Every finding on record at Horizon Health and Rehabilitation Center

Based on interview, record review, and document review, the facility failed to ensure a resident's medical record was updated to reflect a physician established medication stop date for a psychotropic medication and a psychotropic medication verbal consent contained two witness signatures for 1 of 43 sampled residents (Resident 109). The deficient practice had the potential to result in continued administration of psychotropic medication beyond the physician established duration and lacked documented verification of informed consent for psychotropic medication use. Findings include:Resident 109 (R109) was admitted [DATE], with diagnosis including depression, and anxiety disorder.A Care Plan dated 04/18/2026, documented R109 was currently taking psychotropic medications for mood and/or behavior such as restlessness, sadness, mood changes, and irritability. A physician order dated 04/20/2026, documented Hydroxyzine Hydrochloride 25 milligram (mg) tablet, special instructions included mood and/or behavior of restlessness, every 6 hours, as needed (PRN). The order end date was documented as open-ended. A Pharmacist Consultation Report dated 04/01/2026 through 04/23/2026, documented a recommendation to evaluate R109's PRN Hydroxyzine HCl order. The rationale for the recommendation included Centers for Medicare & Medicaid Services (CMS) requirements limiting PRN non-antipsychotic psychotropic drugs to 14 days unless the prescriber documented the diagnosed specific condition treated, rationale for the extended time period, and duration of the PRN order. The consultation report documented the physician accepted the recommendation with modification, maintained the current dose, documented gradual dose reduction was not appropriate due to risk of decompensation, and established a stop date/duration of 06/07/2026. R109's medical record lacked documented evidence the Hydroxyzine HCl order was updated to reflect the physician established stop date of 06/07/2026. On 05/21/2026 at 3:30 PM, the Director of Nursing (DON), acknowledged R109's Hydroxyzine HCl order had not been updated to reflect the physician establish stop/duration date of 06/07/2026. The DON acknowledged the order stop date should have been updated in the medical record and confirmed failure to update the order could have resulted in extended administration of the medication beyond the physician-established duration. A facility policy titled Principles of Medication Management revised 04/17/2024, documented the Interdisciplinary Team will ensure that each resident's drug/medication regimen is developed, managed, monitored, and modified to promote or maintain the resident's highest practicable mental, physical, and psychosocial wellbeing. The facility should ensure medications that run the course of a specific dosage regimen, when so ordered are stopped accordingly. A Care Plan initiated 05/01/2026, documented R109 had self-care deficit with functional abilities (self-care and mobility) related to impaired mobility, impaired balance, drug-induced Parkinsonism, Anemia, depression, anxiety, neuralgia, muscle spasms, and pain. R109 required total dependence with activities of daily living. On 05/19/2026 at 9:57 AM, R109 was in bed with bilateral arms flexed at the elbows toward the head and positioned closely against the torso. Bilateral wrists were positioned outward. Observation identified limited upper extremity movement. A Minimum Data Set assessment dated [DATE], documented a Brief Interview for Mental Status score of 12, R109 was cognitively intact. A physician order dated 04/20/2026, documented Hydroxyzine Hydrochloride 25 milligram (mg) tablet, special instructions included mood and/or behavior of restlessness, every 6 hours, as needed (PRN). A physician order dated 04/20/2026, documented Citalopram 20 mg tablet, once a day. Special instructions included mood and/or behavior of sadness. A physician order dated 04/20/2026, documented Quetiapine 100 mg tablet, every 8 hours. Special instructions included mood and/or behavior of mood changes. A Consent for Psychoactive Medication dated 04/18/2026, documented verbal consent was given to use psychoactive medications. The psychotropic medication ordered was Hydroxyzine. The consent form documented only one handwritten staff signature identified as a Licensed Practical Nurse (LPN). A Consent for Psychoactive Medication dated 04/18/2026, documented verbal consent was given to use psychoactive medications. The psychotropic medication ordered was Citalopram. The consent form documented only one handwritten staff signature identified as a Licensed Practical Nurse (LPN). A Consent for Psychoactive Medication dated 04/18/2026, documented verbal consent was given to use psychoactive medications. The psychotropic medication ordered was Quetiapine. The consent form documented only one handwritten staff signature identified as a Licensed Practical Nurse (LPN). On 05/21/2026 at 3:30 PM, the Director of Nursing (DON), acknowledged R109's verbal consents for psychoactive medication use lacked the second signature required to validate the verbal consents. The DON confirmed two staff members were required to witness and sign the verbal consents and acknowledged a second staff signature should have been obtained. On 05/22/2026 at 9:30 AM, the Infection Preventionist (IP), acknowledged R109's verbal consents for the use of Hydroxyzine, Citalopram, and Quetiapine lacked the signature of a second staff witness. The IP explained two staff members should have witnessed and signed the verbal consents to ensure accuracy and adherence to facility policy requirement of two staff signatures for verbal consents. A facility policy titled Medication Management Psychotropic Drugs - Use of, revised 04/17/2025, documented a consent would have been completed for each psychotropic medication prescribed. Consents could be obtained in two ways, which included resident/patient or legal representative's given written consent or telephone consents were acceptable when the required information was discussed with the resident/patient or legal representative and documented in the chart. If a telephone consent was received, it required the signature of two witnesses.

Based on observation, interview, record review, and document review, the facility failed to ensure a resident received a shower as scheduled for 1 of 43 sampled residents (Resident 85). This deficient practice had the potential to compromise the resident's hygiene, comfort, dignity, and overall quality of life.Findings include: Resident 85 (R85) was admitted on [DATE], with diagnoses including incomplete paraplegia secondary to suspected spinal cord infarction and depression.On 05/19/2026 at 8:30 AM, R85 was observed in their room and appeared ungroomed. The resident presented with a strong, noticeable body odor consistent with infrequent bathing. The odor was detectable upon entering the room and included a sour, musty smell. R85 verbalized showers were supposed to be provided on Mondays and Thursdays but reported they had only been receiving bed baths instead.The Minimum Data Set (MDS) quarterly assessment dated [DATE] indicated R85 was dependent on staff for toileting hygiene and required substantial to maximal assistance for showers.A physician order dated 10/15/2025, documented the resident's bathing schedule as Bath/Shower on Mondays and Thursdays, 6:00 AM - 2:00 PM.A physician order dated 10/15/2025 documented the following bathing schedule: Bath/Shower on Mondays and Thursdays between 6:00 AM - 2:00 PM. The point of care history, which documents activities of daily living including resident hygiene, showed that R85 received a shower on 05/21/2026 at 9:49 AM. The record was amended by a CNA at 12:33 PM, invalidating the original entry due to wrong resident and documented a complete bed bath was performed.On 05/21/2026 at 11:35 AM, R85 reported no shower had been provided as scheduled that day. R85 reported although showers were scheduled for Mondays, on Thursdays they typically received only bed baths. The resident stated the assigned certified nursing assistant (CNA) did not provide the shower due to being unable to locate a sling for the Hoyer lift (a mechanical lifting device used to safely transfer individuals who cannot bear weight or assist with transfers).On 05/21/2026 at 11:40 AM, the CNA assigned to R85 explained a shower was not provided that morning because the resident required total assistance and a Hoyer lift, but no slings for the lifting device were available at the time. The CNA reported a bed bath would be provided instead and acknowledged that the shower should not have been documented as completed.On 05/21/2026 at 11:45 AM, during an inspection of the laundry area. A laundry services staff confirmed approximately 20 Hoyer lift slings were available for use. The staff member presented three clean, ready-for-use slings.On 05/21/2026 at 11:48 AM, the Environmental Services (EVS) manager confirmed Hoyer lift slings were available in the laundry room. The EVS Manager explained nursing staff used the slings throughout the day, after which they were sent to the laundry to be washed and stored.The point of care history from 02/01/2026 to 05/19/2026 showed R85 received only 3 showers and 12 complete bed baths out of 31 scheduled bathing opportunities (16 Mondays and 15 Thursdays). The record indicated the resident refused the shower on one occasion. All remaining entries documented as baths reflected partial bed baths.On 05/21/2026 at 2:40 PM, R85 indicated that a bed bath had been provided but not the shower they were expecting.On 05/22/2026 at 12:30 PM, the Director of Nursing (DON) indicated it was the expectation for residents to receive showers according to their scheduled bathing plan and for all services provided to be accurately documented in the medical record.The facility policy titled Activities of Daily Living, Optimal Function, dated 05/05/2023, documented the facility would provide necessary care to all residents that were unable to carry out activities of daily living on their own to ensure they maintain proper grooming and hygiene.The facility policy titled Shower/Bathing, dated 05/05/2023, stated showering and bathing promote personal hygiene and help stimulate circulation. The policy indicated staff were to provide bathing on scheduled shower days or upon resident request.

Based on interview, record review and document review, the facility failed to ensure prescribed medication was ordered timely, available, and administered, which resulted in a four-day delay in medication administration for 1 of 43 sampled residents (Resident 129). The deficient practice had the potential to result in interruption of prescribed medication therapy and adverse clinical outcomes related to delayed medication administration. Findings include:Resident 129 (R129) was admitted [DATE], with diagnoses including malignant neoplasm of prostate, acute kidney failure, and secondary malignant neoplasm of bone. R129 expired on [DATE].A physician order dated [DATE], documented Erleada (a medication used for prostate cancer treatment) 60 milligrams (mg), give 4 tablets once a day.A nursing progress note dated [DATE], documented the cancer center was contacted to refill the medication and delivery was expected on [DATE]. R129's medical record review revealed the medication was placed on hold from [DATE] through [DATE] due to medication unavailability.R129's medical record documented R129 was hospitalized from [DATE] through [DATE].An Oncology Pharmacy Delivery Ticket documented, Erleada 60 mg tablet, quantity 120. Shipped date [DATE], to arrive [DATE] via overnight service. Upon R129's return to the facility from hospitalization, a physician order dated [DATE] documented, Erleada 60 mg, give 4 tablets once a day.A Medication Administration Record for [DATE] documented the medication was not administered from [DATE] through [DATE].On [DATE] at 10:12 AM, a Licensed Practical Nurse (LPN), explained Erleada was obtained from the cancer center rather than the facility's routine pharmacy provider and delays in delivery occasionally occurred. The LPN acknowledged the medication should have been ordered prior to running out on [DATE] to ensure continued availability for R129.On [DATE] at 12:52 PM, the Assistant Director of Nursing (ADON), confirmed the medication was delivered to the facility on [DATE] and should have been available upon the resident's return to the facility from the hospital. The ADON explained staff did not locate the medication and placed another order, resulting in delayed administration. The ADON confirmed the medication was not available to be administered to the resident from [DATE] through [DATE]. The ADON acknowledged the medication should have been ordered timely, located upon the resident's return from the hospital, and administered as prescribed.A facility policy titled Mediation Management revised [DATE], documented the Interdisciplinary Team will ensure that each resident's drug/medication regimen is developed, managed, monitored, and modified to promote or maintain the resident's highest practicable mental, physical, and psychological wellbeing.

Based on observation, interviews, record review, and document review, the facility failed to ensure medication was properly secured for 1 of 43 sampled residents (Resident 11). This deficient practice had the potential to place the resident at risk for medication errors and unintended access to the medication.Findings include: Resident 11 (R11) was admitted on [DATE] with diagnoses including hyperlipidemia, solitary pulmonary nodule, bipolar disorder, and anxiety disorder.On 05/19/2026 at 3:20 PM, a medication cup with a white powdery substance was observed on R11's bedside table. R11 did not know what the white powder was or who had placed it on the bedside table. R11 reported the white powder did not belong to them. On 05/19/2026 at 3:25 PM, a Licensed Practical Nurse (LPN) reported the medication cup with the white powder found on the resident's bedside table was an antifungal medication. The LPN was unsure whether the medication should have been kept in the resident's room or why it had been left there. The LPN indicated R11 was confused and legally blind.On 05/20/2026 at 8:38 AM, the Assistant Director of Nursing (ADON), explained if a resident refused or did not take prescribed medication, the nurse must return the medication to the medication cart and document the reason the dose was not administered. The ADON confirmed medications were not to be left at the resident's bedside at any time. The ADON indicated leaving medications unattended posed a safety risk, as any resident could potentially ingest or misuse the medication by placing it in their mouth or eyes.On 05/20/2026 at 9:09 AM, the Director of Nursing (DON) indicated medications were not to be left on a resident's bedside table unless there was a specific physician's order permitting bedside medication administration. The DON clarified that such an order would only be appropriate if the residents were alert and oriented times three. The DON explained if a resident was not alert and oriented, medications must never be left at the bedside under any circumstances. The DON confirmed leaving medications unattended created a significant safety risk, including the possibility the resident may not understand how to correctly take or apply the medication, or another resident could access and ingest the medication, potentially causing harm.A physician order dated 04/24/2023, documented R11 was not permitted to self administer medications.The Care plan dated 09/07/2023 documented R11 had an alteration in vision due to a history of traumatic brain injury (TBI).On 05/22/2026, R11 medical record showed there was no evidence indicating a self medication assessment form had been completed.The facility's policy titled Bedside Storage of Medication, revised on 04/17/2024, stated a written order for bedside medication storage was required to be placed in the resident's medical record. The policy also required an assessment to determine the resident's capability to self administer medications, using a self medication assessment form to document any limitations.

Based on observation, interview, record review, and document review, the facility failed to ensure an oxygen concentrator used to administer oxygen to a resident was maintained in sanitary conditions for 1 of 43 sampled residents (Resident #56). This deficient practice had the potential to increase the resident's risk of infection, compromise respiratory hygiene, and reduce the effectiveness of the oxygen delivered.Findings include:R56 was admitted on [DATE], with diagnoses including anemia, epilepsy, diabetes, and hypertension.A physician order dated 11/30/2025 documented for Oxygen (O2) to be administered at 2 liters per minute as needed via nasal cannula to maintain O2 saturation greater than 92%. On 05/19/2026 at 8:00 AM, R56 was observed in bed receiving oxygen via nasal cannula at 2 liters per minute from an oxygen concentrator. The grille of the concentrator's air filter was visibly dusty. A sticker on the device indicated the last preventive maintenance had been performed in December 2024.On 05/20/2026 at 12:40 PM, the Director of Maintenance confirmed the observation and explained that the oxygen concentrators were rented from a contractor responsible for preventive maintenance. The Maintenance Director acknowledged the dusty air filter and grille could cause insufficient air intake, preventing the concentrator from producing quality medical-grade oxygen and should have been cleaned or replaced.The facility policy titled Electrical Safety Checks for Rental Equipment documented cleaning and filter maintenance, preventive maintenance, and manufacturer-required services of vendor-owned equipment should remain the responsibility of the contracted vendor.The facility policy titled Equipment Round General dated 02/12/2024, indicated staff should verify oxygen equipment in use, and inlet filter on oxygen concentrator should have been visually inspected and cleaned or replaced as necessary.

