Every finding on record at Holly Manor Rehab and Nursing

Based on resident interview, staff interview, clinical record review and facility document review, it was determined that the facility staff failed to resolve grievances voiced regarding linen supplies in 10 of 11 months of resident council meetings reviewed. The findings include: The facility staff failed to resolve ongoing grievances regarding shortages of washcloths and towels voiced during resident council meetings in 10 of 11 months reviewed. On 6/3/25 at 1:30 p.m., an interview was conducted with Resident #1 (R1) who stated that there was an ongoing problem with a lack of towels and washcloths at the facility. R1 stated that often the night shift did not have enough linens to get people up and they had to wait for the day shift to get them up when the linens were delivered. R1 stated that often the day shift had to wait for the linens to be delivered before they could get residents up and some were not able to get to the dining room for breakfast because of this. R1 stated that the facility had stopped using disposable wipes for incontinence care and the staff were using wash cloths now which was causing a shortage. On R1's most recent MDS (minimum data set) assessment, a quarterly assessment with an ARD (assessment reference date) of 4/2/25, the resident was assessed as being cognitively intact for making daily decisions. On 6/3/25 at 2:58 p.m., an interview was conducted with Resident #9 (R9) who stated that the care at the facility depended on who was working and there were days when it took a while for them to get her out of bed. R9 stated that there were problems with a lack of towels and washcloths at the facility and they talked about it in their meetings. On R9's most recent MDS assessment, an annual assessment with an ARD of 5/13/25, the resident was assessed as being cognitively intact for making daily decisions. On 6/4/25 at 1:09 p.m., an interview was conducted with Resident #13 (R13) who stated that staff had advised her that she was allowed one towel and one washcloth per day. R13 stated that she did not understand why the staff were so stingy with them. On R13's most recent MDS assessment, an admission assessment with an ARD of 4/8/25, the resident was assessed as being moderately impaired for making daily decisions. Review of the facility resident council minutes documented in part, - 7/10/24 . would like more towels - 8/14/24 . Need washcloths and sheets . A Grievance/Suggestion Communication form dated 8/14/24 documented in part, 8/15/24 wash cloths have been ordered . - 10/9/24 . We're running out of towels, rags, and washcloths . A Grievance/Suggestion Communication form dated 10/9/24 documented in part, . The closets are filled 2 times daily and linen is being hoarded. DON (director of nursing) addressed issue in a meeting on 10/10 . - 11/13/24 . residents are requesting more washcloths and linens . Most residents would like to be up and in their real [sic] chairs earlier to attend activities . - 12/11/24 . no washcloths, bathing times delayed . A Grievance/Suggestion Communication form dated 12/11/24 documented in part, .There were complaints that there were no washcloths, which caused their bathing times to be delayed. [Name of environmental services (EVS) director] explained that the matter was being handled, and they were in the process of figuring out who is hoarding the clean linen. The matter is being taken care of . Follow up action: Continue to do a closet fill up on each unit 2-3 times a day to accommodate residents and continue to educate nursing staff on hoarding issue . - 1/8/25 . There were complaints that there were no washcloths, which caused their bathing times to be delayed. [Name of EVS director] explained that the matter was being handled, and they were in the process of figuring out who is hoarding the clean linen. He stated laundry was found in certain rooms in the closets and under the beds. The matter is being taken care of. [Name of EVS director] also shared that new washing machine had been ordered . A Grievance/Suggestion Communication form dated 1/8/25 documented in part, .There were complaints that there were no washcloths, [Name of EVS director] explained that the matter was being handled, and they were in the process of figuring out who it is hoarding clean linen was located in bags on [NAME]. It was found in closets and under the beds, the matter is being taken care of . - 2/26/25 . beds are not getting changed in a timely manner. There is bathing schedule delay due to lack of clean towels . A Grievance/Suggestion Communication form dated 2/26/25 documented in part, .Beds are not getting changed in a timely manner. [Name of R1] states you can't get bath because there's no clean towels . It documented the concern referred to nursing, laundry, housekeeping and dietary department. - 3/13/25 . They would like more washcloths . A Grievance/Suggestion Communication form dated 3/19/25 failed to evidence documentation regarding washcloth concerns. - 4/9/25 . They would like more washcloths . A Grievance/Suggestion Communication form dated 4/9/25 failed to evidence concerns regarding washcloths. - 5/28/25 . issues with getting washcloths, pads & towels . There were no grievance/suggestion communication forms regarding the resident council concerns regarding washcloths, pads & towels. On 6/3/25 at 4:03 p.m., an interview was conducted with OSM (other staff member) #12, LTC (long term care) ombudsman. OSM #12 stated that she had been working with the facility for quite a while to try to get the linen shortages fixed for the residents. She stated that she attended the resident council meetings by invitation from the residents and they complained every month about a lack of towels, washcloths and pads. OSM #12 stated that baths, showers and getting residents out of bed were delayed due to a lack of linens. She stated that she had conducted spot checks in the linen closets and would find no linen available. OSM #12 stated that when she asked she was told that the aides were stealing the linens, then she was told that they were hoarding them in the rooms. She stated that she did rounds with the director of environmental services and checked resident rooms where they suspected linens were being hoarded and found nothing. OSM #12 stated that she spoke to residents, and no one knew of any hoarding areas for linen. She stated that the facility had stopped using disposable wipes a while back and staff were using washcloths for incontinence care which had drastically increased the usage and demand. On 6/4/25 between 8:47 a.m. and 9:04 a.m. observations were made of the facility unit linen closets. The findings included the following: - Grace unit (30 beds) linen closet 18 washcloths and 23 towels available. - [NAME] unit (60 beds) linen closet 16 washcloths and 9 towels available. - [NAME] unit (30 beds) linen closet 18 washcloths and 16 towels available. On 6/4/25 at 9:13 a.m. an observation of the laundry clean linen area revealed 25 towels and no washcloths on the shelf. On 6/4/25 at 8:50 a.m., an interview was conducted with CNA (certified nursing assistant) #2 who stated that there were times when they ran out of linens. She stated that when they ran out they went to the laundry and asked for more. CNA #2 stated that they used to have disposable wipes for incontinence care, but they stopped using them and now they used washcloths and towels which caused them to use a lot. She stated that she could not say it made the job harder, but it took more washcloths to clean the resident if they had large bowel movements and she would not want to put the washcloth on her face after that even if it had been washed. She stated that she has had residents that were not able to be gotten out of bed on the night shift due to a lack of linens. On 6/4/25 at 8:56 a.m., an interview was conducted with CNA #6 who stated that the linen was normally stocked in the morning between 8-9 am. She stated that there were times when she ran out of towels and washcloths, but she went to laundry to get more as needed. On 6/4/25 at 12:25 p.m., an interview was conducted with CNA #5 who stated that they used washcloths and towels for incontinence care and bathing of residents. She stated that all linens were sent to the laundry for cleaning, and they disposed of anything that was too soiled to be washed. CNA #5 stated that there were times when they ran out of linens, and they had to call the laundry to bring more up or go down to get more linens. She stated that usually they came within 15 minutes, but residents had to wait until they got the linens to provide the care. CNA #5 stated that this morning the linen closet was stocked when she arrived, but this was unusual because it was not always stocked during the day. She stated that she had some residents who had their bathing or getting out of bed delayed due to a lack of linens. CNA #5 stated that she was not aware of any staff who threw away soiled linens or hoarded them. She stated that she had received report a couple of times from the night shift saying that they could not get a resident up because they did not have any linen and that was within the past four months. On 6/4/25 at 9:05 a.m., an interview was conducted with LPN (licensed practical nurse) #8 who stated that in the past they recalled concerns from residents about not being able to get up due to a lack of towels and washcloths, but they had educated the laundry, and they were doing much better and stocking twice a day before the shift change. On 6/4/25 at 9:13 a.m., an interview was conducted with OSM #5, the director of environmental services who stated that they had been working at the facility since February of 2024. She stated that the linen situation was in dire straits when she first started, and she had been working to resolve the issues. OSM #5 stated that she kept a supply of new towels and washcloths as a backup for emergencies in the back of the laundry and in her office. She stated that the staff used the washcloths as wipes, and she found that some of the aides were throwing them away in the trash. OSM #5 stated that starting in April 2025 she had hired a night shift laundry person to stock the closets in the mornings to see if that would help the situation. She stated that she had conducted some room audits which found some hoarded linens in resident rooms and she had worked with the unit managers to educate the staff. On 6/4/25 at 4:20 p.m., an interview was conducted with ASM (administrative staff member) #2, the director of nursing. ASM #2 stated that since she started working at the facility in February 2025 they had done a lot of education and monitoring of the linen. She stated that they had found that the staff were throwing soiled linens in the trash and they had started ordering more. She stated that they also found that staff were hoarding linens in rooms and other employees were not aware where the linen was. ASM #2 stated that they had taken it upon themselves to try to continuously replenish the laundry on the floors. On 6/5/25 at 9:26 a.m., an interview was conducted with OSM #11, acting activities director. OSM #11 stated that she did not attend the resident council meetings but she understood that the former activities director used to go to the resident council meetings, write down any concerns and the communicate them to the appropriate department by the grievance form. She stated that the residents often complain to her that the laundry runs out of towels and washcloths and the staff do not have any available to get them up and dressed. OSM #11 stated that the residents had complained recently to her about delays in getting up due to linens not being available. On 6/5/25 at 12:53 p.m., an interview was conducted with ASM #1, administrator who stated that since she had been in the position she has made sure that towels and washcloths were ordered at least once a month. She stated that she had created a form that the CNAs could carry that asked them if they had enough linen and she did that for a month or two. She stated that she rounded in the mornings to see if there were washcloths, towels and everything they needed on the units. ASM #1 stated that she had asked EVS to hire the night laundry person. She stated that the housekeeping director thought that the staff were throwing away the washcloths and towels and she continued to authorize the orders for additional linens and was not aware of any current issues. Review of facility invoices for towel and washcloth orders documented orders placed on 7/19/24, 8/8/24, 12/6/24, 12/19/24, 1/16/25, 2/18/25, 3/12/25, 4/15/25, and 5/13/25. The facility policy Resident Rights documented in part, . The resident has the right to and the facility must make prompt efforts to resolve grievances the resident may have . On 6/5/25 at 2:47 p.m., ASM #1, the administrator, ASM #6, the regional director of clinical services, ASM #7, the regional director of operations, ASM #8, the risk nurse and ASM #9, the regional human resources were made aware of the concern. No further information was presented prior to exit.

Based on staff interview, facility document review, and clinical record review, the facility staff failed to follow professional standards of practice for four of 13 residents in the survey sample, Residents #1, #5, #7, and #9. The findings include: 1. For Resident #1 (R1), the facility staff failed to administer multiple medications in a timely manner on 12/25/24. A review of R1's clinical record revealed the following physician's orders: 12/27/23-Pseudoephedrine 30mg (milligrams)-one tablet by mouth three times a day for seasonal allergies. 5/15/23-Baclofen 20mg-one tablet by mouth three times a day for spinal stenosis (narrowing of the spine). 1/23/24-Azelastine 137mcg (micrograms)-two sprays in both nostrils two times a day for nasal congestion. 5/13/24-Simvastatin 40mg-one tablet by mouth at bedtime for high cholesterol. 6/16/24-Magnesium Oxide 400mg-one tablet by mouth two times a day for rhabdomyolysis (skeletal muscle breakdown). 9/11/24-Baclofen 5mg-one tablet by mouth three times a day for muscle spasms. A review of a medication administration audit report for 12/25/24 revealed the following: -Pseudoephedrine was scheduled at 7:00 a.m. and was administered at 12:34 p.m. -Pseudoephedrine was scheduled at 8:00 p.m. and was administered at 10:08 p.m. -Baclofen (20mg) was scheduled at 9:00 a.m. and was administered at 12:27 p.m. -Azelastine was scheduled at 7:00 a.m. and was administered at 12:35 p.m. -Azelastine was scheduled at 8:00 p.m. and was administered at 10:07 p.m. -Simvastatin was scheduled at 8:00 p.m. and was administered at 10:08 p.m. -Magnesium Oxide was scheduled at 7:00 a.m. and was administered at 12:33 p.m. -Baclofen (5mg) was scheduled at 9:00 a.m. and was administered at 12:28 p.m. On 6/5/25 at 9:25 a.m., an interview was conducted with RN (registered nurse) #1. RN #1 stated nurses should administer medications within one hour before or one hour after the medications are scheduled so residents are not overmedicated and are getting their doses correctly. On 6/5/25 at 2:59 p.m., ASM (administrative staff member) #1 (the administrator) was made aware of the above concern. The facility policy titled, Medication Administration documented, 14. Medications are administered within 60 minutes of scheduled time . No further information was presented prior to exit. 2. For Resident #5 (R5), the facility staff failed to administer multiple medications in a timely manner on 12/25/24. A review of R5's clinical record revealed the following physician's orders: 1/29/24-hydralazine 50mg (milligrams)-one tablet by mouth three times a day for high blood pressure. 11/19/24-Carvedilol 3.125mg by mouth two times a day for high blood pressure. 12/18/24-Brimonidine Tartrate 0.2%- one drop in the left eye two times a day for increased eye pressure. A review of a medication administration audit report for 12/25/24 revealed the following: -hydralazine was scheduled at 7:00 a.m. and was administered at 10:36 a.m. -hydralazine was scheduled at 11:00 a.m. and was administered at 2:42 p.m. -hydralazine was scheduled at 8:00 p.m. and was administered at 9:43 p.m. -Carvedilol was scheduled at 6:00 p.m. and was administered at 9:43 p.m. -Brimonidine Tartrate was scheduled at 7:00 a.m. and was administered at 10:36 a.m. On 6/5/25 at 9:25 a.m., an interview was conducted with RN (registered nurse) #1. RN #1 stated nurses should administer medications within one hour before or one hour after the medications are scheduled so residents are not overmedicated and are getting their doses correctly. On 6/5/25 at 2:59 p.m., ASM (administrative staff member) #1 (the administrator) was made aware of the above concern. No further information was presented prior to exit. 3. For Resident #7 (R7), the facility staff failed to administer multiple medications in a timely manner on 12/25/24. A review of R7's clinical record revealed the following physician's orders: 5/28/24-levetiracetam 500mg (milligrams) by mouth two times a day for seizure like activity. 10/26/24-Tylenol 500mg-two tablets by mouth two times a day for pain. A review of a medication administration audit report for 12/25/24 revealed the following: -levetiracetam was scheduled at 5:00 p.m. and was administered at 11:07 p.m. -Tylenol was scheduled at 5:00 p.m. and was administered at 11:07 p.m. On 6/5/25 at 9:25 a.m., an interview was conducted with RN (registered nurse) #1. RN #1 stated nurses should administer medications within one hour before or one hour after the medications are scheduled so residents are not overmedicated and are getting their doses correctly. On 6/5/25 at 2:59 p.m., ASM (administrative staff member) #1 (the administrator) was made aware of the above concern. No further information was presented prior to exit. 4. For Resident #9 (R9), the facility staff failed to administer multiple medications in a timely manner on 12/25/24. A review of R9's clinical record revealed the following physician's orders: 6/15/23-tramadol 50mg (milligrams)-one tablet by mouth three times a day for pain. 2/18/24-Diclofenac 1% gel-apply to shoulder and neck two times a day for arthritic pain. 9/7/24-Miralax 17 grams by mouth two times a day for constipation. A review of a medication administration audit report for 12/25/24 revealed the following: -tramadol was scheduled at 9:00 a.m. and was administered at 10:59 a.m. -Diclofenac was scheduled at 6:00 p.m. and was administered at 10:05 p.m. -Miralax was scheduled at 9:00 a.m. and was scheduled at 11:00 a.m. On 6/5/25 at 9:25 a.m., an interview was conducted with RN (registered nurse) #1. RN #1 stated nurses should administer medications within one hour before or one hour after the medications are scheduled so residents are not overmedicated and are getting their doses correctly. On 6/5/25 at 2:59 p.m., ASM (administrative staff member) #1 (the administrator) was made aware of the above concern. No further information was presented prior to exit.

