Every finding on record at Hazelhurst Court Care and Rehabilitation Center

Based on interview and observation, the facility failed to ensure adherence to established laundry maintenance protocols related to dryer lint trap cleaning. This deficient practice has the potential to affect 58 residents. Findings Include:During an observation on 03/28/2026 at 8:40 AM it was observed that the lint filter of the second dryer that is located near the window had not been cleaned.During an interview on03/28/2026, at 10:52 AM, the Environmental Services Director (ESD) stated that lint traps are required to be cleaned after each use or, at a minimum, every hour, with staff required to document completion. However, the ESD confirmed that the lint trap in the second dryer had not been cleaned in accordance with facility policy. The ESD also confirmed that if the lint filters are not cleaned it could cause a fire.

Based on observation, interviews, and policy titled Food Storage the facility failed to ensure that food was properly labeled and dated and in sanitary conditions to prevent foodborne illness. The practice has the potential to affect 55 residents of 58. Findings include:A tour with dietary manager on 03/27/2026 at 8:20 AM revealed the following concerns:1.Observation on 03/27/2026 of the freezer was found with a large bag of broccoli opened and not labeled, two packs of dumplings that were past the expiration date, a pack of spinach that had passed the expiration date, and a box of what appeared to be frozen cinnamon rolls that were open with no date or label.2. Observation on 03/27/2026 of the pantry revealed four boxes of lasagna and one gallon jug of Worcestershire sauce, that were not dated.3. Observation on 03/27/2026 in the kitchen at one of the perp stations revealed five seasoning containers that were opened and not dated, one pancake and waffle syrup that was opened and not dated, two cans of cooking spray that were open and not dated, one gallon bottle of barbeque sauce open and not dated, two bottles of lemon juice opened and not dated, one bag of brownie mix with an expired date, one bag of corn meal mix open and not dated, one container of salt with an expired date, and one jar of mayonnaise that was not dated.Interview during the tour with Dietary Manager of the kitchen on 03/27/2026 confirmed all of the surveyor 's identified concerns. Further interview revealed that she is responsible to ensure all food is labeled with open dates/ expired dates to ensure safety of residents. The Dietary Manager revealed she will educate her staff again on labeling and dating food items.

Based on observations, resident and staff interviews, and record review, the facility failed to ensure nail care was provided for one of 24 sampled residents (R) (R28) reviewed for Activities of Daily Living (ADL) care. Specifically, R28 was observed with long, untrimmed fingernails with visible debris containing a brown substance underneath the nail beds.Findings include:Record review of the facility's policy titled Resident Hygiene dated January 2025 under the Policy section revealed, Bathing includes cleaning and trimming fingernails and toenails, shaving facial hair, washing the entire body, and shampooing residents hair. Under the section titled Care of Fingernails/Toenails the Policy statement revealed, Nail care includes daily cleaning and regular trimming. Nail trimming diabetic residents are per MD (Medical Director) order. Podiatry care is scheduled as needed for those residents with identified podiatry needs.Record review of the Electronic Medical Record (EMR) revealed, R28 had diagnoses that included but not limited to, type 1 diabetes mellitus with hyperglycemia, other reduced mobility, and need for assistance with personal care. Record review of R28's admission Minimum Data Set (MDS) assessment dated [DATE] under Sections C (Cognitive Patterns), a Brief Interview for Mental Status (BIMS) score of 7; Section E (Behavior) for the Rejection of Care section revealed, behavior not exhibited and Section GG (Functional Status) revealed that the resident was dependent on staff to provide ADL care.Record review of the facility's bath schedule revealed, R28 was scheduled on Monday, Wednesday, and Fridays on night shift.Record review of the facility's Documentation Survey Report from January 2026 through March 2026 revealed no evidence of refusal for ADL bathing or personal hygiene related to nail care.Observations on 03/27/2026 at 9:38 AM, at 1:46 PM, and on 03/28/2026 at 8:25 AM, revealed R28 had long, untrimmed fingernails with visible debris containing a brown substance underneath the nail beds.During an observation and interview on 03/28/2026 at 9:45 AM with Certified Nursing Assistant (CNA) AA, she confirmed R28 had long, untrimmed fingernails with a brown substance underneath them.Observation and interview on 3/28/2026 at 9:50 AM with Licensed Practical Nurse (LPN) BB and CNA CC both confirmed R28 had long, untrimmed fingernails with a brown substance underneath them. LPN BB revealed she was the nurse assigned to R28 and that nurses and CNAs were responsible for nail care. During an interview on 03/28/2026 at 10:06 AM with the Director of Nursing confirmed that R28's fingernails were long, untrimmed and had a brown substance underneath them. She revealed that her expectations was staff provide nail care on bath days as scheduled. During an interview on 03/29/2026 at 8:45 AM with Registered Nurse (RN) Unit Manager, she confirmed R28 had a diagnosis of diabetes. She reported that CNAs were responsible for providing nail care to residents and that Nurses were responsible for trimming the nails of residents who were diabetics. Her expectations of staff were to offer nail care on bath days and as needed. The RN Unit Manager reported that if she had refused or they were uncomfortable with cutting R28 nails, they should have documented this.

Based on observations, record reviews, staff interviews, and review of the facility's policy titled, Respiratory System Management, the facility failed to ensure a concentrator was in working order so that the physician's order for oxygen administration was followed for one of 14 residents (R) (R31) reviewed for oxygen administration. The deficient practice had the potential to place the resident at risk for medical complications, unmet needs and a diminished quality of life.Findings include:Review of the facility's undated policy titled Respiratory System Management under the section titled Oxygen, Administration-Nasal Cannula procedures 1. Check the physician's orders in the resident's clinical record 5. turn the flow meter to the ordered flow rate. Review of the of medical record for R31 revealed diagnoses that included but are not limited to acute chronic respiratory failure with hypoxia.Review of 31's admission Minimum Data Set (MDS) assessment dated [DATE] revealed, Sections C (Cognitive Patterns)- a Brief Interview of Mental Status (BIMS) of 7; Section J (Health Conditions)-Shortness of Breath (SOB); Section O (Special Treatments, Procedures, and Programs)- received oxygen therapy Review of Physician Orders dated 02/14/2026 revealed orders for oxygen at two liters per minute via nasal canula. Observations on 03/27/2026 at 8:50 AM and 2:25 PM revealed R31 lying in bed receiving oxygen therapy via nasal canula at 1.5 liters per minute. Observation on 03/28/2026 at 9:12 AM revealed R31 lying in bed receiving oxygen via nasal cannula at 1.5 liters per minute.Observation and rounding on 03/28/2026 at 9:32 AM with the Director of Nursing (DON) revealed R31 lying in bed receiving oxygen via nasal cannula at 1.5 liters per minute. The DON revealed nurses were responsible for making sure the oxygen setting was set on the prescribed rate during medication pass and rounding. The DON verified the rate should be set at two liters per minute. Interview on 03/28/2026 at 9:34 AM with Licensed Practical Nurse (LPN) GG confirmed the physician order for R31's oxygen was 2 LPM. She revealed she checks the oxygen setting during each medication pass and during rounding. She stated she had not checked R31's oxygen as of 9:34 AM. Interview on 03/29/26 at 8:30 AM with the DON revealed she checked the oxygen rate of R31 around 7:45 AM and it was off by a half liter due to the concentrator being faulty. She stated she contacted someone to fix the concentrator. She was unsure how long the concentrator had been broken.