Based on observation, interview, and document review, the facility failed to maintain proper food storage practices in the dry storage area, and temperature control in the refrigerators. The deficient practice had the potential to compromise food safety and increase the risk of foodborne illness among residents. Findings include: On 06/10/2025 at 8:40 AM, a kitchen inspection was conducted alongside a cook, during which the following deficiencies were identified: - A refrigerator used for storing tray line salads, ham, salami, shredded and sliced cheese displayed a temperature of 42°F on its thermometer screen. However, an internal check showed temperatures ranging between 45-50°F. A bag of shredded cheese registered 50°F, while a packet of salami held at 45°F. The temperature log for June 2025 did not document any readings above 40°F, and the refrigerator lacked an internal thermometer for verification. The Kitchen Manager confirmed the recorded food temperatures. - A second refrigerator in the tray line used for storing beverages, including dairy products, displayed a temperature of 42°F, while an internal thermometer measured 50°F. A one quarter liter of whole milk recorded 42°F. This observation was confirmed by the Kitchen Manager, who also observed ice covering the condenser, acknowledging that the refrigerator required defrosting. - In the dry storage, several expired food items were found, including: A baker lane container with sugar had expiration date 02/02/2025. A baker lane container with oatmeal had expiration date 07/05/2024. A baker lane container with white rice had expiration date 08/12/2024. A baker lane container with flour had expiration date 08/12/2024. A baker lane container with brown rice did not document expiration date. On 06/10/2025 at 11:00 AM, the Kitchen Manager stated staff should have been regularly inspecting and labeling food items to ensure expired products were identified and removed in a timely manner. The facility's Food Services Plan, effective from 01/01/2022 to 01/01/2027, outlined requirements for maintaining refrigerator temperatures at 40°F, ensuring that refrigerator thermometers are functional and properly calibrated, and regularly monitoring temperatures. Additionally, the policy specified that food items must not exceed the manufacturer's use-by date.

Based on observation, interview, record review and document review, the facility failed to ensure a resident's yelling and disruptive behaviors were addressed for 1 of 26 sampled residents (Resident 55). The deficient practice deprived other residents of the right to live in a peaceful environment with comfortable noise levels permitting for a restful night's sleep. Findings include: Resident 55 (R55) R55 was admitted on [DATE] and readmitted on [DATE], with diagnoses including insomnia, anxiety disorder and major depressive disorder. On 06/10/2025 at 9:45 AM, R55 was overheard from the hallway yelling, help! help! help! A Licensed Practical Nurse (LPN1) entered R55's room. Upon leaving R55's room, the LPN indicated R55 yelled all the time. On 06/10/2025 at 9:52 AM, R55 was seated in wheelchair and reported being unhappy in the facility due to not getting along with roommate and expressed was upset over being transported to the main dining room where R55 remained all night accompanied by a nurse. R55 indicated the nurse removed the resident from the unit to allow other residents to sleep because the resident yelled constantly. R55 acknowledged yelling constantly because the resident had difficulty sleeping and did not want to take any medications for sleep. On 06/10/2025 at 10:00 AM, R55's roommate Resident 109 (R109) sat in motorized wheelchair and indicated R55 yelled constantly day and night and cussed at staff which was disturbing to R109. On 06/12/2025 in the afternoon, R55 was observed asleep and unarousable in wheelchair by the front desk. On 06/13/2025 at 9:50 AM, R109 indicated R55 yelled day and night which disrupted R109's normal sleep patterns and R109 was able to sleep yesterday afternoon because staff brought R55 to the receptionist to allow R109 to rest. R109 confirmed the nurse had to bring R55 to the main dining room on the evening of 06/09/2025 to allow other residents in the unit to sleep. R109 indicated staff were fully aware of R55's behaviors but had run out of moves because nothing worked for R55. On 06/13/2025 at 11:06 AM, Resident 58 (R58) whose room was next to R55's room indicated being bothered by R55's constant yelling and stated, I am lucky to get three hours of sleep. On 06/13/2024 at 2:33 PM, Resident 122 (R122) who resided in the room directly across from R55's, was seated in walker on the front patio. R122 indicated being bothered by R55's constant yelling and had expressed this with the staff but the resident did not know what was being done for R55. On 06/13/25 at 10:29 AM, LPN2 indicated being familiar with R55 and R109 who did not get along mostly due to R55's behaviors. According to LPN2, R109 was protective of staff and did not like it whenever R55 became verbally abusive towards staff. LPN2 indicated being aware Residents 109, 58 and 122 had expressed being bothered by R55's constant yelling and LPN2 was informed R55 needed to be removed from the room just to allow R109 to get some sleep. LPN2 indicated reporting R55's behaviors to the Assistant Director of Nursing (ADON1) and the DON but LPN2 was not aware of the leadership's plans for R55. LPN2 indicated all residents had the right to exist in a peaceful, homelike environment free from disruptive noise and R55's constant yelling was depriving other residents of peace and sleep. Review of medical record revealed R55's yelling behaviors were identified and documented by nursing staff almost daily. The medical record lacked documented evidence R55's yelling and disruptive behaviors were communicated to the psychiatric provider. On 06/13/2025 at 11:12 AM, ADON1 indicated being aware of R55's yelling behaviors which occurred frequently. ADON1 indicated being informed R55 had to be transported to the main dining room on the evening of 06/09/2025 to allow other residents to sleep. The ADON explained the facility tried room changes and one-on-one conversations but did not know what else could be done for the resident. The ADON indicated residents had the right to live in a peaceful homelike environment free from disruptive noise. On 06/13/25 at 11:32 AM, the Administrator indicated being aware of R55's yelling behaviors which affected other residents as evidenced by the night nurse needing to remove the resident from the unit on the evening of 06/09/2025 to allow other residents to sleep. According to the Administrator, the facility had tried room changes and separating R55 from other residents, but nothing seemed to work. The Administrator indicated residents had the right to live in a peaceful homelike environment free from disruptive noise. On 06/13/25 at 11:56 AM, the DON indicated being aware R55 had psychiatric diagnoses including major depressive disorder, insomnia and anxiety disorder and confirmed R55 was not on any psychotropic medications. The DON was familiar with R55's yelling and disruptive behaviors and was made aware R55's behaviors were affecting other residents particularly those who were near R55's room. The DON indicated all residents had the right to live in a peaceful, homelike environment free from disruptive noise and the DON acknowledged R55's behaviors were depriving other residents of peace and sleep. The Resident's Rights policy (undated) documented each resident had the right to a homelike atmosphere which is safe, clean with comfortable noise levels.

Based on observation, interview and document review, the facility failed to ensure residents have a right to make choices about aspects of their life in the facility which are significant to the resident for 1 of 26 sampled residents (Resident 89) and 3 unsampled residents (Residents 29, 32, and 61). The failure to accommodate the residents' preferences and choices had the potential risk to cause psychosocial distress to the residents. Findings include: The facility is located off a major street close to the downtown areas and the parking lot is combined with the neighboring hospital. The facility had a secured covered patio in the back of the facility off the Activity Room. This patio area had a covered area which is complete with misters, lights, plants, and numerous park benches to sit and enjoy the quiet peaceful outdoor air. Resident 89 (R89) was admitted to the facility on [DATE] with diagnosis of paraplegia, cellulitis, and a puncture wound with a foreign body. R89 had a Brief Interview for Mental Status (BIMS) score of 15 indicating no cognitive impairment. On 06/10/2025 in the afternoon, R89 stated would like one thing to be changed so residents would be allowed to go out and sit in the back patio area of the building. R89 asserted residents must be back in the facility by 6:00 PM or 7:00 PM. R89 affirmed during the summertime, this was when the sun was just starting to go down and the temperatures were also going down to where it was nice enough to be outside. However, the facility would not let residents stay outside past 7 PM because there was no one available after this time to chaperone the residents. During the Resident Council Meeting on 06/11/2025 in the afternoon, unsampled Resident 29 (R29) stated residents were not permitted to stay outside on the back patio of the building past 7:30 PM. Resident 32 and Resident 61 both confirmed this was in fact correct. R29 expressed the council was told residents had to go back inside the building at 7:30 PM due to a few residents using the back patio to smoke, and since smoking was not allowed in the facility, the patio was locked by 7:30 PM when Activity Staff went home. R23 asserted because of a few residents not following the rules, the rest of the residents were punished. On 06/12/2025 at 12:59 PM, the Administrator stated given the facility's location, the facility recommended the residents come back in around 7:30 PM in the summer. For safety, when it gets dark, the facility staff had the residents come inside. There were no current outdoor places for the residents to go. The outdoor patio was closed at night because there were some residents who were trying to smoke on the patio at night. The Administrator stated was not aware the resident council was inquiring about the use of the patio after the curfew times. To the Administrator's knowledge, there was one resident who wanted to try to smoke in the patio area, so the facility decided to close the patio. The Administrator was unaware if the facility had tried alternatives to closing the patio. The Administrator asserted it was important the facility did not have smoking inside the building. The Administrator acknowledged was aware a resident had complained could not access outside fresh air which did not smell of cigarette smoke. On 06/12/2025 at 2:32 PM, the Activity Director (AD) stated the time the patio closed was at 8pm. The AD acknowledged had heard from the Resident Council, residents were upset because could not utilize the patio after 8pm. After 8pm was when the sun goes down and when it gets cooler so the residents can go out to enjoy the patio. The AD was not sure who the one person was, but there were a few residents who were caught smoking on the patio before the facility closed it. The AD also acknowledged no alternatives to locking the door to the patio were tried. The AD expressed it was not fair for the non-smokers who wanted to be able to get some fresh air when it starts to get cooler later in the day in the summer. On 06/12/2025 at 2:56 PM the Director of Nursing (DON) stated the patios are closed around 8 pm. The DON clarified the facility closed the patios at 8 PM because the facility did not have anyone to supervise the patios after 8pm. The DON further clarified the patios need to be monitored for safety. The DON also acknowledged the patio gates to the outside were always locked making it a secured patio. The DON stated there were a few residents caught smoking, and the facility had to close the patio. The DON acknowledged the non-smokers had let the facility know the residents wanted to use the outdoor spaces. The DON agreed the residents who did not smoke should not be penalized for those smokers who broke the rules. The DON also acknowledged the residents did not have the ability make their own life choices at this time regarding the patio availability. On 06/12/2025 a policy restricting the residents from going out to sit in the secured patio area after 8 PM was requested. The Administrator affirmed the facility did not have a policy relating to the patio restrictions. The facility's Resident Rights document (regarding self-determination and Participation), documented the resident had a right to and the facility must promote and facilitate resident self-determination through support of resident choice, including but not limited to the resident's choice of activities, schedules, healthcare and providers of healthcare services consistent with his/her interests, and assessments and plans of care. The resident had the right to make choices about aspects of his or her life in the facility that are significant to the resident.