Based on resident interview, staff interview, facility document review and clinical record review, it was determined the facility staff failed to implement the comprehensive care plan for three of 13 residents, Residents #12, #7, and #1. The findings include: 1a. For Resident #12 (R12), the facility staff failed to implement the comprehensive care plan for the administration of antibiotics. The comprehensive care plan dated, 5/20/25, documented in part, Focus: General Infection: the resident has an infection to the GI (gastrointestinal) system. Interventions: Administer medications as ordered. The physician orders dated 5/20/25, documented, Ciprofloxacin HCL (hydrochloride)(1) Oral Tablet 500 MG (milligrams); Give 1 tablet by mouth one time a day related to diverticulitis of intestine, part unspecified, without perforation or abscess without bleeding for 4 days. The physician order dated, 5/21/25, documented, Flagyl Oral Tablet (2) 500 MG; Give 1 tablet by mouth three times a day related to Diverticulitis of intestine, part unspecified, without perforation or abscess without bleeding for 3 days. The May 2025 MAR (medication administration record) documented the above order. The medication was to be administered at 4:00 a.m. On 5/20/25 at 4:00 a.m. the space to sign off the medication was blank. The May 2025 MAR documented the above order. On 5/24/25 for the 10:00 a.m. and 2:00 p.m. dose, a 9 (See progress notes) was documented. There were no nurse's notes dated 5/20/25 at 4:00 a.m. that addressed the missing dose of Cipro. The nurse' note dated 5/24/25 at 3:12 p.m. documented, Order complete. A second nurse's note dated, 5/24/25 at 3:12 p.m. documented, Order complete. An interview was conducted with LPN (licensed practical nurse) #6 on 6/4/25 at 1:23 p.m. The above MAR was reviewed with LPN #6 regarding the Flagyl. LPN #6 stated that when she went to give the medication, there was none in the cart, so she assumed the medication had been completed as it was ordered on 5/21/15 and the three days would have been up. LPN #6 stated, That was my error, I just thought since the order was for 5/21/25, the three days was up. When asked the purpose of the care plan, LPN #6 stated it's so everyone can go along with it to help the resident. The team can do it together and it should be followed. The facility policy, Care Planning - Comprehensive Person - Centered, documented in part, 2.The facility will develop and implement a comprehensive person-centered care plan for each resident, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs as identified throughout the comprehensive Resident Assessment Instrument (RAI) process. ASM (administrative staff member) #1, ASM #6, the regional director of clinical services and ASM #7, the regional director of operations, were made aware of the above concern on 6/5/25 at 2:49 p.m. No further information was provided prior to exit. References: 1. Ciprofloxacin is used to treat or prevent certain infections caused by bacteria such as pneumonia; gonorrhea (a sexually transmitted disease); typhoid fever (a serious infection that is common in developing countries); infectious. This information was obtained from the following website: https://medlineplus.gov/druginfo/meds/a688016.html. 2. Flagyl (Metronidazole) is used to treat infections of the reproductive system, gastrointestinal (GI) tract, skin, heart, bone, joint, lung, blood, nervous system, and other areas of the body. This information was obtained from the following website: https://medlineplus.gov/druginfo/meds/a689011.html 1b. For Resident #12, the facility staff failed to implement the comprehensive care plan for the treatment of pain. The comprehensive care plan dated, 5/27/25, documented in part, Focus: Risk for Pain: the resident is at risk for pain or pain related to advanced age, chronic conditions, peripheral vascular disease, recent hospitalization, treatments. Focus: Administer medications as ordered. Notify MD (medical doctor) as indicated. Observe for physical indicators of pain such as bracing, guarding or pulling back and notify MD as indicated. An interview was conducted with R12 on 6/3/25 at 2:30 p.m. When asked if he had pain, R12 stated at that moment his pain level was a six out of 10. He stated the staff give him Tylenol for it. R12 stated it dulls the pain but doesn't take it away. A second interview was conducted with R12 on 6/4/25 at 8:43 a.m. He stated he was a bit drowsy as he had just taken his Tylenol. He was asked if the Tylenol helped his pain, R12 stated that if he could get something stronger than Tylenol, he'd take it. The physician orders dated, 5/19/25, documented, Tylenol 8-hour Arthritis Pain Oral Tablet Extended Release (acetaminophen) (1); Give 2 tablets by mouth every 8 hours as needed for mild pain 1-5. The May 2025 MAR (medication administration record) documented the above order. The Tylenol was documented as administered on the following dates and time with the documented pain scale score: 5/19/25 at 11:53 p.m. - 4 5/20/25 at 6:53 p.m. - 6 5/21/25 at 10:56 a.m. - 6 5/22/25 at 4:46 a.m. - 9 5/22/25 at 2:15 p.m. - 6 5/23/25 at 8:26 p.m. - 6 5/25/25 at 12:31 a.m. - 6 5/27/25 at 9:13 p.m. - 8 5/28/25 at 2:42 p.m. - 6 5/30/25 at 8:48 a.m. - 5 5/31/25 at 6:59 p.m. - 6 Only two times was the medication administered according to the physician orders. The June 2025 MAR documented the order for Tylenol. The Tylenol was documented as administered on the following dates and time with the documented pain scale score: 6/1/25 at 11:37 p.m. - 7 6/4/25 at 7:49 a.m. - 5 The Tylenol was not administered per the physician orders on 6/1/25. An interview was conducted with LPN (licensed practical nurse) #6 on 6/4/25 at 1:23 p.m. When asked the purpose of the care plan, LPN #6 stated it's so everyone can go along with it to help the resident. The team can do it together and it should be followed. ASM (administrative staff member) #1, ASM #6, the regional director of clinical services and ASM #7, the regional director of operations, were made aware of the above concern on 6/5/25 at 2:49 p.m. No further information was provided prior to exit. References: 1. Acetaminophen may also be used to relieve the pain of osteoarthritis (arthritis caused by the breakdown of the lining of the joints). Acetaminophen is in a class of medications called analgesics (pain relievers) and antipyretics (fever reducers). It works by changing the way the body senses pain and by cooling the body. This information was obtained from the following website: https://medlineplus.gov/druginfo/meds/a681004.html. 2. For Resident #7 (R7), the facility staff failed to offer nonpharmacological interventions prior to the administration of as-needed pain medications in May 2025. A review of R7's clinical record revealed the following orders: 5/5/24 Tramadol HCl (1) Oral Tablet 50 MG (Tramadol HCl) *Controlled Drug* Give 1 tablet by mouth every 4 hours as needed for moderate pain 5 to 10 for 14 Days. 5/21/24 Tramadol HCl Oral Tablet 50 MG (Tramadol HCl) *Controlled Drug* Give 1 tablet by mouth every 6 hours as needed for moderate pain for 14 Days. A review of R7's May 2025 MAR (medication administration record) and progress notes revealed the resident was not offered nonpharmacological interventions prior to administering as-needed Tramadol on the following dates and times: 5/5/25 at 7:30 p.m.; 5/6/24 at 5:41 a.m.; 5/11/25 at 1:33 p.m.; 5/12/25 at 8:45 a.m.; 5/12/25 at 12:26 p.m.; 5/12/25 at 4:30 p.m.; 5/23/25 at 8:47 p.m.; 5/24/25 at 8:51 a.m. A review of R7's care plan dated 2/3/25 and updated 5/12/25 revealed, in part: The resident has a risk for pain .attempt nonpharmacological interventions for pain such as repositioning, comfort therapy, or passive ROM (range of motion) as tolerated. R7 was not interviewable during the survey. On 6/3/25 at 2:36 p.m., RN (registered nurse) #1, a unit manager, was interviewed. She stated the purpose of a care plan is to make sure the resident is being cared for to meet their individual needs. She added: The care plan tells us how to meet the resident's needs. She explained that all staff are responsible to make sure the care plan is being followed for each resident. On 6/5/25 at 2:48 p.m., ASM (administrative staff member) #1, the administrator, and ASM #6, the regional director of clinical services, were notified of these concerns. No additional information was provided prior to exit. Reference 1. Tramadol is used to relieve moderate to moderately severe pain. This information is taken from the website https://medlineplus.gov/druginfo/meds/a695011.html. 3. For Resident #1 (R1), the facility staff failed to implement the comprehensive care plan to administer Debrox as ordered on 1/24/25. On the most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 4/2/25, the resident scored 15 out of 15 on the BIMS (brief interview for mental status) assessment, indicating they were cognitively intact for making daily decisions. The comprehensive care plan for R1 documented in part, Hearing: [Name of R1] is at risk for hearing deficit r/t (related to) often times having cerumen impaction. Date Initiated: 01/14/2025. Under Interventions it documented in part, Administer medication and treatments as ordered. Date Initiated: 01/14/2025 . The physician orders for R1 documented in part, - Debrox Solution (Carbamide Peroxide) Instill 5 drop in both ears two times a day for cerumen impaction for 4 Days Place 5 gtts in ear canal(s). Soak x's 15 minutes. after 4days Flush with warm H20. Repeat until clear. Report any significant findings to M.D. Order Date: 01/23/2025. Start Date: 01/24/2025. The eMAR (electronic medication administration record) for R1 dated 1/1/25-1/31/25 documented the order listed above. It further documented R1 receiving the medication on 1/25/25-1/27/25. The eMAR failed to evidence administration of the Debrox solution on 1/24/25 at 6:00 a.m. and 6:00 p.m. On 6/4/25 at 2:17 p.m., an interview was conducted with RN (registered nurse) #1. RN #1 stated that the purpose of the care plan was to show the needs of the resident and their individual plan of care. She stated that the care plan should be implemented to provide the care and meet the needs. RN #1 stated that they had a stock of over-the-counter medications kept at the facility and the nurses could pull them out to start using them when they had an order for it. RN #1 reviewed R1's eMAR dated 1/1/25-1/31/25 and stated that Debrox was a stock medication at the facility, and she was not sure why the doses were not administered on 1/24/25 but it looked like the resident did not get the full four-day treatment as ordered. She stated that if the medication was not available the nurse should have notified the nurse practitioner and gotten a hold order, changed the administration dates and times and notified the resident and the responsible party. On 6/4/25 at 3:59 p.m., an interview was conducted with ASM #3, nurse practitioner who stated that when Debrox was ordered she expected nursing staff to administer it as ordered. On 6/5/25 at 2:47 p.m., ASM #1, the administrator, ASM #6, the regional director of clinical services, ASM #7, the regional director of operations, ASM #8, the risk nurse and ASM #9, the regional human resources were made aware of the concern. No further information was presented prior to exit.

Based on observations and staff interview, it is determined that the facility staff failed to prepare and serve food in a sanitary manner in one of two facility kitchens. The findings include: On 04/14/2025 an observation of the facility's kitchen revealed the following: On 06/04/2025 at 11:00 a.m. to 1:15 p.m., an observation in the facility's (Name of Facility Kitchen) revealed OSM (other staff member) #3, cook, plating lunch trays for the [NAME], [NAME], and Grace units and the [NAME] dining room. Observations of OSM #3 revealed he had a beard and mustache and had a covering over the beard, but it did not extend over the mustache. Further observation revealed that OSM #3 did not have his mustache covered while plating the lunch trays. On 06/04/2025 at approximately 1:40 p.m. an interview was conducted with OSM #3. When asked to describe the procedure for facial hair when working in the kitchen, he stated that beards and mustaches were to be covered to prevent hair from falling into the food. When informed of the observation described above OSM #3 stated that he was unaware that his mustache was not covered. On 06/04/2025 at approximately 1:05 p.m. an observation in the facility's (Name of Facility Kitchen) kitchen revealed OSM #4 cooking fish filets, raising and lowering the deep fry baskets while wearing gloves. Further observation revealed OSM #4 dumping the cooked fish filets into a four-inch-deep pan and arranging the filets while wearing the same gloves she used to raise and lower the deep fry baskets. On 06/04/2025 at approximately 1:41 p.m. an interview was conducted with OSM #4. When informed of the observation of handling the fish filets for the resident's meal, she stated that she should have not touched the resident's food with her hands. On 06/04/2025 at approximately 11:30 a.m. an observation of the (Name of Facility Kitchen) accessory table next to the steam table revealed a container of chicken salad. OSM # 3, cook, was asked to obtain the temperature of the chicken salad. Using a digital thermometer, he read a temperature of 53 degrees. Further observation revealed immediately after the temperature was obtain, a sandwich was made, placed on a plate, put on a resident's lunch tray and sent out of the kitchen for a resident's lunch. On 06/05/2025 at approximately 4:05 p.m., an interview was conducted with OSM #2, dietary manager. When informed of the observation of OSM #3 not having his mustache covered while plating resident's lunch, she stated that all facial hair, beards and mustaches, should be covered to prevent hair from falling into the resident's food. When informed of the observation of OSM #4 as stated above she stated that OSM #$ should have changed her gloves before handling the resident's food to prevent contamination. When informed of the observation of the chicken salad temperature and being sent to a resident, she stated that the holding temperature should have been 41 degrees or lower and should not have been served. On 06/05/2025 at approximately 3:05 p.m., ASM (administrative staff member) #1, administrator, and ASM #6, director of clinical services, were made aware of the above findings. No further information was provided prior to exit.

Based on observation and staff interview, it was determined that the facility staff failed to serve palatable food on one of three units observed, [NAME] unit. The findings include: On 06/04/2025 at t approximately 1:15 p.m. a test tray consisting of pureed fish, pureed broccoli, mashed potatoes, whole broccoli florets, whole fish fillet were placed on a cart and sent to the [NAME] Unit. The cart was followed by this and another surveyor and OSM (other staff member) #2, dietary manager. At approximately 1:26 p.m., the last lunch tray was served to a resident on the [NAME] Unit and OSM #2 was asked to remove the test tray from the cart and proceeded to take the temperatures of the food. The pureed fish was 140° (degrees) F (Fahrenheit), pureed broccoli at 144° F, mashed potatoes 140° F, whole fish fillet at 135° F, and the whole broccoli florets at 135° F. After tasting the food listed above OSM #2 stated that the pureed food did not have any flavor and agreed it was not palatable. When asked about seasoning for the food she stated that they do not add any seasoning to the food. She further stated that the kitchen supplies packets of salt and pepper on the units for residents who want and are allowed salt and/or pepper. When ask if she suppled any type of salt-substitute for resident who cannot have salt she stated no and that if a resident wanted it, it would be supplied by the resident's family. The facility's policy Food and Nutrition Services Staff documented in part, 4. Food will be palatable, attractive, and served in a timely manner at proper temperatures. On 06/05/2025 at approximately 3:05 p.m., ASM (administrative staff member) #1, administrator, and ASM #6, director of clinical services, were made aware of the above findings. No further information was provided prior to exit.

Based on resident interview, staff interview, facility document review and clinical record review, it was determined that the facility staff failed to ensure one of 13 residents in the survey sample was free of significant medication errors, Resident #1. The findings include: For Resident #1 (R1), the facility staff failed to ensure they were free of significant medication errors A) on 11/8/24 when fluorouracil 5% cream (1) was applied to the neck when it was supposed to be applied to the chest and B) on 9/27/23, 11/19/23, and 5/31/24 when Debrox (2) ear drops were administered into the eye and C) on 12/25/24 when Baclofen 20mg (3) was administered late. On the most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 4/2/25, the resident scored 15 out of 15 on the BIMS (brief interview for mental status) assessment, indicating they were cognitively intact for making daily decisions. The assessment documented R1 receiving scheduled pain medication. On 6/3/25 at 1:30 p.m., an interview was conducted with R1 who stated that he went to the dermatologist who had frozen a spot on his chest and when he went back for the follow up visit they had ordered a chemotherapy cream. R1 stated that LPN (licensed practical nurse) #9 had applied the chemotherapy cream to his neck rather than the skin cancer lesion on his chest and caused a reddened area that was treated with hydrocortisone. R1 stated that he had multiple problems with ear wax buildup in the right ear and had Debrox ordered multiple times to soften the ear wax. He stated that there were three times when nurses had administered the ear drops into his eye which caused it to burn like fire and was painful. A) The facility staff failed to administer fluorouracil 5% cream to the correct location on 11/8/24. The physician orders for R1 documented in part, - Fluorouracil External Cream 5 % (Fluorouracil (Topical)) Apply to spot on left chest topically two times a day for actinic keratosis for 3 Weeks apply a thin film only on the spot. Stop for open sores, pain, or bleeding even if they develop before 3 weeks. But redness and scabbing is expected. Leave open to air. Pregnant women should avoid admin. Order Date: 10/30/2024. Start Date: 10/30/2024. The progress notes for R1 documented in part, - 11/08/2024 11:02 (11:02 a.m.) Situation: The Change In Condition/s reported on this CIC Evaluation are/were: Change in skin color or condition . Nursing observations, evaluation, and recommendations are: the fluorouracil 5% cream was applied to spot on the left side of neck when it was supposed to be applied to left chest. Redness noted and resident c/o (complains of) slight burning feeling. Md office called and new order obtained for hydrocortisone 2.5% ointment bid x 1 week . - 11/08/2024 11:19 (11:19 a.m.) Note Text: Residents wife updated on new order for red spot on residents left side of his neck. On 6/4/25 at 2:17 p.m., an interview was conducted with RN (registered nurse) #1 who stated that prior to medication administration the nurse checked the physician order with the medication itself and followed the five rights of medication administration (right medication, right time, right dose, right person, right route). She stated that they also documented the medication as administered. On 6/5/25 at 9:35 a.m., an interview was conducted with LPN (licensed practical nurse) #9 who stated that the fluorouracil cream had been applied to R1's neck and caused an irritated area which they treated with hydrocortisone cream. LPN #9 stated that the fluorouracil cream was supposed to be applied to the skin cancer area on the chest. On 6/5/25 at 12:37 p.m., an interview was conducted with OSM (other staff member) #7, pharmacist who stated that fluorouracil cream was used for skin lesions and skin cancer. She stated that the usage was to apply sparingly just to the area being treated by the physician, wearing gloves when applying and covering loosely to contain the cream. She stated that since it was used to treat cancer some thought of it as a chemotherapy drug but if it was used appropriately there was no concern. OSM #7 stated that normal gloves were indicated when applying the cream and pregnant women should avoid coming in contact with it. She stated that the cream should only be applied to the skin lesion being treated because it was used to disrupt the cells and used to kill the cancer cells. OSM #7 stated that if the cream was applied to healthy skin it would cause irritation, redness and pain would be subjective to the resident. B) The facility staff failed to administer Debrox ear drops correctly on 9/27/23, 11/19/23, and 5/31/24. The physician orders for R1 documented in part, - Debrox Solution 6.5 % (Carbamide Peroxide) Instill 5 drop in right ear two times a day for excess cerumen for 4 Days. Start Date: 09/26/2023. - Debrox Otic Solution 6.5 % (Carbamide Peroxide (Otic)) Instill 5 drop in right ear two times a day for cerumen impaction for 3 Days x 3 days until irrigation performed per NP (nurse practitioner). Start Date: 11/18/2023. - Debrox Solution 6.5 % (Carbamide Peroxide) Instill 5 drop in both ears two times a day for Cerumen for 4 Days. Start Date: 05/29/2024. Review of the facility medication error report for R1 dated 11/19/23 documented in part, Per [Name of staff member], she took Debrox ear drops out of the Tears eye drop box and did not check the label on the vial and then proceeded put debrox in res L-eye .Nurse immediately flushed res eye with NS (normal saline). Supervisor spoke with resident's wife and then spoke with FNP (family nurse practitioner) and received new orders which were initiated. Res denied any pai [sic] at that time . A report dated 9/29/23 documented in part, The nurse on shift administered Debrox ear drops in the residents' eyes instead of Natural Tears drops to the residents' eyes on the evening of 9/27/23. The resident reported to this writer (DON) (director of nursing) that when he received his eye drops on the evening of 9/27/23 when the drops were administered the drops burned his eyes. He reported this to the nurse and she flushed his eyes immediately. The resident stated that his eyes were sore and a little blurry .This error was reported to the NP and the resident's eyes was assessed and there was no redness at that time but he resident did state his eyes were a little sore and a little blurry. There were no further adverse reactions noted . A report dated 5/31/24 documented in part, Nurse in patient's room administering morning medications. The patient requested his eye drops, and his ear drops. The patient's eye drops were placed in the ear drops container and the ear drops were placed in the eye drops box. Nurse grabbed both containers while talking with the patient concerning his medications and his care. Nurse accidentally placed ear drops in the patients left eye. Patient complained about his left eye is burning. Nurse flushed the patient's left eye with a large amount of water . Patient's eyes flushed with large amounts of water. Patient stated his eye is fine. Nurse applied artificial tears to the patient's left eye. Patient states his eye feels better, and he is able to see out of his left eye without difficulty . On 6/4/25 at 2:17 p.m., an interview was conducted with RN (registered nurse) #1 who stated that prior to medication administration the nurse checked the physician order with the medication itself and followed the five rights of medication administration (right medication, right time, right dose, right person, right route). She stated that they also documented the medication as administered. On 6/5/25 at 12:37 p.m., an interview was conducted with OSM (other staff member) #7, pharmacist who stated that Debrox was used to loosen up excessive ear wax and the drops were to go in the ear only. She stated that if they were placed in the eye they would be uncomfortable and cause burning, redness, stinging and swelling. She stated that the eye should be immediately flushed out and there would be no permanent effects that she knew of. OSM #7 stated that there was a risk of corneal abrasion because the solution was not filtered for particulates like eye drops were so it should not be placed in anything other than the ear. C) The facility staff failed to administer the medication Baclofen (a muscle relaxant) in a timely manner. A review of R1's clinical record revealed the following physician's orders: 5/15/23-Baclofen 20mg-one tablet by mouth three times a day for spinal stenosis (narrowing of the spine). 9/11/24-Baclofen 5mg-one tablet by mouth three times a day for muscle spasms. A review of a medication administration audit report for 12/25/24 revealed the following: -Baclofen (20mg) was scheduled at 9:00 a.m. and was administered at 12:27 p.m. -Baclofen (5mg) was scheduled at 9:00 a.m. and was administered at 12:28 p.m. On 6/5/25 at 9:25 a.m., an interview was conducted with RN (registered nurse) #1. RN #1 stated nurses should administer medications within one hour before or one hour after the medications are scheduled so residents are not overmedicated and are getting their doses correctly. On 6/5/25 at 10:43 a.m., an interview was conducted with OSM (other staff member) #7 (the pharmacist). OSM #7 stated it is important for a resident who is prescribed Baclofen to receive the medication as scheduled because it is for muscle spasms and the resident may present with discomfort if the medication is not administered as scheduled. OSM #7 further stated that if Baclofen is not administered as scheduled and a resident receives doses too close together, the resident may experience an increase in drowsiness, mental confusion and/or a higher risk for falls. The facility policy Medication Administration General Guidelines dated 01/23 documented in part, Medications are administered as prescribed in accordance with manufacturers' specifications, good nursing principles and practices and only persons legally authorized to do so . Verify medication is correct three (3) times before administering the medication. a. When pulling medication package from med cart. b. When dose is prepared. c. Before dose is administered . Medications are administered within 60 minutes of schedule time, except before or after meal orders, which are administered based on mealtimes . On 6/5/25 at 2:47 p.m., ASM (administrative staff member) #1, the administrator, ASM #6, the regional director of clinical services, ASM #7, the regional director of operations, ASM #8, the risk nurse and ASM #9, the regional human resources were made aware of the concerns. No further information was presented prior to exit. Reference: (1) Fluorouracil cream and topical solution are used to treat actinic or solar keratoses (scaly or crusted lesions [skin areas] caused by years of too much exposure to sunlight). Fluorouracil cream and topical solution are also used to treat a type of skin cancer called superficial basal cell carcinoma if usual types of treatment cannot be used. Fluorouracil is in a class of medications called antimetabolites. It works by killing fast-growing cells such as the abnormal cells in actinic keratoses and basal cell carcinoma. This information was obtained from the website: https://medlineplus.gov/druginfo/meds/a605010.html (2) Debrox (for the ears) is used to soften and loosen ear wax, making it easier to remove . Avoid getting Debrox in your eyes or mouth . This information was obtained from the website: https://www.drugs.com/mtm/debrox-otic.html (3) Baclofen is used to treat pain and certain types of spasticity (muscle stiffness and tightness) from multiple sclerosis, spinal cord injuries, or other spinal cord diseases. Baclofen is in a class of medications called skeletal muscle relaxants. Baclofen acts on the spinal cord nerves and decreases the number and severity of muscle spasms caused by multiple sclerosis or spinal cord conditions. It also relieves pain and improves muscle movement . It usually is taken 3 times a day at evenly spaced intervals. Follow the directions on your prescription label carefully, and ask your doctor or pharmacist to explain any part you do not understand. Take baclofen exactly as directed. Do not take more or less of it or take it more often than prescribed by your doctor. This information was obtained from the website: https://medlineplus.gov/druginfo/meds/a682530.html