Based on record review and interviews with staff and family representative, and facility policy titled, Resident Trust Fund, the facility failed to notify the resident and/or residents' responsible party when their personal funds were within $200 of the Social Security Income (SSI) limit and when accounts had exceeded the amount for one of 39 accounts reviewed, resident (R)45. Findings include:Facility policy Resident Trust Fund dated 07/1/2025 revealed 6. Monitoring Balances: Per OBRA regulations, a resident on medical assistance must be notified whenever their funds are within $200 of their resource asset limit. Fund balances for Medicaid recipients should be monitored monthly by the Resident Trust Custodian to ensure that state maximum balances are not exceeded. The Resident Trust Custodian is responsible for sending a notification letter to the resident/responsible party whenever their funds are within $200 of their resource limit.Review of R45's medical record revealed she was diagnosed with but not limited to dementia in other diseases classified elsewhere, severe without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety, cognitive communication deficit, and dementia in other diseases classified elsewhere, mild, with agitation. The quarterly Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of five, indicating severe cognitive impairment.Review of the Resident Statement Landscape report dated revealed R45's trust fund accounts exceeded the SSI limit of $2000 for 12 months, February 2025 to February 2026.During an interview on 03/28/2026 at 12:39 PM with the [NAME] President (VP) of Revenue Cycle Management for [NAME] revealed there is no longer a Business Officer Manager (BOM) working in the facility, rather she handles all of the resident accounts. The VP reported she was informed to keep resident fund accounts under $2000 to qualify for Medicaid. She admitted that since she took over R45's account she has not followed up with the Medicaid Eligibility Officer regarding the resident's account being over $2000 for the last 12 months. The VP stated the resident is now in a Medicaid eligibility review period and will lose her Medicaid. The VP advised she was unsure if the resident and or her representative were receiving written notifications that R45's account was over $2000. She stated the receptionist oversees notifying residents and or their representatives.Interview on 03/28/2026 at 12:59 PM with receptionist revealed that part of her responsibility was to notify residents and or their representatives of their accounts reaching within $200 of $2000. She stated she has not sent any written notifications to R45's representative since she started in June 2025 but did give them to R45. She acknowledged the resident's BIMS was a 5 which indicates a severe cognition impairment. Interview on 03/29/2026 at 10:30 AM with R45's representative, a family member, revealed the facility keeps in contact with her and notifies her of any changes that R45 may have. The representative stated she was recently at the facility on March 11, 2026, for the resident's care plan meeting. She confirmed that she had never received any financial notices or statements from the facility. Interview on 03/29/2026 at 10:55 AM with Social Services revealed she contacted R45's family representative to ask her to spend down the resident's account by prepaying burial/funeral arrangements. Social Services revealed she did not notify the family representative that R45's account was over $2000 because she does not handle resident finances.

Based on observations, resident and staff interviews, and record review, the facility failed to follow the comprehensive care plan for a resident requiring assistance with personal hygiene (nail care) and oxygen therapy management for two of 24 residents (R) (R28 and R31) sampled. This deficient practice had the potential to place the residents at risk for unmet care needs. Findings include: Review of the facility's policy titled RAI/CARE PLANNING MANAGEMENT dated August 2017 under the Interim Care Plan section revealed, C. Based on the nursing admission assessment, the attending physician orders and other information, immediate resident needs are identified, effective interventions are implemented and measurable goals are established . Further review of the policy under the The Care Plan section revealed, The Baseline care plan will be the guide for the comprehensive care plan. 1. Record review of the Electronic Medical Record (EMR) revealed that R28 had diagnoses that included but not limited to, type 1 diabetes mellitus with hyperglycemia, other reduced mobility, and need for assistance with personal care. Record review of the care plan date initiated 12/25/2025 revealed R28 required assistance with bathing related to decreased mobility, weakness, cognitive impairment, or safety concerns with interventions that included but not limited to: assist resident with bathing as needed per resident schedule, monitor skin for redness, breakdown, rashes, or bruising during bathing and nurse to assist resident with nail care on scheduled bath days and prn. Record review of the facility's bath schedule revealed, R28 was scheduled on Monday, Wednesday, and Fridays on night shift. Observations on 03/27/2026 at 9:38 AM, at 1:46 PM, and on 3/28/2026 at 8:25 AM, revealed R28 had long, untrimmed fingernails with visible debris containing a brown substance underneath the nail beds. During an observation and interview on 03/28/2026 at 9:45 AM with Certified Nursing Assistant (CNA) AA, she confirmed R28 had long, untrimmed fingernails with a brown substance underneath them. CNAs and Nurses were responsible for providing nail care on bath days. Observation and interview on 03/28/2026 at 9:50 AM with Licensed Practical Nurse (LPN) BB and CNA CC both confirmed R28 had long, untrimmed fingernails with a brown substance underneath them. LPN BB revealed she was the nurse assigned to R28 and that nurses and CNAs were responsible for nail care. Interview on 03/29/2026 at 8:20 AM with Registered Nurse (RN) MDS Coordinator revealed that she was responsible for developing care plans and that her expectation of staff was to follow the care plan. 2. Review of the medical record for R31 revealed diagnoses that included but are not limited to acute chronic respiratory failure with hypoxia. Review of Physician Orders dated 02/14/2026 revealed orders for oxygen at two liters per minute via nasal canula. Review of care plan revealed a diagnosis acute respiratory failure with hypoxia. Interventions included but not limited to: Administer medications as prescribed or per standing order. Interview on 03/28/2026 at 9:44 AM with Minimum Data Set (MDS) Coordinator revealed she develops and enters care plans. She revealed R31's physician order was for the oxygen rate to be set at two liters per minute. The MDS Coordinator revealed her expectations of staff were to follow the care plan and confirmed 1.5 liters per minute was the wrong setting.

Based on staff interviews, record reviews, and the Director of Nursing (DON) job description, facility nursing administration failed to provide effective oversight to ensure that facility nursing staff assessed and implemented the correct Advance Directive for one of 11 sampled residents (R)(1) reviewed for Advanced Directives. This failure resulted in CPR not being provided for R1, whose Advanced Directive care plan specified she was a Full Code.On [DATE], a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation had caused or had the likelihood to cause serious injury, harm, impairment, or death to residents.The facility's Administrator and DON were informed of the Immediate Jeopardy (IJ) on [DATE], at 2:15 pm. The noncompliance related to the IJ was identified to have existed on [DATE].An acceptable Removal Plan was received on [DATE]. Based on the validation of the Removal Plan, the State Survey Agency determined that the corrective plans and the immediacy of the deficient practice were removed on [DATE]. Findings included:The facility had a job description for the Director of Nursing. The job duties and responsibilities sections included care plan and assessment functions. The care plan and assessment functions included a responsibility to ensure that medical and nursing care is administered in accordance with the resident's wishes, including the implementation of advance directives.R1 was admitted to the facility on [DATE] and had diagnoses that included cerebral atherosclerosis, dysphagia, gastro-esophageal reflux disease, anemia, constipation, hypertension, and hyperlipidemia. A review of R1's clinical record revealed a [DATE] Advanced Directive physician's order. The physician's order specified that R1 was a Full Code and to attempt CPR.A review of the Facility Notification of Hospice Admission/Change form revealed that R1 was admitted to hospice services on [DATE]. The admitting diagnosis was cerebral atherosclerosis. Following R1's admission to hospice services, an updated Physician Orders for Life Sustaining Treatment (POLST) form, dated [DATE], was completed. The POLST form specifies attempting CPR. Therefore, R1 remained a Full Code. During an interview on [DATE] at 4:11 pm, Registered Nurse (RN) Unit Manager GG confirmed that R1's Responsible Party wanted R1's Advanced Directives to remain a full code status. A review of progress notes revealed a [DATE] 6:55 pm nurse's note entry by Licensed Practical Nurse (LPN) HH, that staff alerted her that R1 was deceased . A subsequent nurse's note entry on [DATE] at 7:00 pm documented that R1 was assessed and is noted to have no pulse or respirations, and skin is cool to the touch. The note further documented that the Director of Nursing, Administrator, RN unit manager, Nurse Practitioner, and hospice nurse were notified. A review of hospice documentation revealed a [DATE] Visit Note Report that documented the hospice RN pronounced R1's death on [DATE] at 7:31 pm. However, there was no evidence that facility nursing staff attempted CPR on R1 when she was noted to have no pulse or respirations, as specified in her Advanced Directives.During an interview on [DATE] at 1:52 pm, the DON confirmed that CPR was not attempted on R1 on [DATE]. She stated that R1 was fairly new, being on hospice services, and what she gathered through interviews was that the night and day shift nurses thought that once a resident was receiving hospice services, they were a Do Not Resuscitate (DNR). The DON stated that R1's death occurred during the shift change (7:00 am-7:00 pm nursing staff going off shift and 7:00 pm-7:00 am nursing staff coming on shift). The DON stated there were six nurses at the facility, including herself. The DON stated that it was an hour and a half after the hospice nurse had left the facility, and that hospice staff then called the facility to inform them that R1 was a Full Code. During a subsequent interview on [DATE] at 3:10 pm, the DON stated that she was still at the facility, in the parking lot, with RN Unit Manager EE when they were notified that R1 was deceased , and they re-entered the facility. The DON stated that night shift nurses (LPN DD and LPN HH) were in R1's room, and the day shift nurses (LPN BB and LPN CC) were at the nursing station charting. The DON went to R1's room and observed R1 to have fixed pupils and to be cold. The DON stated that nursing staff were already on the phone notifying hospice. The DON stated that after she got home, later in the evening, she received a phone call from LPN HH, letting her know that R1 had been a Full Code.Cross-reference to F678

