sick. He said he spoke with the Clinical Resource Liaison to discuss options and about transferring residents out to other facilities, and to reach out to other facilities to get more staff. The DON further stated that on the evening of June 27, 2020, he received the results of the COVID testing for staff which had taken place on June 22, and that multiple staff had tested positive. He said that same evening, they were short staffed. He said he called out to agency staffing, but found they were requesting hazard pay of 1.5 times the normal rate or $5.00 - $10.00 more per hour. He said the Administrator hesitated to hire them based on that factor. He said a staff from another facility came in, and he also called upon existing staff to cover the other two positions. The DON said that on June 28, administrative staff decided to implement their emergency staffing plan and began having staff work two 12 hour shifts the following day. He said they called their staff that evening to let them know. He said the facility reached crisis or emergency status on June 29, 2020 (one day prior to the survey team entering the building) and that they implemented their emergency staffing plan. He stated he would provide documentation of the efforts that had been made to abate the staffing issues. A list of actions taken to abate the staffing crisis was presented by the Clinical Director (staff #57) on July 2, 2020 at 3:20 p.m. Beginning June 15, 2020, the documentation included the need for additional nurses had been discussed during a conference call. A conference call dated June 22, 2020, included the need to hire 5 nurses and 5 CNAs. Another phone conversation with corporate was done on June 22, 2020, which included discussing staffing and registry. On June 28, 2020, two area facilities were contacted regarding their ability to house additional residents, but neither of the facilities had room. On June 29, 2020 during a corporate call with the Executive Directors and Resources, the possibility of transferring residents out of the facility was again discussed. Another call on June 29, 2020 with corporate included discussing staffing, registry, and the transfer of residents. Per the documentation, a call was made to a nursing registry service on June 29, 2020, but there were no nurses available. On June 30, 2020, a medical group was contacted and a contract was signed regarding procurement of CNAs and nurses. On July 1, 2020 (the day of the IJ), two other area facilities were contacted regarding their ability to house additional residents, but neither facility had room. Also on July 1, 2020, the documentation indicated that contact was made with three nursing registries in an attempt to procure staff and that they were waiting for responses. According to the documentation, the facility had various discussions regarding staffing issues, however, no action was taken in an attempt to increase staff until June 29 and June 30, when staffing agencies were contacted. In addition, there was no evidence that the facility had reached out to the county for assistance with staffing concerns anytime from June 25 through July 2, 2020. Review of the Facility Health and Rehabilitation Facility Assessment updated on March 27, 2020, revealed if the facility needs to activate its Emergency Operations Plan, staff may be called back to work additional shifts and staff may be cross trained to help with additional tasks. The assessment included that agency personnel will be employed through contractual agreements and those staff with mild symptoms will be assigned to work with COVID-19 positive residents only. Per the assessment, the COVID-19 residents will be housed in a separate wing with dedicated staff, so that staff are not intermingling, and non-positive staff will work with non-positive residents to the extent possible. -During the survey, an interview was conducted with direct care staff (staff #9). Staff #9 stated that symptoms consistent with COVID-19 began on June .2020. Staff #9 stated that on that day, he/she told the staffing coordinator (staff # 23) and the DON of the new onset of cough and a sore throat, but was still assigned to work on a non COVID unit. Staff #9 said when screened that day, he/she answered yes to cough and sore throat. Staff #9 said that he/she was screened by housekeeping staff (staff #91) that day. During the interview, the screening log for that day was discussed. The log showed that staff #91 had signed the log for screening staff #9 that day. Further review of the log revealed the answers to cough and sore throat were marked no. Staff #9 said the housekeeping staff (staff #91) must have checked no. In an interview with staff #91, she did not recall screening staff #9 on that day. Continued in the interview, staff #9 stated that a few days later when screened for a shift on June .2020, he/she answered yes to the screening questions regarding new onset for headache, sore throat and loss of taste and smell. Staff #9 said there were several employees saying they were having new onset of symptoms, but no one was making a big deal about it. Staff #9 said that another staff member told him/her that they were experiencing many sick staff, so they did not want any call offs. Staff #9 stated on this same day, the Administrator reported that his/her test result was positive for COVID-19, and was reassigned to work on the COVID hall. Review of the screening log for that day revealed yes for headache and sore throat, and for taste and smell a yes and a no was marked. -During the survey, an interview was conducted with direct care staff (staff #73). Staff #73 said that he/she was symptomatic (today) but was working, as they had no staff. Staff #73 said he/she was originally assign (TRUNCATED)