2. For Resident #12(R12), the facility staff failed to manage the resident's pain. On the most recent MDS (minimum data set) assessment, an admission assessment, with an assessment reference date of 5/22/25, the residents scored a 14 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was not cognitively impaired for making daily decisions. The resident was admitted to the facility with diagnoses that included but were not limited to: muscle weakness, peripheral vascular disease, and an open arterial wound to the right ankle. An interview was conducted with R12 on 6/3/25 at 2:30 p.m. When asked if he had pain, R12 stated at that moment his pain level was a six out of 10. He stated the staff give him Tylenol for it. R12 stated it dulls the pain but doesn't take it away. A second interview was conducted with R12 on 6/4/25 at 8:43 a.m. He stated he was a bit drowsy as he had just taken his Tylenol. He was asked if the Tylenol helped his pain, R12 stated that if he could get something stronger than Tylenol, he'd take it. The physician orders dated, 5/19/25, documented, Tylenol 8-hour Arthritis Pain Oral Tablet Extended Release (acetaminophen) (1); Give 2 tablets by mouth every 8 hours as needed for mild pain 1-5. The May 2025 MAR (medication administration record) documented the above order. The Tylenol was documented as administered on the following dates and time with the documented pain scale score: 5/19/25 at 11:53 p.m. - 4 5/20/25 at 6:53 p.m. - 6 5/21/25 at 10:56 a.m. - 6 5/22/25 at 4:46 a.m. - 9 5/22/25 at 2:15 p.m. - 6 5/23/25 at 8:26 p.m. - 6 5/25/25 at 12:31 a.m. - 6 5/27/25 at 9:13 p.m. - 8 5/28/25 at 2:42 p.m. - 6 5/30/25 at 8:48 a.m. - 5 5/31/25 at 6:59 p.m. - 6 Only two times was the medication administered according to the physician orders. The June 2025 MAR documented the order for Tylenol. The Tylenol was documented as administered on the following dates and time with the documented pain scale score: 6/1/25 at 11:37 p.m. - 7 6/4/25 at 7:49 a.m. - 5 The Tylenol was not administered per the physician orders on 6/1/25. The comprehensive care plan dated, 5/27/25, documented in part, Focus: Risk for Pain: the resident is at risk for pain or pain related to advanced age, chronic conditions, peripheral vascular disease, recent hospitalization, treatments. Focus: Administer medications as ordered. Notify MD (medical doctor) as indicated. Observe for physical indicators of pain such as bracing, guarding or pulling back and notify MD as indicated. An interview was conducted with LPN (licensed practical nurse) #7 on 6/4/25 at 2:12 p.m. The above MARs were reviewed with LPN #7. When asked if the resident's pain level is greater than 5 as per the order, what should the nurse do, LPN #7 stated the resident should have something stronger ordered for greater than five, and if they don't the nurse needs to contact the nurse practitioner for something stronger. The MARs were again reviewed with LPN #7, when asked if the nurses were following the physician orders, LPN #7 stated, no. ASM (administrative staff member) #1, ASM #6, the regional director of clinical services and ASM #7, the regional director of operations, were made aware of the above concern on 6/5/25 at 2:49 p.m. No further information was provided prior to exit. References: 1. Acetaminophen may also be used to relieve the pain of osteoarthritis (arthritis caused by the breakdown of the lining of the joints). Acetaminophen is in a class of medications called analgesics (pain relievers) and antipyretics (fever reducers). It works by changing the way the body senses pain and by cooling the body. This information was obtained from the following website: https://medlineplus.gov/druginfo/meds/a681004.html. Based on resident interview, staff interview, facility document review, and clinical record review, the facility staff failed to implement a complete pain management program for 2 of 13 residents in the survey sample, Residents #7 and #12. The findings include: 1. For Resident #7 (R7), the facility staff failed to offer nonpharmacological interventions prior to the administration of as-needed pain medications in May 2025. A review of R7's clinical record revealed the following orders: 5/5/24 Tramadol HCl (1) Oral Tablet 50 MG (Tramadol HCl) *Controlled Drug* Give 1 tablet by mouth every 4 hours as needed for moderate pain 5 to 10 for 14 Days. 5/21/24 Tramadol HCl Oral Tablet 50 MG (Tramadol HCl) *Controlled Drug* Give 1 tablet by mouth every 6 hours as needed for moderate pain for 14 Days. A review of R7's May 2025 MAR (medication administration record) and progress notes revealed the resident was not offered nonpharmacological interventions prior to administering as-needed Tramadol on the following dates and times: 5/5/25 at 7:30 p.m.; 5/6/24 at 5:41 a.m.; 5/11/25 at 1:33 p.m.; 5/12/25 at 8:45 a.m.; 5/12/25 at 12:26 p.m.; 5/12/25 at 4:30 p.m.; 5/23/25 at 8:47 p.m.; 5/24/25 at 8:51 a.m. R7 was not interviewable during the survey. On 6/3/25 at 2:36 p.m., RN (registered nurse) #1, a unit manager, was interviewed. She stated before a nurse administered an as-needed pain medication, the nurse should attempt nonpharmacological interventions to alleviate the resident's pain. If these nonpharmacological interventions do not work, then the medication should be administered. She stated the nonpharmacological attempt should be documented either on the MAR or in a progress note. On 6/5/25 at 2:48 p.m., ASM (administrative staff member) #1, the administrator, and ASM #6, the regional director of clinical services, were notified of these concerns. A review of the facility policy, Pain Management, revealed, in part: Pain management is a multidisciplinary care process that includes the following .Effectively recognizing the presence of pain .Addressing the underlying causes of the pain .Developing and implementing approaches to pain management .Identifying and using specific strategies for different levels and sources of pain .Modifying approaches as necessary .Nonpharmacological interventions may be appropriate alone or in conjunction with medications. No additional information was provided prior to exit. Reference 1. Tramadol is used to relieve moderate to moderately severe pain. This information is taken from the website https://medlineplus.gov/druginfo/meds/a695011.html.

Based on staff interview, facility document review, and clinical record review, the facility staff failed to ensure a resident was free from an unnecessary psychotropic medication for one of 13 residents in the survey sample, Resident #10. The findings include: For Resident #10 (R10), the facility staff failed to ensure the physician documented the duration for the use of prn (as needed) lorazepam and failed to attempt non-pharmacological interventions prior to the administration of prn lorazepam. A review of R10's clinical record revealed a physician's order dated 2/12/25 for lorazepam 2mg/ml (milligrams/milliliters)- 0.25ml by mouth every four hours as needed for anxiety, sleeplessness, seizure activity or shortness of breath. A nurse practitioner note dated 4/1/25 documented, Continue Lorazepam, this is a PRN, she doesn't need it very often but she does need it due to her schizophrenia. Further review of R10's clinical record failed to reveal nurse practitioner or physician documentation regarding the intended duration of use for prn lorazepam. A review of R10's MARs (medication administration records) for February 2025, March 2025, and May 2025 revealed the resident was administered prn lorazepam on 2/14/25, 3/6/25, 3/9/25, and 5/20/25. Further review of R10's clinical record (including the MARs and nurses' notes for those dates) failed to reveal the facility staff attempted non-pharmacological interventions prior to the administration of prn lorazepam on those dates. On 6/5/25 at 9:25 a.m., an interview was conducted with RN (registered nurse) #1. RN #1 stated she did not know what the physician should document regarding the use of prn lorazepam. On 6/5/25 at 10:01 a.m., another interview was conducted with RN #1. RN #1 stated non-pharmacological interventions should be individualized and should be attempted prior to the administration of prn lorazepam. RN #1 stated nurses should evidence the attempt of non-pharmacological interventions by documenting a progress note. On 6/5/25 at 2:59 p.m., ASM (administrative staff member) #1 (the administrator) was made aware of the above concern. The facility policy titled, Antipsychotic Medication Use documented, 14. The need to continue PRN orders for psychotropic medications beyond 14 days requires that the practitioner document the rationale for the extended order. The duration of the PRN order will be indicated in the order. No further information was presented prior to exit.

Based on staff interview, facility document review, and clinical record review, the facility staff failed to provide ADL (activities of daily living) care for one of 13 residents in the survey sample, Resident #8. The findings include: For Resident #8 (R8), the facility staff failed to provide personal hygiene on multiple shifts in March 2025 and May 2025. A review of R8's ADL records for March 2025 and May 2025 failed to reveal personal hygiene (combing hair, brushing teeth, washing/drying face and hands) was provided on the following dates/shifts (as evidenced by blank spaces on the records): 3/10/25 during the day shift. 3/17/25 through 3/20/25 during the evening shift. 3/22/25 through 3/23/25 during the evening shift. 5/17/25 during the day shift. On 6/4/25 at 2:23 p.m., an interview was conducted with CNA (certified nursing assistant) #2. CNA #2 stated personal hygiene consists of mouth care, nail care, perineal care, and washing under residents' arms/applying deodorant. CNA #2 stated residents' bodies should be washed once per shift, mouth care should be done in the morning and after each meal, and she washes under residents' nails if their nails are dirty. CNA #2 stated CNAs evidence personal hygiene was provided by documenting this every shift in the ADL records. On 6/5/25 at 2:59 p.m., ASM (administrative staff member) #1 (the administrator) was made aware of the above concern. The facility policy titled, Activities of Daily Living (ADLs) documented, Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene. No further information was presented prior to exit.

Based on staff interview, facility document review, and clinical record review, the facility staff failed to provide sufficient nursing staff for three of 13 residents in the survey sample, Residents #1, #5, and #9. The findings include: 1. For Resident #1 (R1), the facility staff failed to provide a sufficient number of nurses during the day shift on 12/25/24. One nurse cared for 54 residents. A review of an as-worked nursing schedule dated 12/25/24 revealed one nurse worked during the day shift on the [NAME] unit. A resident census form dated 12/25/24 documented 54 residents resided on the [NAME] unit on that date. R1 resided on the [NAME] unit. A review of R1's clinical record revealed the following physician's orders: 12/27/23-Pseudoephedrine 30mg (milligrams)-one tablet by mouth three times a day for seasonal allergies. 5/15/23-Baclofen 20mg-one tablet by mouth three times a day for spinal stenosis (narrowing of the spine). 1/23/24-Azelastine 137mcg (micrograms)-two sprays in both nostrils two times a day for nasal congestion. 6/16/24-Magnesium Oxide 400mg-one tablet by mouth two times a day for rhabdomyolysis (skeletal muscle breakdown). 9/11/24-Baclofen 5mg-one tablet by mouth three times a day for muscle spasms. A review of a medication administration audit report for 12/25/24 revealed the following: -Pseudoephedrine was scheduled at 7:00 a.m. and was administered at 12:34 p.m. -Baclofen (20mg) was scheduled at 9:00 a.m. and was administered at 12:27 p.m. -Azelastine was scheduled at 7:00 a.m. and was administered at 12:35 p.m. -Magnesium Oxide was scheduled at 7:00 a.m. and was administered at 12:33 p.m. -Baclofen (5mg) was scheduled at 9:00 a.m. and was administered at 12:28 p.m. On 6/4/25 at 2:40 p.m., an interview was conducted with LPN (licensed practical nurse) #2. LPN #2 stated two nurses are supposed to work during the day shift on the [NAME] unit, but she was the only nurse who worked on the unit during the day shift on 12/25/24. LPN #2 stated the night shift nurse had already worked 16 hours and stayed until approximately 9:30 a.m. but then left. LPN #2 stated that between 7:00 a.m. and 9:30 a.m., the night shift nurse called staff and tried to obtain coverage for a second nurse but did not provide resident care or administer medications. On 6/5/25 at 8:52 a.m., an interview was conducted with OSM (other staff member) #6 (the nursing scheduler). OSM #6 stated two nurses should work on the [NAME] unit during the day shift. OSM #6 stated she thought two nurses were scheduled for the [NAME] unit during the day shift on 12/25/24 and something happened but she would check. OSM #6 reviewed her computerized scheduling application and stated it would not allow her to review how many nurses were scheduled for the [NAME] unit during the day shift on 12/25/24. On 6/5/25 at 2:59 p.m., ASM (administrative staff member) #1 (the administrator) was made aware of the above concern. The facility policy titled, Staffing documented, Our facility provides sufficient numbers of staff with the skills and competency necessary to provide care and services for all residents in accordance with resident care plans and the facility assessment. No further information was presented prior to exit. 2. For Resident #5 (R5), the facility staff failed to provide a sufficient number of nurses during the day shift on 12/25/24. One nurse cared for 54 residents. A review of an as-worked nursing schedule dated 12/25/24 revealed one nurse worked during the day shift on the [NAME] unit. A resident census form dated 12/25/24 documented 54 residents resided on the [NAME] unit on that date. R5 resided on the [NAME] unit. A review of R5's clinical record revealed the following physician's orders: 1/29/24-hydralazine 50mg (milligrams)-one tablet by mouth three times a day for high blood pressure. 12/18/24-Brimonidine Tartrate 0.2%- one drop in the left eye two times a day for increased eye pressure. A review of a medication administration audit report for 12/25/24 revealed the following: -hydralazine was scheduled at 7:00 a.m. and was administered at 10:36 a.m. -hydralazine was scheduled at 11:00 a.m. and was administered at 2:42 p.m. -Brimonidine Tartrate was scheduled at 7:00 a.m. and was administered at 10:36 a.m. On 6/4/25 at 2:40 p.m., an interview was conducted with LPN (licensed practical nurse) #2. LPN #2 stated two nurses are supposed to work during the day shift on the [NAME] unit, but she was the only nurse who worked on the unit during the day shift on 12/25/24. LPN #2 stated the night shift nurse had already worked 16 hours and stayed until approximately 9:30 a.m. but then left. LPN #2 stated that between 7:00 a.m. and 9:30 a.m., the night shift nurse called staff and tried to obtain coverage for a second nurse but did not provide resident care or administer medications. On 6/5/25 at 8:52 a.m., an interview was conducted with OSM (other staff member) #6 (the nursing scheduler). OSM #6 stated two nurses should work on the [NAME] unit during the day shift. OSM #6 stated she thought two nurses were scheduled for the [NAME] unit during the day shift on 12/25/24 and something happened but she would check. OSM #6 reviewed her computerized scheduling application and stated it would not allow her to review how many nurses were scheduled for the [NAME] unit during the day shift on 12/25/24. On 6/5/25 at 2:59 p.m., ASM (administrative staff member) #1 (the administrator) was made aware of the above concern. 3. For Resident #9 (R9), the facility staff failed to provide a sufficient number of nurses during the day shift on 12/25/24. One nurse cared for 54 residents. A review of an as-worked nursing schedule dated 12/25/24 revealed one nurse worked during the day shift on the [NAME] unit. A resident census form dated 12/25/24 documented 54 residents resided on the [NAME] unit on that date. R9 resided on the [NAME] unit. A review of R9's clinical record revealed the following physician's orders: 6/15/23-tramadol 50mg (milligrams)-one tablet by mouth three times a day for pain. 9/7/24-Miralax 17 grams by mouth two times a day for constipation. A review of a medication administration audit report for 12/25/24 revealed the following: -tramadol was scheduled at 9:00 a.m. and was administered at 10:59 a.m. -Miralax was scheduled at 9:00 a.m. and was scheduled at 11:00 a.m. On 6/4/25 at 2:40 p.m., an interview was conducted with LPN (licensed practical nurse) #2. LPN #2 stated two nurses are supposed to work during the day shift on the [NAME] unit, but she was the only nurse who worked on the unit during the day shift on 12/25/24. LPN #2 stated the night shift nurse had already worked 16 hours and stayed until approximately 9:30 a.m. but then left. LPN #2 stated that between 7:00 a.m. and 9:30 a.m., the night shift nurse called staff and tried to obtain coverage for a second nurse but did not provide resident care or administer medications. On 6/5/25 at 8:52 a.m., an interview was conducted with OSM (other staff member) #6 (the nursing scheduler). OSM #6 stated two nurses should work on the [NAME] unit during the day shift. OSM #6 stated she thought two nurses were scheduled for the [NAME] unit during the day shift on 12/25/24 and something happened but she would check. OSM #6 reviewed her computerized scheduling application and stated it would not allow her to review how many nurses were scheduled for the [NAME] unit during the day shift on 12/25/24. On 6/5/25 at 2:59 p.m., ASM (administrative staff member) #1 (the administrator) was made aware of the above concern.