Based on staff interviews, record review, and review of facility policies titled Emergency Response Management and Cardiopulmonary Resuscitation (CPR), the facility failed to assess and implement life-sustaining measures for one of 11 sampled residents (R)(1). This failure resulted in CPR not being provided for R1, who was found unresponsive, and whose Advanced Directives specified attempting CPR. On [DATE], a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation had caused or had the likelihood to cause serious injury, harm, impairment, or death to residents. The facility's Administrator and Director of Nursing (DON) were informed of the Immediate Jeopardy (IJ) on [DATE], at 2:15 pm. The noncompliance related to the IJ was identified to have existed on [DATE]. An acceptable Removal Plan was received on [DATE]. Based on the validation of the Removal Plan, the State Survey Agency determined that the corrective plans and the immediacy of the deficient practice were removed on [DATE]. Findings included:The facility had an Emergency Response Management policy, dated [DATE]. Section d of the General Policy and Procedure included that in the event of cardiac/respiratory arrest, initiate CPR if the resident is a full code and notify Emergency Management Services (EMS), and the physician for further orders. The facility had a Cardiopulmonary Resuscitation (CPR) policy, dated [DATE]. Section 3 of the Procedure portion of the policy includes delegating a specific individual to check physician orders; CPR order/Do Not Resuscitate (DNR) status. R1 was admitted to the facility on [DATE] and had diagnoses that included cerebral atherosclerosis, dysphagia, gastro-esophageal reflux disease, anemia, constipation, hypertension, and hyperlipidemia. A review of R1's clinical record revealed a [DATE] Advanced Directive physician's order. The physician's order specified that R1 was a Full Code and to attempt CPR.A review of the Facility Notification of Hospice Admission/Change form revealed that R1 was admitted to hospice services on [DATE]. The admitting diagnosis was cerebral atherosclerosis. Following R1's admission to hospice services, an updated Physician Orders for Life Sustaining Treatment (POLST) form, dated [DATE], was completed. The POLST form specifies attempting CPR. Therefore, R1 remained a Full Code. During an interview on [DATE] at 4:11 pm, Registered Nurse (RN) Unit Manager GG confirmed that R1's Responsible Party wanted R1's Advanced Directives to remain a full code status. A review of progress notes revealed a [DATE] 6:55 pm nurse's note entry by Licensed Practical Nurse (LPN) HH, who staff alerted her that R1 was deceased . A subsequent nurse's note entry on [DATE] at 7:00 pm documented that R1 was assessed and noted to have no pulse or respirations, and skin was cool to the touch. The note further documented that the Director of Nursing, Administrator, RN unit manager, Nurse Practitioner, and hospice nurse were notified. A review of hospice documentation revealed a [DATE] Visit Note Report that documented the hospice RN pronounced R1's death on [DATE] at 7:31 pm. However, there was no evidence that facility nursing staff attempted CPR on R1 when she was noted to have no pulse or respirations, as specified in her Advanced Directives.During an interview on [DATE] at 1:52 pm, the DON confirmed that CPR was not attempted on R1 on [DATE]. She stated that R1 was fairly new, being on hospice services, and what she gathered through interviews was that the night and day shift nurses thought that once a resident was receiving hospice services, they were a Do Not Resuscitate (DNR). The DON stated that R1's death occurred during the shift change (7:00 am-7:00 pm nursing staff going off shift and 7:00 pm-7:00 am nursing staff coming on shift). The DON stated there were six nurses at the facility, including herself. The DON stated that it was about an hour and a half after hospice had left the facility when hospice staff called the facility and notified them that R1 was a Full Code.A review of the Daily Clinical Assignment sheet, dated [DATE], revealed that the nurses assigned to R1 were LPN BB for the day shift (7:00 am-7:00 pm) and LPN HH for the night shift (7:00 pm-7:00 am). Certified Nursing Assistant (CNA) AA was listed as R1's day shift CNA. During an interview on [DATE] at 3:09 pm, LPN BB confirmed she worked on [DATE]. She stated that she had last checked on R1 when she gave R1 her evening medications, that R1 was a little more tired at that time, but alert and accepted her medications. When LPN BB was questioned about how she became aware that R1 had passed away, LPN BB stated she found out after the fact (on [DATE], while still at the facility); one of the nurses came to the nurses' station, and she overheard them talking about it. LPN BB stated that around 6:30 pm (on [DATE]), she had already counted (controlled) medications with the on-coming night shift nurse (LPN HH) and handed her the (medication cart) keys. When LPN BB was questioned about whether CNA AA had asked for assistance in R1's room prior to it becoming known that R1 had passed, LPN BB stated that CNA AA had stepped out in the hall and asked who the nurse was for R1. LPN BB stated that CNA AA was told by LPN CC (the other day shift nurse working with LPN BB on [DATE]) that LPN HH (on-coming night shift nurse) had taken over. During an interview on [DATE] at 10:58 am, CNA AA confirmed she worked the day shift (7:00 am-7:00 pm) on [DATE] and was assigned to R1. CNA AA stated that around supper time, she went into R1's room; she had already been in there before to reposition her for supper and get her upright (in bed). She went back into R1's room and offered to help R1 with her supper, but R1 told her no and said she was not feeling well. CNA AA stated R1 felt cold, so she went and told LPN BB about it and that R1 did not want to eat. CNA AA stated she continued to pass out supper trays. When she came back around to check on R1 again, it was around 6-something, and R1 was cold. CNA AA stated she stepped to the door (of R1's room) and said she needed help, and the nurses came down. CNA AA confirmed that CNA FF also came into R1's room and then told the nurses. During an interview on [DATE] at 1:38 pm, LPN HH stated that on [DATE], she had come in to work and gotten a report from the day shift nurse (LPN BB). They counted the (medication) carts, and she (LPN HH) took the keys. LPN HH stated that she then stepped outside to chat with her boss. While outside, CNA FF came outside and told her that R1 had passed away. LPN HH stated that she then came back inside and went to R1's room. R1 had no respirations and no pulse, and her eyes were fixed and dilated. LPN HH confirmed she did not look at R1's code status herself, nor did any of the other nurses who were there. During an interview on [DATE] at 7:43 am, CNA FF (who worked the [DATE] night shift 7:00 pm-7:00 am) stated she was alerted to something being wrong by CNA AA, who had come to R1's door and called out the resident's name twice. CNA FF said she could tell something was wrong by the tone of CNA AA's voice. CNA FF stated she went and told the nurses at the nursing station (LPN BB and LPN CC) that R1 was deceased . CNA FF stated that LPN BB responded that she was not in charge anymore, to go get LPN HH, and LPN CC backed LPN BB up and said they had already turned in the keys. Neither nurse went to R1's room. CNA FF went looking for LPN HH and located her outside, and let her know that R1 was deceased and LPN HH came inside.