Based on observation, interview, record review, and document review, the facility failed to review and follow up on a Preadmission Screening and Resident Review (PASRR) level 2, following a resident's psychiatric hospitalization for 1 of 26 sampled residents (Resident #57), and failed to ensure referrals for PASRR level 2 screening were completed for 4 of 26 sampled residents (Residents #121, 64, 55, and 67). The deficient practice had the potential to delay necessary specialized services and interventions for the residents, and could have impacted their placement, overall care and well-being.Findings include:A Preadmission Screening and Resident Review (PASRR) is a federally mandated process that ensures individuals with mental disorders or intellectual and developmental disabilities are not inappropriately placed in nursing facilities for long-term care, and it helps determine the most suitable and least restrictive setting, ensuring access to necessary services and supports. The facility's PASRR documentation policy dated 06/09/2023, indicated referrals were required for Level II residents or individuals with newly identified mental health or intellectual disabilities following a significant change in status. The policy documented the facility was expected to promptly notify the state-designated authority in such cases. Residents readmitted after psychiatric hospitalization or displaying new behavioral symptoms were to be referred for evaluation. Resident #57 (R57)R57 was originally admitted on [DATE], and re-admitted on [DATE], with diagnoses including intraparenchymal hemorrhage, status post craniotomy, anxiety, depression and agitation.The Minimum Data Set (MDS) quarterly assessment (MDS is a standardized assessment tool used in nursing homes and skilled nursing facilities to collect comprehensive information about residents' health and functional status) dated 02/04/2025, revealed neurological diagnoses included hemiplegia and seizure disorder, and psychiatric diagnoses included anxiety and bipolar disorder.In the MDS discharge assessment dated [DATE], neurological diagnoses included hemiplegia and seizure disorder, and psychiatric diagnoses included anxiety and bipolar disorder.A nursing progress note dated 04/08/2025, revealed R57 expressed feelings of depression, citing not seeing their children and their recent birthday as contributing factors. R57 communicated a desire to harm themself, which was reaffirmed upon subsequent assessment and redirection efforts were unsuccessful, leading to arrangements for hospital evaluation and treatment via legal hold (a situation where an individual is placed under involuntary psychiatric care due to concerns about their safety) for medical and psychiatric clearance.A hospital admission document dated 04/16/2024, revealed R57 was admitted to emergency department (ED) complaining of being suicidal with a plan to cut the wrists. Working diagnosis included suicidal ideation and schizoaffective disorder. The criteria for admission revealed behavioral health condition, symptom or finding for which observation care had failed, or was not considered appropriate. The hospital Discharge summary dated [DATE], documented R57's admission following an acute bipolar exacerbation, characterized by severe mood disturbances, suicidal ideation, and emotional distress. Prior to hospitalization, R57 reported feelings of hopelessness, expressed a plan for self-harm, and experienced worsening symptoms despite attempts at coping. The discharge summary indicated that due to the severity of their condition, R57 was medically cleared, placed on a legal hold, and admitted to the psychiatric unit for further treatment. Upon discharge, diagnoses included post-traumatic stress disorder. R57 was re-admitted to the facility on [DATE] at 11:30 PM, following hospitalization for an acute exacerbation of bipolar disorder and post-traumatic stress disorder, marked by suicidal ideation, depressed mood, racing thoughts, and flight of ideas. A Psychiatric evaluation dated 04/18/2025, documented R57 was recently hospitalized due to moderately worsening symptoms of severe depression and suicidal ideation with plan to self-inflict injuries. Baseline care plan dated 04/20/2025, documented R57 was re-admitted following an acute hospitalization due to depressed mood and suicidal ideation, resulting in a legal hold. Care approaches included implementation of PASRR recommendations to address mental health needs.The medical record lacked documented evidence a PASRR Level 2 evaluation was conducted after R57's return to the facility, despite R57's acute change in condition. The previous PASSR Level 1 screening dated 05/03/2021, determined R57 had no mental illness, intellectual disability, or related condition. This PASRRA 1 screening was no longer an accurate assessment for R57's current mental health conditions given their recent psychiatric hospitalization and legal hold. On 06/12/2025 at 1:00 PM, the MDS Coordinator explained the diagnoses documented in the MDS assessment were derived not only from the discharge summary but also from the attending physician's history, physical examination, medication administration records, and progress notes. The MDS Coordinator acknowledged unfamiliarity with the criteria for PASRR Level 2 screening, stating that such inquiries would typically be addressed by the Social Worker who was recently hired and may not be aware of the screening process for PASRR level 2. The MDS Coordinator confirmed the last quarterly MDS assessment did not include the new diagnoses of PTSD documented in the hospital discharge summary and the severe depression documented in the post hospitalization psychiatric evaluation conducted on 04/18/2025.Following a review of the agency's website responsible for conducting PASRR screenings, the MDS Coordinator identified a PASRR Level 2 determination dated 04/23/2025. Upon verification, the MDS Coordinator confirmed this screening result was not incorporated into R57's medical records and affected the accuracy of the last MDS assessment, preventing the development of a comprehensive care plan to address R57's updated conditions.The PASRR screening level 2 dated 04/23/2025, which had been referred by the hospital on [DATE], revealed R57 met the criteria to be admitted in a nursing facility level of service and may be admitted if the facility was able to provide or arrange specialized services including individual and family psychotherapy, psychiatric follow ups, monitoring and advocacy services.Resident #121 (R121)Resident #121 was admitted on [DATE] with diagnoses including anxiety.The MDS initial assessment indicated R121 had psychiatric diagnoses including anxiety, depression, and bipolar disorder.The history and physical dated 03/31/2025 documented only anxiety as a psychiatric diagnosis.The hospital Discharge summary dated [DATE] listed anxiety as one of the discharge diagnoses, with no mention of other psychiatric conditions.A psychiatric evaluation dated 04/03/2025 identified bipolar disorder, which was not present at the time of admission.R121's medical record lacked documented evidence that a PASRR Level 2 evaluation was conducted upon the emergence of the new psychiatric diagnosis.On 06/12/2025 at 2:32 PM, the facility's Administrator explained the former Social Worker retired in February 2025, and the substitute was on leave. As a result, the facility hired a new Social Worker, who was still undergoing training and was not familiar with the PASRR screening process. The Administrator acknowledged gaps in Social Worker services may have impacted the PASRR process and care planning, potentially affecting timely assessments and specialized service coordination. Resident 64 (R64)R64 was admitted on [DATE], with diagnoses including schizoaffective disorder.A PASRR Level One dated 08/20/2025 documented no mental illness, no intellectual disability, no related condition, and no dementia.The Quarterly Minimum Data Set, dated [DATE], documented R64 had active diagnoses including anxiety disorder and schizophrenia.R64's medical record lacked documented evidence R64 was referred for a new level of care (LOC) assessment after being admitted with diagnoses including schizoaffective disorder.On 06/13/2025 at 8:40 AM, the Assistant Director of Nursing (ADON) confirmed R64's diagnosis of schizoaffective disorder and use of psychotropic medications; however, no PASRR Level Two or referral was in place. The ADON explained responsibility for PASRR belonged to Social Services, but the department head was unavailable due to a family emergency.On 06/13/2025 at 8:45 AM, the Social Services Assistant indicated the Social Services Director was responsible for PASRR, expressed no knowledge of the process, and confirmed no PASRR Level Two or referral was in place. Resident 55 (R55)R55 was admitted on [DATE] and readmitted on [DATE], with diagnoses including insomnia, anxiety disorder and major depressive disorder. R55's PASRR level one dated 04/26/2022, revealed R55 did not have mental illness, mental retardation, related condition or dementia. The medical record lacked documented evidence R55 was referred for a new level of care (LOC) assessment after being admitted with diagnoses including major depressive disorder, anxiety disorder and insomnia. On 06/13/2025 in the afternoon, the DON reviewed R55's PASSR level one and indicated R55 should have been referred for a new LOC assessment or a PASSR level two due to psychiatric diagnoses being identified after completion of PASSR level one on 04/26/2022. Resident 67 (R67)R67 was admitted to the facility on [DATE], with diagnoses including diffuse traumatic brain injury, bipolar disorder, anxiety disorder, and unspecified dementia. R67 had a Brief Interview for Mental Status (BIMS) score of three indicating severe cognitive impairment.On 06/10/2025 in the afternoon, R67 stated had been at the facility for four days. The resident felt the facility overall was a decent place to reside. Although, the resident seemed confused as the resident thought were living in the Falls Housing Community off interstate five in California. A PASARR level one document dated 10/28/2021, revealed R67 did not have dementia, mental illness (MI), intellectual disability (ID), mental retardation (MR), or any related condition (RC) and was deemed appropriate for nursing facility placement. R67's medical record revealed traumatic brain injury was diagnosed on [DATE], bipolar disorder was diagnosed on [DATE], anxiety disorder was diagnosed on [DATE], and R67's unspecified dementia was diagnosed on [DATE].The medical record lacked documented evidence R67 was referred for a PASARR level two screening. On 06/11/2025 in the afternoon, the Medical Records Staff, Minimum Data Set (MDS) Staff, and Social Services staff indicated there were no other PASSAR information available for R67 which indicated a PASSAR II referral had been sent since the resident's original admission of 04/24/2023.The facility's policy titled PASARR Documentation Policy, documented any resident with newly evident or possible serious mental disorder, intellectual disorder, or a related condition must be referred by the facility to the appropriate state-designated mental health or intellectual disability authority for review.The Division of Health Care Financing and Policy- Medicaid Services Manual- for Nursing Facilities Policy dated 05/01/2015, documented when an individual has been identified with possible indicators of mental illness, intellectual disabilities or related condition, a PASARR Level II screening must be completed to evaluate the individual and determine if nursing facility services and/or specialized services are needed and can be provided in the nursing facility. Examples include: a resident who exhibits behavioral, psychiatric, or mood related symptoms suggesting a presence of a mental disorder (where dementia is not the primary diagnoses), or an intellectual disability or related condition was not previously identified and evaluated through PASARR. Social services would be responsible for keeping track of each resident's PASARR screening status and referring to appropriate authority.

Based on record review, interview, and document review, the facility failed to develop and implement a comprehensive care for post-traumatic stress disorder (PTSD) reflecting a resident's new mental health conditions and following a new Preadmission Screening and Resident Review (PASRR) Level 2 screening determination for 1 of 26 sampled residents (Resident #57). The deficient practice had the potential to compromise the resident's mental health management, leading to inadequate treatment, delayed interventions, and a lack of necessary support services. Findings include: A Preadmission Screening and Resident Review (PASRR) is a federally mandated process that ensures individuals with mental disorders or intellectual and developmental disabilities are not inappropriately placed in nursing facilities for long-term care, and it helps determine the most suitable and least restrictive setting, ensuring access to necessary services and supports. Resident #57 (R57) R57 was originally admitted on [DATE], and re-admitted on [DATE], with diagnoses including intraparenchymal hemorrhage, status post craniotomy, anxiety, depression and agitation. The Minimum Data Set (MDS) quarterly assessment (MDS is a standardized assessment tool used in nursing homes and skilled nursing facilities to collect comprehensive information about residents' health and functional status) dated 02/04/2025, revealed neurological diagnoses included hemiplegia and seizure disorder, and psychiatric diagnoses included anxiety and bipolar disorder. A nursing progress note dated 04/08/2025, revealed R57 expressed feelings of depression, citing not seeing their children and their recent birthday as contributing factors. R57 communicated a desire to harm themself, which was reaffirmed upon subsequent assessment and redirection efforts were unsuccessful, leading to arrangements for hospital evaluation and treatment via legal hold (a situation where an individual is placed under involuntary psychiatric care due to concerns about their safety) for medical and psychiatric clearance. In the MDS discharge assessment dated [DATE], neurological diagnoses included hemiplegia and seizure disorder, and psychiatric diagnoses included anxiety and bipolar disorder. A hospital admission document dated 04/16/2024, revealed R57 was admitted to emergency department (ED) complaining of being suicidal with a plan to cut the wrists. Working diagnosis included suicidal ideation and schizoaffective disorder. The criteria for admission revealed behavioral health condition, symptom, or finding for which observation care had failed, or was not considered appropriate. The hospital Discharge summary dated [DATE], documented R57's admission following an acute bipolar exacerbation, characterized by severe mood disturbances, suicidal ideation, and emotional distress. Prior to hospitalization, R57 reported feelings of hopelessness, expressed a plan for self-harm, and experienced worsening symptoms despite attempts at coping. The discharge summary indicated that due to the severity of their condition, R57 was medically cleared, placed on a legal hold, and admitted to the psychiatric unit for further treatment. Upon discharge, diagnoses included post-traumatic stress disorder (PTSD). R57 was re-admitted to the facility on [DATE] at 11:30 PM, following hospitalization for an acute exacerbation of bipolar disorder and post-traumatic stress disorder, marked by suicidal ideation, depressed mood, racing thoughts, and flight of ideas. A Psychiatric evaluation dated 04/18/2025, R57 was recently hospitalized due to moderately worsening symptoms of severe depression and suicidal ideation with plan to self-inflict injuries. Baseline care plan dated 04/20/2025, documented R57 was re-admitted following an acute hospitalization due to depressed mood and suicidal ideation, resulting in a legal hold. Care approaches included implementation of PASRR recommendations to address mental health needs. The medical record lacked documented evidence a comprehensive care plan to manage and care for PTSD was developed and implemented. The medical record lacked documented evidence a PASRR Level 2 evaluation was conducted after their return to the facility, despite R57's acute change in condition. The previous PASSR Level 1 screening dated 05/03/2021, determined R57 had no mental illness, intellectual disability, or related condition. This PASRRA 1 screening was no longer an accurate assessment for R57 current mental health conditions given their recent psychiatric hospitalization and legal hold. On 06/12/2025 at 1:00 PM, the MDS Coordinator explained the diagnoses documented in the MDS assessment were derived not only from the discharge summary but also from the attending physician's history, physical examination, medication administration records, and progress notes. The MDS Coordinator acknowledged unfamiliarity with the criteria for PASRR Level 2 screening, stating that such inquiries would typically be addressed by the Social Worker who was recently hired and could probably not be aware of the screening process for PASRR level 2. The MDS Coordinator confirmed the last quarterly MDS assessment did not include the new diagnoses of PTSD documented in the hospital discharge summary and the severe depression documented in the post hospitalization psychiatric evaluation conducted on 04/18/2025. Following a review of the agency's website responsible for conducting PASRR screenings, the MDS Coordinator identified a PASRR Level 2 determination dated 04/23/2025, which had been referred by the hospital on [DATE]. Upon verification, the MDS Coordinator confirmed this screening result was not incorporated into R57's medical records and affected the accuracy of the last MDS assessment, preventing the development of a comprehensive care plan to address R57's updated conditions. The PASRR screening level 2 dated 04/23/2025, revealed R57 met the criteria to be admitted in a nursing facility level of service and may be admitted if the facility was able to provide or arrange specialized services including individual and family psychotherapy, psychiatric follow ups, monitoring and advocacy services.

Based on observation, interview, record review, and document review, the facility failed to ensure a new skin impairment was communicated to the wound care team in accordance with facility protocol for 1 of 26 sampled residents (Resident 118). This deficiency placed the resident at risk for wound complication. Findings include: Resident 118 (R118) R118 was admitted to the facility on [DATE], with diagnoses including acute and chronic respiratory failure with hypercapnia and ingrown nail. On 06/10/2025 at 8:38 AM, R118 laid in bed with feet exposed. A blackened area was observed on the tip of R118's right great toe. R118 explained the podiatrist had tried to remove R118's ingrown nail on 06/03/2025 but had to stop when R118 complained of pain. R118 indicated not knowing what the blackened area on the toe was and had communicated the concern to multiple staff but the resident had not heard back from anyone. A physician's order dated 03/28/2025 documented a consultation with Podiatry. A podiatry consult dated 06/03/2025, revealed R118 was seen by the podiatrist and was treated for thick, yellow toenails. Treatment included mycotic toenail debridement, trimming of long, thin, colorless nails, and simple nail trimming. On 06/12/2025 at 01:07 PM, the Wound Care Nurse reported being aware the podiatrist had attempted to remove the ingrown nail on the right great toe on 06/03/2025, but the provider had to stop when R118 expressed pain. The Wound Care Nurse reported evaluating R118's right great toe and described the blackened area as dried blood versus necrotic tissue which was painful when touched. The wound care nurse confirmed being told by R118 the concern had been communicated to multiple staff however no one had reported the skin issue to the wound care team. On 06/12/25 at 01:28 PM, R118 laid in bed with feet exposed. The Wound Care Nurse was present when R118 repeated having told multiple staff of the toe discoloration and pain, but no one had gotten back to R118 regarding the concern. The Wound Care Nurse indicated the toe discoloration and pain were considered abnormal findings and expected nursing staff to notify the wound care team of new skin impairment or complication immediately. On 06/12/2025 at 01:28 PM, the Certified Nursing Assistant (CNA) verbalized being assigned to R118 on 06/11/2025 and 06/12/2025. The CNA indicated noticing the blackened area on the right toe 06/11/2025 and reported it to the licensed Practical Nurse (LPN) on duty who said would check on it, but the CNA did not know if the LPN had done so. The CNA indicated expecting the nurse to contact the physician or the wound care team if R118 had a skin impairment. On 06/12/2025 at 01:31 PM, the (LPN) indicated having been assigned to R118 last week, but LPN did not notice R118's discolored toe until today. The LPN reported attempting to apply socks on R118's right foot this morning, but R118 refused, stating the toes were tender. The LPN indicated the LPN to whom the CNAs reported the discolored toe on 06/11/2025 should have reported it to the wound care team. On 06/12/25 at 01:43 PM, the Wound Care Nurse indicated expecting nurses to report skin impairments immediately to avoid delays in appropriate interventions. The Wound Care Nurse stated it was difficult to determine how long the delay in reporting was and stated delay in communication meant a delay in proper interventions which placed R118 at risk for infection and worsening pain. On 06/12/25 at 01:49 PM, the Assistant Director of Nursing (ADON) indicated the CNAs' form called STOP and WATCH, the CNAs filled out whenever a change in condition was identified. According to the ADON, the purpose of the form was so CNAs could protect themselves in case the nurse they reported the abnormal finding to, forgot to address the reported change of condition. The ADON confirmed the CNA who identified R118's discolored toe with pain on 06/11/2025, failed to complete a Stop and Watch form for R118. The ADON indicated expecting CNAs to inform nurses of new skin impairments immediately, and nurses were expected to communicate with the wound care team for timely interventions. The ADON stated delays in communication translate to delays in intervention, which place the resident at risk for infection and pain. On 06/13/2025 at 10:39 AM, the wound care physician was inside R118's room and described the blackened area on R118's right great toe as hyper-granulation tissue or a scab and not dried blood. The physician indicated being aware the podiatrist performed an ingrown nail removal on 06/03/2025 wherein only a portion of the ingrown nail was removed due to R118's complaints of pain. The physician reported the wound care team was informed of R118's discoloration of the toe and reports of pain on 06/12/2025 and indicated expecting nurses to notify the wound care team sooner to prevent wound complications. The physician indicated after the wound care team was notified of R118's skin issues, infectious disease was involved, and prophylactic antibiotic had been ordered. The wound physician verbalized a delay in communication meant a delay in proper interventions and placed the resident at risk for complications such as infection and worsening pain. The facility policy titled Wound Care: Skin Checks, revised July 1, 2015, documented CNA would perform skin checks daily, as this allows for earlier identification and intervention. The facility policy titled Wound Care, Licensed Nurse Skin Checks, revised July 1, 2015, documented all residents will have a thorough weekly skin evaluation performed by a licensed nurse.

