Every finding on record at Jasper Point of Journey LLC

Based on observations, staff interviews, record review, facility policy review, and review of Centers for Disease Control and Prevention (CDC) guidance, the facility failed to establish and maintain an infection prevention and control program (IPCP) for recording incidents of infections identified under the facility's IPCP, surveillance, tracking and trending, and the corrective actions taken by the facility and failed to ensure heavy duty gloves were available for the laundry room for 49 of 49 census residents. These failed practices had the potential to affect the 49 residents residing in the facility.Findings include:Review of a facility's policy titled, Laundry Handling & Processing Policy, dated 2/1/2025, indicated .Laundry in a healthcare facility may include bed sheets, blankets, towels' personal clothing' patient apparel, gowns, and other linens. The overall risk of disease transmission during the laundry process is low, infection has not been linked to laundry procedures in residential care facilities, even when consumer versions of detergents and laundry additives are used. Employees must don appropriate PPE [Personal Protective Equipment] (e.g., tear-resistant reusable gloves, gown/apron, and/or face shield/goggles) to sort personals prior to washing.Review of a facility's policy titled, Infection Prevention and Date Control Program, dated 3/20/2025, indicated .This facility has established and maintains an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections as per accepted national standards and guidelines.Review of a document titled, Centers for Disease Control (CDC).National Healthcare Safety Network (NHSN).Long Term Care Facility Component Tracking Infections in Long-Term Care Facilities., located at https://www.cdc.gov/nhsn/pdfs/ltc/ltcf-manual-508.pdf, dated January 2020, indicated .Surveillance is defined as the ongoing systematic collection, analysis, interpretation, and dissemination of data. A facility infection prevention and control (IPC) program should use surveillance to identify infections and monitor performance of practices to reduce infection risks among residents, staff, and visitors. Information collected during surveillance activities can be used to develop and track prevention priorities for the facility. When conducting surveillance, facilities should use clearly defined surveillance definitions that are collected in a consistent way. This method ensures accurate and comparable data regardless of who is performing surveillance.1. During an interview on 11/21/2025 at 1:26 pm, the Director of Nursing (DON) stated he was the current Infection Preventionist (IP). The DON stated he was in the process of completing September 2025 and October 2025 infection control surveillance. During this interview, a review was conducted of the data from February 2025 through August 2025 and the following data was missing: no surveillance, no tracking or trending, and no line listing of the residents who had current infections and the corrective action taken. The DON stated there was no evidence that IC audits were completed by the previous DONs. The DON stated it was important to have line listing of people who have infections and who were on antibiotics to ensure the residents were on the proper antibiotics and if corrective action needed to be taken. The DON stated that the facility needed a visual representation to look for trends and localizations of certain infections. The DON confirmed there was no surveillance data from February 2025 to August 2025 and confirmed there was no associated analysis. 2. An observation was conducted on 11/21/2025 at 1:53 pm, and there were no heavy-duty gloves available for the laundry room staff to use. The DON was present and confirmed this observation. During an interview on 11/21/2025 at 1:54 pm, the Accounts Manager for Laundry Services confirmed that there were no heavy-duty protective gloves present for the staff to utilize.During an interview on 11/21/2025 at 1:58 pm, Laundry Aide (LA) 1 confirmed she never used heavy-duty gloves when sorting soiled laundry and only utilized disposable gloves. During an interview on 11/21/2025 at 2:04 pm, the Accounts Manager stated it was important for staff to use the heavy-duty gloves while sorting soiled linens since it was a potential infection control matter and staff could get poked by a used needle.