Based on staff interviews and record review, the facility failed to ensure that the Advanced Directive care plan was implemented for one of 11 sampled residents (R)(R1). This failure resulted in CPR not being provided for R1, whose Advanced Directive care plan specified she was a Full Code. On [DATE], a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation had caused or had the likelihood to cause serious injury, harm, impairment, or death to residents.The facility's Administrator and Director of Nursing were informed of the Immediate Jeopardy (IJ) on [DATE], at 2:15 pm. The noncompliance related to the IJ was identified to have existed on [DATE].An acceptable Removal Plan was received on [DATE]. Based on the validation of the Removal Plan, the State Survey Agency determined that the corrective plans and the immediacy of the deficient practice were removed on [DATE]. Findings included:A review of the electronic medical record (EMR) revealed that R1 was admitted to the facility on [DATE] and had diagnoses that included cerebral atherosclerosis, dysphagia, gastro-esophageal reflux disease, anemia, constipation, hypertension, and hyperlipidemia. A review of R1's clinical record revealed a [DATE] Advanced Directive physician's order. The physician's order specified that R1 was a Full Code and to attempt CPR.A review of R1's care plan revealed a [DATE] Advanced Directive care plan that documented R1 was a Full Code. The care plan included an intervention, dated [DATE], to attempt resuscitation (CPR). A review of the Facility Notification of Hospice Admission/Change form revealed that R1 was admitted to hospice services on [DATE]. The admitting diagnosis was cerebral atherosclerosis. Further review of R1's care plan revealed an [DATE] care plan which R1 was under the care of hospice services. Following R1's admission to hospice services, an updated Physician Orders for Life Sustaining Treatment (POLST) form, dated [DATE], was completed. The POLST form specifies attempting CPR. Therefore, R1 remained a Full Code. During an interview on [DATE] at 4:11 pm, Registered Nurse (RN) Unit Manager GG confirmed that R1's Responsible Party wanted R1's Advanced Directives to remain a full code status. A review of progress notes revealed a [DATE] 6:55 pm nurse's note entry by Licensed Practical Nurse (LPN) HH, that staff alerted her that R1 was deceased . A subsequent nurse's note entry on [DATE] at 7:00 pm documented that R1 was assessed and noted to have no pulse or respirations, and skin was cool to the touch. The note further documented that the Director of Nursing, Administrator, RN unit manager, Nurse Practitioner, and hospice nurse were notified. A review of hospice documentation revealed a [DATE] Visit Note Report that documented the hospice RN pronounced R1's death on [DATE] at 7:31 pm. However, there was no evidence that facility nursing staff attempted CPR on R1 when she was noted to have no pulse or respirations, as specified in her Advanced Directives care plan.During an interview on [DATE] at 1:52 pm, the DON confirmed that CPR was not attempted on R1 on [DATE]. She stated that R1 was fairly new, being on hospice services, and what she gathered through interviews was that the night and day shift nurses thought that once a resident was receiving hospice services, they were a Do Not Resuscitate (DNR). The DON stated that R1's death occurred during the shift change (7:00 am-7:00 pm nursing staff going off shift and 7:00 pm-7:00 am nursing staff coming on shift). Cross-reference to F678

Based on observations, staff interviews, record review, and review of the facility policy titled, Tracheostomy Care, the facility failed to wash/sanitize hands and change gloves during tracheostomy care for one of one resident (R) (14) reviewed for tracheostomy care, and the facility failed to properly dispose of soiled items. This failure increased R14's risk for infection. Findings include: Review of the facility policy titled, Respiratory System Management Standard, dated August 2021, revealed: Tracheostomy care procedure Nursing actions. 3. [NAME] clean gloves and remove the used tracheostomy dressing being careful to keep the tracheostomy tube in place. 4. Remove used gloves and discard per facility standard. 5. perform hand hygiene. Review of the undated Admission Record for R14 located in the Electronic Medical Record (EMR), revealed R14 was admitted to the facility with multiple diagnoses including but not limited to tracheostomy status, acute respiratory failure with hypoxia, respiratory disorder, unspecified, dependence on supplemental oxygen, and cerebral palsy. Review of R14's care plan revealed R14 had a tracheostomy related to diagnosis of acute respiratory failure, respiratory disorder, cerebral palsy, intellectual disabilities, dependence on supplemental O2, and persistent vegetive state. Observations made on 2/1/2025 at 10:00 a.m. revealed R14 lying in bed with head of the bed elevated. R14 was non-verbal. Tracheostomy was in place and secured with ties. Oxygen (O2) via trach collar at 5 liters (L)/minute. Trach care observation on 2/1/2025 at 11:10 am provided by wound care nurse Registered Nurse (RN) AA and assisted by Licensed Practical Nurse (LPN) CC revealed both RN AA and LPN CC washed hands with soap and water, and donned Personal Protective Equipment (PPE) before providing trach care. LPN CC washed her hands with soap and water during the procedure after donning and doffing gloves. RN AA did not wash her hands after donning and doffing gloves. Observation revealed RN AA washed her hands with soap and water before donning gloves before procedure. RN AA placed a pulse oximeter on R14 right fourth digit finger. RN AA removed her gloves, donned gloves and placed a chux pad on the bedside table. RN AA opened the package with the trach collar, opened the inner cannula package, and opened the trach care kit. LPN CC removed inner cannula and 4x4 dressing from R14 trach and placed it in the trash. LPN CC removed her gloves, washed her hands with soap and water, and donned gloves. LPN CC opened a bottle of saline and poured it into trach kit . RN AA removed gloves and donned gloves from the trach care kit. RN AA removed drape from the kit and placed the drape over R14 chest area. RN AA and LPN CC removed the trach collar and threw it in. LPN CC removed her gloves, washed her hands with soap and water and donned gloves. RN AA dipped a Q-tip in saline and swabbed under the right side of the trach collar attached to R14. RN AA wet a 4x4 gauze in the saline and wiped the left side of the trach collar and wiped under the bottom of the trach collar. RN AA cleaned around the trach stoma with a wet 4x4 gauze. RN AA placed 4x4 dressing under trach stoma. RN AA threw chux pad in trash, removed PPE and washed her hands with soap and water. RN AA and LPN CC placed a new trach collar under R14 trach stoma. LPN CC removed PPE and washed her hands with soap and water. RN AA placed soiled towels in a yellow plastic trash bag and placed the bag on the floor next to the plastic container that contained trach supplies. The container of trach supplies was on the floor between a red trash can and the yellow plastic trash bag containing the soiled towels. The yellow plastic trash bag remained on the floor for two hours after trach care was provided. Interview with LPN CC on 2/1/2025 at 11:05 am revealed she does not provide trach care. LPN CC stated that she assists the treatment nurse with trach care. She stated that she has been working at the facility for two years and she has not received an in-service on trach care. Interview with wound care nurse RN AA on 2/1/2025 at 11:30 am revealed RN AA acknowledged that she did not wash her hands before donning and doffing gloves throughout trach care procedure. RN AA stated that she should have washed her hands every time she took her gloves off, but she did not want to leave the resident. RN AA stated that she received a trach care in-service about two years ago. An interview with the Director of Nursing (DON) on 2/1/2025 at 12:35 pm, who stated that her expectations is for the treatment nurse to wash her hands before the procedure (trach care), and to change gloves before, during, and after the procedure. An interview with LPN BB on 2/1/2025 at 1:30 pm revealed LPN BB removed the yellow trash bag from floor in room R14. LPN BB stated that the trash bag should not have been on the floor.