Based on observation, interview, record review, and document review, the facility failed to ensure interventions were implemented to identify hazards and risks associated with smoking, and residents who smoked were adequately monitored or supervised for 2 of 16 sampled residents (Residents 91 and 99), and 1 unsampled resident (Resident 97), identified as smokers. This deficient practice had the potential to result in fire hazards and compromise the safety and well-being of the residents, staff, and others in the facility.Findings include:A facility policy titled Smoking Regulation, revised 11/01/2017, documented the facility was highly encouraged to maintain a smoke-free environment. If the facility chose not to remain smoke-free, facility leadership was required to establish an appropriate and safe environment for smoking to reduce the risk to residents who smoked, minimize exposure to secondhand smoke for others, and reduce the risk of fire. Smoking without direct supervision was not permitted. Possession of smoking materials (lighters, matches, cigarettes, etc.) in resident rooms or on the person was prohibited. When smoking was permitted during a resident stay, facility staff were required to receive and safeguard all smoking materials.Resident 91 (R91)R91 was admitted on [DATE], with diagnoses including chronic obstructive pulmonary disease and heart failure.On 06/10/2025 at 3:00 PM, R91 reported being a smoker and acknowledged keeping a lighter in a pants pocket while the roommate's Oxygen (O2) was on, in close proximity. R91 indicated being wheelchair-bound, able to propel self, smoked outside near a tree within the facility premises, did not require staff assistance, and was not supervised during smoking. R91 reported running out of cigarettes for a few days and indicated a sister would be bringing more.The Observation Detail List report dated 05/12/2025, documented R91 as a chain smoker.A document titled Smoking Residents, listed R91 as a smoker.A final written warning for violation of the no-smoking policy dated 05/202/2025, documented it was acknowledged and signed by R91.On 06/10/2025 at 3:15 PM, the Assistant Director of Nursing (DON) indicated R91 was alert, oriented, and identified as a smoker. The Assistant Director of Nursing (ADON) confirmed possession of a lighter in R91's pants pocket. The ADON retrieved the lighter and provided education regarding the non-smoking policy. The ADON indicated a smoking assessment was completed and a care plan developed. On 06/12/2025 at 11:01 AM, a Licensed Practical Nurse (LPN) explained a smoking assessment and inventory of smoking materials were completed upon admission of residents who smoked. The LPN was uncertain about the current smoking policy but indicated a transition was underway toward establishing a designated smoking area with assigned staff. The LPN acknowledged inconsistent enforcement of the non-smoking policy and indicated R91 was non-compliant despite repeated counseling. The LPN had not personally observed R91 smoking but confirmed frequent smoking behavior. The LPN expressed the physician notification and education attempts were made but hindered by unclear enforcement protocols regarding smoking.On 06/12/2025 at 11:20 AM, the ADON indicated assessments and inventories were completed at admission. The ADON indicated facility was identified as non-smoking, with plans to establish a designated smoking area and staff monitoring. The ADON reported R91 was non-compliant, continued smoking, and refused nicotine patches. The ADON indicated the physician and social services were aware, but discharge was delayed due to social worker turnover. The ADON explained the issue had been ongoing since having been discussed during Quality Assurance and Performance Improvement (QAPI) meetings and thirty-day discharge notices had been issued to non-compliant residents. The ADON indicated despite confiscation efforts, residents continued obtaining smoking supplies. The ADON described the issue as a daily challenge with ineffective interventions and inconsistent enforcement. The ADON confirmed the residents who smoked outside were not monitored.On 06/12/2025 at 11:39 AM, the Social Services Assistant (SSA) confirmed no active discharge plan for R91 related to non-compliance with smoking. The SSA indicated R91 had signed a no-smoking agreement upon admission and the leadership had discussed transitioning R91 to a smoking-permitted facility. The SSA explained additional personnel were assigned to redirect smokers, but monitoring and education efforts had not resolved the issue. The SSA indicated the residents were frequently observed smoking at the entrance with approximately 10 smokers daily on different times. The SSA indicated the issue had persisted since the previous year, and family members had voiced concerns regarding secondhand smoke exposure at the entrance. The SSA indicated despite consistent confiscation and patch offerings, residents refused interventions. On 06/12/2025 in the afternoon, a Certified Nursing Assistant (CNA) in Unit 2 indicated the facility was a non-smoking facility. The CNA indicated the residents continued to smoke near the entrance and in the parking area and were not monitored. The CNA indicated smoking materials were confiscated during the week of survey.On 06/13/2025 at 7:32 AM, another CNA indicated R91 was non-compliant and had previously stored smoking supplies in the bedside drawer. During inspection, no smoking supplies were found, however a cigarette butt was observed on the bedside table. The CNA confirmed the observation.On 06/13/2025 at 8:05 AM, the ADON inspected R91's wheelchair at the facility front entrance and found three lighters and four packages of matchsticks. R91 became visibly upset, denied having cigarettes, and propelled the wheelchair toward the tree.R15 was admitted on [DATE] and readmitted on [DATE], with diagnoses including chronic kidney disease, diabetes mellitus, and muscle weakness.On 06/13/2025 at 7:40 AM, R15, who was R91's roommate, was alert, oriented, and verbally responsive. R15 confirmed R91 was a known smoker with supplies brought in by family. R15 indicated smoking did not occur inside the room, but cigarettes were finished near the facility entrance. R15 reported the outdoor patio had been closed four to five months earlier due to suspected inappropriate activity.Resident 97 (R97)R97 was admitted on [DATE], with diagnoses including nicotine dependence, cognitive communication deficit, Parkinson's disease, bipolar disorder with psychotic features, and hypertension.On 06/13/2025 at 7:15 AM, R97 and another resident were observed smoking in the parking lot without staff supervision. No staff were present in proximity.On 06/13/2025 at 7:25 AM, a Hospitality Aide (HA) assisted R97 back into the facility and confirmed R97 had been smoking earlier. The HA explained two HAs were assigned to monitor smoking supplies and inspect rooms of known smokers. The HA reported families brought smoking materials to the residents. An inspection of R97's room found no lighters or cigarettes.On 06/13/2025 at 7:30 AM, R97 was seated in a wheelchair at the room door and confirmed smoking in the parking lot. R97 reported receiving the cigarette from a friend and had no smoking supplies. R97's breath smelled of smoke.On 06/13/2025 at 7:32 AM, the CNA assigned to R97 indicated the facility transitioned from smoking to non-smoking status in recent years. The CNA indicated the residents were not permitted to keep smoking supplies. The CNA indicated the leadership had conducted inspections earlier in the week, but families continued to bring supplies. The CNA reported R97 borrowed cigarettes. On 06/13/2025 at 8:00 AM, the ADON and HA accompanied the surveyor to the front of the facility. The HA confirmed observing R97 smoking in the parking lot, approximately 25 feet from the entrance. The ADON explained the residents were not allowed to smoke on facility's premises. The ADON explained smoking commonly occurred near a tree 50 to 60 feet from the entrance, outside facility property. The ADON confirmed R97 violated rules by smoking within the parking lot.On 06/11/2025 in the morning, four residents attended the resident council meeting. Residents indicated awareness the facility was a non-smoking facility but reported the presence of active smokers.Resident 29, who served as the Resident Council President, indicated the side yard patio near the activities room had restricted access due to previous misuse for smoking, despite the facility-wide smoking prohibition. The patio was locked by 7:30 PM. Resident 29 stated staff had explained supervision could not be provided for residents who insisted on smoking outside facility premises, but the no-smoking rule could be enforced within the premises. Residents reported awareness active smokers smoked outside the front entrance of the facility. Residents recalled the January Resident Council meeting during which non-smoking residents complained about the inability to get fresh air due to the presence of smokers.Resident 32 indicated daily walks were taken around the building for exercise and reported continued exposure to cigarette smoke near the front entrance, expressing dislike for the smell. Resident 61 reported going outside twice daily for fresh air and noted the persistent presence of cigarette smoke. Resident 99 (R99)R99 was admitted [DATE], with diagnosis including other specified depressive episodes, bipolar disorder current episode hypomanic, and anxiety disorder due to known physiological condition. A document titled Horizon Health and Rehabilitation Center (HHRC) Smoking Residents, listed R99 as a smoker.A final written warning of non-compliance in regard to the facility's No-Smoking Policy was signed by R99 and dated 05/20/2025. Care Plan dated 06/20/2024, documented R99 was a non-complaint smoker, did not follow facility's nonsmoking policy.R99's Smoking Risk (Acuity) Review dated 05/19/2025, documented smoking materials as cigarettes, carried matches/lighter, frequency of use was every few hours, and listed smoked in unauthorized areas as a severe problem.On 06/13/2025 at 8:57 AM, R99 was observed walking continuously back and forth in the hallways. R99 was dressed in street clothes and wore a purse over the shoulder. R99 reported was a smoker and had cigarettes and a lighter in the purse, while pointed to the purse hanging on the shoulder. R99 explained would go outside the facility to smoke. R99 acknowledged was aware it was a nonsmoking facility. R99's facial expression changed with noticeable flushing, stopped speaking, and abruptly ended the interaction by walking away.On 06/13/2025 at 9:30 AM, the Assistant Director of Nursing (ADON), reported R99 had been educated many times about the nonsmoking policy. R99 became very agitated when smoking paraphernalia was confiscated and shortly after would obtain more smoking paraphernalia. The ADON reported had been unable to determine how R99 would obtain more smoking paraphernalia.On 06/13/2025 at 12:10 PM, a Certified Nursing Assistant (CNA), reported lighters and cigarettes were confiscated, and residents were educated and reminded continuously it was a nonsmoking facility. The CNA reported was unsure of how residents obtained more smoking paraphernalia after the items were confiscated.

Based on observation, interview, record review, and document review, the facility failed to ensure the Foley catheter was assessed timely, the physician was notified of foul-smelling urine, the change in condition was documented, and the urinary drainage bag was changed as ordered for 1 of 26 sampled residents (Resident 104). This deficient practice had the potential to contribute to urinary tract infection, compromised skin integrity, and overall health status. Findings include: Resident 104 (R104) R104 was admitted on [DATE], with diagnoses including neoplasm of the kidney and obstructive and reflux uropathy. A Physician order dated 08/21/2024, documented to change Foley drainage bag weekly on Sunday. A Physician order dated 10/16/2024, documented an indwelling Foley catheter, 16 French, inflated with 10 cubic centimeters (cc), for benign prostatic hyperplasia (BPH). The order indicated the Foley catheter may be changed as needed for obstruction or dislodgement. A Physician order dated 10/16/2024, documented may irrigate Foley catheter with 60 cc sterile water as needed for sediments/obstruction as needed. A Care Plan dated 10/15/2024, documented R104 had an indwelling catheter related to BPH and recurrent urinary tract infections. Interventions included providing catheter care as ordered, monitor and document urinary output. The goal was for R104 to remain free from urinary tract infections for 90 days. On 06/10/25, at 9:59 AM, R104 was observed in bed with eyes closed. A urinary drainage bag, undated and in place, contained approximately 450 cc of dark yellow to amber-colored urine with visible sediment. On 06/11/25, at 1:49 PM, R104 was observed in bed, awake and verbally responsive. R104 verbalized the Foley catheter and urinary drainage bag had not been changed. R104 verbalized the diaper had been soaking wet and staff attributed the moisture to leakage from the insertion site, but the Foley had not been changed in over a month. R104 indicated had frequent urinary tract infections. On 06/11/25 at 1:51 PM, a Licensed Practical Nurse (LPN) verified the Foley catheter in place was a 16 French with a 10-cc water balloon. The LPN confirmed the urinary tubing contained sediment build-up, the urinary bag appeared old and discolored, and the urine was cloudy with a foul odor. The LPN indicated the Foley catheter should have been changed if leaking, the urinary bag should have been replaced as needed, and a physician's order should have been implemented and documented. R104's medical record lacked documented evidence the Foley catheter was assessed timely, the physician was notified of foul-smelling urine, the change in condition was documented, and the urinary drainage bag was changed as ordered. On 06/11/25 at 2:05 PM, the Assistant Director of Nursing (ADON) indicated a physician's order was required for residents with an indwelling Foley catheter, including justification, management, and ongoing assessment. Staff were expected to follow physician orders. The ADON confirmed R104 had concentrated amber-colored urine with a foul odor at the time of the catheter change, indicating a change in condition that should have been reported, with a Situation-Background-Assessment-Recommendation (SBAR) initiated and documented. No documentation was found of leakage, urinary tract infection symptoms, or SBAR initiation. The ADON stated the order directed weekly catheter changes, documented in the Treatment Administration Record (TAR); however, although recorded as changed on June 1 and 8, 2025, the catheter was not changed. The ADON explained changes were performed as needed, but the active order specified weekly changes and should have been clarified. The ADON confirmed the presence of foul-smelling urine, a tarnished and discolored drainage bag, and visible sediment. The urinary bag appeared old, and a reported change in condition should have prompted assessment and catheter replacement. The ADON indicated nursing staff were expected to notify the physician and document the change; however, this was not completed. On 06/12/25 at 11:31 AM, the Director of Nursing (DON) indicated residents with Foley catheters had diagnoses supporting continued use. Physician orders were required for catheter care, including maintaining cleanliness and discontinuing use when appropriate. Some residents had indwelling catheters due to underlying medical conditions. The DON stated the Foley catheter should have been flushed if occluded and changed if leaking. If foul-smelling urine was present, prompt assessment and physician notification were expected to obtain an order for urine collection, catheter change, and documentation. A facility policy titled Catheter-Urinary Catheter Cleaning and Maintenance - Lippincott Nursing Procedures, 9th Ed., pages 432-435, revised 05/05/2023, directed staff to monitor intake and output as ordered, observe for changes in urine volume and color, and notify the practitioner of abnormal findings. A facility policy titled Physician and Other Communication/Change of Condition, revised 05/05/2023, directed staff to complete a resident assessment, including any interventions provided. Staff were to complete a Situation-Background-Assessment-Recommendation (SBAR), notify the physician, and document all assessments and changes in the resident ' s condition in the medical record. Changes and new interventions were to be reflected in the individualized care plan. All attempts to notify physicians and family members or legal representatives were to be thoroughly documented in the medical record.