Based on staff interview, facility document review, and clinical record review, the facility staff failed to provide physician services for three of 13 residents in the survey sample, Residents #1, #5, and #9. The findings include: 1. For Resident #1 (R1), the facility staff failed to provide an individualized response to a nurse's inquiry regarding medication administration when the nurse was responsible for caring for 54 residents. A review of a nursing schedule dated 12/25/24 revealed one nurse worked during the day shift on the [NAME] unit. A resident census form dated 12/25/24 documented 54 residents resided on the [NAME] unit on that date. R1 resided on the [NAME] unit. A review of R1's clinical record revealed the following physician's orders: 12/27/23-Pseudoephedrine 30mg (milligrams)-one tablet by mouth three times a day for seasonal allergies. 5/15/23-Baclofen 20mg-one tablet by mouth three times a day for spinal stenosis (narrowing of the spine). 1/23/24-Azelastine 137mcg (micrograms)-two sprays in both nostrils two times a day for nasal congestion. 6/16/24-Magnesium Oxide 400mg-one tablet by mouth two times a day for rhabdomyolysis (skeletal muscle breakdown). 9/11/24-Baclofen 5mg-one tablet by mouth three times a day for muscle spasms. A review of a medication administration audit report for 12/25/24 revealed the following: -Pseudoephedrine was scheduled at 7:00 a.m. and was administered at 12:34 p.m. -Baclofen (20mg) was scheduled at 9:00 a.m. and was administered at 12:27 p.m. -Azelastine was scheduled at 7:00 a.m. and was administered at 12:35 p.m. -Magnesium Oxide was scheduled at 7:00 a.m. and was administered at 12:33 p.m. -Baclofen (5mg) was scheduled at 9:00 a.m. and was administered at 12:28 p.m. On 6/4/25 at 2:40 p.m., an interview was conducted with LPN (licensed practical nurse) #2. LPN #2 stated two nurses are supposed to work during the day shift on the [NAME] unit, but she was the only nurse who worked on the unit during the day shift on 12/25/24. LPN #2 stated the night shift nurse had already worked 16 hours and stayed until approximately 9:30 a.m. but then left. LPN #2 stated that between 7:00 a.m. and 9:30 a.m., the night shift nurse called staff and tried to obtain coverage for a second nurse but did not provide resident care or administer medications. LPN #2 stated she called ASM (administrative staff member) #3 (the nurse practitioner) and told her she was the only nurse on the [NAME] unit and medications were going to be late. LPN #2 stated ASM #3 said she could not give orders for everybody, and LPN #2 would have to use her nursing judgement and critical thinking. LPN #2 stated she administered medications to every resident on the unit using her best judgment. LPN #2 stated she could not administer medications that were ordered three times a day because the medications were administered late, and the medications would be given too close to the next dose. On 6/4/25 at 4:14 p.m., an interview was conducted with ASM #3. ASM #3 stated that on 12/25/24, LPN #2 called her and told her she was behind on the medication pass. ASM #3 stated she did not remember the details of what she and LPN #2 discussed and did not document any notes. ASM #3 stated she did not remember if she and LPN #2 discussed each resident, but they discussed important medications that could not be missed. ASM #3 stated she would have to refer to LPN #2 on who they discussed. On 6/5/25 at 10:43 a.m., an interview was conducted with OSM (other staff member) #7 (the pharmacist). OSM #7 stated it is not optimal to have missed or late medications. OSM #7 stated some medications work over such a long period of time and some medications are more critical. OSM #7 stated when some critical medications are missed or late, there could be serious adverse effects, and this depends on each person and each medication. On 6/5/25 at 2:59 p.m., ASM (administrative staff member) #1 (the administrator) was made aware of the above concern. The facility policy titled, Physician Services documented, 1. The resident's attending physician participates in the resident's assessment and care planning, monitoring changes in resident's medical status, providing consultation or treatment when called by the facility, and overseeing a relevant plan of care for the resident. No further information was presented prior to exit. 2. For Resident #5 (R5), the facility staff failed to provide an individualized response to a nurse's inquiry regarding medication administration when the nurse was responsible for caring for 54 residents. A review of a nursing schedule dated 12/25/24 revealed one nurse worked during the day shift on the [NAME] unit. A resident census form dated 12/25/24 documented 54 residents resided on the [NAME] unit on that date. R5 resided on the [NAME] unit. A review of R5's clinical record revealed the following physician's orders: 1/29/24-hydralazine 50mg (milligrams)-one tablet by mouth three times a day for high blood pressure. 12/18/24-Brimonidine Tartrate 0.2%- one drop in the left eye two times a day for increased eye pressure. A review of a medication administration audit report for 12/25/24 revealed the following: -hydralazine was scheduled at 7:00 a.m. and was administered at 10:36 a.m. -hydralazine was scheduled at 11:00 a.m. and was administered at 2:42 p.m. -Brimonidine Tartrate was scheduled at 7:00 a.m. and was administered at 10:36 a.m. On 6/4/25 at 2:40 p.m., an interview was conducted with LPN (licensed practical nurse) #2. LPN #2 stated two nurses are supposed to work during the day shift on the [NAME] unit, but she was the only nurse who worked on the unit during the day shift on 12/25/24. LPN #2 stated the night shift nurse had already worked 16 hours and stayed until approximately 9:30 a.m. but then left. LPN #2 stated that between 7:00 a.m. and 9:30 a.m., the night shift nurse called staff and tried to obtain coverage for a second nurse but did not provide resident care or administer medications. LPN #2 stated she called ASM (administrative staff member) #3 (the nurse practitioner) and told her she was the only nurse on the [NAME] unit and medications were going to be late. LPN #2 stated ASM #3 said she could not give orders for everybody, and LPN #2 would have to use her nursing judgement and critical thinking. LPN #2 stated she administered medications to every resident on the unit using her best judgment. LPN #2 stated she could not administer medications that were ordered three times a day because the medications were administered late, and the medications would be given too close to the next dose. On 6/4/25 at 4:14 p.m., an interview was conducted with ASM #3. ASM #3 stated that on 12/25/24, LPN #2 called her and told her she was behind on the medication pass. ASM #3 stated she did not remember the details of what she and LPN #2 discussed and did not document any notes. ASM #3 stated she did not remember if she and LPN #2 discussed each resident, but they discussed important medications that could not be missed. ASM #3 stated she would have to refer to LPN #2 on who they discussed. On 6/5/25 at 10:43 a.m., an interview was conducted with OSM (other staff member) #7 (the pharmacist). OSM #7 stated it is not optimal to have missed or late medications. OSM #7 stated some medications work over such a long period of time and some medications are more critical. OSM #7 stated when some critical medications are missed or late, there could be serious adverse effects, and this depends on each person and each medication. On 6/5/25 at 2:59 p.m., ASM (administrative staff member) #1 (the administrator) was made aware of the above concern. No further information was presented prior to exit. 3. For Resident #9 (R9), the facility staff failed to provide an individualized response to a nurse's inquiry regarding medication administration when the nurse was responsible for caring for 54 residents. A review of a nursing schedule dated 12/25/24 revealed one nurse worked during the day shift on the [NAME] unit. A resident census form dated 12/25/24 documented 54 residents resided on the [NAME] unit on that date. R9 resided on the [NAME] unit. A review of R9's clinical record revealed the following physician's orders: 6/15/23-tramadol 50mg (milligrams)-one tablet by mouth three times a day for pain. 9/7/24-Miralax 17 grams by mouth two times a day for constipation. A review of a medication administration audit report for 12/25/24 revealed the following: -tramadol was scheduled at 9:00 a.m. and was administered at 10:59 a.m. -Miralax was scheduled at 9:00 a.m. and was scheduled at 11:00 a.m. On 6/4/25 at 2:40 p.m., an interview was conducted with LPN (licensed practical nurse) #2. LPN #2 stated two nurses are supposed to work during the day shift on the [NAME] unit, but she was the only nurse who worked on the unit during the day shift on 12/25/24. LPN #2 stated the night shift nurse had already worked 16 hours and stayed until approximately 9:30 a.m. but then left. LPN #2 stated that between 7:00 a.m. and 9:30 a.m., the night shift nurse called staff and tried to obtain coverage for a second nurse but did not provide resident care or administer medications. LPN #2 stated she called ASM (administrative staff member) #3 (the nurse practitioner) and told her she was the only nurse on the [NAME] unit and medications were going to be late. LPN #2 stated ASM #3 said she could not give orders for everybody, and LPN #2 would have to use her nursing judgement and critical thinking. LPN #2 stated she administered medications to every resident on the unit using her best judgment. LPN #2 stated she could not administer medications that were ordered three times a day because the medications were administered late, and the medications would be given too close to the next dose. On 6/4/25 at 4:14 p.m., an interview was conducted with ASM #3. ASM #3 stated that on 12/25/24, LPN #2 called her and told her she was behind on the medication pass. ASM #3 stated she did not remember the details of what she and LPN #2 discussed and did not document any notes. ASM #3 stated she did not remember if she and LPN #2 discussed each resident, but they discussed important medications that could not be missed. ASM #3 stated she would have to refer to LPN #2 on who they discussed. On 6/5/25 at 10:43 a.m., an interview was conducted with OSM (other staff member) #7 (the pharmacist). OSM #7 stated it is not optimal to have missed or late medications. OSM #7 stated some medications work over such a long period of time and some medications are more critical. OSM #7 stated when some critical medications are missed or late, there could be serious adverse effects, and this depends on each person and each medication. On 6/5/25 at 2:59 p.m., ASM (administrative staff member) #1 (the administrator) was made aware of the above concern. No further information was presented prior to exit.