Based on observations, staff interviews, and review of the facility policies titled, Food Storage the facility failed to discard food from the stand-up cooler by the expiration date. This deficient practice had the potential to affect 50 of 53 residents receiving an oral diet. Findings include: Review of the facility policy titled Food Storage, revealed under Procedure: 15. Leftover food is stored in covered containers or wrapped carefully and securely. Each item is clearly labeled and dated before being refrigerated. Leftover food is used within 48 hours or discarded. The tour of the kitchen on [DATE] started at 8:23 am with the Dietary Manager (DM). The following concerns were identified during the tour in the stand-up cooler: 1. A resealable plastic bag that contained sliced ham with an expiration date [DATE]. 2. A plastic container of chicken and noodles with an expiration date of [DATE]. Interview on [DATE] at 8:35 am with the DM who confirmed the expired ham and chicken and noodles and discarded them. She stated her expectation was that staff throw away items before they are expired. The risks would be illness to the residents.

Based on observation, record review, resident and staff interviews, and the facility policy, MENUS, the facility failed to ensure they offered an appealing option of similar nutritive value to residents for lunch and dinner meals and failed to provide preferences for meals for one resident (R) 30. This deficient practice had the potential to affect 50 of 53 residents receiving an oral diet. Findings include: The facility tile, MENUS not dated, revealed, well planned menus aide in meeting the nutritional and psychosocial needs of the residents and are developed, taking into consideration certain budgetary allowances, available personnel, and equipment. When changes in the menus are needed, the changes must provide equal nutritive value. A Resident Council meeting was held on 2/2/2025 during the survey. Residents, specifically R40, revealed that the facility does not have an alternate menu and that if they do not like what is being served their only option is to ask for a sandwich or soup. Other residents expressed concerns regarding lack of choices for food being served. Reveal of the facility's fall/winter 2024 menu revealed no alternate meal choice on the menu for lunch or dinner. Interview on 2/1/2025 at 10:34 am with the Dietary Manager (DM) revealed that the vendor provides menus to the facility and they are without an alternate meal choice. She revealed residents are offered a sandwich, soup, or both as an alternate. Interview on 2/1/2025 at 12:40 pm with Dietary Aid (DA) FF revealed there is no alternate menu for residents. She revealed she offers residents that do not like what is on the menu a sandwich or soup. Interview on 2/1/2025 at 12:45 pm with DA GG revealed there is no alternate choice on the menu for residents. She revealed if a resident did not like what was being offered she would offer them sandwich or soup. Interview on 2/1/2025 with the Registered Dietician (RD) at 12:53 pm revealed that she reviews and signs off on menus that are issued by Sysco. She confirmed there are no alternate choices on the menus that provide two hot entrees but residents can request a sandwich with protein or soup. She revealed she has never been provided an alternate meal menu. She believed due to budget reasons, no one from the facility has ever requested alternative menus from Sysco. Interview on 2/2/2025 at 9:08 am with the administrator revealed he was aware that residents do not have an alternate menu but states a sandwich and soup are always available. 41165 During the initial screening on 1/31/2025 at 8:55 am, R30 stated that if she does not like the meal that is served, she is not offered, and she does not get an alternate meal. Observations made on 1/31/2025 through 2/2/2025 revealed there were no alternate meals listed on the menu, and there was not an alternate meal on the hot steam tray unit during meal service. 1/31/2025 at 12:03 pm, R30 stated that she has been at the facility for one year. She stated that she never has a choice of meals. R30 stated again that if she does not like what is served, she is not offered, and she does not get an alternate meal. Interview with the Registered Dietician (RD) on 2/1/2025 at 12:53 pm revealed that she was aware that there is not an alternate meal listed on the menu. She stated that residents can have a sandwich or soup, but she was not sure what the sandwich choice was. RD stated that she was not in charge of the budget. She stated that she has never been provided an alternate meal menu. Interview with DON on 2/2/2025 at 8:48 am revealed that she knows that residents are offered a peanut butter and jelly sandwich, she stated that if they're having a meal and they don't want it they offer them sandwiches. Interview with the Administrator on 2/2/2025 at 9:30 am, he stated that he was aware that residents are not offered a hot alternate meal. He stated that they are offered a sandwich or soup. The Administrator stated that residents could get a grilled cheese sandwich.

Based on observations, record reviews, staff interviews, and review of the facility's policy titled, Respiratory System Management Standard, the facility failed to ensure that the physician's order for oxygen administration was followed for three of 13 Residents (R) (R12, R7, and R14) reviewed for oxygen administration. The deficient practice had the potential to place the resident at risk for medical complications, unmet needs and a diminished quality of life. Findings include: Review of the facility's undated policy titled Respiratory System Management Standard under the section titled Oxygen Therapy Protocol revealed, Procedures to follow in order: 1. Check the physician's orders in the resident's clinical record 10. set the oxygen flow rate as ordered. 1. Review of R12's Electronic Medical Record (EMR) revealed diagnoses that included but not limited to Chronic Obstructive Pulmonary Disease (COPD), hypoxemia and shortness of breath. Review of R12's Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed, Sections C (Cognitive Patterns)- a Brief Interview of Mental Status (BIMS) of 14; Section J (Health Conditions)-Shortness of Breath (SOB) or trouble breathing when lying flat; Section O (Special Treatments, Procedures, and Programs)- received oxygen therapy while a resident. Review of R12's Physician Orders dated 12/25/2024 revealed orders for oxygen (O2) at 3 (three) liters (L) per nasal cannula (NC) for shortness of breath (SOB). Observation on 1/31/2025 at 8:00 am revealed R12 lying in bed receiving O2 therapy via (by way of) nasal cannula from the oxygen concentrator set at 7 (seven) L/min (minute). Observation on 2/1/2025 at 10:20 am revealed R12 lying in bed receiving O2 therapy via nasal cannula from the oxygen concentrator set at 7 L/min. Observation and Interview on 2/1/2025 at 10:30 am with Licensed Practical Nurse EE and the Director of Nursing (DON) revealed, R12 lying in bed receiving O2 therapy via nasal cannula from the oxygen concentrator set at 7 L/min. LPN EE revealed that she was responsible for making sure the oxygen setting was correct. She revealed that she usually checked the oxygen settings during medication pass however, she had not checked it. LPN EE confirmed the oxygen was set at 7L/min. LPN EE reviewed R12's physician orders to verify the correct oxygen setting and confirmed that oxygen was to be administered at 3L/min via NC. An interview on 2/1/2025 at 10:35 am with DON revealed, her expectations of staff that they ensure oxygen was administered as ordered. She stated they should be checking oxygen settings during their medication pass and as needed. 49675 2. Review of the medical record for R7 revealed diagnoses that included but are not limited to COPD, unspecified. Review of 7's Quarterly MDS assessment dated [DATE] revealed, Sections C (Cognitive Patterns)- a Brief Interview of Mental Status (BIMS) of 9; Section J (Health Conditions)-Shortness of Breath (SOB) with exertion or trouble breathing when lying flat; Section O (Special Treatments, Procedures, and Programs)- received oxygen therapy. Review of Physician Orders dated 8/31/2023 revealed orders for oxygen at two liters per minute via nasal canula as needed. Observation on 1/31/2025 at 9:30 am revealed R7 lying in bed receiving oxygen therapy via nasal canula at three liters per minute. Observation on 2/1/2025 at 8:36 am revealed R7 lying in bed receiving oxygen via nasal cannula at three liters per minute. Observation and rounding on 2/1/2025 at 10:30 am with LPN BB revealed R7 lying in bed receiving oxygen via nasal cannula at three liters per minute. LPN BB revealed that she was responsible for making sure the oxygen setting was set on the prescribed rate during morning medication pass. She admitted she did not check the rate and confirmed the oxygen was set on three, not the prescribed rate. LPN BB reviewed R7's physician orders and verified the rate should be set at two liter per minute. Interview on 2/1/2025 at 10:35 am with the DON revealed her expectations are that staff ensure oxygen is administered as ordered. She stated nurses should be checking oxygen settings during their medication pass since oxygen is a medication. 3. Review of the medical record for R14 revealed diagnoses that included but are not limited to acute respiratory failure without hypoxia. Review of 14's Quarterly MDS assessment dated [DATE] revealed, Sections C (Cognitive Patterns)- BIMS of 99, unable to determine Section O (Special Treatments, Procedures, and Programs)- received oxygen therapy. Review of Physician Orders dated 5/1/2024 revealed orders for oxygen at four liters per minute via trach collar. Observation on 1/31/2025 at 8:50 am revealed R14 lying in bed receiving oxygen therapy via trach collar at five liters per minute. Observation on 2/1/2025 at 8:40 am revealed R14 lying in bed receiving oxygen via trach collar at five liters per minute. Observation and rounding on 2/1/2025 at 10:30 am with LPN BB and the DON revealed R14 lying in bed receiving oxygen via nasal cannula at five liters per minute. LPN BB revealed that she was responsible for making sure the oxygen setting was set on the prescribed rate during morning medication pass. She admitted she did not check the rate and confirmed the oxygen was set on five, not the prescribed rate. LPN BB reviewed R14's physician order and verified the rate should be set at four liters per minute. Interview on 2/1/2025 at 10:35 am with the DON revealed her expectations are that staff ensure oxygen is administered as ordered. She stated nurses should be checking oxygen settings during their medication pass since oxygen is a medication.