Based on observation, interview, record review, and document review, the facility failed to ensure enteral feeding orders administered through the gastrostomy tube were followed as ordered, and total volume delivered was monitored and documented for 1 of 26 sampled residents (Resident 34). This deficient practice had the potential to result in inadequate nutritional and fluid intake, leading to malnutrition, dehydration, electrolyte imbalances, impaired wound healing and increased susceptibility to infections. Findings include: Resident 34 (R34) R34 was admitted on [DATE], with diagnoses including risk for malnutrition due to impaired food and fluid intake, diabetes mellitus, dementia and gastrostomy. On 06/10/2025 at 10:10 AM, R34 was observed in bed with the head of bed elevated 30 to 45 degrees. Nepro 1.8 (a liquid therapeutic nutritional supplement specifically designed to help meet nutritional needs) was hung on a pole, with the tube feeding (TF) bag approximately full at 1000 milliliters (mL). The bag was labeled 06/10/2025 at 4:40 AM, with an indicated rate of 35 mL/hour. The water bag was at approximately 1000 mL, labeled with the resident's name, but lacked an infusion rate and staff initials. TF was not flowing at the time of observation. A physician order dated 02/14/2025 documented Nepro 1.8 at 35 mL/hour for 15 hours daily or until a total volume of 525 mL was infused. Date and label each tubing, monitor for tolerance. On 06/10/2025 at 11:33 AM, TF remained connected to R34 but was not flowing at the time of observation. On 06/13/2025 in the morning, TF via enteral pump was observed turned off. A Licensed Practical Nurse (LPN) explained R34 was dependent on enteral feedings due to dysphagia (difficulty swallowing) and was receiving hospice services. The LPN indicated TF started at 2:00 PM and ended at 5:00 AM. The LPN confirmed the enteral feeding pump history showed a total feed volume of 1,452 mL over three days, reflecting a deficit of 123 mL. The 30-day total was 13,823 mL, reflecting a cumulative deficit of 1,927 mL. On 06/13/2025 at 10:13 AM, the Assistant Director of Nursing (ADON) explained if TF was initiated at 2:00 PM, it should have been administered for the prescribed duration or until the ordered volume was completed. The ADON clarified the ordered volume must be administered in full, regardless of interruptions. The ADON indicated inadequate delivery placed the resident at risk for weight loss and stated the current weight remained stable. A review of the June Medication Administration Record (MAR) revealed lacked documented evidence the total TF volume was consistently monitored or recorded. On 06/13/2025 at 10:00 AM, the Registered Dietitian (RD) explained R34 was entirely dependent on tube feeding, with no oral intake. The current TF order was 35 mL per hour over 15 hours daily, totaling 525 mL/day or 15,750 mL over 30 days. The actual administered volume was 13,823 mL, reflecting a 1,927 mL deficit. The RD confirmed the deficit was clinically significant, particularly for a resident with no oral intake. The RD indicated the TF provided complete nutrition, including essential fatty acids, vitamins, and minerals. The RD indicated failure to deliver the full ordered volume placed the resident at risk for weight loss and nutritional deficiencies. The RD reported R34's TF met approximately 88.9% of daily caloric needs and 72.8% of protein needs. The RD identified protein intake as suboptimal and below the recommended goal. The RD recalled a request to nursing staff to begin documenting total volume delivered was made in November 2024, shortly after hire, but had not been implemented. The RD confirmed TF volume was not consistently monitored or documented in the MAR and expressed this failure placed the resident at risk for unintentional weight loss and unmet nutritional needs. On 06/13/2025 at 1:34 PM, the physician indicated it was essential to maintain nutritional status through consistent enteral feeding as ordered to support metabolic balance and reduce the risk of skin breakdown. The physician confirmed staff were expected to follow TF orders as prescribed. A facility policy titled Enteral Feeding - Documentation, revised 06/20/2023, documented licensed nursing staff would monitor residents receiving enteral nutrition daily and document according to facility guidelines, including recording intake and output amounts.

Based on observation, interview, record review and document review, the facility failed to ensure 1) a resident's yelling and disruptive behaviors were communicated to the psychiatric provider and 2) the resident was referred to the behavioral services provider for psychotherapy services for 1 of 26 sampled residents (Resident 55). The deficient practice potentially had a negative impact on the resident of concern's overall well-being and deprived other residents of the right to live in a peaceful environment free from disruptive noise. Findings include: Resident 55 (R55) R55 was admitted on [DATE] and readmitted on [DATE], with diagnoses including insomnia, anxiety disorder and major depressive disorder. Psychiatric provider not informed On 06/10/2025 at 9:45 AM, R55 was overheard from the hallway yelling, help! help! help! A Licensed Practical Nurse (LPN1) entered R55's room. Upon leaving R55's room, the LPN indicated R55 yelled all the time. On 06/10/2025 at 9:52 AM, R55 was seated in wheelchair and reported being unhappy in the facility due to not getting along with roommate and expressed was upset over being transported to the main dining room where R55 remained all night accompanied by a nurse. R55 indicated the nurse removed the resident from the unit to allow other residents to sleep because the resident yelled constantly. R55 acknowledged yelling constantly because the resident had difficulty sleeping and did not take any medications for sleep. On 06/10/2025 at 10:00 AM, R55's roommate Resident 109 (R109), sat in motorized wheelchair and indicated R55 yelled constantly day and night and was verbally abusive towards staff which R109 found disturbing. On 06/12/2025 in the afternoon, R55 was observed asleep and unarousable in wheelchair in the lobby by the front desk. On 06/13/2025 at 9:50 AM, R109 indicated R55 yelled day and night which disrupted R109's normal sleep patterns. R109 reported being able to nap yesterday afternoon because staff brought R55 to the receptionist to allow R109 to rest. R109 confirmed the nurse had to bring R55 to the main dining room on the evening of 06/09/2025 to allow other residents in the unit to sleep. R109 indicated staff were fully aware of R55's behaviors but had run out of moves because nothing worked for R55. On 06/13/2025 at 11:06 AM, Resident 58 (R58) whose room was next to R55's room indicated being bothered by R55's constant yelling and stated, I am lucky to get three hours of sleep. On 06/13/2024 at 2:33 PM, Resident 122 (R122) who resided in the room directly across from R55's, was seated in walker on the front patio. R122 indicated being bothered by R55's constant yelling and had expressed this with the staff but the resident did not know what was being done for R55. On 06/13/25 at 10:29 AM, LPN2 indicated being familiar with R55 and R109 who did not get along mostly due to R55's behaviors. According to LPN2, R109 was protective of staff and did not like it whenever R55 became verbally abusive. LPN2 indicated being aware Residents 109, 58 and 122 had expressed being bothered by R55's constant yelling and LPN2 was informed R55 needed to be removed from the room just to allow R109 to get some sleep. LPN2 indicated reporting R55's behaviors to the Assistant Director of Nursing (ADON1) and the DON but LPN2 was not aware of the leadership's plans for R55. LPN2 indicated all residents had the right to exist in a peaceful, homelike environment free from disruptive noise and R55's constant yelling was depriving other residents of peace and sleep. A psychiatric consult report dated 12/17/2024, revealed R55 was seen by psychiatric provider due to refusing to go to dialysis treatments. The report documented R55 was currently not on any psychotropic medications and nursing was instructed to monitor R55's mood changes and consult psychiatry for any concerns. Review of medical record revealed R55's yelling behaviors were identified and documented by nursing staff almost daily. The medical record lacked documented evidence R55's yelling and disruptive behaviors were communicated to the psychiatric provider. On 06/13/2025 at 11:12 AM, ADON1 indicated being aware of R55's yelling behaviors which occurred frequently. ADON1 indicated being informed R55 had to be transported to the main dining room on the evening of 06/09/2025 to allow other residents to sleep. The ADON explained the facility tried room changes and one-on-one conversations but did not know what else could be done for the resident. On 06/13/25 at 11:32 AM, the Administrator indicated being aware of R55's yelling behaviors which affected other residents as evidenced by the night nurse needing to remove the resident from the unit on the evening of 06/09/2025 to allow other residents to sleep. According to the Administrator, the facility had tried non-pharmacological interventions such as room changes, separating R55 from other residents but the Administrator deferred to the DON regarding pharmacological interventions. On 06/13/2025 at 11:59 AM, the psychiatric nurse practitioner (NP) confirmed R55 was a patient whom the NP saw only one time on 12/17/2024 when R55 refused to go to dialysis treatments. The NP indicated not being aware of R55's yelling and disruptive behaviors since no one from the facility had communicated R55's behaviors with the NP. The provider indicated whenever mood or behavior changes were identified, the facility must request a psychiatric consult to allow the NP to re-evaluate R55 and provide education regarding appropriate interventions such as medications. On 06/13/25 at 11:56 AM, the DON indicated being aware R55 had psychiatric diagnoses including major depressive disorder, insomnia and anxiety disorder and confirmed R55 was not on any psychotropic medications. The DON was familiar with R55's yelling and disruptive behaviors and was made aware the night nurse had to take R55 to main dining room on the evening of 06/09/2025 so the other residents could sleep. The DON acknowledged non-pharmacological interventions which included room changes and separating R55 from other residents were ineffective. The DON indicated facility staff were fully aware of R55's disruptive behaviors and how it had negatively impacted other residents, but no one thought to refer R55 for a psychiatric consult which would have given the psychiatric provider the chance to discuss appropriate interventions sooner. Referral for Psychotherapy Services On 06/13/25 at 1:43 PM, ADON2 indicated R55 was a Tier one resident which were residents with yelling and disruptive behaviors. According to ADON2, the facility had contracted with a private vendor who had a government contract with Medicaid. The Behavioral Health Services (BHS) provider would place behavior residents in Tiers (one, two or three) based on review of facility documentation and inter-disciplinary team (IDT) reports. Once a resident was identified to benefit from bedside psychotherapy services, the vendor would obtain Medicaid approval and if approved the resident would receive bedside psychotherapy services. ADON2 indicated R55 should have been identified by the IDT for BHS referral to be able to be considered for psychotherapy services. The DON reviewed medical record and confirmed R55 had not been seen by BHS nor referred by the IDT for psychotherapy services and should have been. The Behavioral Health Services policy revised 06/09/2023, documented each resident must receive and the facility must provide necessary behavioral health care and services to attain and maintain the highest practicable physical, mental and psycho-social well-being. Provided services and attempts to provide services would be documented in the resident's medical record.

Based on observation, interview, document review, and record review, the facility failed to ensure target behaviors were monitored for a resident receiving medication to treat Post Traumatic Stress Disorder (PTSD) for 1 of 26 sampled residents (Resident #26). This deficient practice had the potential to cause the residents to use unnecessary medication, which may result in possible adverse effects. Findings include: Resident 26 (R26) R26 was admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses including chronic respiratory failure with hypercapnia and post-traumatic stress disorder (PTSD). A physician's order dated 04/02/2025 documented Prazosin capsule two milligrams (mg) by mouth every 12 hours for PTSD, target behaviors: night terrors. The psychotropic consult report dated 01/20/2019 documented R26 had a history of being abused as a child and witnessing a violent crime. R26 experienced night terrors related to the incident and had trouble sleeping. R26's medical record lacked documented evidence target behaviors were being monitored for R26 related to the medication Prazosin. On 06/12/25 at 12:05 PM, the Assistant Director of Nursing (ADON) indicated being familiar with R26. The ADON confirmed R26 had been on Prazosin for PTSD for many years, with target behaviors of night terrors. The ADON explained Prazosin was not a psychotropic medication but was ordered for off-label use to address R26's PTSD. The ADON indicated if a medication was used to treat a psychiatric diagnosis such as PTSD, target behaviors must still be monitored. The ADON confirmed R26's night terrors were not being monitored per the physician's order. The ADON indicated the purpose of monitoring Prazosin medication was to identify adverse effects and to determine if the medication was effective. On 06/12/25 at 12:06 PM, the Director of Nursing (DON) explained that Prazosin was an alpha-blocker (a cardiovascular drug) which could be used to improve sleep quality and reduce nightmares. The DON corroborated the ADON's interview, stating medications used for psychotropic diagnoses even if used off-label, must be monitored for target behaviors. The DON indicated monitoring psychotropic medications ensured adverse effects were identified and the medication is effective, particularly in this case for night terrors. The Psychotropic Drugs policy, revised 04/17/2024, documented the facility would monitor and document the resident's response to psychotropic medications for efficacy and adverse consequences. Symptoms, behaviors, and side effects were to be monitored.

Based on observation, interview, document review, and record review, the facility failed to ensure a medication error rate of less than 5% was obtained during medication pass. There were 31 opportunities observed, which revealed three errors. The medication error rate was 9.68%. Failure to follow physician orders during medication administration had the potential to cause harm or injury to residents. Findings include: Resident 82 (R82) R82 was admitted on [DATE], with diagnosis including hemiplegia affecting left nondominant side, major depressive disorder recurrent severe without psychotic features, and generalized anxiety disorder. On 06/12/2025 at 7:17 AM, a Licensed Practical Nurse (LPN) prepared and administered R82 six medications including Aspirin 81 milligrams (mg) one tablet by mouth and Vistaril (hydroxyzine pamoate) 25 mg (a medication used to treat anxiety), one capsule by mouth. R82's medical record lacked a physician order for Aspirin 81 mg one tablet by mouth. A Physician order dated 11/15/2024, documented Multivitamin (multivitamin-minerals (min)-iron-folic acid (fa)-vit K) tablet, 18 mg, iron-400 micrograms (mcg) oral, once a day at 9:00 AM. A Physician order dated 11/20/2024, documented Vistaril (hydroxyzine pamoate) capsule, 25 mg, amount 1, oral. Special instructions documented for anxiety and poor sleep, do not change the time, twice a day at 9:00 AM and 9:00 PM. A Care Plan edited 05/31/2025, documented R82 had potential for complications related to blood thinning medication and anticoagulant use. R82 had restlessness related to anxiety. Approach included to administer medication as ordered. On 06/12/2025 at 9:23 AM, the LPN, confirmed had administered R82 Aspirin 81 mg one tablet. The LPN acknowledged R82 did not have a physician order for Aspirin 81 mg, and it was administered in error. The LPN acknowledged did not administer the Multivitamin 18 mg, iron-400 mcg tablet. The LPN explained mistook the Aspirin bottle for the Multivitamin bottle, the Aspirin was given to R82 in error and the Multivitamin was not administered as ordered. The LPN confirmed the physician order for Vistaril (hydroxyzine pamoate) 25 mg 1 capsule included specific instruction not to change the time of administration. The LPN acknowledged the Vistaril (hydroxyzine pamoate) 25 mg 1 capsule should have been administered at 9:00 AM as ordered and it was administered at 7:17 AM in error. The LPN acknowledged medication should have been administered as ordered by the physician. On 06/12/2025 at 9:32 AM, the Assistant Director of Nursing (ADON), confirmed R82 did not have a physician order for Aspirin, and it was administered in error. The ADON explained R82 had a physician order for Multivitamin which was not administered and should have been administered instead of the Aspirin. The ADON reported Vistaril (hydroxyzine pamoate) 25 mg had physician instructions not to change the time of administration of 9:00 AM and confirmed it was administered too early at 7:17 AM, outside of the time ordered by the physician. The ADON reported medication had to be administered as ordered. On 06/13/2025 at 10:58 AM, the Pharmacist Consultant, during a phone interview, explained was concerned R82 was administered Aspirin instead of a Multivitamin due to the resident already taking another anticoagulant. The Pharmacist Consultant explained the Aspirin had the potential to cause bleeding. The Pharmacist Consultant reported the expectation was for staff to follow orders and administer the correct medication at the appropriate time as specified by the physician. On 06/13/2025 at 11:24 AM, the Nurse Practitioner (NP), during a phone interview, acknowledged was the prescriber of R82's Vistaril (hydroxyzine pamoate) 25 mg order. The NP explained ordered the medication to be given at 9:00 AM and 9:00 PM, with instructions not to change the time, due to the resident experiencing consistent episodes of anxiety in the morning and to help with sleep in the evenings. The NP reported the expectation was for the medication to be administered as ordered. A facility policy titled Nursing Policies and Procedures, Medication Management Program revised 05/05/2023, documented preparing for the medication pass included staff understanding the eight medication rights including the right drug and the right time.