2. For Resident #12, the facility staff failed to administer antibiotics, Flagyl and Cipro, per the physician orders. The physician orders dated 5/20/25, documented, Ciprofloxacin HCL (hydrochloride)(1) Oral Tablet 500 MG (milligrams); Give 1 tablet by mouth one time a day related to diverticulitis of intestine, part unspecified, without perforation or abscess without bleeding for 4 days. The physician order dated, 5/21/25, documented, Flagyl Oral Tablet (2) 500 MG; Give 1 tablet by mouth three times a day related to Diverticulitis of intestine, part unspecified, without perforation or abscess without bleeding for 3 days. The May 2025 MAR (medication administration record) documented the above order. The medication was to be administered at 4:00 a.m. On 5/20/25 at 4:00 a.m. the space to sign off the medication was blank. The May 2025 MAR documented the above order. On 5/24/25 for the 10:00 a.m. and 2:00 p.m. dose, a 9 (See progress notes) was documented. There were no nurse's notes dated 5/20/25 at 4:00 a.m. that addressed the missing dose of Cipro. The nurse' note dated 5/24/25 at 3:12 p.m. documented, Order complete. A second nurse's note dated, 5/24/25 at 3:12 p.m. documented, Order complete. The comprehensive care plan dated, 5/20/25, documented in part, Focus: General Infection: the resident has an infection to the GI (gastrointestinal) system. Interventions: Administer medications as ordered. An interview was conducted with RN (registered nurse) #1, on 6/4/25 at approximately 2:00 p.m. When asked how a nurse evidences that she has administered a medication, RN #1 stated the nurse checks it off on the MAR documentation. On the MAR, you will see a check mark and initials in the block for administration. An interview was conducted with LPN (licensed practical nurse) #6 on 6/4/25 at 1:23 p.m. The above MAR was reviewed with LPN #6 regarding the Flagyl. LPN #6 stated that when she went to give the medication, there was none in the cart, so she assumed the medication had been completed as it was ordered on 5/21/15 and the three days would have been up. LPN #6 stated, That was my error, I just thought since the order was for 5/21/25, the three days was up. ASM (administrative staff member) #1, ASM #6, the regional director of clinical services and ASM #7, the regional director of operations, were made aware of the above concern on 6/5/25 at 2:49 p.m. No further information was provided prior to exit. References: 1. Ciprofloxacin is used to treat or prevent certain infections caused by bacteria such as pneumonia; gonorrhea (a sexually transmitted disease); typhoid fever (a serious infection that is common in developing countries); infectious. This information was obtained from the following website: https://medlineplus.gov/druginfo/meds/a688016.html. 2. Flagyl (Metronidazole) is used to treat infections of the reproductive system, gastrointestinal (GI) tract, skin, heart, bone, joint, lung, blood, nervous system, and other areas of the body. This information was obtained from the following website: https://medlineplus.gov/druginfo/meds/a689011.htm Based on resident interview, staff interview, facility document review and clinical record review, it was determined that the facility staff failed to follow physician orders for two of 13 residents in the survey sample, Residents #1 and #12. The findings include: 1. For Resident #1 (R1), the facility staff failed to A) initiate Fluorouracil 5% cream (1) treatment in a timely manner after the order was received from the dermatologist on 10/21/24 and B) failed to administer Debrox (2) as ordered on 1/24/25. On the most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 4/2/25, the resident scored 15 out of 15 on the BIMS (brief interview for mental status) assessment, indicating they were cognitively intact for making daily decisions. On 6/3/25 at 1:30 p.m., an interview was conducted with R1 who stated that he went to the dermatologist who had frozen a spot on his chest and when he went back for the follow up visit they had ordered a chemotherapy cream. R1 stated that when he returned to the facility and the nurses got the prescription they delayed getting the cream started saying that they needed special gloves to apply it and that they needed to move him to an isolation room while he was getting the cream. R1 stated that he did not start the cream until after he contacted the ombudsman who came to the facility and became involved. He stated that when the staff started the medication they were using regular gloves and a Q-Tip to apply the medication. R1 stated that he had multiple problems with ear wax buildup in the right ear and had problems with the nurses not completing the full treatment of Debrox as ordered by the physician. He stated that it took four months to get his ears cleaned out after multiple treatments with Debrox and flushing and he still had problems and was going to follow up with an ENT (ear, nose and throat) specialist in the future. A) A dermatology prescription dated 10/21/24 for R1 documented in part, . Use 5-fluorouracil cream on the left chest (regular gloves fine to use to apply) twice a day for 4-6 weeks, stopping for open sores, pain, or bleeding. Does not need to be quarantined when using it. It will only affect abnormal cells. Once you stop 5-fluoruracil cream, start using hydrocortisone 2.5% ointment on the left chest for 2 weeks. Qty: **1 (one) each** Refill: **0 (Zero)** The prescription documented a fax date and timestamp of 10/21/2024 5:00:17 pm. The physician orders for R1 documented in part, - Fluorouracil External Cream 5 % (Fluorouracil (Topical)) Apply to spot on left chest topically two times a day for actinic keratosis for 3 Weeks apply a thin film only on the spot. Stop for open sores, pain, or bleeding even if they develop before 3 weeks. But redness and scabbing is expected. Leave open to air. Pregnant women should avoid admin. Order Date: 10/30/2024. Start Date: 10/30/2024. The eMAR (electronic medication administration record) for R1 dated 10/1/24-10/31/24 documented in part, Fluorouracil External Cream 5 % (Fluorouracil (Topical)) Apply to spot on left chest topically two times a day for actinic keratosis for 3 Weeks apply a thin film only on the spot. Stop for open sores, pain, or bleeding even if they develop before 3 weeks. But redness and scabbing is expected. Leave open to air. Pregnant women should avoid admin. Start Date: 10/30/2024 2000 (8:00 p.m.). The eMAR documented the first dose of the medication administered to R1 on 10/30/24 at the 8:00 p.m. dose. On 6/4/25 at 3:33 p.m., an interview was conducted with LPN (licensed practical nurse) #8 who stated that she recalled that there were some discussions about the cream that was ordered for R1, and the former unit manager had discussed contacting the dermatologist to clarify whether they needed special gloves to apply it or if R1 needed isolation. She stated that when residents went out for a doctor appointments they took a binder with a consult note for them to complete with any new orders and the nurse signed off on the orders upon return. On 6/4/25 at 3:59 p.m., an interview was conducted with ASM (administrative staff member) #3, nurse practitioner who stated that they cared for R1 since November of 2024, and he was already receiving the cream to his chest at the time she came. She stated that she was not aware of any delays in starting the treatment. On 6/5/25 at 12:37 p.m., an interview was conducted with OSM (other staff member) #7, pharmacist who stated that fluorouracil cream was used for skin lesions and skin cancer. She stated that the usage was to apply sparingly just to the area being treated by the physician, wearing gloves when applying and covering loosely to contain the cream. She stated that since it was used to treat cancer some thought of it as a chemotherapy drug but if it was used appropriately there was no concern. OSM #7 stated that normal gloves were indicated when applying the cream and pregnant women should avoid coming in contact with it. She stated that they had filled the prescription and found out that it had not been used when R1 contacted her asking why his medication had not been filled. She stated that she had told R1 that it had been filled and was sent to the facility already. She stated that she found out that the former director of nursing felt that the staff needed special gloves to apply the cream and that R1 needed to be in isolation so there was a delay in starting his treatment. B) The physician orders for R1 documented in part, - Debrox Solution (Carbamide Peroxide) Instill 5 drop in both ears two times a day for cerumen impaction for 4 Days Place 5 gtts in ear canal(s). Soak x's 15 minutes. after 4days Flush with warm H20. Repeat until clear. Report any significant findings to M.D. Order Date: 01/23/2025. Start Date: 01/24/2025. The eMAR (electronic medication administration record) for R1 dated 1/1/25-1/31/25 documented the order listed above. It further documented R1 receiving the medication on 1/25/25-1/27/25. The eMAR failed to evidence administration of the Debrox solution on 1/24/25 at 6:00 a.m. and 6:00 p.m. Review of the facility provided list of house stock medications documented in part, Ear Wax Removal Drops 15ml (0.5 fl oz) (Carbamide Peroxide) Debrox Gen as being in house stock supply. On 6/4/25 at 2:17 p.m., an interview was conducted with RN (registered nurse) #1. RN #1 stated that they had a stock of over-the-counter medications kept at the facility and the nurses could pull them out to start using them when they had an order for it. RN #1 reviewed R1's eMAR dated 1/1/25-1/31/25 and stated that Debrox was a stock medication at the facility, and she was not sure why the doses were not administered on 1/24/25 but it looked like the resident did not get the full four-day treatment as ordered. She stated that if the medication was not available the nurse should have notified the nurse practitioner and gotten a hold order, changed the administration dates and times and notified the resident and the responsible party. On 6/4/25 at 3:59 p.m., an interview was conducted with ASM (administrative staff member) #3, nurse practitioner who stated that when Debrox was ordered she expected nursing staff to administer it as ordered. The facility policy Medication Orders failed to evidence guidance for following physician orders. The facility policy Medication Administration General Guidelines dated 01/23 documented in part, Medications are administered as prescribed in accordance with manufacturers' specifications, good nursing principles and practices and only persons legally authorized to do so . On 6/5/25 at 2:47 p.m., ASM #1, the administrator, ASM #6, the regional director of clinical services, ASM #7, the regional director of operations, ASM #8, the risk nurse and ASM #9, the regional human resources were made aware of the concerns. No further information was presented prior to exit. Reference: (1) Fluorouracil cream and topical solution are used to treat actinic or solar keratoses (scaly or crusted lesions [skin areas] caused by years of too much exposure to sunlight). Fluorouracil cream and topical solution are also used to treat a type of skin cancer called superficial basal cell carcinoma if usual types of treatment cannot be used. Fluorouracil is in a class of medications called antimetabolites. It works by killing fast-growing cells such as the abnormal cells in actinic keratoses and basal cell carcinoma. This information was obtained from the website: https://medlineplus.gov/druginfo/meds/a605010.html (2) Debrox (for the ears) is used to soften and loosen ear wax, making it easier to remove. This information was obtained from the website: https://www.drugs.com/mtm/debrox-otic.html

Based on staff interview and clinical record review, it was determined that the facility staff failed to review or revise the comprehensive care plan for one of 13 residents, Residents in the survey sample, Resident #11 (R11). The findings include: For R11, the facility staff failed to review or revise comprehensive care plan following a fall on 03/10/2025. R11 was admitted to the facility with diagnosis that included but was not limited to dementia (1). On the most recent comprehensive MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 05/14/2024, R11 scored 4 (four) out of 15 on the BIMS (brief interview for mental status), indicating R11 was severely impaired of cognition for making daily decisions. The facility's nursing note for R11 dated 03/10/2025 documented, Writer was informed by activities worker that resident was on floor. writer went in room with cna (certified nursing assistant). resident was lying on floor, alert and oriented, resident did not hit head, no bruising lacerations or bleeding, neuro checks in place per facility policy, resident was placed back in bed, call bell within. RP (responsible party) was left a voicemail and notified ADON (assistant director of nursing) and provider about fall, vital signs obtained per facility protocol. no new orders were given. The facility's fall investigation for R11 dated 03/10/2025 documented in part, Incident description Writer was informed by activities worker that resident was on floor. writer went in room with cna. resident was lying on floor, alert and oriented, resident did not hit head, no bruising lacerations or bleeding, neuro checks in place per facility policy, resident was placed back in bed, call bell within. RP was left a voicemail and notified ADON (assistant director of nursing) and provider about fall, vital signs obtained per facility protocol. no new orders were given. Was this incident witnessed: N (no). Injury Type: No injuries observed at time of incident. Review of R11's comprehensive care plan with a revision date of 02/05/2025 failed to evidence documentation of R11's fall on 03/23/2024. On 06/05/2025 at approximately 2:45 p.m., an interview was conducted with RN (registered nurse) #4, MDS coordinator. When asked to describe the procedure regarding a resident's care plan following a fall she stated that the care plan is review after each fall and revisions are made if they are needed. After reviewing R11's fall care plan RN #4 stated that a revision was not needed but it was reviewed. When asked for the documentation or evidence that the care plan was reviewed regarding R11's fall on 03/10/2025, she stated that there was no documentation of a review. The facility's policy Care Planning - Comprehensive Person-Centered documented in part, The Care Planning/Interdisciplinary Team is responsible for the review and updating of care plans: b. When there has been a significant change in the resident's condition; On 06/05/2025 at approximately 3:05 p.m., ASM (administrative staff member) #1, administrator, and ASM #6, director of clinical services, were made aware of the above findings. No further information was provided prior to exit. Reference: (1) A loss of brain function that occurs with certain diseases. It affects memory, thinking, language, judgment, and behavior. This information was obtained from the website: https://medlineplus.gov/ency/article/000739.htm.

2. For Resident #10 (R10), the facility staff failed to notify the resident representative the resident was vomiting and placed on contact precautions on 2/19/25. A review of R10's clinical record revealed a nurse's note dated 2/19/25 that documented the resident was placed on contact isolation precautions due to vomiting during the previous day. Further review of R10's clinical record failed to reveal the resident's representative was notified regarding this change in condition on 2/18/25 or 2/19/25. On 6/4/25 at 2:40 p.m., an interview was conducted with LPN (licensed practical nurse) #2. LPN #2 stated a resident's representative should be made aware of the resident's change in condition as soon as possible and this is evidenced by documenting a nurse's note. On 6/5/25 at 2:59 p.m., ASM (administrative staff member) #1 (the administrator) was made aware of the above concern. The facility policy titled, Change in a Resident's Condition documented, The facility will promptly notify the resident, his or her physician/practitioner, and representative of changes in the resident's medical/mental condition and/or status. No further information was presented prior to exit. Based on resident interview, staff interview, clinical record review, and facility document review, it was determined the facility staff failed to notify the physician or the responsible party of a change in condition for two of 13 residents in the survey sample, Residents #1 and #10. The findings include: 1. For Resident #1 (R1), the facility staff failed to notify the physician of complaints of burning and pain to the neck and the residents repeated request to call the on-call physician for treatment on 12/2/24. On the most recent MDS (minimum data set) assessment, a quarterly assessment with an ARD (assessment reference date) of 4/2/2025, the resident scored a 15 out of 15 on the BIMS (brief interview for mental status) assessment, indicating the resident was cognitively intact for making daily decisions. The assessment documented no behaviors. On 6/3/25 at 1:30 p.m., an interview was conducted with R1 who stated that he had an area of skin cancer on his chest that was treated with a chemotherapy cream. R1 stated that a nurse had applied the chemotherapy cream to his neck by mistake and caused a chemical burn because it was only supposed to be applied to the cancer area on the chest. R1 stated that a few weeks after that the area on the neck started burning and hurting and he had asked the evening nurse to call the on-call physician, and she had refused to call. He stated that the nurse told him that it was not an emergency and that he did not have an order for the hydrocortisone cream that he was requesting, and she would put it in the book for the nurse practitioner the next day. R1 stated that he had told her that it was an emergency to him and asked her to call the on-call doctor for an order for hydrocortisone but she stated that there was nothing on his neck and it was not an emergency. He stated that the nurse came in twice more during the night and kept telling him that there was no order for the hydrocortisone and that she was not going to call the on-call physician to get one because his neck was fine every time he asked her to call. The progress notes for R1 documented in part, - 12/02/2024 19:30 (7:30 p.m.) Note Text: Writer approached by resident to apply cream to neck (hydrocortisone cream) stating my neck is burning from my chemical burn I received over 2 weeks ago. Writer then assessed area, no visible marks were apparent to resident's neck area, no redness no swelling nor visible irritation. Writer then assessed resident active orders and notes and notified resident that per active orders and from derm (dermatology) note. Hydrocortisone is not to start until 12/12. Also, that resident and RP (responsible party) was made aware and agreeable to this order. Resident then insisted that I notify the on-provider for non-emergent request. Writer advised resident that this request would be placed in Np (nurse practitioner) communication book. Resident then stated to writer No you need to call the DON (director of nursing) and On-call now cause I have their numbers, and I will contact them, writer then replied that he could contact anyone, but as a licensed nurse and after hours I did not see nor note any emergency to notify on-call for hydrocortisone cream. Resident's vital were obtained WNL (within normal limits), resident not in any distress during any assessment, resident was assessed through entire shift, resident also made aware that if any changes were noted that appeared emergent I would notify On-call. - 12/03/2024 01:39 (1:39 a.m.) Note Text: Resident received scheduled medication as order, Vital obtained, WNL (within normal limits), no redness, irritation, nor swelling noted. Resident noted with skin area to chest as noted only. Neck area dry and intact. Will continue to monitor. - 12/03/2024 03:39 (3:39 a.m.) Note Text: Writer enters room for reassessment to neck area; resident had complaints of burning and pain to area. At this time, no redness, swelling, irritation noted to area. Resident noted in bed with eyes closed during entering of room. Resident appeared to be in no distress. No further complaints made during time since last assessment, no further request made at this time. Resident became upset and irate raising voice, when resident asked writer if I had located and read Derm not [sic] from 10/21 writer advised resident yes at this time, and that there areas that needs clarification and that this matter would be passed on to [Name of former unit manager] in the am for follow as the dermatologist office is closed at this time. 12/03/2024 07:05 (7:05 a.m.) Note Text: Writer enters resident room for medication administration, neck assessed, no irritation, no swelling, redness noted to area. Resident updated on status. Continues to state that neck has chemical burn. UM (unit manager) notified of issues and concerns. Medication administered and accepted without difficulty. VS WNL (vital signs within normal limits) at this time. - 12/03/2024 14:05 (2:05 p.m.) Note Text: Hydrocortisone External Gel 1 % Apply to neck topically as needed for as needed for neck burning for 7 Days. On 6/4/25 at 3:33 p.m., an interview was conducted with LPN (licensed practical nurse) #8 who stated that there was an on-call provider available after 7:00 p.m. each day and on weekends. She stated that the staff had a protocol that they followed for calling the on-call provider and had standing orders that they were able to implement for some things. She stated that any non-emergent issues that could wait until the next day were put in the provider book for follow up the next day. LPN #8 provided a printed paper that she stated hung at the nurse's station which contained a stop sign and contained procedures that addressed when to call the on-call provider. When asked if a resident was requesting for the on-call provider to be called due to complaints of skin burning and pain, LPN #8 stated that the nurse should call the on-call provider because it was the residents right. On 6/4/25 at 3:59 p.m., an interview was conducted with ASM (administrative staff member) #3, nurse practitioner. ASM #3 stated that she followed R1 at the facility since November 2024 but was not completely familiar with the cream he was receiving and never saw the chemical burn on his neck. She stated that she did see him on 12/3/24 when he complained of burning but it looked healthy. ASM #3 stated that she was in the facility Monday through Friday and staff could call her until 7:00 p.m. and after that they called the on-call provider. She stated that the criteria for calling the on-call provider was if a resident needed medications, had acute problems, was having shortness of breath or any new or acute symptoms. She stated that she felt it would be a case-by-case situation and R1 was insistent that he needed the Hydrocortisone for his neck, so she had prescribed it but felt that medically there was no need for it. She stated that as far as whether the nurse called the on-call provider she could not speak to that. On 6/5/25 at 11:06 a.m., an interview was conducted with LPN #5 who stated that R1 had complained of his neck burning and hurting on 12/2/24 when she was caring for him. She stated that R1 had not had any treatment to the neck for about a week and a half, so she had assessed the area and did not see any marks, so she put it in the book for the nurse practitioner to follow up the next day. She stated that R1 wanted her to call the on-call physician, but she felt that she did not need to call, and she told him that she would go in and check him every two hours to make sure the area did not change. She stated that she had called the unit manager and the director of nursing at the time, and they said they would assess his neck the next morning. The facility policy Change in a Resident's Condition documented in part, Policy: The facility will promptly notify the resident, his or her physician/practitioner, and representative of changes in the resident's medical/mental condition and/or status (e.g., changes in level of care, billing/payments, resident rights, etc.) . On 6/5/25 at 2:47 p.m., ASM #1, the administrator, ASM #6, the regional director of clinical services, ASM #7, the regional director of operations, ASM #8, the risk nurse and ASM #9, the regional human resources were made aware of the above concern. No further information was obtained prior to exit.

Based on staff interview, facility document review, and clinical record review, the facility staff failed to inform a resident/resident representative of the risks, benefits, and alternatives of medication treatment for one of 13 residents in the survey sample, Resident #10. The findings include: For Resident #10 (R10), the facility staff failed to inform the resident/resident representative of the risks, benefits, and alternatives of medication treatment for the use of the anti-anxiety medication lorazepam (used to treat anxiety). A review of R10's clinical record revealed a physician's order dated 2/12/25 for lorazepam 2mg/ml (milligrams/milliliters)- 0.25ml by mouth every four hours as needed for anxiety, sleeplessness, seizure activity or shortness of breath. Further review of R10's clinical record failed to reveal the facility staff informed the resident or the resident's representative of the risks, benefits, and alternative treatments for the use of lorazepam. On 6/5/25 at 9:25 a.m., an interview was conducted with RN (registered nurse) #1. RN #1 stated that when lorazepam is initiated, the resident and resident representative should be made aware of the targeted behaviors, side effects, black box warnings, and asked if they are aware of any alternative treatments that may work instead of the medication. On 6/5/25 at 2:59 p.m., ASM (administrative staff member) #1 (the administrator) was made aware of the above concern. The facility policy titled, Resident Rights documented, 12. The Resident has a right to be fully informed in advance about care and treatment and any changes in that care or treatment that may affect the Resident's well-being. No further information was presented prior to exit.

Based on observation, staff interview, clinical record review, and facility, it was determined that facility staff failed to provide respiratory care and services for one of 13 residents in the survey sample, Resident #5 (R5). For R5, the facility staff failed to obtain a physician's order for the use of oxygen. The findings include: R5 was admitted to the facility with diagnoses that included but were not limited to respiratory failure (1). On the most recent MDS (minimum data set), an admission assessment with an ARD (assessment reference date) of 03/23/2025, R5 scored 15 out of 15 on the BIMS (brief interview for mental status), indicating R5 was cognitively intact for making daily decisions. On 06/03/2025 at approximately 12:25 p.m. an observation revealed R5 receiving oxygen at three liters per minute by nasal cannula (2). The physician's order for R5 dated 06/03/2025 documented in part, Oxygen 3 (three) via (by) NC (nasal cannula) continuous. Order Date: 06/03/2025. Audit Details. Created Date: 06/03/2025. 1445 (2:45 p.m.). On 06/04/2025 at approximately 3:00 p.m. an interview was conducted with RN 9registered nurse) #1, unit manager. When informed of the observation of R5 receiving oxygen as stated above, RN #1 stated that there was no physician's order for R5's oxygen at the time of the surveyor's observation. No further information was provided prior to exit. References: (1) When not enough oxygen passes from your lungs into your blood. This information was obtained from the website: https://www.nlm.nih.gov/medlineplus/respiratoryfailure.html. (2) Tubing used to deliver oxygen at levels from 1 to 6 L/min. The nasal prongs of the cannula extend approx. 1 cm into each naris and are connected to a common tube, which is then connected to the oxygen source. This information was obtained from the website: http://medical-dictionary.thefreedictionary.com/nasal+cannula.