Based on record reviews, interviews, and review of the facility's policy Bed Hold, the facility failed to provide a notice of bed hold for one of two residents (R)(R17) reviewed for hospitalization . Findings include: Facility policy titled Bed Hold, revised on 3/3/2020 revealed Policy: A copy of the bed hold agreement is also provided to the resident or responsible party prior to a resident's transfer to a hospital or start of a therapeutic leave. 2. In case of emergency transfer the resident or responsible party is provided with written notification within 24 hours of the transfer. R17 was admitted to the facility on [DATE] with diagnoses that include but are not limited to unspecified dementia, unspecified severity, without behavioral disturbance and type 2 diabetes mellitus with hyperglycemia. Review of medical records revealed R17 was transferred to the hospital from the facility, on 5/13/2024 and again on 12/18/2024. Further review revealed no evidence of the provision of a notice of bed hold provided to R17's representative on either date. An unsigned bed hold agreement was located in the resident's record for 12/18/2024. During a phone interview on 2/1/2025 at 4:26 pm with the resident's representative revealed the facility did not provide a written bed hold agreement to the representative on 5/13/2024 or 12/18/2024. Interview on 2/2/2025 at 8:41 am with Licensed Practical Nurse (LPN) EE revealed that when a resident is discharged to the hospital, she completes a document in the electronic health record and prints that document to give to emergency medical services which includes a bed hold agreement. She revealed the facility does not send or give a written bed hold agreement to the representative or the resident. During an interview on 2/2/2025 at 8:44 am with the Business Officer Manager (BOM), it was revealed the facility will call the family representative and notify them of the bed hold agreement but does not provide anything in writing. Interview on 2/2/2025 at 8:51 am with the Director of Nursing (DON) revealed the resident is given the bed hold agreement and facility will call family or the representative. She verified nothing in writing is given to the representative because the facility knows the resident is returning to the facility.

Based on record reviews and interviews, and review of the facility's policy Transfer/Discharge Outside the Facility, the facility failed to provide a written reason for transfer to the resident or their representative for one of two residents reviewed for hospitalization , resident (R) 17. Findings include: Review of the facility policy titled Transfer/Discharge Outside the Facility , dated February 2015 revealed The resident/patient and/or family/responsible party will be notified of the transfer in writing, except when a transfer is due to an unplanned, acute clinical need. This type of transfer will be communicated verbally, with written documentation to follow in the medical record. R17 was admitted to the facility on [DATE] with diagnoses that include but are not limited to unspecified dementia, unspecified severity, without behavioral disturbance and type 2 diabetes mellitus with hyperglycemia. Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed R17's Brief Interview for Mental Status (BIMS) score was unable to be determined. Review of medical records revealed R17 was transferred to the hospital from the facility, on 5/13/2024 and again on 12/18/2024. Further review revealed no evidence of the provision of a reason for transfer/discharge provided to R17's representative on either date. Phone interview on 2/1/2025 at 4:26 pm with the resident's representative revealed the facility failed to provide a written reason for transfer/discharge to the representative on 5/13/2024 and 12/18/2024. Interview on 2/2/2025 at 8:17 am with Licensed Practical Nurse (LPN) CC, revealed the facility does not provide anything in writing to the resident or representative as to reason for discharge/transfer. During an interview on 2/2/2025 at 8:41 am, LPN EE revealed that when a resident is discharged to the hospital, she completes a document in the electronic health record and prints that document to give to emergency medical services which includes a reason for transfer. She revealed the facility does not provide a written reason for transfer/discharge to the representative or the resident. During an interview on 2/2/2025 at 8:44 am with the Business Officer Manager (BOM), revealed the facility will call the family representative and notify them of the reason for transfer/discharge but does not provide anything in writing. An interview on 2/2/2025 at 8:51 am with the Director of Nursing (DON) revealed the facility will call family or representative to notify the reason for transfer/discharge. She verified nothing in writing is given to the representative because the facility knows the resident is returning to the facility.

Based on Observations, staff interviews, and review of facility documents, the facility failed to maintain a clean and homelike environment for one of 24 rooms (Rm 33). Specifically, the facility failed to ensure Rm 33 privacy curtain was free of brown stains, and a white chalky substance on the curtain. Findings include: Observations on 1/31/2025 at 8:47 am, 2/1/2025 at 8:30 am, and 2/2/2024 at 8:42 am of privacy curtain for Rm 33 bed A revealed curtain had brown stain on the outer aspect of the curtain and a white chalky substance on the bottom hem of the curtain facing the door. Review of the facility document titled Complete Room Cleaning revealed under Purpose: The complete room cleaning schedule insures that each resident room is discharge-cleaned on a monthly basis. Under section labeled Patient Room (l) Cubicle Curtains- check and report any soil or damage to supervisor. Review of the deep clean schedule for December 2024 revealed room [ROOM NUMBER] was deep cleaned on 12/4/2024, in January 2025 room [ROOM NUMBER] was not on the schedule as being deep cleaned, and for February 2025 room [ROOM NUMBER] was not on the schedule to be cleaned. Conformation walking rounds conducted on 2/2/2025 at 8:45 am with the Administrator and housekeeping Account Manager confirmed observations of privacy curtain for Rm 33 during rounds. During an interview on 2/2/2025 at 9:00 am with the Account Manager revealed that each resident's room is deep cleaned monthly to include the vents, privacy curtains are removed and replaced if soiled, wiping down the walls, cleaning the windowsills, bed frames, sweeping and mopping the floors. Further interview also revealed that during the daily cleanings there are five steps that are followed that include checking the curtains for any stains so that they can be replaced if needed. During an interview on 2/2/2025 at 9:05 am with Housekeeper HH revealed that she cleaned room [ROOM NUMBER] this morning and did not notice that the curtains were soiled and needed to be changed. During the interview staff member also stated that when she cleans the resident's room, she starts by taking out the trash and then wipe down everything in the room cleaning the bathroom last. Staff member again confirmed that she did not check the privacy curtains when cleaning room [ROOM NUMBER]. During an interview on 2/2/2025 at 9:15 am with the Administrator, housekeeping follows a five and seven step process for cleaning the residents' rooms that included checking the curtains for any stains and to ensure that the curtains are in good repair. It was further revealed that he expected the housekeeping staff to follow those steps to ensure that the residents' environment is clean at all times.