Based on record review, document review and interview, the facility failed to ensure a resident was provided information about the right to formulate an advanced directive for 1 of 26 sampled residents (Resident #67). The deficient practice has the potential to deprive the resident of their right to determine their life status. Findings include: Resident #67 (R67) R67 was admitted to the facility on [DATE], with diagnoses including diffuse traumatic brain injury, bipolar disorder, anxiety disorder, and unspecified dementia. R67 had a Brief Interview for Mental Status (BIMS) score of three indicating severe cognitive impairment. A resident document titled Resident Face Sheet documented the resident was the responsible party and the daughter, sister, and brother-in-law were the emergency contacts. The facility was not able to provide any advanced directive documents such as: Power of Attorney paperwork, Guardian paperwork, a Physician Order for Life-Sustaining Treatment (POLST) form, or any other Advanced Directive paperwork for R67. The physician wrote an open-ended order dated 04/24/2023 with the description: Code Status: Full. On 06/10/2025 in the afternoon, an interview with R67 revealed the resident seemed confused. The resident thought was living in the Falls Housing Community off interstate five in California. On 06/11/2025 in the afternoon, the Director of Social Services (DSS) stated was not sure why the physician wrote an order for a full code for the resident when a full code is the default designation when no advanced directive is in place. The DSS affirmed a physician order is not considered a valid advanced directive. The DSS acknowledged since the resident had a low cognition (BIMS of three), there was no discussion with the resident on advanced directives since the resident lacked decisional capacity. This also meant the resident did not have the capacity to fill out the POLST form. The facility policy titled, Advance Directives, revised 06/09/2023, documented upon admission to the facility, the facility designee will determine the resident's decision-making capacity and identify the resident's primary decision maker and review the resident's existing choices with the resident or legal representative. The facility designee will also develop a care plan for all advanced directives; identifying, clarifying, and periodically reviewing, as part of the comprehensive care planning process, the existing care instructions and whether the resident or resident representative wishes to change or continue these instructions.

Based on interview and document review, the facility failed to ensure a Quality Assurance Performance Improvement (QAPI) plan was in place. This deficient practice has the potential to negatively affect the outcomes of resident care and the quality of each resident's life. Findings include: On 06/13/2025 at 1:20 PM, the Administrator acknowledged the facility did not have a specific QAPI plan in place. The Administrator explained the facility was using their QAPI policy as their plan. A facility policy titled, Quality Assurance and Performance Improvement Program Committee Guidelines, revised on 12/03/2019, did not identify the requirement of developing a QAPI Plan containing the processes that will guide the nursing home's efforts in assuring care and services are maintained at acceptable levels of performance and continually improved. However, it did document the QAPI Plan is used to guide the organizational and facility performance improvement efforts. According to the state operations manual, the facility is required to develop a QAPI plan and present its plan to federal and state surveyors at each annual recertification survey and upon request during any other survey, and to CMS upon request. The QAPI plan should describe the process for identifying and correcting quality deficiencies. Key components of the process include tracking and measuring performance; establishing goals and thresholds for performance measurement; identifying and prioritizing quality deficiencies; systematically analyzing underlying causes of systemic quality deficiencies; developing and implementing corrective action or performance improvement activities; and monitoring or evaluating the effectiveness of corrective action/performance improvement activities and revising as needed. On 06/13/2025 in the afternoon, the Administrator confirmed the facility did not have a specific QAPI plan in place. The Administrator provided Quality Assurance & Performance Improvement continuing education course materials which documented the QAPI Plan should have a vision statement, mission statement, purpose statement, and guiding principles individualized for the facility. It also stated the program plan can serve as a guide for the program. The Administrator conceded the QAPI policy should be part of the plan, but the plan should be tailored to reflect the specific units, programs, departments, and unique population the facility serves, as identified in the facility assessment.

Based on observation, interview, and document review, the facility failed to 1) procure a clean food preparation environment and 2) ensure food products that needed to be refrigerated were kept in a safe temperature range by accurately monitoring the temperature of the walk-in refrigerator. The deficient practice could potentially expose residents to foodborne illnesses. Findings included: On 07/09/24 in the morning, an inspection was conducted with the kitchen manager in the kitchen area. The following issues were identified: 1) Cleanliness: - The exhaust hood over the stove was greasy and visibly dusty outside. - The oven was visibly soiled with greasy matter and dust outside and greasy with food debris inside. - Food debris was observed on the floor behind the oven, stove, and pressure cook. - The floor in the room preparation area was visibly soiled with food debris. A fan was on the floor, blowing air to the table where hamburger patties were being prepared. - The air conditioning (AC) vents were visibly dusty. - An AC vent in the dishwashing area was visibly corroded, with the paint peeling apart. On 07/09/2024 at 9:30 AM, the kitchen manager indicated the oven and the exhaust hood were cleaned monthly but should be cleaned more often. The kitchen manager acknowledged that fans could not be used in the kitchen, and food exposed to the air blown by the fan would be discarded. 2) Walk-in Refrigerator: At 9:40 AM, the temperature reading in the external thermometer of the walk-in refrigerator indicated 44 degrees Fahrenheit ( F). The temperature log located at the door of the walk-in refrigerator documented a temperature of 40 F was obtained in the morning. The two thermometers situated inside the refrigerator read 58 F each. The kitchen manager indicated that the door of the walk-in refrigerator was opened several times during meal preparation, which could be the reason the temperature dropped. It was suggested the temperature be checked in one hour. On 07/09/2024 at 11:09 AM, the temperature of the walk-in refrigerator was rechecked. The two internal thermometers read 54 F. The kitchen manager confirmed the observation and verbalized the temperature should have been between 38 and 40 F and the food products should have been relocated to another refrigerator. The kitchen manager stated a report would be submitted to the maintenance department. On 07/09/2024 at 12:30 PM, the walk-in refrigerator was checked again. The temperature in the internal thermometers continued at 54 F. Temperatures were obtained from food products, including a milk carton and a bag of smoked sausages. The temperature was 56 F, confirmed by the kitchen manager, who indicated the food products would be relocated to another refrigerator. The kitchen manager indicated some products were received in the morning such as the orange juice that needed to be keep frozen and dairy products including milk. On 07/10/2024 at 7:35 AM, a follow-up inspection of the walk-in refrigerator was performed. The temperature in the internal thermometers continued at 56 F. The temperature was 56 F. There were food products at dangerous temperatures, including three boxes of oranges with labels indicating to keep them frozen. The orange juices in the boxes were not frozen. Additionally, some condiments needed to be refrigerated, including mayonnaise, cheese, two boxes of buttery spread, vegetables, a soy sauce container, whipped topping, sandwiches, sliced ham, sliced turkey, health shake, raw and boiled egg, yogurt, sour cream, and some vegetables. The kitchen manager disposed of the items and acknowledged that the food was in a dangerous zone temperature. The kitchen manager indicated staff did not check the two thermometers inside the refrigerators; instead had used the outside thermometer and documented that temperature. The facility policy titled Food Safety in Receiving and Storage, dated 06/20/2023, documented a thermometer should be kept in each refrigerator and that the refrigerator's ambient temperature should be maintained between 34 and 40 F.