Based on observations, record review, resident family member and staff interviews, and facility policy review, the facility failed to ensure personal information was kept confidential for one of one resident (Residents (R) 10) reviewed for privacy of 34 sample residents. This failure had the potential to cause emotional distress.Findings include:Review of a facility's undated policy titled, Your Rights and Protections as a Nursing Home Resident indicated .As a nursing home resident, you have certain rights and protection under Federal and state law that help ensure you get the care and services you need. You have the right to be informed, make your own decisions, and have your personal information kept private.Review of R10's electronic medical record (EMR) titled admission Record located under the Profile tab indicated the resident was admitted to the facility on [DATE] with a diagnosis of Alzheimer's disease.Review of R10's quarterly Minimum Data Set (MDS) located under the MDS tab with an Assessment Reference Date (ARD) of 8/29/2025 indicated the resident had a Brief Interview for Mental Status (BIMS) score of nine out of 15 which, revealed the resident was moderately cognitively impaired.During an observation conducted on 11/17/2025 at 10:30 pm, R10 was in bed. On the right side of her bed hanging from the wall was a document titled, Bowel and Bladder Record Data Collection Tool, dated 11/17/2025, which indicated the staff was collecting data on the resident for bowel and bladder cares.During an observation conducted on 11/18/2025 at 1:57 pm, the Bowel and Bladder Record Data Collection Tool, dated 11/18/2025, was hanging on the right side of R10's bed. R10 was sitting in her wheelchair. An interview was conducted with a Family Member (F1) during this observation. F1 stated the resident had church members who would visit her and this confidential information was posted for anyone to read. An attempt was made to interview R10, but it was not successful.During an interview on 11/19/2025 at 9:56 am, Certified Nurse Aide (CNA) 1 confirmed that the Bowel and Bladder Record Data Collection Tool was always kept on R10's wall next to her bed.During an interview on 11/21/2025 at 1:20 pm, the Administrator stated that it was his understanding that the Bowel and Bladder Record Data Collection Tool was in R10's side table drawer and not on the wall posted in the resident's room.

Based on resident family member and staff interviews, record review, and facility policy review, the facility failed to include proper reasons for a discharge/transfer for one of one resident (Resident (R) 10) reviewed for discharge of 34 sample residents. This had the potential for the resident to have significant stress. Findings include:Review of a facility's policy titled, Transfer and Discharge (including AMA [Against Medical Advice]), dated 3/20/2025 indicated .It is the policy of this facility to permit each resident to remain in the facility, and not transfer or discharge the resident from the facility, except in limited circumstances. This policy applies to all residents regardless of their payment source. Once admitted , the resident has the right to remain at the facility unless their transfer or discharge meets one of the following specified exemptions.The transfer or discharge is necessary for the resident's welfare and the resident's needs cannot be met in the facility.The transfer or discharge is appropriate because the resident's health has improved sufficiently so that the resident no longer needs the services provided by the facility.The safety of individuals in the facility is endangered due to the clinical or behavioral status of theResident.The health of individuals in the facility would otherwise be endangered.The resident has failed, after reasonable and appropriate notice, to pay or have paid under Medicare or Medicaid for his or her stay at the facility. Nonpayment applies if the resident does not submit the necessary paperwork for third party payment or after the third party, including Medicare or Medicaid, denies the claim and the resident refuses to pay for his or her stay.The facility ceases to operate.Review of R10's electronic medical record (EMR) titled admission Record located under the Profile tab indicated the resident was admitted to the facility on [DATE] with a diagnosis of Alzheimer's disease.Review of R10's quarterly Minimum Data Set (MDS) located under the MDS tab with an Assessment Reference Date (ARD) of 8/29/2025 indicated the resident had a Brief Interview for Mental Status (BIMS) score of nine out of 15, which revealed the resident was moderately cognitively impaired.Review of an untitled document, provided by the facility, referred to as an involuntary transfer/discharge notice, dated 10/22/2025 and sent to R10's Family Member (F) 1. The letter revealed .Due to concerns that have been addressed by the facility but have not been deemed acceptable by the Responsible Party. These events have caused the need for this 30-Day Notice to transfer or discharge.A review of R10's EMR failed to contain evidence that the facility staff were unable to provide care for the resident. In addition, the clinical records failed to indicate that the resident was a danger to self or to others.During an interview on 11/18/2025 at 1:49 pm, F1 stated he was aware the reasons for the involuntary transfer/discharge notice were inappropriate and had currently appealed the facility's decision.During an interview on 11/21/2025 at 1:20 pm, the Administrator confirmed R10 was not a danger to self or to others and this was an oversight on the transfer/discharge requirements.