Based on observations, record reviews, staff interviews, and review of the facility's policy titled, RAI/Care Planning Management, the facility failed to follow the care plan related to providing oxygen as ordered for three of 13 Residents (R) (R12, R7, and R14) reviewed for oxygen administration. The deficient practice had the potential to place the resident at risk for medical complications, unmet needs and a diminished quality of life. Findings include: Review of the facility's undated policy titled RAI/Care Planning Management under Interim Baseline Care Plan revealed, Under the section titled, The Care Plan revealed, .The Interim Baseline Care plan will be the guide for the comprehensive care plan Care plans are to be accessible for clinical staff in order to facilitate care plan interventions or to update as indicated due to resident condition change. 1. Record review of Electronic Medical Record (EMR) for R12 revealed diagnoses that included Chronic Obstructive Pulmonary Disease (COPD), hypoxemia and shortness of breath. Review of Physician Orders dated 12/25/2024 for R12 revealed, orders for oxygen (O2) at 3 (three) liters (L) per nasal cannula (NC) for shortness of breath (SOB). Review of care plan with revision date of 11/18/2024 revealed, R12 has DX (diagnosis) COPD with interventions that included, but not limited to: Administer medications as ordered with date initiated, 12/12/2024 and O2 as ordered with date initiated, 8/4/2023. Observation on 1/31/2025 at 8:00 am revealed R12 receiving O2 therapy via (by way of) nasal cannula from the oxygen concentrator set at 7 (seven) L/min (minute). Observation on 2/1/2025 at 10:20 am revealed R12 receiving O2 therapy via nasal cannula from the oxygen concentrator set at 7 L/min. Observation and Interview on 2/1/2025 at 10:30 a.m. with Licensed Practical Nurse EE and the Director of Nursing (DON) revealed, R12 receiving O2 therapy via nasal cannula from the oxygen concentrator set at 7 L/min. LPN EE reviewed R12's physician orders to verify the correct oxygen setting and confirmed that oxygen was to be administered at 3L/min via NC. Interview on 2/1/2025 at 2:18 pm with Minimum Data Set (MDS) Coordinator revealed she was responsible for developing and entering care plans. She reviewed R12 physician orders and verified the oxygen rate was to be set at three liters per minute. She then reviewed the care plan and verified the care plan stated, oxygen as ordered. She confirmed that staff failed to follow the care plan. The MDS Coordinator revealed her expectations of staff were to follow the care plan. She revealed the care plan clearly says, oxygen as ordered. Interview on 2/1/2025 at 2:28 pm DON confirmed the facility failed to follow the care plan for R12 related to oxygen. She revealed she expects her nurses to check the rates during med pass and to provide care per the physician orders and care plans. 49675 2. Review of the medical record for R7 revealed diagnoses that included but are not limited to COPD, unspecified. Review of Physician Orders dated 8/31/2023 revealed orders for oxygen at two liters per minute via nasal canula as needed. Review of care plan with revision date of 8/3/2024 revealed a diagnosis of COPD. Interventions included but not limited to: Administer medications as ordered with date initiated, 10/10/2022 and oxygen via nasal canula with date initiated 10/10/2022. Interview on 2/1/2025 at 2:20 pm with Minimum Data Set (MDS) Coordinator revealed she develops and enters care plans. She reviewed R7's physician orders and verified the oxygen rate was to be set at two liters per minute. Next, she reviewed and verified the care plan stated, administer medications as ordered. She confirmed that staff failed to follow the care plan. The MDS Coordinator revealed her expectations of staff were to follow the care plan. 3. Review of the medical record for R14 revealed diagnoses that included but are not limited to acute respiratory failure without hypoxia. Review of Physician Orders dated 5/1/2024 revealed orders for oxygen at four liters per minute via trach collar. Review of care plan with revision date of 6/1/2024 revealed a diagnosis of acute respiratory failure and respiratory disorder. Interventions included but not limited to: oxygen via trach collar as ordered, initiated on 6/29/2023. Interview on 2/1/2025 at 2:20 pm with the MDS Coordinator who reviewed R14's physician orders and verified the oxygen rate was to be set at four liters per minute. Next, she reviewed and verified the care plan stated, oxygen via trach collar as ordered. She confirmed that staff failed to follow the care plan. The MDS Coordinator revealed her expectations of staff were to follow the care plan. Interview on 2/1/2025 at 2:28 pm DON confirmed the facility failed to follow the care plan for R14 related to oxygen. She revealed she expects her nurses to check the rates during med pass and to provide care per the physician orders and care plans.

Based on observations, staff interviews, and review of the facility policy titled, Disposal of Garbage/Rubbish , the facility failed to ensure the outdoor garbage and refuse area was maintained in a sanitary manner. Findings include: Review of the facility policy titled Disposal of Garbage/Rubbish review date 1/13/2023 revealed under Procedure: 8. Outside dumpsters provided by garbage pickup services will be kept closed and the surrounding area will be kept free of litter. During the initial observation of the dumpster on 9/8/2023 at 8:50 a.m. with Dietary Manager, revealed the dumpster was open with bags of trash visible. Continued observation also revealed what appeared to be a bag of dirty diapers on the ground around the dumpster as well as gloves, flies, and bugs on top of the open dumpster. The dietary manager confirmed that the dumpster was open and should be closed without trash on the ground around the dumpster. Interview on 9/9/2023 at 8:53 a.m. with the Dietary Manager, she confirmed and agreed that the dumpster was open and should be closed and stated that the dietary staff and Maintenance were responsible for maintaining the dumpster area in a sanitary condition. During a follow up observation of the dumpster on 9/10/2023 at 8:30 a.m. revealed the dumpster was open from the side with trash visible. During an observation of the dumpster area on 9/10/23 at 8:49 a.m. with the Administrator the dumpster was open from the side with trash visible. The Administrator agreed the dumpster is open and should be closed, and trash should not be on the ground around the dumpster. He revealed that the dietary staff is responsible for maintaining and keeping the dumpster area clean.

Based on observation, record review, staff interviews, and review of the facility policy titled, Use of Restraints. The facility failed to ensure that one of 59 residents (R) (R1) was free from physical restraints while in the facility. The deficient practice had the potential to prevent R1 from attaining and maintaining their highest practicable well-being and ensuring that their dignity and quality of life was maintained. Findings include: Review of the facility undated policy titled, Use of Restraints, under Procedure: This facility will not impose physical restraints for purposes of discipline or convenience. 1. Prior to the initiation of a physical restraint or psychotropic medication(s), clinicians will thoroughly assess the resident's mental/cognitive, behavior and physical status. This assessment will address other interventions that may be symptoms or the cause of the situation. Alternatives, less restrictive measures, to the use of a physical or chemical restraint must be initiated and recorded, including effectiveness of any/all alternatives employed. Clinicians and the attending physician must determine that physical restraint is a measure of last resort to protect the safety of the resident or others. 3. Unless there is an actual emergency, a physical restraint or psychotropic medication will not be initiated until the need for such a restraint is discussed thoroughly with the resident and/or resident representative and written consent is obtained. Observation on 9/9/2023 at 2:19 pm revealed resident was resting in bed with eyes closed. There were no indications of distress noted during observation. Record review revealed resident was admitted to the facility with diagnoses that included but not limited to dementia, major depressive disorder, and intellectual disabilities. Review of Annual Minimum Data Set (MDS) dated [DATE] revealed in Section C (Cognitive Patterns) C0500 a Brief Interview for Mental Status (BIMS) score of three indicating resident had a severe cognitive impairment. Section D (Mood) D0200 indicated that resident had trouble concentrating on things, such as reading the newspaper or watching television two to six days during the look back period for the assessment. Section E (Behavior) E0200 indicated that resident did have behavioral symptoms directed towards self and others one to three days during look back period of the assessment. Review of Facility Reported Incident (FRI) investigation dated 5/19/2023 revealed Certified Nursing Assistant (CNA) DD discovered R1 had a sheet tied over her and reported it to the Licensed Practical nurse (LPN) who in turn reported the incident to the Administrator, Director of Nursing, Responsible Party, and the Medical Doctor. According to the report the sheet was thrown over R1 double knotted and tied to the bed on all four corners. An additional sheet was placed over the top of the tied sheet hiding it from plain view. Interview on 9/9/2023 at 3:01 pm with CNA DD revealed that she was scheduled to work the 11-7 shift that night and was assigned to R1 for care. During her rounds at approximately 2:30 am R1 was in bed with a sheet draped over her. When the sheet was pulled back to provide care for resident it was noted that the sheet was tied to the bed on all four corners preventing resident from moving. Further interview also revealed that the incident was reported to the charge nurse and the sheets were removed from the resident by cutting the sheet with scissors. Interview on 9/9/2023 with the Administrator revealed that R1 was physically restrained by tying resident to the bed with sheets that were removed by staff after discovery. The incident was reported to the State Agency, Police, residents' representative, physician, and Adult protective Services (APS). There was an investigation that was completed which included statements from staff, skin assessment of the resident to ensure there were no injuries, and suspension of the staff member that was suspected to have restrained the resident until investigation was completed. Further interview also revealed that there had not been any proof that determined who actually restrained the resident but did acknowledge that the incident did occur.