Based on observation, interview, record review, and document review, the facility failed to ensure a safe and sanitary environment was maintained and residents were assessed in order to prevent the spread of communicable disease, specifically not following policies, processes or guidelines related to the novel coronavirus (COVID-19) for 17 of 18 sampled residents (Resident #'s 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 16, 17 and 18). Findings include: A facility policy titled Infection Control Prevention and Control Policies and Procedures, dated ,[DATE] with reference to CDC (Center for Disease Control) documented: a) If possible, do not place patients/residents with epidemiologically significant organisms with patients/residents who are immunocompromised, have wounds, or invasive devices. Droplet lsolation: b) Patient/Resident Placement Place the patient/resident in a private room, if possible. When a private room is not available, place the patient/resident in a room with a patient(s)/resident(s) who has active infection with the same microorganism but with no other infection (cohorting). When a private room is not available and cohorting is not achievable, maintain spatial separation of at least 3 feet between the infected patient/resident and other patients/residents and visitors. Wear a mask when working within 3 feet of the patient/resident. The facility policy titled Isolation Precautions Including Standard/Universal Precautions dated [DATE], documented the transmission-based precautions would be applied based on the epidemiology of the infectious disease syndrome. The policy indicated gloves should be changed between task and procedure on the same resident after having contact with contaminated materials. The policy documented non-critical equipment should be disinfected after being used. The policy revealed the appropriate placement of the resident was a significant component of the infection control program. When possible, residents with highly transmissible disease should be placed in a private room. CDC Guidelines documented facilities should consider implementing a respiratory protection program that is compliant with the Occupational Safety and Health Administration (OSHA) respiratory protection standard for employees if not already in place. The program should include medical evaluations, training, and fit testing. Additionally, the guidelines indicated as a measure to limit HCP exposure and to conserve Personal Protective Equipment (PPE), facilities could consider designating entire units within the facility, with dedicated HCP, to care for patients with known or suspected COVID-19. Dedicated means that HCP are assigned to care only for these patients during their shift. The Centers for Medicare and Medicaid Services (CMS) document titled COVID-19 Long-Term Care Facility Guidance dated [DATE], documented the Nursing Homes should immediately ensure compliance with all CMS and the Centers for Disease Control and Prevention (CDC) guidance related to infection control. In accordance with previous CDC guidance, every resident should be assessed for symptoms and have their temperature checked every day. The Guidance indicated the facilities should separate residents who have COVID-19 from patients and residents who do not, or have an unknown status, and implement consistent assignment, or have separate staffing to provide care for COVID-19-positive and COVID-19-negative patients. The U.S Department of Labor Guidance on Preparing Workplaces for COVID-19 dated [DATE], and provided by the facility, revealed employees were obligated to provide their workers with PPE needed to keep them safe while performing their duties. The guidance documented workers including those employees who worked within 6 feet of positive or suspected of being infected with COVID-19 residents, needed to use N-95 respirators or better approved by the National Institute for Occupational Safety and Health (NIOSH) under a respiratory protection program that included fit-testing, training and medical exam. Safe Environment- Resident assessment: Resident #6 (R6) R6 was admitted on [DATE], with [DIAGNOSES REDACTED]. R6's room was in the upper section of the 59A - 63B Hallway, close to the Resident Care Manager's (RCM) office and the Nurse's station. Nurses Progress Notes dated [DATE], documented R6 had a temperature of 100.3 degrees Fahrenheit with coughing and sneezing. The Vitals Report revealed R6's temperature on [DATE] was 98.9 degrees Fahrenheit (F). The medical record lacked documented evidence the resident's temperature levels were checked from [DATE] through [DATE]. There were no vital signs documented for blood pressure, pulse, respiratory rate nor Oxygen saturation levels for the resident. The resident had not been placed on isolation precautions. Nurses progress notes dated [DATE], documented R6's lips were purple, had difficulty breathing with a 91% Oxygen saturation on two liters of Oxygen via nasal cannula. The resident was transferred to an acute care hospital for [MEDICAL CONDITION] and was admitted to the Intensive Care Unit. Notification received from the Administrator dated [DATE], revealed R6 tested positive for the novel coronavirus (COVID-19). R6 expired on [DATE] at the hospital. Resident #8 (R8) (Roommate of R6) R8 was admitted on [DATE] and readmitted on [DATE], with [DIAGNOSES REDACTED]. R8's room was in the upper section of the 59A - 63B Hallway, close to the RCM's office and the Nurse's station. The medical record lacked documented evidence R8 was transferred to a dedicated quarantine area in the facility for a possible COVID-19 exposure, after the facility was informed R8's roommate had tested positive for COVID-19. R8 was placed on isolation in the same room on the same unit with other residents with no known exposure to [MEDICAL CONDITION]. No dedicated staff were assigned to this area. A Nurse's Progress Note dated [DATE], revealed R8 was on contact isolation as of [DATE]. The resident was not demonstrating signs and symptoms of fever, cough, loss of appetite or shortness of breath. A Physician order [REDACTED]. A Nurse's Progress Note dated [DATE], revealed R8 remained on isolation and remained asymptomatic. A Physician order [REDACTED]. On [DATE] at 3:08 PM, R8 was in bed inside the room. There were no signs posted outside the resident's room or anywhere near the resident's room to indicate R8 was on droplet precautions. On [DATE] at 3:36 PM, the Infection Preventionist indicated R8 was not on isolation due to not showing any symptoms for the past 72 hours. Isolation had been discontinued for the resident. The Infection Preventionist confirmed being aware R8's roommate had tested positive for COVID-19. The Infection Preventionist indicated R8 did not need to be quarantined in a separate area in the facility because R8 remained on isolation in their own room. R8 had remained in the same unit with other residents who had not been known to have been exposed to [MEDICAL CONDITION] and without dedicated staff members. The Infection Preventionist indicated not being aware of the physician order [REDACTED]. A Microbiology Result dated [DATE], documented R8 was tested on [DATE]. R8 tested positive for COVID-19. Resident #9 (R9) R9 was admitted on [DATE] and readmitted on [DATE], with [DIAGNOSES REDACTED]. R9's room was in the middle section of the 53A - 58B Hallway. A Nurse's Progress Note dated [DATE] at 7:34 PM, documented R9 had a temperature of 101.7 degrees F. A physician order [REDACTED]. A Physician Assistant's Note dated [DATE], documented given the COVID-19 pandemic, the resident was examined from the door, a nurse was at the bedside. A Nurse's Progress Note dated [DATE], documented R9 had a urine infection and pneumonia and would be started on antibiotics. Physician Notes dated [DATE] - [DATE], documented given the COVID-19 pandemic, the resident was examined from the door. A Nurse's Progress Note dated [DATE], documented R9 was started on intravenous [MEDICATION NAME] antibiotic for a urinary tract infection. A Nurse's Progress Note dated [DATE], late entry on [DATE], revealed R9 was placed in a single room for an active infection, symptomatic as manifested by fever, increased work of breathing and required Oxygen at four liters. Nurse's Progress Notes on [DATE], documented R9 had increased work of breathing, respiratory rate was 28 breaths per minute, on Oxygen at five liters, oxygen saturation of 84%, and was afebrile. R9 was transferred to the acute care hospital and admitted to the Intensive Care Unit. A Physician order [REDACTED]. Notification was received from the Administrator dated [DATE], revealed the resident tested positive for COVID-19. Resident #10 (R10) (Roommate of R9) R10 was admitted on [DATE] and readmitted on [DATE], with [DIAGNOSES REDACTED]. R10's room was in the middle section of the 53A - 58B Hallway. A Nurse's Progress Note dated [DATE], late entry on [DATE] documented R10 was on isolation for observation and monitoring secondary to exposure to respiratory symptoms. The resident would be monitored for changes in oxygen saturation, temperature, changes in appetite, bowel regime and nausea. The medical record lacked documented evidence R10 was transferred to a dedicated quarantine area in the facility for a possible COVID-19 exposure. R10 was placed on isolation in the same room on the same unit with other residents with no known exposure to [MEDICAL CONDITION]. No dedicated staff were assigned to this area. A Physician order [REDACTED]. A Nurse's Progress Note dated [DATE], documented a physician order [REDACTED]. The test kit was scheduled to arrive on [DATE]. A Physician order [REDACTED]. A Physician Assistant Note dated [DATE], documented a COVID-19 test was ordered to rule out the infection secondary to R10 having been exposed to a roommate who had tested positive for COVID-19. The resident was examined from the door because no personal protective equipment was available. A Nurse's Progress Note dated [DATE], documented laboratory results received which detected COVID-19. A Physician order [REDACTED]. Resident #11 (R11) R11 was admitted on [DATE], with [DIAGNOSES REDACTED]. R11's room was in the lower section of the 31A - 36B Hallway, close to the Administrator's office and the Rehabilitation Department. The Vitals Report revealed R11's Oxygen saturation levels: [DATE] - 88% on room air [DATE]- 89% on room air The medical record lacked documented evidence the Certified Nursing Assistant reported R11's Oxygen saturation levels to the nurse or the physician was notified. A Nurse Progress Notes dated [DATE] at 7:00 AM, documented R11's Oxygen saturation was 76% at room air. The resident was given Oxygen via nasal canula and the physician was notified. The resident was placed on six liters of Oxygen and saturation level went up to 92%. A Nurse Progress Note dated [DATE] at 11:55 AM, documented the physician saw the resident who was on four liters of Oxygen with an oxygen saturation level of 85%. The physician ordered to send the resident to the acute care hospital. A Physician order [REDACTED]. A Nurse Progress Note dated [DATE], documented the resident was admitted to the Intensive Care Unit at the acute care hospital. Notification was received from the Administrator dated [DATE], revealed R11 tested positive for COVID-19 virus. Resident #16 (R16) (Roommate of R11) R16 was admitted on [DATE] and readmitted on [DATE], with [DIAGNOSES REDACTED]. R16's room was in the lower section of the 31A - 36B Hallway, close to the Administrator's office and the Rehabilitation Department. The medical record lacked documented evidence R16 was transferred to a dedicated quarantine unit due to possible exposure after R16's roommate had tested positive for COVID-19. R16 remained in isolation in the same room, on the same unit with other residents not known to have been exposed to the COVID-19 virus. No dedicated staff were assigned to this area. Resident #13 (R13) R13 was admitted on [DATE], with [DIAGNOSES REDACTED]. R13's room was in the upper section of the 59A - 63B Hallway, close to the RCM office. A Nurse's Progress Note dated [DATE], documented R13 had an elevated temperature of 100.6 F, was hypoxic and had altered mental status. The medical record lacked documented evidence R13 was transferred to a dedicated quarantine area. A Physician order [REDACTED]. A Microbiology Results Report dated [DATE], revealed COVID-19 was detected for R13. Resident #17 (R17) (Roommate of R13) R17 was admitted on [DATE] and readmitted on [DATE], with [DIAGNOSES REDACTED]. R17's room was in the upper section of the 59A - 63B Hallway, close to the RCM office. The medical record lacked documented evidence R17 was quarantined in another area in the facility after a possible exposure to COVID-19, when R17's roommate had tested positive for [MEDICAL CONDITION] on [DATE]. R17 remained on isolation in the same room, in the same unit with other residents not known to have been exposed to the COVIE-19 virus. No dedicated staff were assigned to this area. Resident #14 (R14) R14 was admitted on [DATE] and readmitted on [DATE], with [DIAGNOSES REDACTED]. R14's room was in the upper section of the 48A - 52B Hallway. A Nurse's Progress Note dated [DATE], documented the nurse would continue to monitor the resident's temperature. Last noted temperature was 99.0 F. The medical record lacked documented evidence R14 was transferred to a dedicated quarantine area. A Nurse's Progress Note dated [DATE] at 6:27 PM, revealed R14's temperature was 100.6 F and the nurse practitioner ordered to send the resident to the acute hospital. A Physician order [REDACTED]. A Microbiology Results Report received [DATE], revealed COVID-19 was detected for R14. Resident #18 (R18) (Roommate of R14) R18 was admitted on [DATE], with [DIAGNOSES REDACTED]. R18's room was in the upper section of the 48A - 52B Hallway. A Nurse's Progress Note dated [DATE], documented R18 was on contact isolation. The medical record lacked documented evidence R18 was quarantined in another area of the facility after a possible exposure to COVID-19, when R18's roommate had shown signs and symptoms of [MEDICAL CONDITION] and was sent to the acute care hospital. R18 remained isolated in the same room, on the same unit with other residents not known to have been exposed to [MEDICAL CONDITION]. No dedicated staff were assigned to this area. On [DATE] at 11:00 AM, the Administrator, Director of Nursing (DON) and Infection Preventionist indicated the residents (R8, R10, R16, R17 and R18) who have had possible exposure to COVID-19 when their roommates tested positive for [MEDICAL CONDITION], did not need to be quarantined to another unit because these residents were isolated in their own room. The DON indicated there would be a greater risk of spreading [MEDICAL CONDITION] if these residents were transferred to one dedicated unit. Resident #12 (R12) R12 was admitted on [DATE], with [DIAGNOSES REDACTED]. R12's room was in the lower section of the 1A - 5B Hallway. A Physician Note dated [DATE], documented R12 had mild coughing and low-grade fever of 99.2 degrees F. Chest x-ray showed diffuse congestion right-sided infiltrate with no lobar consolidation. R12's oxygen saturation was 86%. The resident was started on intravenous fluids and antibiotics. A Physician order [REDACTED]. A Physician order [REDACTED]. The medical record lacked documented evidence R12 was transferred to a dedicated quarantine area. The resident had been wheeling self around the facility. A Nurse's Progress Note dated [DATE], documented R12 was transferred to the acute care hospital secondary to shortness of breath, labored breathing and oxygen saturation dropped to 60% while on five liters of Oxygen. A Physician Note dated [DATE], documented R12 was transferred to the Intensive Care Unit in the acute care hospital. A Microbiology Result Report dated [DATE], revealed COVID-19 was detected in R12. Resident #7 (R7) R7 was admitted on [DATE], with [DIAGNOSES REDACTED]. R7's room was in the middle of the 48A - 52B Hallway. A Nurse's Progress Note dated [DATE], documented R7 had a fever, temperature was 101.6 degrees F. Tylenol 650 milligrams was administered to R7. The medical record lacked documented evidence the resident's temperature level was rechecked after Tylenol was administered on [DATE] at 10:54 PM and the resident's temperature levels were monitored on [DATE] through [DATE]. The Vitals Report revealed on [DATE], R7's Oxygen saturation level was 91% on room air. The medical record lacked documented evidence the resident's Oxygen saturation level was checked on [DATE] through [DATE]. The medical record lacked documented evidence R7 was transferred to a dedicated quarantine area with dedicated staffing. A Nurse's Progress Note dated [DATE], documented R7 was transferred to the acute care hospital due to Oxygen saturation of 88% on room air, 90% on two liters of Oxygen per nasal cannula. A Microbiology Result received from the hospital on [DATE], revealed R7 tested positive for COVID-19 on [DATE]. Resident #1 (R1) R1 was admitted on [DATE], with [DIAGNOSES REDACTED]. R1 resided in room [ROOM NUMBER]-A. Vitals report documented the following vitals: [DATE] at 12:12 AM: Temperature (T)-100 degrees F, no O2 Saturation (Sat) documented. [DATE] at 12:24 PM: 98.9 F, no O2 Sat. The medical record lacked documented evidence R1 was transferred to a dedicated quarantine area with dedicated staff members. A nursing progress note dated [DATE] at 7:14 PM, revealed R1 was vomiting at 11:00 AM. The note indicated the resident did not complain of pain, shortness of breath or distress. Vitals signs documented temperature 98.1 degrees F. The note revealed the [MEDICAL TREATMENT] center was notified about the resident's conditions and the center requested to cancel the [MEDICAL TREATMENT]. A nursing progress note dated [DATE] at 3:21 PM, revealed the [MEDICAL TREATMENT] center called the facility to report R1 had temperature of 100.4 degrees F and was returned to the facility with recommendation from the nephrologist to send the resident to the Emergency Department. Resident #2 (R2) R2 was originally admitted on [DATE] and re-admitted on [DATE], with [DIAGNOSES REDACTED]. R2 resided in room [ROOM NUMBER]-B Vitals report documented the following vitals signs: [DATE] at 1:34 PM: T- 99.6 degrees F. Pulse rate not documented, no O2 Sat recorded. [DATE] at 10:03 PM: T- 100.1 degrees F. [DATE] at 11:28 PM: T- 99.8 degrees F. O2 Sat 95 %. [DATE] at 8:24 PM: T- 100.4 degrees F. O2 Sat 94 %. [DATE] at 11:28 PM: T- 99.8 degrees F. O2 Sat 95 %. [DATE] at 5:28 AM: T- 106.5 degrees F. [DATE] at 6:21 AM: T- 100.1 degrees F. O2 Sat 95 % [DATE] at 9:15 AM: T- 99.8 degrees F. O2 Sat 97 % A nursing progress note dated [DATE] at 7: 52 PM, indicated R2's temperature was 100.4 degrees Farenheit and Tylenol was given by the [MEDICAL TREATMENT] facility due to fever at [MEDICAL TREATMENT]. A nursing progress note dated [DATE] at 5:28 AM, documented R2 had temperature of 106.5 degrees Farenheit. A nursing progress note dated [DATE] at 2:10 PM, indicated a report was given to an acute care facility regarding the transfer of R2 for COVID-19 test. The medical record lacked documented evidence R2 was transferred to a dedicated quarantine area with dedicated staff members. Resident # 3 (R3) R3 was admitted on [DATE], with [DIAGNOSES REDACTED]. R3 resided in room [ROOM NUMBER]-A. Vitals report documented the following vital signs: [DATE] at 1:43 PM, T- 100.8 degrees F. [DATE] at 8:43 AM: T- 100 degrees Farenheit, O2 Saturation (Sat) 83 % with oxygen (O2) at 2 liters per minute (lpm). [DATE] at 1:56 PM, T- 100 degrees Farenheit, O2 Sat 94 % with O2 at 4 lpm. [DATE] at 4:30 PM, T- 101.2 F, O2 Sat 97 % with O2 at 2 lpm. [DATE] at 3:41 PM, T- 100 degrees Farenheit, O2 Sat 81 % with 02 at 3 lpm. [DATE] at 3:50 PM, O2 Sat 81 % with O2 at 3 lpm. A nursing progress note dated [DATE] at 7:25 AM, revealed R3 had complained of elevated temperature at 102.4 F. At 9 :45 AM, the temperature was re-checked at 101.9 F. The attending physician was made aware. A Chest X-ray was ordered and the resident was placed in droplet isolation. The record revealed R3 was placed on [MEDICATION NAME] and [MEDICATION NAME] but the cough and fever progressed. The resident was treated at the facility until [DATE], when R3 developed [MEDICAL CONDITION] and was transferred to an acute care facility. The medical record lacked documented evidence R3 was transferred to a dedicated quarantine area with dedicated staff members. Resident #4 (R4) R4 was admitted on [DATE], with [DIAGNOSES REDACTED]. R4 resided in room [ROOM NUMBER]-B. Review of the vitals report from [DATE] through [DATE], revealed R4 did not complain of fever or respiratory symptoms until [DATE], when a spike in the temperature occurred (100 degrees F). On [DATE] at 1:42 PM, the vitals report documented R4 had an oxygen saturation of 85 % while receiving oxygen at 3 liters per minute. A progress note dated [DATE] at 3:13 AM, documented R4 had a temperature spike to 100 degrees F. The note indicated the attending physician was notified and ordered a chest X-ray and laboratory works. A progress note dated [DATE] at 1:00 PM, indicated a COVID sample was obtained. A progress note dated [DATE] a 4:18 PM, revealed new orders were obtained and oxygen was increased to 4 liters per minute with no distress or shortness of breath noted afterwards. The medical record lacked documented evidence R4 was transferred to a dedicated quarantine area with dedicated staff members. A progress note dated [DATE] at 2:12 AM, documented R4 was transferred to an acute care facility secondary to chest X-ray findings and oxygen saturation of ,[DATE] %. Resident #5 (R5) R5 was originally admitted on [DATE] and re-admitted on [DATE], with [DIAGNOSES REDACTED]. R5 resided in room [ROOM NUMBER]-A. A progress note dated [DATE] at 7:03 PM, revealed R5 was in droplet isolation with temperature of 98.2 degrees F and oxygen saturation of 98 % on room air. No shortness of breath identified. A progress note dated [DATE] at 8:52 AM, indicated R5 complained of a spike in temperature (101.1 degrees F). Attending Physician was notified and laboratory work ordered. A progress note dated [DATE] at 6:47 PM, indicated R5 temperature was 100.1 and Tylenol was administered. A chest X-ray was ordered. The medical record lacked documented evidence R5 was transferred to a dedicated quarantine area with dedicated staff members. On [DATE] at 11:15 AM, the DON indicated moving residents who have had a possible exposure to COVID-19 to another section in the facility had not been done. These residents were located throughout the facility in isolation. The residents were being monitored for signs and symptoms. The DON indicated moving the residents from one area to another area within the facility would essentially leave the previous rooms still contaminated. The DON indicated not having the ability to move the residents. When asked about the Centers for Disease Control and Prevention (CDC) and Centers for Medicare and Medicaid Services (CMS) recommendations to move residents suspected to have COVID-19 from exposure to their roommates to a separate unit within the facility, the DON stated, I could review it. On [DATE] at 3:25 PM, the Infection Preventionist indicated the facility decided not to move the residents into a separate area because they were isolated in their rooms. Isolation precautions would be discontinued for the residents when their roommate tested negative for COVID-19. If the results were still pending, the residents would be kept in isolation. If the roommate tested positive for COVID-19, then the residents would remain in isolation for 14 days and monitored for signs and symptoms of COVID-19. The Infection Preventionist indicated the guidelines from CDC and CMS were changing so often and they had not received any clear guidance on what to follow. The Infection Preventionist indicated it was not possible to assign dedicated staff to an isolated/quarantine unit because the facility did not have enough staff. The Infection Preventionist explained a lot of nursing staff had tested positive for COVID-19 and were symptomatic. The staff were not allowed to work, and the facility could not assign designated staff to a quarantine/isolation unit because they did not have enough staff to cover just one unit. Safe- Sanitary Environment, not following policy/process: - On [DATE] at 1:30 PM, an Environmental Services (EVS) worker was cleaning room [ROOM NUMBER]. The room had a sign for contact isolation and a cart at the door of the room contained clean personal protective equipment (PPE). The EVS worker was wearing gloves, mask and gown. The EVS worker came out of the isolation room four times to get supplies from the cleaning cart located outside the room. The EVS worker did not remove the contaminated PPE and did not perform hand hygiene after coming out of the room and touching clean supplies in the cart with the contaminated gloves. After finishing the clean-up, the EVS worker removed the contaminated PPE and discarded it into the cleaning cart's trash can. During the observation, it was noted the EVS worker touched the facial mask with the contaminated glove four times. On [DATE] at 1:45 PM, the EVS worker explained deep cleaning had been performed since the resident in room [ROOM NUMBER] was in isolation. The EVS worker was not aware the PPE had to be removed and hand hygiene performed every time the worker came out of the room and prior to touching the cleaning cart. The EVS worker indicated the face mask was big and fell down and needed to be adjusted, reason why the mask was touched several times. The EVS worker was not aware the contaminated PPE had to be discarded into the biohazard container located inside the isolation room. - On [DATE] at 1:55 PM, a Certified Nursing Assistant (CNA) removed the biohazard trash receptacle and the Personal Protective Equipment (PPE) cart from room [ROOM NUMBER]. The CNA placed the biohazard receptacle filled with contaminated trash over the PPE cart and moved it to the biohazard room. The CNA acknowledged it was not appropriate to place the biohazard trash receptacle over the PPE cart. The CNA indicated the biohazard trash receptacle and the PPE cart were removed since the resident verbalized the infection was over and the isolation was not needed. Review of the medical record for the resident in isolation in room [ROOM NUMBER] (Resident #15) revealed a physician order [REDACTED]. The record lacked documented evidence of a physician order [REDACTED]. On [DATE] at 2:00 PM, a Licensed Practical Nurse (LPN) confirmed R15 was in isolation due to a MDRO urinary tract infection. The LPN could not explain why the CNA removed the biohazard trash receptacle and the PPE cart. - On [DATE] at 2:10 PM, a CNA entered room [ROOM NUMBER] with a vital signs machine and obtained vital signs (temperature, pulse and blood pressure) from a resident in A bed (near the door). The CNA then proceeded to obtain vitals signs in room [ROOM NUMBER] to a resident in A bed. The CNA did not disinfect the vital sign machine between use with resident #15. The State Surveyor stopped the procedure before being performed. The CNA acknowledged the machine was not disinfected after being used with the first resident and indicated the vital signs machine should be cleaned once daily. On [DATE] at 2:15 PM, a LPN explained the vital sign machine should have been cleaned before and after use with a resident. - On [DATE] at 2:30 PM, a CNA came out from isolation room [ROOM NUMBER] and removed the PPE outside the room, rolled the contaminated gown and walked in the hallway looking for a trash can. The CNA touched her clothes with the contaminated EPP. On [DATE] at 12:48 PM, the Infection Control Nurse explained staff should remove the PPE prior to exiting an isolation room, perform hand hygiene and dispose the contaminated PPE in the biohazard receptacle located in the room. - On [DATE] around 2:45 PM, three CNAs and 2 LPNs were asked about the N-95 respirator fit test and the training. The staff members affirmed they had not performed the fit test and had not received specific training for the use of the respirator. On [DATE] at 9:15 AM, seven staff members including three CNAs, an Administrative Clerk, one EVS worker and two LPNs were wearing N-95 masks in the quarantine and the isolation unit. One EVS worker entered the Quarantine Unit wearing a regular face mask. The DON confirmed the fit test for the use of the N-95 respirators had not been performed. The CDC Guidelines documented the facilities should consider implementing a respiratory protection program that is compliant with the OSHA respiratory protection standard for employees if not already in place. The program should include medical evaluations, training, and fit testing. - On [DATE] at 8:50 AM in the quarantine area, vital sign equipment owned by a staff member were found on a table in the hallway. The equipment(TRUNCATED)