Based on staff interviews, record review, and facility policy review, the facility failed to ensure a resident and Resident Representative (RR) received a written transfer agreement and bed hold notice for one (Resident (R)59) out of two reviewed for transfers from a sample of 34 residents. This failure had the potential to affect the resident and their RR by not having the knowledge of where and why a resident was transferred and/or how to appeal the transfer, if desired, and contribute to the possibility of denial of re-admission and loss of the resident's home following a hospitalization for residents transferred to the hospital.Findings include:Review of facility's policy titled, Transfer and Discharge (including AMA) dated 3/20/2025 indicated, 3. The facility's transfer/ discharge notice will be provided to the resident and resident's representative in a language and manner in which they can understand. The notice will include all of the following at the time it is provided: a. The specific reason and basis for transfer or discharge; b. The effective date of transfer or discharge; c. The specific location (such as the name of the new provider or description and/ or address if the location is a residence) to which the resident is to be transferred or discharged .Review of the facility's undated policy titled, Bed Hold Policy indicated, Regardless of a resident's payer status, you are required to notify all long-term resident and/ or family in advance with a bed hold notice . If necessary, you may document a conversation with family by phone using name, date, time, and details of conversation on bed hold form. You must still mail out the bed hold.Review of R59's Progress Notes located under the Prog Note tab in the Electronic Medical Record (EMR) dated 2/1/2025 at 3:40 pm revealed the resident was transported to the emergency room.Review of R59's EMR revealed no documentation that R59 or the RR was provided the transfer notice or bed hold policy for the hospital transfer dated 2/1/2025. An interview on 11/21/2025 at 3:31 pm with the Social Services Director (SSD) revealed she was unable to locate the transfer notice/ bed hold notice for the resident's transfer to the hospital on 2/1/2025.An interview on 11/21/2025 at 3:45 pm with the Administrator revealed the facility sent the transfer notice to the hospital and social services called the RR.

Based on record review and resident and staff interviews, the facility failed to ensure the comprehensive assessment accurately reflected a facility fall for one (Resident (R) 4) of two residents reviewed for falls in the sample of 34 residents. This failure had the potential for unmet care needs.Findings include:Review of R4's admission Record located under the Profile tab of the electronic medical record (EMR) revealed the resident was admitted on [DATE] with diagnoses of muscle weakness, difficulty walking, and a need for assistance with personal care.Review of R4's hospital After Visit Summary paperwork located under the Misc tab of the EMR dated 7/3/2025 revealed the resident had a fall resulting in a contusion of left shoulder and a closed head injury.Review of R4's Care Plan located under the Care Plan tab of the EMR revealed the resident was at risk for falls or fall related injury related to having impaired mobility. On 7/3/2025, the Care Plan revealed the resident had a fall. Staff were educated/reeducated on proper procedure when using a Hoyer lift (mechanical lift), date initiated 7/3/2025.Review of R4's quarterly Minimum Data Set (MDS) located under the MDS tab in the EMR with an Assessment Reference Date (ARD) of 8/15/2025 revealed the resident did not have any falls. During an interview with R4 on 11/18/2025 at 10:57 am, she confirmed she had a fall from the mechanical lift and was sent to the emergency room.During an interview on 11/21/2025 at 1:05 pm with the Regional Minimum Date Set Coordinator (MDSC) she confirmed R4's fall on 7/3/2025 should have been documented on her quarterly MDS with an ARD of 8/15/2025 to ensure accuracy.