Based on observation, staff interview and facility document review, the facility staff failed to post complete nurse staffing information for three of three reviewed days. The findings include: The facility staff failed document the facility name on the daily nurse staffing sheets. Review of the facility's Nurse Staffing Data dated 06/03/2025, 06/04/2025 and 06/05/2025 sheet failed to evidence the name of the facility. On 06/05/2025 at approximately 2:40 p.m., an interview was conducted with OSM (other staff member) #6, scheduler. OSM #6 stated that she was responsible for post the nurse staffing each day. After reviewing the nurse staffing sheets as dated above she acknowledged that the sheets did not identify the name of the facility. She further stated that she was not aware that the name of the facility was required on the nurse staffing sheets. The facility's policy Posting Nurse Staffing Information it documented in part, The facility will post the following information daily, at the beginning of each shift. The posting shall include: a. The facility name. On 06/05/2025 at approximately 3:05 p.m., ASM (administrative staff member) #1, administrator, and ASM #6, director of clinical services, were made aware of the above findings. No further information was provided prior to exit.

Based on observation, staff interview, and facility document review, the facility staff failed to maintain the garbage areas in a sanitary manner for one of one trash compactor and two of ten trash bins. The findings include: The facility staff failed to ensure the door/lids on the trash compactor and two trash bins were kept closed when not in use. On 8/26/24 at 4:00 p.m., an observation of the trash compactor was conducted. The side door of the compactor was open and multiple bags of trash were observed in the compactor. On 8/27/24 at 1:52 p.m., an observation of the outside trash bins was conducted. The lids on two bins were open and multiple bags of trash were observed in the bins. On 8/27/24 at 2:43 p.m., an interview was conducted with OSM (other staff member) #2 (the regional director of maintenance) and OSM #3 (the maintenance director). OSM #2 stated the side door on the trash compactor and the lids on the trash bins should be kept closed to keep animals out. On 8/27/24 at 4:21 p.m., ASM (administrative staff member) #1 (the administrator) and ASM #2 (the director of nursing) were made aware of the above concern. The facility policy titled, Food-Related Garbage and Refuse Disposal documented, 5. Garbage and refuse containing food waste will be stored in a manner that is inaccessible to pests. No further information was presented prior to exit.

Based on observation, staff interview, and facility document review, the facility staff failed to maintain a complete infection control program and implement infection control practices for one of 50 residents in the survey sample, Resident #33. The findings include: 1. The facility staff failed to evidence infection surveillance for January 2023 through December 2023. A review of the facility infection control program for January 2023 through December 2023 failed to reveal a system of surveillance. There was only a binder containing multiple Antibiotic Timeout forms for multiple residents. On 8/28/24 at 9:16 a.m., an interview was conducted with RN (registered nurse) #4 (the infection control nurse who was not employed at the facility during 2023). RN #4 stated every day he documents all infections on a tracking log spreadsheet then color codes the infections on a floor plan of rooms so he can evaluate if there is a group of a certain infection and so he knows if there is an infection control challenge that he needs to address. RN #4 was shown the 2023 binder of antibiotic timeout forms and stated it was not possible to track and identify clusters of infections if only those forms were utilized. On 8/28/24 at 11:44 a.m , ASM (administrative staff member) #1 (the administrator) and ASM #2 (the director of nursing) were made aware of the above concern. The facility policy titled, Infection Prevention and Control Program documented, 6. Surveillance- a. Process surveillance (adherence to infection prevention and control practices) and outcome surveillance (incidence and prevalence of healthcare acquired infections) are used as measures of the IPCP (infection prevention and control program) effectiveness. b. Surveillance tools are used for recognizing the occurrence of infections, recording their number and frequency, detecting outbreaks and epidemics, monitoring employee infection, monitoring adherence to infection prevention and control practices, and detecting unusual pathogens with infection control implications. No further information was presented prior to exit. 2. For Resident #33 (R33), RN (registered nurse) #2 failed to implement infection control practices while preparing and administering medications to the resident. On 8/26/24 at 4:21 p.m., RN #2 was observed preparing medications for R33. RN #2 dropped a 100 mg (milligrams) tablet of bupropion (an antidepressant medication) on top of the medication cart then picked the tablet up with his bare hand and placed the pill in the medication cup. RN #2 placed two other pills in the medication cup then stated the tablet of bupropion was the wrong medication. RN #2 placed his finger in the medication cup to hold the two other pills in the cup while he disposed of the bupropion. RN #2 placed another medication into the medication cup then administered the medications to R33. On 8/27/24 at 3:01 p.m., an interview was conducted with LPN (licensed practical nurse) #1. LPN #1 stated that if a pill is dropped on top of the medication cart, then it should be discarded. LPN #1 stated that if there are multiple pills in a medication cup and one pill needs to be discarded, she would discard all pills and re-pour the medications or a nurse should put on gloves to remove the pill from the cup. On 8/27/24 at 4:21 p.m., ASM (administrative staff member) #1 (the administrator) and ASM #2 (the director of nursing) were made aware of the above concern and the facility did not have a specific policy regarding the above concern. No further information was presented prior to exit.

Based on observation, resident interview, facility staff interview, facility document review, and clinical record review, the facility staff failed to provide care and services in a manner to promote resident dignity for four of 50 residents in the survey sample, Residents #96, #31, #67, and #157. The findings include: 1. For Resident #96 (R96), the facility staff failed to treat him with dignity after he vomited. On the most recent MDS (minimum data set), an admission assessment dated [DATE], R96 was coded as having no cognitive impairment for making daily decisions, having scored 15 out of 15 on the BIMS (brief interview for mental status). He was coded as requiring staff assistance for ADLs (activities of daily living). On 8/26/24 at 2:46 p.m., R96 was sitting up in bed. He stated that last Saturday, 8/24/24, he woke up very early in the morning, around 6:00 a.m. LPN (licensed practical nurse) #4 was at his bedside administering a tube feeding. As LPN #4 walked away from his bed towards the bathroom, he experienced severe nausea. He called out to the nurse, then vomited a large amount. He stated he caught some of the emesis in a basin, but much of it landed on his clothing and bed linens. He stated a CNA (certified nursing assistant) came in the room, but he could not remember the CNA's name. He stated the CNA placed a clean towel over his chest, and walked out of the room, along with LPN #4. He stated no one came in to clean him up and change his bed linens until after 9:00 a.m. that morning. He stated this made him feel dirty and humiliated. A review of R96's clinical record revealed no evidence of this incident. On 8/29/24 at 7:30 a.m., LPN #4 were interviewed. She stated she remembered the morning that R96 vomited. She had worked the night shift, and was providing the resident's early morning tube feeding. She stated within about five minutes of finishing administering his tube feeding, he vomited it all back up. She stated the CNA working with her put a towel across the resident's chest, and walked out the door with her. She stated: I thought she was going to get supplies to clean him up. She stated if the resident was left dirty for several hours, the resident was not being treated with dignity. The CNA in question was not available for interview during the survey. A review of R96's care plan dated 7/12/24 revealed, in part: [R96] has an ADL self-care deficit .Physical assist as needed. On 8/29/24 at 3:40 p.m., ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing, ASM #6, the regional director of clinical operations, ASM #7, the regional director of clinical operations, and ASM #8, the regional director of operations, were informed of these concerns. A review of the facility policy, Dignity, revealed, in part: Each resident shall be cared for in a manner that promotes or enhances his or her sense of well-being, level of satisfaction with life, and feelings of self-worth and self-esteem .Residents will be treated with dignity and respect at all times. No further information was provided prior to exit. 31753 2. For Resident #31 (R31), the facility staff failed to serve lunch in a dignified manner. Other residents seated at the same table as R31 were served a meal and R31 was not served food until 11 minutes later. On 8/26/24 at 12:52 p.m., R31 was observed sitting at a table in the dining room. At this time, two other residents were observed seated at the same table and eating lunch. R31 was not served any food until 1:03 p.m. On 8/27/24 at 1:32 p.m., an interview was conducted with OSM (other staff member) #1 (the dietary manager). OSM #1 stated the dietary aides were responsible for serving meals in the dining room and everyone at the same table should be served food at the same time so no resident is just sitting there waiting. OSM #1 stated that if she was seated at a table where other residents were eating and she was not served, I would be like where is my food? On 8/27/24 at 4:21 p.m., ASM (administrative staff member) #1 (the administrator) and ASM #2 (the director of nursing) were made aware of the above concern. The facility policy titled, Food and Nutrition Services failed to document information regarding a diginified dining experience. No further information was presented prior to exit. 42106 3. For Resident #67 (R67), the facility staff failed to promote dignity on 9/30/23 during the night shift (11:00 p.m. to 7:00 a.m.), the staff failed to provide ADL (activities of daily living) assistance or assist the resident to bed. On the most recent MDS (minimum data set), a significant change assessment with an ARD (assessment reference date) of 7/3/24, R67 scored seven out of 15 on the BIMS (brief interview for mental status) assessment, indicating the resident was severely impaired for making daily decisions. The resident was assessed as being dependent on staff for toileting, personal hygiene and transfers. The quarterly MDS assessment with an ARD of 12/8/23 documented R67 scoring 15 out of 15 on the BIMS assessment, indicating they were cognitively intact for making daily decisions at that time, and being dependent on staff for toileting, personal hygiene and transfers. On 8/26/24 at 2:13 p.m., an observation was made of R67 in their room. R67 was observed in bed watching videos on an electronic device. A family member was observed sitting at R67's bedside. At that time, an interview was conducted with R67's family member who stated that on R67 had recently declined and been placed under hospice care. R67's family member stated that they had multiple concerns regarding the care that was received at the facility and stated that on 9/30/23, R67 had been left sitting up in the wheelchair all night long after returning to the facility from a leave with family. She stated that R67 had asked the staff to put them back to bed and they had not done it and the staff had told them that it was because R67 was refusing to go to bed. She stated that R67 had been left sitting in the wheelchair in soiled clothing and not assisted back to bed the entire night and not cleaned up until the day shift staff got there the next day. The progress notes for R67 documented in part, - 09/29/2023 07:50 Note Text: Resident went OOF (out of facility) this morning as per his routine, facility aware. Resident had morning meds w/o difficulty before leaving. - 09/30/2023 22:42 (10:42 p.m.) Note Text: Aide offered to put resident down after writer finished medication pass, refused 3x to go to bed and stated wanted to sit on commode for an hour before bed advised that due to pressure sore risks and skin integrity complications that this was strongly advised against. Brief on and intact, offered to help change brief, denied assistance. Passed in report that resident refused help offered to him. The progress notes for R67 failed to evidence documentation of any further attempts to provide care to R67 during the night shift on 9/30/2023 or refusal of care. Review of the ADL documentation report for R67 dated 9/1/23-9/30/23 failed to evidence any ADL care provided, transfer assistance provided, refusal of care or behaviors displayed by R67 on the night shift (11:00 p.m. to 7:00 a.m.) shift of 9/30/23. The comprehensive care plan for R67 documented in part, [Name of R67] has an ADL self-care performance deficit AEB (as evidenced by) spinal stenosis, osteoarthritis, & pain. Date Initiated: 02/01/2024. Revision on: 02/01/2024. Under Interventions it documented in part, .Physical assist as needed with ADLs. Date Initiated: 05/30/2023. Revision on: 06/14/2023 . On 8/28/24 at approximately 8:45 a.m., ASM (administrative staff member) #1, the administrator stated that the RN (registered nurse) who wrote the progress note on 9/30/23 and the CNA (certified nursing assistant) who worked on the unit that R67 resided on 9/30/23, no longer worked at the facility. On 8/29/24 at 11:20 a.m., an interview was conducted with CNA #7. CNA #7 stated that residents were rounded on every two hours to check for needs such as incontinence care, water, pain and turning and repositioning. She stated that the care that they provided to the resident was evidenced as done by their documentation in the ADLs each shift in the computer. She stated that she was not aware of any residents who would be left up in their wheelchair all night unless that was what they requested or if it was a behavior and it would be reported to the nurse and documented. She stated that when she worked with R67, they were complaint with care. On 8/30/24 at 10:00 a.m., an interview was conducted with CNA #8. CNA #8 stated that when a resident refused care, they let the nurse know and returned to the resident later with the nurse to re-attempt the care. She stated that if the resident still refused the care it was documented in the medical record in the ADLs and the nurse also documented the refusal and reported it. On 8/29/24 at approximately 3:40 p.m., ASM #1, the administrator, ASM #2, the director of nursing, ASM #6, the regional director of clinical operations, ASM #7, the regional director of clinical operations, RN #4, the assistant director of nursing and infection preventionist, and ASM #8, the regional director of operations were made aware of the concern. No further information was provided prior to exit. 27660 4. For Resident #157 (R157), the facility staff failed to treat the resident in a dignified manner, telling the resident to void in her brief. On the most recent MDS (minimum data set) assessment, an admission assessment, with an assessment reference date of 8/13/24, the resident scored an 11 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was moderately impaired for making daily decisions. In Section H - Bladder and Bowel, the resident was coded as being occasionally incontinent of urine and frequently incontinent of bowel. An interview was conducted with R157 on 8/26/24 at 3:55 p.m. When asked if the staff treat her with dignity and respect, R157 stated when she has to go to the bathroom, the staff tell her to pee in your diaper. She stated the staff tell her they are going on break and can't change her at that time. When asked how that makes her feel, R157 stated that it's embarrassing to go in the brief and makes her feel bad. R157 stated that when she has to wait and can't hold her urine any longer, she voids in the brief and many times it goes through to her clothing, so she is soaking wet. She stated that is not a good feeling to be wet. An interview was conducted with CNA (certified nursing assistant) #7 on 8/29/24 at 11:15 a.m. When asked if a resident puts on their call bell for assistance, what does she do, CNA #7 stated if she is available, she will assist the resident, if she is not available she will get someone else to assist the resident. Have you ever told or heard a staff member tell a resident to pee in their diaper, CNA #7 stated, no. CNA #7 was asked if she has ever or heard anyone tell a resident they have to wait for assistance as they are going on break, CNA #7 stated, no. ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing, ASM #6, the regional director of clinical operations, ASM #7, the regional director of clinical operations, ASM #8, the regional director of operations and RN (registered nurse) #4, the assistant director of nursing, were made aware of the above findings on 8/29/24 at 3:41 p.m. No further information was provided prior to exit.