Based on interview, clinical record review, and document review, the facility failed to ensure the physician's orders for medication and bowel monitoring were followed for 2 of 6 sampled residents (Resident #1 and #5). The facility failed to ensure medication was prescribed by a physician prior to administration for 1 of 6 sampled residents (Resident #1). The facility failed to ensure bowel monitoring was done every shift for 4 of 6 sampled residents (Resident #1, #3, #4 and #5) in accordance with their policy. Findings include: The facility provided documentation entitled, Nursing Physical Assessment of the Older Adult "A Study Guide", Unit IX: Urinary Incontinence and Constipation in the Older Adult. #2 Constipation: Bowel frequency less than 3 times per week, untreated may lead to fecal impaction and bowel obstruction. A. Risk Factors: decreased physical activity...prolonged bed rest... The documentation indicated selected drugs known to be associated with high risk for constipation included; Iron supplements ([MEDICATION NAME] sulfate) and Narcotics ([MEDICATION NAME] and [MEDICATION NAME]). Clinical symptoms included anorexia, complaints of abdominal/rectal fullness, abdominal distention and fecal impaction. Resident #1 Resident #1 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The resident expired on [DATE]. Resident #1's physician's orders dated [DATE] through [DATE], documented monitor bowel movements every shift. The current physician's orders dated [DATE], for Resident #1 did not did not contain orders for laxative or suppositories. The [DATE], Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. The MAR indicated [REDACTED]. The MAR indicated [REDACTED]. The area on the MAR for the ,[DATE] shift lacked documentation the resident's bowel moments were monitored on [DATE], [DATE], [DATE], [DATE] and [DATE]. The facility provided documentation from their computerized documentation system dated [DATE] through [DATE]. The documentation contained entries dated [DATE] at 11:08 AM, a medium stool, [DATE] at 1:20 PM, a large stool, [DATE] at 7:58 PM, a medium and [DATE] at 11:53 AM, a medium stool. Documentation on the MAR's and from the computer system indicated Resident #1 did not have a bowel movement on [DATE], [DATE], [DATE], [DATE] (4 days), [DATE], [DATE] and [DATE]. The Nurse's Notes dated [DATE] and [DATE], lacked documentation to indicate the physician had been informed Resident #1 had not had a bowel movement since [DATE]. The Nurse's Notes dated [DATE], documented resident complained of constipation, one episode of small bowel movement, refused medications and "did not cover BS (blood sugar) due to not eating." Able to make needs known to staff. On [DATE] at 9:40 AM, a Nurse's note documented received an order for [REDACTED]. The x-ray revealed a small ileus and some stool. The physician was notified. Orders received for clear liquids and repeat KUB in the morning. On [DATE] at 6:15 PM, the Nurse's note documented resident found expired by nurse. The writer had just spoken to the resident at 6:05 PM. The resident complained of not feeling well. Resident skin was cold and clammy. Temperature was 96.8. The KUB of the abdomen done on [DATE], indicated modest small bowel ileus. Some measure of constipation also suggested. On [DATE] at 10:45 AM, Licensed Nurse (LN) #3 stated the facility's bowel monitoring process was if the resident had no bowel movement in three days the physician would be called for Milk of Magnesia (MOM). If the MOM did not work after 1 day then a suppository would be given and if no results from the suppository the physician would be contacted. LN #3 verbalized some residents had orders for MOM and some did not. If there was no order the physician would be contacted. On [DATE] at 11:18 AM, a Certified Nursing Assistant (CNA) stated when residents had a bowel movement she wrote it down on a piece of paper and gave it to the nurse. The information was also put into the computer system. On [DATE] at 1:15 PM, LN #1 stated she came into work on [DATE], and received shift report. LN #1 stated she had been told Resident #1 had an emesis times 2 and not had a bowel movement in 4 days. LN #1 stated during shift report she was told Resident #1 had 2 suppositories and the abdomen was soft but distended. LN #1 stated she wanted to see what was going on if the resident had 2 suppositories, with no results and loss of appetite. LN #1 stated she assessed Resident #1, the abdomen was soft, distended and had bowel sounds. The bowel sounds were not high pitched or hyperactive. LN #1 stated after she had assessed Resident #1, she notified the physician and asked for a KUB. LN #1 stated she notified the physician with the results of the KUB. LN#1 verbalized the information given in the interview had not been documented in the medical record. On [DATE], in the afternoon, the Director of Nursing (DON) verbalized the expectation was if a resident was having emesis to chart on the resident every day. This was a change in condition. The DON stated it was not clear from the Nurse's notes why the physician had ordered a KUB. The DON agreed the documentation in the medical record should reflect the resident's condition and the care provided. On [DATE], the facility faxed Nurse's Notes for Resident #1, indicated the notes were late entries. The documents were not in the medical record on [DATE], when an onsite visit was completed and chart copies were obtained. An (undated) late entry into the Nurse's notes dated [DATE] at 1:00 AM, documented the resident complained of no bowel movement for 4 days. The resident's abdomen distended, bowel sounds present but sluggish. At 3:00 AM, a [MEDICATION NAME] suppository was given. No hard BM (stool) noted upon insertion. An (undated) late entry into the Nurse's notes dated [DATE] at 3:30 AM, documented no result from suppository at present. Continue side turns. The resident was not complaining of pain and had no emesis. CNA's reported some gas release when turned. An (undated) late entry into the Nurse's notes dated [DATE] at 5:30 AM, still with no results from suppository. Resident had been drinking water through the night. Side to side turns also continued. Resident "states It doesn't hurt, but it's pretty uncomfortable". Will continue to monitor. The facility provided Nurse's Notes dated [DATE] at 2:15 PM, a late entry for [DATE]. The Nurse's Notes documented the night shift reported the resident had an emesis over the weekend times 2 and the night nurse gave a suppository with no effect. The writer assessed the resident. The resident's abdomen was distended, soft, bowel sounds present times 4, no complaints of pain or discomfort, no nausea or vomiting at this time. The night shift advised the writer the resident had not had a bowel movement 4 days. The writer sent a written text to the physician asking for a KUB. Advised the physician the resident had no bowel movement in 4 days, stomach distention but soft, 2 suppositories given with no results, resident "has LOA (loss of appetite) and vomiting over the weekend". The physician responded okay. At 1:04 PM, the writer sent a written text to the physician and provided the results of the KUB which indicated mild ileus and some stool. The physician responded with orders for clear liquid and repeat the KUB in the morning. The writer asked if the physician wanted an enema or "anything for stool". The physician responded "maybe tomorrow". The documentation received from the facility did not indicate the physician had given orders for a [MEDICATION NAME] suppository. On [DATE], the [DATE] MAR indicated [REDACTED]. On [DATE] at 7:45 AM, LN # 2 stated he had worked on [DATE], [DATE], [DATE] and [DATE] and was off on the weekend. LN #2 indicated he was not aware Resident #1 had any emesis prior to his death. LN #2 stated when he returned to work on [DATE], after the weekend he heard the CNA's complaining that Resident #1 had complained he did not have a bowel movement and nothing had been done. LN #2 stated when he saw Resident #1, the resident told him he had not had a bowel movement in 4 days. The resident was holding his stomach and saying this is not right. LN #2 verbalized the resident's abdomen was distended with slow bowel sounds and he knew something was wrong. LN #2 stated he checked the documentation in the medical record and saw the resident had no bowel movement and knew the resident was telling him the truth. LN #2 stated after 4 days MOM would take ,[DATE] hours to work and he wanted to find out what was going on. LN #2 stated he used his nursing judgement, gave a suppository and kept monitoring the resident. LN #2 indicated the facility's policy for bowel monitoring was staff were to document every shift the bowel movements and if no bowel movement times 3 days give MOM, if MOM was not effective give a suppository and fleets after that. LN #2 stated you definitely need a physician's order to give MOM or a suppository and "I neglected to look for the order". During the interview on [DATE], LN #2 verbalized Resident #1 had a "[MEDICAL CONDITION]" and refused to get out of bed. LN #2 stated he had worked at the facility for [AGE] years and had never seen Resident #1 out of bed. LN #2 verbalized Resident #1 was alert and orientated times 3 and would usually eat during the night shift. The resident would eat the food his family or the activity staff brought in or he would ask the CNA's to get him food from the vending machine. LN #2 stated on [DATE], Resident #1 did not eat during the shift. LN #2 stated Resident #1 was on opoid pain medications which would cause constipation. LN #2 stated the late entry into the medical record was done on [DATE] after 10:30 PM and placed under the DON's door. LN #2 stated he had been rushed in the morning and over looked documenting on Resident #1. LN #2 stated he forgot and the next day when he returned to work the resident had died . On [DATE] at 7:40 AM, CNA# 3 stated he had worked on [DATE] through [DATE] and had been assigned rooms ,[DATE]. Resident #1 was in room [ROOM NUMBER] A. On Friday night [DATE], he observed Resident #1 sitting up in bed eating potato chips which the resident loved. CNA #3 indicated Resident #1 usually ate potato chips, apples or oranges during the night shift. During the interview, CNA #3 stated on [DATE], Resident #1 had his call light on and was sitting up in bed with a pink "pail" on his chest trying to throw up. He noticed the resident's gown was wet and his stomach was "bloated". CNA #3 stated he told the Nurse. The nurse stated "I know" and gave the resident a suppository. CNA #3 stated he changed the resident and placed him on his right side. CNA #3 stated he and the other CNA's had rolled Resident #1 side to side and he had massaged the resident's stomach to "help move things". CNA #3 stated Resident #1 complained of being uncomfortable because he was "bloated". CNA #3 stated on the night of [DATE], Resident #1 had not been eating as he usually did. CNA #3 verbalized the next day he came into work and was told the resident had expired. CNA #3 verbalized he had heard staff grumbling over the weekend that Resident #1 had complained of constipation and no one did anything. On [DATE] at 3:10 PM, CNA #4 stated she worked the ,[DATE] shift and was assigned to care for Resident #1 on [DATE] and [DATE]. CNA #4 stated Resident #1 had thrown up a couple of times each day, had a "bloated stomach and could not eat. CNA #4 verbalized the nurse on duty was aware of this. CNA #4 stated the nurse gave Resident #1 a suppository over the weekend. CNA #4 indicated Resident #1 had not complained to her that he was in pain. On [DATE] at 3:15 PM, CNA #5 stated she was assigned to care for Resident #1 on [DATE] on the ,[DATE] shift. CNA #5 verbalized the resident "did not poop that day". CNA #5 stated the resident's stomach was "bloated" and you could tell his stomach was kinda hard". CNA #5 stated Resident #1 did not eat his dinner that night, he only drank the juice on the meal tray. Resident #5 Resident #5 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The resident had physician's orders for [MEDICATION NAME] Sodium 100 mg twice a day for constipation, Milk of Magnesia (MOM) 30 milliliters (ml) daily as needed for constipation and [MEDICATION NAME] 15 mg every 8 hours for pain. The MAR indicated [REDACTED]. The MAR indicated [REDACTED]. The [DATE], MAR indicated [REDACTED]. The computer system lacked documentation Resident #5 had a bowel movement on [DATE], [DATE], [DATE] and [DATE]. On [DATE] at 10:30 AM, Resident #5 stated she usually had a bowel movement every day. The resident stated if she went longer than a couple of days, it hurt to have a bowel movement and was uncomfortable. Resident #3 Resident #3 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The MAR indicated [REDACTED]. The MAR for all three shifts were blank from [DATE] through [DATE]. On [DATE] at 11:15 AM, a LN stated she was not sure why there was no bowel monitoring done. The documentation form in the computerized documentation system dated [DATE] through [DATE], indicated there were nine entries into the system to track the bowel monitoring for Resident #3 during this time period. The documentation dated [DATE], [DATE] and [DATE] indicated Resident #3 had a bowel movement. The MAR indicated [REDACTED]. The MAR indicated [REDACTED]. The MAR indicated [REDACTED]. Resident #4 Resident #4 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The [DATE], MAR indicated [REDACTED]. The MAR indicated [REDACTED]. The computerized system lacked documentation to indicate from [DATE] through [DATE], bowel monitoring was done every shift for Resident #4. The MAR indicated [REDACTED]. The MAR indicated [REDACTED]. On [DATE] at 11:10 AM, a staff member was not able to locate documentation in the medical record bowel monitoring had been done for Resident #4. On [DATE] in the afternoon, the facility's policy on bowel monitoring and the documentation for late entries were requested. The facility provided documentation entitled, Nursing Physical Assessment of the Older Adult "A Study Guide", Unit IX: Urinary Incontinence and Constipation in the Older Adult. The facility did not provide a written policy for the documentation of late entrees into the clinical record. Complaint #NV 413