Based on observations, staff interviews, record review, and facility policy review, the facility failed to ensure residents' care plans reflected current level of care for two of 34 sample residents (Resident (R) 4 and R54) reviewed for care plans. This failure had the potential to affect resident care outcomes. Findings include:Review of the policy titled, Comprehensive Care Plans, dated 3/20/2025, revealed, It is the policy of the facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that include measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs.1.Review of R4's admission Record located under the Profile tab of the electronic medical record (EMR) the resident was admitted to the facility on [DATE] with a diagnosis of Post Traumatic Stress Disorder (PTSD) and bipolar disorder.Review of Resident 4's Progress Notes located under the Prog Note tab in the EMR revealed on 2/26/2025 the resident had trauma screening conducted that indicated PTSD and bipolar disorder.Review of Resident 4's Care Plan located under the Care Plan tab of the EMR did not document PTSD or bipolar disorder.Review of Resident 4's quarterly Minimum Data Set (MDS) located under the MDS tab in the EMR with an Assessment Reference Date (ARD) of 8/15/2025 revealed a Brief Interview for Mental Status (BIMS) score of 15 out of 15, which indicated R4 was cognitively intact. The MDS further revealed R4 sometimes self-isolated. Diagnoses revealed bipolar disorder and PTSD.During an interview with the Regional Minimum Data Set Coordinator (MDSC) on 11/21/2025 at 1:05 pm, the MDSC confirmed R4 should have been care planned for PTSD and bipolar disorder so there would be interventions in place if issues were to arise from the diagnoses. 2.Review of R54's admission Record located in the Profile tab of the electronic medical record (EMR) revealed he was admitted to the facility on [DATE] with anxiety disorder and depression. The record also revealed he was diagnosed with psychotic disorder with hallucinations on 5/13/2025.Review of R54's significant change of condition Minimum Data Set (MDS) assessment, with an assessment reference date (ARD) of 8/18/2025 and located in the MDS tab of the EMR, revealed a Staff Assessment for Mental Status (SAMS), which indicated short- and long-term memory problems. The MDS also indicated R54 had diagnosis of anxiety disorder, depression, and psychotic disorder. Review of R54's Care Plan, revealed there were no care plans addressing R54's diagnosis of major depressive disorder or psychotic disorder with hallucinations. During an interview on 11/21/2025 at 1:05 pm, the Regional MDSC stated there should be care plans for major depressive disorder and psychotic disorder. The care plan gives staff directions when behaviors are exhibited.

Based on record review, resident and staff interviews, and facility policy review, the facility failed to ensure one (Resident (R)4) out of four reviewed for accidents out of a total sample of 34 residents was properly secured during a Hoyer lift (mechanical lift) transfer and sustained a fall. This had the potential for the resident to sustain serious injury. Findings include:Review of a facility's policy titled, Accidents and Supervision, dated 2/1/2024, indicated . The resident environment will remain as free of accident hazards as is possible. Each resident will receive adequate supervision and assistive devices to prevent accidents.Identifying hazard(s) and risk(s).Evaluating and analyzing hazard(s) and risk(s).Implementing interventions to reduce hazard(s) and risk(s).Monitoring for effectiveness and modifying interventions when necessary.Review of R4's admission Record located under the Profile tab of the electronic medical record (EMR) revealed the resident was admitted on [DATE] with diagnoses of muscle weakness, difficulty walking, and a need for assistance with personal care.Review of R4's quarterly Minimum Data Set (MDS) located under the MDS tab in the EMR with an assessment reference date (ARD) of 8/15/2025 revealed a Brief Interview for Mental Status (BIMS) score of 15 out of 15, indicating the resident was cognitively intact. The MDS noted that R4 was dependent on staff for transferring.Review of R4's Progress Notes located under the Prog Note tab of the EMR dated 7/3/2025 at 12:30 pm revealed the resident had a fall from a mechanical (Hoyer) lift.Review of R4's hospital after visit summary paperwork located in the EMR under the Misc tab dated 7/3/2025 revealed the resident had a fall resulting in a contusion of left shoulder and a closed head injury. There resident was not admitted to the hospital and no new orders were received. Review of R4's Care Plan located under the Care Plan tab of the EMR revealed the resident was at risk for falls or fall related to having impaired mobility. The Care Plan noted the resident had a fall on 7/3/2025 and staff was educated/reeducated on proper procedure when using Hoyer lift, date initiated 7/3/2025.During an interview with R4 on 11/18/2025 at 10:57 am, she confirmed she had fallen from the mechanical lift and was sent to the emergency room.During an interview with Administrator on 11/21/2025 at 3:45 pm, the Administrator confirmed the resident had fallen from a mechanical lift that was being operated by one staff member and two staff members should have been present. The Administrator confirmed staff were educated and trained on the proper use of the mechanical lift and that the Certified Nursing Assistant (CNA) involved was suspended for three days and retrained.