Based on staff interview, facility document review and clinical record review, the facility staff failed to provide adequate supervision to prevent injury for one of 33 residents in the survey sample, Resident #61, resulting in harm of past non-compliance. The findings include: The facility staff failed to supervise and assist Resident #61 (R61) with breakfast on 11/2/22. The resident spilled oatmeal on themselves and was diagnosed with a second degree burn on the forearm that required treatment with silver sulfadiazine cream (1). A facility investigation concluded the burn was caused by the spilled oatmeal. On the most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 8/27/22, the resident scored 0 out of 15 on the BIMS (brief interview for mental status), indicating the resident was severely cognitively impaired for making daily decisions. Section G coded R61 as requiring extensive assistance of one staff with eating. An occupational therapy note dated 6/15/21 documented, Pt. (Patient) was self feeding when OTR/L (occupational therapy employee) arrived into room, taking tray to her mouth and trying to pour it in, getting food on lap. OTR/L provided pt. with a towel to wipe her clothing off/protect it from getting more food on it and provided her with her glasses so she could see the tray better. OTR/L loaded fork with greens and fed it to patient, again with beans/ham with a spoon and also fed it to patient. OTR/L then loaded the spoon and handed it to patient, she brought it to her mouth. Pt. then demonstrated ability to self feed multiple times with Mod (moderate) I to S/SBA (supervision/stand-by assistance). An occupational therapy discharge summary dated 7/8/21 documented, Eating= Partial/moderate assistance. R61's comprehensive care plan dated 6/13/22 documented, (R61) has an ADL (activities of daily living) self-care performance deficit. Interventions: Physical assistance as needed with ADLs. A dietary service line checklist dated 11/2/22 documented the oatmeal temperature was 145 degrees. A nurse's note dated 11/2/22 documented, Resident brought from dining room with oatmeal on [the resident's] shirt. No injuries noted at this time. Clothes changed and placed in Meaningful Life program. A nurse's note dated 11/3/22 documented, Area was observed on resident's right forearm. Area was opened, 8cm (centimeters) L (length) x 3cm W (width). Cleaned area with wound cleaner and applied Non adhesive gauze, wrapped with cling. Was informed by day shift staff that resident had spilt hot oatmeal on (the resident's) arm the day before at breakfast, contacted ADON (assistant director of nursing) that will be on unit to assess the area. Added resident to the physician binder for area to be assessed. Removed bandage. A physician's order dated 11/3/22 documented an order for silver sulfadiazine cream 1% to be applied to R61's right forearm every day. A FRI (facility reported incident) submitted to the state agency on 11/3/22 documented, On 11/03/2022, the facility staff reported that (R61) had a burn noted to her right forearm. The facility Nurse Practicianer (sic) assessed the the (sic) area, a treatment was initiated, and pain medication ordered. A note signed by the wound care nurse practitioner on 11/4/22 documented, Wound #1 Right Forearm is a Full Thickness Without Exposed Support Structures Burn and has received a status of Not Healed. Initial wound encounter measurements are 9.36 cm (centimeters) length x 3.56 cm width with no measureable depth . A nurse's note dated 11/4/22 documented, Resident left facility at 4:50pm with daughter via wheelchair. Daughter stated she was taking resident out to eat dinner. Staff received a call at 8:15pm from (name of hospital), DON (director of nursing) and ADON made aware. Hospital emergency room documentation dated 11/4/22 documented a diagnosis of a second degree (partial thickness) burn. A facility final report dated 11/9/22 documented, TIMELINE OF EVENTS: On 11/02/2022 at about 8am, (R61) was in the [NAME] dining. (R61) was served oatmeal in a bowl, cranberry juice in a plastic cup and toast and eggs on a plate by (OSM [other staff member] #9), dietary aide. While serving other residents in the dining room, (OSM #9) noticed that (R61) had spilled oatmeal on (the resident's) right arm, leg, lap and wheelchair. (OSM #9) left the dining room and went to the [NAME] unit to notify the resident's aide. (OSM#9) located (CNA [certified nursing assistant] #7), CNA and told her about the incident. (CNA #7) went to the dining room and brought (R61) back to room. (CNA #7) noted that (R61) was in the [NAME] dining room with oatmeal on mustard-colored long sleeve shirt (right arm), and the top of (the resident's) green pants (right thigh). While wheeling (R61) to room, (LPN [licensed practical nurse] #6), LPN noted oatmeal on (R61's) right side of the long-sleeved shirt. (CNA #7) informed (LPN #6) that (R61) had spilled oatmeal on self in the dining room. Per (CNA #7), she took off (R61's) shirt and did not see any redness or blisters. She wiped off (R61's) arm to remove the oatmeal that fell off arm. (R61) did not say it was hurting or acted like (the resident) was hurting. (CNA #7) changed (R61's) pants and shirt with another long-sleeved shirt. After changing (R61's) clothing, she placed (R61) at the nurses' station. Per (CNA #7), (R61) spent the rest shift with (activities employee) in activities. (LPN #6), LPN reported that (CNA #7), CNA reported no pain or injury. Numerous other staff were interviewed and none reported any signs or symptoms of pain or injury to (R61). At 730 pm on 11/2/22 (CNA #9), CNA was preparing (R61) for bed, removed the long-sleeved shirt and noted an open area on (the resident's) right arm. No c/o (complaint of) pain voiced. She completed applying (R61's) night gown and notified the assigned nurse, (LPN #4). (LPN #4) said the wound looked like it had been scraped, no blood on arm or clothing. No blisters. Resident unable to answer how it happened. At about 0630 on 11/3/22 (LPN #7), LPN who was providing care to (R61) asked (LPN #4) to look at (R61's) area again. At this point area looked much more like a defined blister. The area was cleansed and a non-adhesive dressing was placed over the open area. The Assistant Director of Nursing (ASM [administrative staff member] #3) also assessed the area of concern and noted for the physician to evaluate (R61's) arm today (11/3/22) on rounds. At about 0815 on 11/3/33 (sic) physician assistant saw resident and silver sulfadiazine cream 1% ordered, lidocaine cream (a numbing agent) ordered. Additional pain medication ordered. Family made aware. SUMMARY OF CRITICAL INFORMATION OBTAINED DURING INVESTIGATION: On 11/02/2022 (R61) spilled oatmeal on (the resident's) right arm in the [NAME] dining room. There was no immediate injury noted. By 11/3/22 the area had developed into a blister. Physician and family were notified and treatment was obtained. CONCLUSION: Upon conclusion of the facility's investigation, the facility can substantiate that (R61) received a burn to (the resident's) right forearm. Through interviews and statement, (R61) obtain (sic) the burn to forearm on 11/02/22, when (the resident) spilled oatmeal on (the resident's) arm while eating breakfast . On 11/16/22 at 7:43 a.m., a CNA was observed feeding R61 and other nursing staff were observed assisting other residents in the dining room. On 11/16/22 at 9:52 a.m., an interview was conducted with OSM #9, dietary aide. OSM #9 stated that on 11/2/22 she was serving breakfast in the dining room and she was the only employee in the room. OSM #9 stated that usually there is nursing staff present in the dining room during meals and she did not know why none were present during breakfast on 11/2/22. OSM #9 stated she served R61 breakfast then continued serving other residents. OSM #9 stated she went back to R61 and the resident had spilled oatmeal on the resident's body and wheelchair. OSM #9 stated she immediately got R61's CNA and the CNA immediately removed R61 from the dining room. On 11/16/22 at 10:38 a.m., an interview was conducted with CNA #7. CNA #7 stated R61 requires assistance with eating. CNA #7 stated R61 can feed self sandwiches and finger foods but must be physically assisted with liquids, soups and oatmeal. CNA #7 stated R61's arms are contracted and the resident can't always bring the spoon up right to the resident's mouth. CNA #7 stated R61 spills a lot of food while using utensils. CNA #7 stated she thought there was no nursing staff in the dining room during breakfast on 11/2/22 but she did not know why. CNA #7 stated that on 11/2/22, she was assisting another resident with care when OSM #9 came to her. CNA #7 stated OSM #9 told her R61 spilled oatmeal on the resident's body so she finished care with the other resident and went to the dining room to get R61. CNA #7 stated R61 had oatmeal on clothing covering the resident's right lower arm and right leg so she took R61 to the bed room and changed the resident's clothes. CNA #7 stated she did not see any redness or skin abnormalities on R61's right arm at that time. On 11/16/22 at 11:19 a.m., an interview was conducted with LPN #6. LPN #6 stated she observed R61's right forearm on 11/2/22 when CNA #7 changed R61's clothes and later during the day around 2:00 p.m. LPN #6 stated she did not see any redness or discoloration of the skin at those times. On 11/16/22 at 1:01 p.m., an interview was conducted with ASM (administrative staff member) #5, physician assistant. ASM #5 stated she was notified of R61's burn the day after the oatmeal spill (11/3/22). ASM #5 stated R61's right forearm was wrapped with soft gauze and an ace bandage. ASM #5 stated she observed R61's right forearm and there was a decent size burn. ASM #5 stated the area was a second degree burn and there clearly had been a blister because the skin was folded like when one has a popped blister. ASM #5 stated the skin color was molted pink mixed with white and there was no visualization of muscle or bone. ASM #5 stated she prescribed treatment for the burn and R61 was evaluated by the wound care nurse practitioner the following day. On 11/16/22 at 1:39 p.m., an interview was conducted with CNA #9. CNA #9 stated that on 11/2/22 around 7:30 p.m., she and a nurse was assisting R61 to bed and noticed a wound on the resident's right forearm. CNA #9 stated it looked like the skin was peeled back and the area was super red. On 11/16/22 at 2:22 p.m., an interview was conducted with LPN #4. LPN #4 stated that on 11/2/22, she helped CNA #9 assist R61 into bed and the CNA told her to look at R61's arm. LPN #4 stated the area on R61's right forearm did not look fresh and it was just red with no skin on it so she left it open to air. LPN #4 stated she thought R61 rubbed the area against something. LPN #4 stated the next morning (11/3/22), the area was more red and moist and day shift staff reported R61 spilled oatmeal on self the previous day. LPN #4 stated she called the ADON and the area was assessed by the ADON and the physician assistant. On 11/16/22 at 3:13 p.m., an interview was conducted with ASM #2, the director of nursing. ASM #2 stated nursing staff is supposed to be present in the dining room to supervise and assist residents with meals. ASM #2 stated she prefers one nurse and two CNAs to be in the dining room during meals but this varies depending on how many residents are present and how many residents need assistance. On 11/16/22 at 6:19 p.m., ASM #4, the interim administrator and ASM #2 were made aware of the above concern. The facility policy titled, Safety and Supervision of Residents documented, POLICY: Our facility strives to make the environment as free from accident hazards as possible. Resident safety and supervision and assistance to prevent accidents are facility-wide priorities. DEFINITIONS: Supervision/Adequate Supervision: refers to an intervention and means of mitigating the risk of an accident. Facilities are obligated to provide adequate supervision to prevent accidents. Adequate supervision is determined by assessing the appropriate level and number of staff required, the competency and training of the staff, and the frequency of supervision needed. This determination is based on the individual resident's assessed needs and identified hazards in the resident environment. Adequate supervision may vary from resident to resident and from time to time for the same resident. The facility policy titled, Assistance with Meals documented, Dining Room Residents: 1. Facility staff will serve resident trays and will help residents who require assistance with eating. 2. Residents who cannot feed themselves will be fed with attention to safety, comfort, and dignity. A facility action plan dated 11/4/22 with a completion date of 11/11/22 documented, ISSUE/CONCERN: 1. Resident received significant injury during breakfast .Root Cause Analysis/Related Factors- What were the reasons/related factors for the identified opportunity, risk or deficient practice? 1. Nursing staff were not in the [NAME] Dining room when incident occurred. 2. Dietary staff delivering meal trays to residents without nursing staff in the [NAME] dining room. Goals/Objectives/Expected Outcome: 1. Nursing staff will be in the dining room at all meal times on the [NAME] Unit. 2. Dietary staff will not deliver meals to residents in the [NAME] dining room until Nursing staff is present. CORRECTION: Resident assessed by PA (physician assistant) and [NAME] (sic) Sulfadiazine Cream 1%, and additional pain medication ordered. 2. Resident assessed by Wound NP (nurse practitioner) and lidocaine cream ordered for resident. 3. OT (Occupational Therapy) consult ordered for resident for clarification meal assistance. 4. Resident care plan updated for assistance with meals. 5. Residents on [NAME] Unit had a skin assessment, no injuries noted. 6. Audit of [NAME] residents' care plans for correct meal assistance/supervision. SYSTEM CHANGES: 1. The dietary will check temperature on 10 trays for correct temperatures prior to passing the trays to the residents in the dining room. 2. Dietary staff will not pass any trays to the residents in the [NAME] dining room until nursing staff are in the Dining Room. 3. Nursing Staff will be present for all meals in the Dining Room. MONITORING/QA (Quality Assurance) OVERSIGHT: Monitoring tools from Nursing and Dietary will be brought to the Morning Meeting 5 times a week to ensure compliance X 3 weeks, then weekly times 3 weeks, then monthly times 3 months. All findings will be brought to QAPI (Quality Assurance Performance Improvement) monthly . All credible evidence from the above action plan was reviewed on 11/16/22. No further information was presented prior to exit. This deficiency is cited at past non-compliance based on the acceptable action plan, no identified concerns with food temperatures, no other residents identified with burns, and observed residents received assistance with eating as applicable. REFERENCE: (1) Silver sulfadiazine is used to prevent and treat infections of second and third degree burns. This information was obtained from the website: https://medlineplus.gov/druginfo/meds/a682598.html