Based on observations, staff interviews, record review, and review of the facility policy titled, Respiratory System Management Standard, the facility failed to ensure the provision of respiratory services in accordance with professional standards for one of one resident (R) (R#19) reviewed for tracheostomy (trach) care. Specifically, the facility failed to provide tracheostomy care supplies to include one size as ordered, and one smaller tracheostomy tube in emergency tracheostomy supplies at bedside. This failure increased R#19's risk for compromise airway and respiratory distress. Findings include: Review of the facility policy titled, Respiratory System Management Standard, dated August 2021, revealed: Tracheostomy care procedure Nursing actions. 3. Don clean gloves and remove the used tracheostomy dressing being careful to keep the tracheostomy tube in place. 4. Remove used gloves and discard per facility standard. 5. perform hand hygiene. Review of Admission Record for R#19 located in the Electronic Medical Record (EMR), revealed R#19 was admitted to the facility with multiple diagnoses including but not limited to tracheostomy status, acute respiratory failure with hypoxia, respiratory disorder, unspecified, dependence on supplemental oxygen, and cerebral palsy. Review of the most recent admission Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 99, which indicated R#19 was unable to complete the interview due to cognitive deficits. Review of the care plan for R#19 revealed a tracheostomy related to dx of acute respiratory failure, respiratory disorder, cerebral palsy, intellectual disabilities, dependence on supplemental O2, and persistent vegetive state. Observations made on 9/8/2023 at 8:34 a.m. revealed R#19 lying in bed with head of the bed elevated. R#19 was non-verbal. Tracheostomy was in place and secured with ties. Oxygen (O2) via trach collar at 4 liters (L)/minute (min). Observation revealed there was no same size trach or smaller size trach at the bedside. Further observations revealed there was not an artificial manual breathing unit (AMBU) bag at the bedside. Review of Physician's Orders for R#19 in the EMR revealed no order for an emergency tracheostomy kit at the bedside. Observation and Interview on 9/9/2023 at 8:06 a.m. of tracheostomy care performed by RN AA and assisted by LPN BB revealed RN AA stated she did not know the size of the trach that R#19 had off the top of her head. RN AA stated that she would have to look it up. RN AA stated that she was going to change the inner cannula, trach ties and trach collar today. RN AA donned gloves without sanitizing or washing her hands and begun suctioning using a [NAME]. RN AA stated that the [NAME] was too big, and she placed the [NAME] on a towel that was on R#19's chest. LPN BB entered the room and donned gloves without sanitizing or washing her hands. LPN BB stated that she was not sure what size trach R#19 had. RN AA removed gloves and placed gloves on the bed next to the towel. RN AA opened an oral trach care kit and donned the sterile gloves without washing or sanitizing hands in between. RN AA removed saline from the kit and poured saline into the container and placed the saline bottle on the bed next to the towel. RN AA opened the hydrogen peroxide swabs, placed the drape over R#19 chest, and cleaned around the inner cannula with the hydrogen peroxide swabs. RN AA placed the hydrogen peroxide swabs on the bed on top of the gloves. LPN BB with gloved hands opened the trach tie. RN AA removed the soiled trach tie from around R#19's neck and picked up the [NAME] and began to suction. RN AA cleaned around the inner cannula with saline gauze. RN AA placed soiled gauze on top of the [NAME]. RN AA removed the inner cannula and replaced it with a new inner cannula. RN AA did not remove gloves, wash, or sanitize her hands between procedures. LPN BB assisted RN AA with putting the trach tie on. RN AA and LPN BB each secured an end of the trach tie. RN AA placed a clean gauze under R#19 trach. RN AA gathered up old inner cannula, trach tie, and soiled gauze and placed them in the trash can in room. RN AA removed trach collar and cleaned it with the towel that the [NAME] was placed on. LPN BB and RN AA placed the trach collar over R#19 trach. LPN BB placed the [NAME] in a Styrofoam cup of water, removed the [NAME] then she placed the [NAME] in the pack that it came in. LPN BB then placed the [NAME] on the nightstand by the suction machine. LPN BB and RN AA removed their gloves, neither washed nor sanitized their hands. LPN BB donned gloves turned the concentrator off and removed the humidifier bottle. LPN BB took the humidifier bottle in the bathroom in R#19 room and rinsed the bottle out. LPN BB filled the bottle with sterile water that was at the bedside, placed the bottle back on the concentrator and turned the concentrator back on. LPN BB removed her gloves, exited the room, and stated that she needed to wash her hands. LPN BB walked towards the nursing station. RN AA exited the room with the soiled towel in her hands and walked down the hall with it. RN AA stood in the hall and stated that she needed to wash her hands too. RN AA entered R#19 room and washed her hands in his bathroom sink. Interview with Registered Nurse (RN) AA on 9/9/2023 8:35 a.m. stated she did not know what size trach R #19 had. When asked by the surveyor what would she do if R#19 trach came out, RN AA stated that she supposes she needs to ask and find out before it comes out. RN AA stated that she has been working at the facility for four years as the Weekend RN Supervisor. RN AA stated that she did not know what an obturator was or what it is used for. RN AA further stated that there was normally stuff in the room to care for the trach. When asked by the surveyor what she meant by stuff she stated stuff to clean the trach with. Interview on 9/9/2023 at 8:35 a.m. with Licensed Practical Nurse (LPN) BB stated she received training/ in-service education related to tracheostomy care. LPN BB stated that she was not sure what size trach R#19 had. LPN BB stated that if R#19's trach came out they would send him to the hospital. She stated that it would probably take about three minutes for EMS to arrive because they are just up the street. LPN BB stated that she would be copying the paperwork to send him out while waiting for EMS to arrive. LPN BB stated that they took everything out of the room, but she was not sure who took it out. The surveyor asked what she meant by everything, LPN BB response was everything like the trach supplies and trach kit. LPN BB stated that R# 19 went out to hospital once because his trach came out. She stated that she had been working at the facility for two years and she was the wound care nurse. LPN BB stated that she had been the wound care nurse since June 2023. LPN BB stated that the wound care nurse usually performs the trach care. LPN BB stated that the respiratory therapist came in and checked them off on trach care. She stated that she knows that they need an AMBU bag at the bed side. She reported that they do not have an AMBU bag at the bedside and did not know why. She stated that she had only seen one AMBU bag in the whole building and that was located on the crash cart. LPN BB stated that she did not know what an obturator was or what it was used for. LPN stated that trach inner cannula change and trach care is a sterile procedure. Interview with the Director of Nursing (DON) on 9/9/2023 at 8:43 a.m. stated that trach supplies are in R#19 room in the closet. DON stated they knew where the supplies were. DON and surveyor walked down to R#19 room. DON opened the closed door and retrieved an AMBU bag. There were no other trach supplies in the closet. DON opened a drawer and retrieved an oral trach care kit. DON confirmed that there was not a trach size ordered or size smaller, or obturator in R#19 room or at bedside. DON stated that R#19's trach came out a week or so ago and she tried to put one back in. She stated that she could not get the trach back in and R#19 was sent out to the hospital for replacement. DON further stated that the nurses knew what to do if R#19's trach came out because they have been in-service.