Based on observations, staff interview, record review, and facility policy review, the facility failed to provide respiratory care in accordance with professional standards for one of one (Resident (R) 21) residents reviewed for respiratory care out of a total sample of 34 residents. Specifically, respiratory equipment, such as nebulizer masks, were not stored in a sanitary manner and physician orders for oxygen levels were not followed. The deficient practice had the potential for a risk of infection and respiratory distress. Findings include:Review of facility's policy titled, Oxygen Administration with a revision date of 2/14/2024, noted Policy: Oxygen is administered to residents who need it, consistent with professional standards of practice, the comprehensive person-centered care plans, and the resident's goals and preferences. Policy Explanation and Compliance Guidelines Oxygen is administered under orders of a physician.Staff shall perform hand hygiene and don (put on) gloves when administering oxygen or when in contact with oxygen equipment. Other infection control measures include. keep delivery devices covered in plastic bag when not in use.Review of facility's policy titled, Oxygen Concentrator with a revision date of 2/16/2025, noted Policy: The purpose of this policy is to establish responsibilities for the care and use of oxygen concentrators. Policy Explanation and Compliance Guidelines:.Oxygen is administered under orders of the attending physician. Use of the concentrator: The nurse shall verify physician's order for the rate of flow and route of administration of oxygen (mask, nasal cannula, etc.) . Keep turned off when set up for use in the resident's room, but not actively in use.Review of R21s admission Record located in the electronic medical record (EMR) under the Profile tab revealed R21 was admitted on [DATE] with a diagnoses of chronic obstructive pulmonary disease (COPD), respiratory failure with low oxygen (hypoxia), chronic cough, and bronchitis.Review of R21s quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 7/30/2025 revealed a Brief Interview for Mental Status (BIMS) score of 15 out of 15, which indicated R21 was cognitively intact. Special Treatments, Procedures, and Programs revealed oxygen therapy.Review of R21s Care Plan located in the EMR under the Care Plan tab revealedR21 had a potential at risk for altered respiratory status related to her diagnoses of COPD, and respiratory failure, date initiated 6/15/2024. Oxygen as ordered, date initiated 6/15/2024.Give nebulizer treatments as ordered, date initiated: 6/15/2024. Oxygen as needed (PRN). R21 used oxygen therapy routinely or as needed and is at risk for ineffective gas exchange. This is related to her diagnosis. of COPD, date initiated 8/8/2024. Administer oxygen therapy per physician's orders, date initiated: 8/8/2024.Review of R21s Physician Orders located in the EMR under the Orders tab revealed keep nebulizer mask stored in a clean storage bag at all times every shift. Start date 8/06/2024. 2 (liters) L Oxygen (as needed) PRN through nasal cannula as needed for hypoxia oxygen saturation below 90% Start Date 9/2/2024. Ipratropium-Albuterol Solution 0.5-2.5 (3) milligrams (MG)/3 milliliter (ML) 3 ml inhale orally every six hours as needed for SOB [shortness of breath] Start date 1/15/2025.During an observation on 11/18/2025 at 10:34 am, R21 was in her room observed with oxygen at three liters per minute (LPM) through nasal cannula. R21 had a nebulizer mask sitting on the bedside table not in a storage bag.During an observation on 11/18/2025 at 3:38 pm, R21 was sitting in bed with oxygen through nasal cannula running at three LPM. R21's nebulizer mask was sitting on the bedside table not in a storage bag.During an observation on 11/19/2025 at 1:40 pm, revealed R21's nebulizer mask was sitting on bedside table not in storage bag.During an interview on 11/21/2025 at 1:39 pm, Assistant Director of Nursing (ADON), at R21's bedside, confirmed the resident's oxygen was set on three liters, and the nebulizer was not in a storage bag.