The facility staff failed to ensure implementation of infection control practices and precautions to prevent the spread of infection and communicable disease during an identified outbreak of a respiratory illness on one of three facility units, (Lee unit). The facility staff were observed not implementing standard and droplet precautions while providing care and services to residents, on isolation precautions for a [MEDICAL CONDITION] respiratory illness on the Lee unit. Staff and a visitor were observed entering isolation rooms without wearing a mask, gowns or gloves and not changing gloves worn while performing care, and duties in the isolation rooms. Fourteen residents, (Resident #18, #19, #20, #22, #21, #23, #4, #25, #27, #29, #28, #24 and #26) residing on the 60 bed Lee unit, exhibited respiratory symptoms requiring transfer to the hospital with admission, resulting in a situation of Immediate Jeopardy. The Findings Include: Surveyor A observations: 1. On [DATE] at 11:45 a.m., surveyors entered the facility on a 2-day complaint investigation regarding an outbreak of respiratory illness-affecting residents in the facility. During tour of the facility on the afternoon of [DATE], and [DATE], multiple observations of facility staff failing to implement Droplet Precautions for residents placed on such isolation were observed. On [DATE] at 11:45 a.m., upon entrance to the facility at the Lee Unit entrance, a sign was observed on the front door, which opened automatically. The 8 ,[DATE] inch by 11-inch sign documented in part the following: Due to reported Pneumonia on Lee Unit, We ask that you postpone your visit, We request that you help us protect the residents by not visiting Lee Unit if you, your children or any of your family members have symptoms, such as chills, fever, cough, sore throat, runny nose. It is extremely important if you been in contact with someone with a cold or these symptoms, or school aged children who may have been in contact with others having these symptoms that you do not visit as you may be carrying a common [MEDICAL CONDITION] or other viruses, which could be passed to a resident without you being aware. We will be happy assist you (sic) in contacting your loved one, by leaving a note, or making a call to them until your symptoms subside. Thank you for your assistance! Remember to observe good handwashing PRIOR to and AFTER all visits. There were three pictures of individuals beneath the writing. One depicted a woman lying with her eyes closed, blowing her nose and holding a cup. The second picture showed a woman leaning over a child touching his forehead with her left hand and a thermometer in her right hand. The third picture showed a child holding her head while a thermometer was in her mouth. There was an identical sign on the Lee Unit receptionist's desk. Observation of the other entrance (Name of facility entrance) revealed there was no signage on the entry door and no signage on the receptionist's desk located at that entrance. On [DATE] at 12:05 p.m., during the initial tour of the facility, no transmission precautions signs were noted on the first unit (Brantley Unit). There was one contact isolation sign on the door of one resident's room the unit (Grace Unit, this was not for respiratory illness) adjacent to the Lee Unit. There was no signage on the doors leading from the Grace Unit to the Lee Unit. The Lee Unit had the capacity for 60 residents and consisted of three hallways. On the nurses' station counter, there was a generic sign distributed by the Minnesota Department of Health, Minnesota Antibiotic Resistance Collaborative and APIC (Association for Professionals in Infection Control and Epidemiology that documented, Stop the spread of germs that make you and others sick! Cover your Cough, Cover your mouth and nose with tissue when you cough or sneeze or cough or sneeze into your upper sleeve, not your hands. Put your used tissue in the waste basket. Clean your Hands after coughing or sneezing. Wash hands with soap and warm water or clean with alcohol-based hand cleaner. There was no sign about the specific respiratory illness on the Lee Unit. On [DATE] at 12:26 p.m., there were 10 rooms observed on the Lee Unit with signs denoting droplet precautions. Nine of the rooms were semi private rooms with two residents and one room was a private room. Only three isolation carts were observed on the 60-bed unit, with one isolation cart on each of the three hallways. The flowing observations of isolation rooms were conducted: On [DATE] at 12:28 p.m., a Droplet Precautions sign was observed on the door of a semi-private room in which Resident #15 resided in the B bed. The door was open. No resident were observed in the room. There was an isolation cart located outside the room. The isolation cart had masks on top of the cart. There were two drawers with yellow gowns visible inside. There was no hand sanitizer and no box of gloves on top of the cart. Review of Resident #15's clinical/ record revealed a physician order [REDACTED]. On [DATE] at 12:31 p.m., a Droplet precaution sign was observed on the wall outside the door of a semiprivate room in which Resident #11 resided in the A bed. The door was open. Resident #11 was in bed eating lunch. There was no isolation cart outside the room. Review of Resident #11's clinical record revealed a physician order [REDACTED]. On [DATE] 12:32 p.m., a Droplet Precaution sign was observed on the door of a semiprivate room, in which Resident #27 resided in the B bed. The door was open and Resident #27 was sitting in a wheelchair coughing audibly while watching television. Review of Resident #27's clinical record revealed the resident was hospitalized on [DATE]. Resident #27 was readmitted to the facility, on [DATE]. A physician's orders [REDACTED].#27 was on Droplet Precautions. On [DATE] at 12:34 p.m., a Droplet Precautions sign was observed on the door of semi-private room in which Resident #9 resided in the B bed. Review of Resident #9's clinical record revealed a physician order [REDACTED]. On [DATE] at 12:36 p.m., a Droplet Precaution sign was observed on the door of room in which Resident #5 resided in the B bed. The door was open. A resident was sitting by the window, reading a book. The other resident was not in the room. Review of Resident #5's clinical record revealed a physician order [REDACTED]. On [DATE] at 12:37 p.m., a Droplet Precaution sign was observed on the door of room in which Resident #3 resided in the A bed. The door was open and a resident was observed sitting by the door in a recliner watching television. There was a mask hanging on the arm of a wheelchair in the room. There was an isolation cart at the door. A review of the chart for Resident #3 revealed the resident had orders for droplet precautions in place starting [DATE] and continuing during the time of the observations on [DATE]. On [DATE] at 12:38 p.m., a Droplet Precaution sign was observed on the door of the room in which Resident #4 resided in B bed. Review of Resident #4's clinical record revealed a physician order [REDACTED]. Surveyor B Observation: On [DATE] at 12:39 p.m., a member of laundry services was observed with a cart approximately 3 feet tall with a blue cover, the laundry staff member walked to the isolation cart outside of the room in which Resident #3 resided in the A bed. The laundry staff member retrieved gloves and a gown from the isolation cart and closed the top drawer. She then donned the gown and gloves. No hand sanitizer was used. The staff member was then observed entering the room with linen in her hands without donning a protective mask. The laundry staff member proceeded to work in the room, exit the room, and without donning a mask, replacing gloves, or performing hand hygiene, proceeded to gather clean linens off the covered clean linens cart and returned to the droplet isolation room. The staff member exited the room a second time, again without replacing any PPE (personal protective equipment), gathered more clean linens off the covered clean linen cart wearing the same gloves, and returned to the isolation room. At approximately 12:41 p.m., the staff member exited the room for a third time, now having doffed PPE, and proceeded to wheel the contaminated laundry cart further down the hall to deliver linens to other resident rooms not identified as being on isolation precautions. Surveyor A observations: On [DATE] at 12:44 p.m., the following: a stop sign and Droplet Precaution sign was observed on the door of the private room in which Resident #14 resided. The door of the room was open. There was no isolation cart located outside the room. Review of Resident #14's clinical record revealed a physician order [REDACTED]. At 12:45 p.m., a Droplet Precaution sign was observed on the door of room in which Resident #30 resided in the B bed. Review of Resident #30's clinical record revealed a physician's progress note for [DATE], which documented in part: CXR (Chest x-ray): Mild patchy by basilar densities left greater than right compatible with pneumonia. At 12:50 p.m., a Droplet Precaution sign was observed on the door of room [ROOM NUMBER]. There was no stop sign on the door. The door to the room was open. The bed closer to the door was unmade. There were no residents in the room. On [DATE], at 12:52 p.m., six residents were observed in the Lee unit activity room with the Activities Assistant. The Activities Assistant was sitting at a table with five residents participating in a coloring activity. There was one resident sitting in a wheelchair near the window. None of the residents nor the staff member were observed wearing masks. Surveyor B observation and interviews: During the course of further investigation of the complaint and after meeting with local Health District staff on [DATE] at 1:28 p.m., surveyors became aware that more than 10 residents had been sent to the hospital for respiratory illness since the outbreak, and at least 3 residents had allegedly died , since [DATE]. The local Health District Director (assigned identifier Employee F) stated they were made aware of a respiratory disease outbreak at the facility on [DATE]. Employee F stated that his office made specific recommendations to the facility to contain the spread of the respiratory illness. The recommendations included but were not limited to, cohorting residents and staff, [MEDICATION NAME] of frequently contacted surfaces, washing hands with soap and water rather than alcohol based hand sanitizer, restricting access to the Lee unit, which was the locus of the outbreak, and placing signage at all entrances to the Lee unit informing visitors of the outbreak. During this interview, (and supported by documentation provided by the facility staff), staff from the local Health District were on-site on [DATE] to obtain swab samples of ill residents, to be sent to the Centers for Disease Control and Prevention (CDC) for testing. Following this visit, Health Department staff met with Facility Staff, including Employee A, the Facility Administrator, and presented the facility staff with written recommendations of actions the facility should take to limit the spread of the outbreak. Both Employee A, the administrator and Employee F, local Health District Director, signed the letter of recommendations. According to Employee F during the same interview on [DATE], facility staff would not agree to sign the letter unless certain elements were edited, which is reflected below. The text of the letter follows: (HEALTH DISTRICT) Recommendations: Pneumonia Outbreak, (FACILITY), (MONTH) 2019 Administrative: · (FACILITY) (struck out, replaced with Lee Wing) is hereby closed to any new residents until the cessation of this outbreak. The facility may re-admit residents who are hospitalized but may not admit any residents who have not had an opportunity for exposure. · Signs shall be placed at all entrances alerting visitors that there is a pneumonia outbreak at the facility. (struck out, replaced with Lee Wing) Visitors should be encouraged to postpone their visit until the outbreak has ceased. · Ensure that First Responders/EMS (emergency medical services)/Paramedics who enter the facility are aware of the outbreak so they may take proper precautions. Surveillance and Reporting: · Maintain a line list including the resident's name, DOB (date of birth), unit, and room, as well as clinical signs and symptoms including cough, coyza, congestion, [MEDICAL CONDITION], whether a chest x-ray has been ordered and results, and any treatment or antibiotics for respiratory complaints. An example line list is provided. Line Lists must be maintained for both (FACILITY AND ADJACENT BUILDING) (struck out and replaced with Lee Wing). This line list must be updated daily and provided to (EMPLOYEE H, the health department epidemiologist) by fax at (FAX NUMBER) by 4:00p.m. daily. · Report immediately by phone any residents who are sent to the hospital with respiratory complaints and/or suspicion of pneumonia. · Maintain a line list of staff who report illness and provide that information daily. · These enhanced surveillance and reporting efforts shall be in place for at least 2 weeks following the cessation of the outbreak, and this time period may be extended to include at least 2 incubation periods if a pathogen is determined as the cause of the outbreak. Infection Control: · Standard plus droplet precautions. All staff providing direct medical care shall don a mask when working with any resident who has a respiratory illness or begins exhibiting respiratory complaints. This includes any residents who are on antibiotics for respiratory illnesses. · Staff shall utilize soap and water for hand hygiene when providing care between residents as some respiratory pathogens are resistant to alcohol-based hand sanitizers (ABHS). ABHS may be utilized in between procedures on the same resident as long as hands are not visibly soiled. Environmental Cleaning: · Bleach shall be used for enhanced environmental cleaning including all high contact surfaces. Social Distancing · Meals shall be served in resident rooms rather than the dining hall. (For Lee Wing Use Only appended to the end of this line) · Group activities shall be discontinued until this outbreak is deemed over. (this line entirely struck out) · All ill residents shall remain on isolation. Signatures follow, document then ends. The document was signed by Employee A and Employee F on [DATE]. Surveyor A interviews and observations: On [DATE] at 4:25 p.m., an interview was conducted with Employee C (the director of compliance) and Employee B (the director of nursing (DON)). Employee C stated we have spoken with (Employee F) and we are following his recommendations. When asked if any staff members had been sick with upper respiratory symptoms since this outbreak, Employee C and Employee B both replied, no. When asked if any of the employees worked on other units. Both stated the employees who worked on the Lee Unit only worked on that unit. Employee C stated the Droplet Precautions signs were posted on the doors of residents who had orders for precautions. On [DATE] at 4:54 p.m., another tour of the Lee Unit was conducted. At the nurses, station was a box of masks. There was no sign about the respiratory illness on that unit. There was a generic sign about cough and cold on the nurse's station desk. There still was no hand sanitizer on the isolation cart near Resident #15's room. There were masks, gowns and gloves in the drawers. On [DATE] at 4:55 p.m., an interview was conducted with LPN (Licensed Practical Nurse) D who stated she had received no training but was informed that some residents were on droplet precautions. LPN D stated she did not know exactly what was going on but as a nurse, she knew to wear a mask when encountering those residents. On [DATE] at 5:18 p.m., an interview was conducted with Employee J who stated she was unsure of exactly what was going on at the facility but knew residents were on Droplet Precautions. Employee J stated she did not have a medical background but was very alarmed when she observed residents on the unit who seemed obviously sick. Some had green mucous coming out of their noses, some were coughing, and others were weak and not their usual selves. Employee J stated she reported what she was seeing to the nurses but did not see anything done. Employee J stated nobody was telling her anything about what needed to be done. Employee J stated she knew of residents who had expired recently due to being ill from this respiratory problem. Employee J stated she had missed five days of work due to being sick with an upper respiratory infection. On [DATE] at 5:30 p.m., an interview was conducted with the Therapy Program Manager (Employee P) who stated he was aware of a respiratory illness on the unit. Employee P stated his staff would limit contact with those residents on Droplet Precautions and provide the services in the resident's rooms since they probably would not be able to tolerate more than ,[DATE] minutes of therapy activities at a time. On [DATE] at 9:45 a.m., tour of the Lee Unit revealed there were three rooms with Droplet Precautions signs posted on their door. The previous day there had been 10 rooms on Droplet Precautions. On [DATE] at 10:50 a.m., an interview was conducted with the Employee C, the director of compliance, who again stated there were no staff members who worked on Lee Unit as well as other units. A copy of the As worked schedule for the past month was requested again. Employee C stated the facility did not have the ability to generate an as worked schedule because the corrections would override the original schedule. On [DATE] at 11:00 a.m., an interview was conducted with the Receptionist for the Lee unit (Employee N) who stated she would ask visitors who they were visiting and if they were sick. Employee N stated she was familiar with the family members who came daily so she did not ask them every day if they were sick. Employee N stated some visitors would visit their family members regardless because they wanted to make sure everything was okay. Interviews were conducted with staff members to determine if any staff members assigned to the Lee Unit worked only on that unit as claimed by Employee C, compliance director. Two employees CNA (Certified Nursing Assistant) B and RN (Registered Nurse) C stated they worked on the Lee Unit and the other units regularly. (Note: CNA B was observed working on the Lee Unit on [DATE] and [DATE]. CNA B was observed working on the Grace Unit on [DATE] and [DATE]). On [DATE] at 12:17 p.m., RN C was interviewed while passing medications on the Grace Unit. RN C stated she also worked on the Lee Unit and that she worked between the two units regularly. RN C stated she had been sick with a sore throat and sniffles recently. Review of the Call in Report for (MONTH) 2019 revealed RN C had unpaid time off and was scheduled for the Lee Unit. The surveyors requested a list of residents who were discharged from the facility to include any who had expired at the facility since (MONTH) 1, 2019. Review of the list revealed the names of residents from the entire facility. Residents identified as being transferred to the hospital within the past month and residents residing on the Lee unit who were on droplet isolation precautions were placed in the survey sample. One of the residents listed on the discharge report as one who expired in the facility was placed in the survey sample as Resident # 38. Resident # 38 was a [AGE] year-old female admitted to the facility on [DATE] and readmitted on [DATE]. Review of the clinical record revealed documentation that Resident # 38 died in the facility on [DATE]. Review of the Nurses Notes for Resident # 38 revealed in part the following documentation: - [DATE] at 3:38 PM wheezing in bilateral upper lungs and a non- productive cough. - [DATE] at 8:59 PM-continues with non productive coughing medicated per orders for coughing with positive results, no signs of respiratory distress . - [DATE] at 9:22 PM-continues with cough and cold symptoms, non productive coughing noted, pulse ox 93% on room air, Temp 98.7, no signs of respiratory distress noted, tolerating scheduled nebulizer treatments. Review of the physician progress notes [REDACTED].>[DATE] -is being seen secondary to congested cough states she had a good day yesterday which was Mother's Day and was able to be out with her family without problems however on returning back both she and her son noted a congested cough. She does have some runny nose but feels that this is quite chronic. She denies any other respiratory symptoms. [DATE] physician progress notes [REDACTED]. She was placed on nebulizer therapy as a precaution for another otherwise fairly unremarkable lung exam. Under assessment included Diagnoses: [REDACTED]. Complications of [MEDICAL CONDITION] ([MEDICAL CONDITION]*) 15. Sudden cardiac death. [MEDICAL CONDITIONS] is a condition in which the heart's function as a pump is inadequate to meet the body's needs. On [DATE] at approximately 11:25 a.m., a housekeeping staff member (Employee M) was observed in Resident #27's room. There was a Red Stop sign notice and a Droplet Precautions sign on the door. An Isolation cart was located outside the room and there was a Housekeeping/Laundry cart near the doorway to the room. Employee M was observed spraying a substance on the bed and wiping the mattress. Employee M did not have on any PPE (Personal Protective Equipment). Employee M did not have on a gown, gloves or mask. Employee M came out of the room with linen in her hand that was removed from the room, and threw it into her cart in the doorway. When interviewed Employee M stated that, she had been employed at the facility for years. Surveyor C observation and interview: On [DATE], at approximately 11:15 a.m., this surveyor noted that Resident #4's room door had an infection control sign taped to the door and an infection control cart located across from the door. The infection control sign documented, Droplet Precautions - See Nurse before Entering. On [DATE] at approximately 11:30 a.m., this surveyor observed a guest in the room sitting beside Resident #4. The guest in Resident #4's room was not wearing a facemask, gloves or gown. A review of Resident #4's clinical record revealed a physician order [REDACTED]. On [DATE] at approximately 12:05 p.m., an interview was conducted with Resident #4's guest. Resident #4's guest was identified as the son of Resident #4. Resident #4's son was asked if he was aware that Resident #4 was on droplet precautions. Resident #4's son stated, My mother was recently readmitted to the facility from the hospital and I didn't know anything about droplet precautions. Resident #4's son was asked if anyone had spoken with him about wearing a facemask, gloves and gown while visiting in the room. Resident #4 stated, No one has told me anything about wearing a face mask, gloves or gown while in the room visiting. On [DATE] at approximately 12:30 p.m., an interview was conducted with LPN (licensed practical nurse) A. LPN A was asked about the process followed by staff for implementing droplet precautions. LPN A stated, An infection control sign is to be placed on or beside the resident's door and an isolation cart should be outside the resident's room which contains face mask, gowns, gloves and hand sanitizer. Any equipment being used on that resident is bought into the room and kept in the room until the resident is removed from isolation. LPN A was asked what staff or guest should do before entering the room of a resident on droplet precautions. LPN A stated, They need to put a face mask, gloves and gown on. They must also wash their hands or use hand sanitizer prior to entering the room. LPN A was asked if Resident #4's son was wearing a facemask, gown and gloves while in the room visiting Resident #4. LPN A stated, I personally did not see him. LPN A was made aware of the above observation of Resident #4's son not wearing a facemask, gloves or gown while in the room visiting Resident #4. LPN A stated, If I had seen him not wearing a face mask, gloves or gown, I would've informed him that he needed to put those items on. The facility policy titled, Droplet Precautions, did not document any information regarding guest consideration for droplet precautions. Surveyor B: Observations revealed there was no PPE available to visitors on the Lee unit. According the Employee B, Director of nursing and Employee C, the Compliance director the most recent resident identified as succumbing to the respiratory illness on the Lee Unit was the day of entrance on [DATE], evidencing continuation of the outbreak. This information was confirmed with the local health department. On [DATE] at 4:32p.m., the team completed the Immediate Jeopardy (IJ) sheet, the LTC (long-term care) Supervisor was contacted by phone, and a conference call was conducted with two other State Agency supervisors. It was determined the facility's failure to implement infection control practices to prevent the spread of infection and communicable disease for residents on droplet isolation created a situation the infection was likely to be transmitted to other residents residing on the Lee Unit, resulting in Immediate Jeopardy (IJ). On [DATE] at approximately 4:52p.m., the Administrator, Employee A and Director of Nursing, Employee B, were made aware of the situation and the concern for IJ. On [DATE] at 7:18p.m., the Administrator, Employee A presented an acceptable plan of correction. On [DATE] at 7:47 p.m. survey staff verified the education of current staff working on the unit through review of credible evidence of education and interviews. The surveyors verified the plan for educating oncoming staff prior to working and determined that the facility had a plan in place to address the immediacy and that staff were being educated on proper isolation and transmission-based precautions. The facility alleged in their plan of correction that all staff in the facility on all shifts would be educated by [DATE]. Surveyor A interview: On [DATE] at 7:30 p.m., an interview was conducted with the Director of Housekeeping (Employee L) who stated the expectation was that the staff should adhere to the guidelines for droplet precautions by wearing a gown, mask and gloves when in those rooms. Employee L stated she was in-service tonight. Employee L stated she was unaware of the recommendations by the Local Health Department. Employee L further stated the Housekeeping Protocols were different for other organisms. The amount of time and the type of chemicals differ for the different organisms. Surveyor B: On ,[DATE] (all shifts) and [DATE] (,[DATE] shift) the survey team verified staff education and implementation of proper isolation and transmission-based precautions and the P[NAME] through observations and interviews for each shift. Review of current identified cases revealed no new cases were identified as occurring after [DATE] and no additional hospitalization s. This was confirmed through review of the facility tracking of the outbreak, observation and with the local health department who were collaborating with the facility and the local hospital. Upon completion of verification, the IJ was abated at 6:05 a.m. on [DATE] and the facility was informed of the abatement at 2:00 p.m. on [DATE]. Upon review of the facility medical records, 14 residents residing on the Lee unit were identified as having been ill with respiratory symptoms sufficient to cause them to be admitted to the hospital and were reviewed in the survey sample. Of these, 11 were eventually, diagnosed with [REDACTED]. The resident's hospitalized residents were: Resident #42 was admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. The most recent Minimum Data Set (MDS) Assessment was an Annual Assessment with an Assessment Reference Date (ARD) of [DATE]. The Brief Interview for Mental Status (BIMS) scored Resident #42 at a 3, indicating severe impairment. Per a nursing note dated [DATE] at 10:30a.m.: Resident up this morning with assist to a wheelchair. Resident still with S/S (signs and symptoms) of cold, runny nose, and cough. Resident observed to be coughing in the dining room and was brought back to the unit for the nurse to assess. Upon assessment resident was noted to be gasping for air. She was looking around at staff members but would not acknowledge that she understood and would not follow commands. Residents skin cold, clammy, and diaphoretic (sweating). Resident skin color noted to be pale. Pulse ox obtained and was at 33% on RA (room air). Resident immediately put on O2 via oxymask (oxygen mask). Resident then became unresponsive with eyes closed. Shallow spontaneous breaths were observed and a carotid pulse was palpable, weak, and thready. Resident was moved from the wheelchair to the floor by staff and no breathing or pulse was detected. CPR (cardiopulmonary resuscitation) was started at 0852 (8:52a.m.) and 911 was called. The AED (automated external defibrillator) was attached per instructions and no shock was advised. CPR and rescue breathing continued. The rescue squad arrived and began their care at 0907(9:07a.m.). Resident left via squad at 0931(9:31a.m.), before departure squad reported a heart rate of 112 and stated that they were able to obtain a blood pressure. Report called to nurse (emergency room -ER NURSE) at (HOSPITAL) ED (emergency department). Resident sister (SISTER) made aware of resident condition and verbalizes understanding. Further review of the facility progress notes revealed that Resident #42 was transferred from the local hospital to a larger hospital for a higher level of care. Per a nursing note dated [DATE] at 2:44p.m.: Spoke with ICU (intensive care unit) nurse from (LARGER HOSPITAL) and states resident has been admitted there. Nurse states that she is stable but not conscious at this time . A CT (computed tomography) scan from the initial hospital ED revealed the following: .Right upper and lower lung base on the right infiltrates are seen. Hospital notes from the larger, second hospital revealed that Resident #42 was placed on a ventilator in the ICU, but did not regain consciousness and her neurological prognosis was very poor. Per the hospital record's Hospital Course document, Resident #42's family elected to withdraw life support on [DATE] and she passed away within about 15 minutes of extubation. Resident #18 was admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. Her most recent MDS (minimum data set) Assessment was a 30 Day Assessment with an ARD (assessment reference date) of [DATE]. The BIMS (brief interview for mental status) scored Resident #18 at 14, indicating very mild impairment. Per a Physician Note dated [DATE] at 8:26 p.m., Resident #18 was hospitalized on that date following her pulse oximetry dropping to 75% on 3L (liters) per minute of oxygen, after ambulating to the bathroom and back. Per the medical doctor note, Her oxygen was increased to 4L per minute and oximetry only increased to ,[DATE]%. She was given a