Based on record review and staff interview, the facility failed to ensure the clinical records were complete for one of three residents (Resident (R) 10) reviewed for pressure ulcers out of a total sample of 34 residents. This failure created the opportunity for inaccurate medical records to be accessible to staff.Findings include:Review of a facility's policy titled, Verbal Orders, dated 2/14/2024, indicated .Physician orders may be received by telephone, by a licensed nurse or other licensed or registered healthcare specialist who are legally authorized to do so.Review of R10's electronic medical record (EMR) titled admission Record located under the Profile tab indicated the resident was admitted to the facility on [DATE] with a diagnosis of Alzheimer's disease.Review of R10's EMR quarterly Minimum Data Set (MDS) located under the MDS tab with an Assessment Reference Date (ARD) of 8/29/2025 indicated the resident had a Brief Interview for Mental Status (BIMS) score of nine out of 15, which revealed the resident was moderately cognitively impaired.Review of a document provided by hospice titled, Patient Care Verbal Order, dated 9/8/2025, indicated .For Pressure Wound: Using aseptic technique perform wound care to coccyx. Remove old dressings from wound then cleanse wound with wound cleanser. [or normal saline] .Gently pat wound dry. Apply skin prep to intact skin surrounding wound. Pack wound with gauze packing. Cover wound with comfort foam dressing. Redress wound 7 x per week. May redress wound as needed for displacement or if dressings are soiled. Perform for duration of end-of-life-care or until healed. As directed. Review of R10's EMR titled Treatment Administration Record (TAR) located under the Orders tab for September 2025 failed to contain evidence that the hospice wound care orders were transcribed correctly. The September 2025 TAR indicated .Sacral wound clean with wound cleanser, fill wound bed with kerlix soaked in wound cleanser and xeroform cover with sacral pad. Daily/PRN [as needed] until resolved.Review of R10's EMR titled TAR located under the Orders tab for October 2025 failed to contain evidence that the hospice wound care orders were transcribed correctly. The 10/25 TAR indicated .Sacral wound clean with wound cleanser, fill wound bed with kerlix soaked in wound cleanser and xeroform cover with sacral pad. Daily/PRN until resolved every day.Review of R10's EMR titled TAR located under the Orders tab for November 2025 failed to contain evidence that the hospice wound care orders were transcribed correctly. The November 2025 TAR indicated .Sacral wound clean with wound cleanser, fill wound bed with kerlix soaked in wound cleanser and xeroform cover with sacral pad. Daily/PRN until resolved every day shift for wound healing.Review of R10's EMR titled Physician Orders located under the Orders tab, dated 11/4/2025, indicated to clean the resident's sacral wound with wound cleanser, fill wound bed with kerlix soaked in wound cleanser and xeroform cover with sacral pad and as needed if loose or soiled.Review of R10's EMR titled Physician Orders located under the Orders tab, dated 11/5/2025, indicated that hospice was to provide wound care by cleaning the resident's sacral wound with wound cleanser, to fill wound bed with kerlix soaked in wound cleanser and apply xeroform with sacral pad daily until resolved.During an interview conducted on 11/21/2025 at 3:59 , the [NAME] President (VP) of Clinical Services confirmed that R10's treatment order was transcribed incorrectly and that the order came through as a verbal order.

Based on staff interview, record review, review of the Centers for Disease Control and Prevention (CDC) guidelines, and facility policy review, the facility failed to offer one of five residents (Resident (R) 26) reviewed for flu/pneumonia vaccinations out of 34 sample residents and/or their representatives the opportunity for the residents to be vaccinated in accordance with nationally recognized standards. In addition, the facility failed to have an acute policy displaying the CDC's recommendation. This practice had the potential to increase the risk for residents to contract pneumonia.Findings include:Review of a facility's policy titled, Infection Prevention and Control Program, dated 3/20/2025, indicated .Residents will be offered the pneumococcal vaccines recommended by the CDC upon admission, unless contraindicated or received the vaccines elsewhere.Review of R26's electronic medical record (EMR) titled, admission Record located under the Profile tab indicated the resident was admitted to the facility on [DATE]. The resident was over the age of 65 at the time of his admission.Review of R26's EMR titled, Immunizations located under the Immun (Immunization) tab indicated the resident had Pneumovax 23 [pneumococcal polysaccharide (PPSV23)] on 1/27/2010.Review of a document provided by the facility titled, admission Packet contained a document titled, Informed Consent for Pneumococcal Vaccine, indicated .The Advisory committee on Immunization Practice recommends two pneumococcal vaccines for adults [AGE] years of age or older' it is recommended that adults 65 or older receive a dose of the pneumococcal conjugate (PCV13) and the pneumococcal polysaccharide (PPSV23) for the best protection against pneumococcal disease.If you are 65 or older and have NOT had a pneumonia vaccine, you should receive one dose of PCV13 now, and in one year get a dose of PPSV23. If you have had a pneumococcal vaccine after the age of 65, then you received the PPSV23, and should receive a dose of PCVl3 at least one year after your last dose of PPSV23.During an interview on 11/21/2025 at 1:26 pm, the Director of Nursing (DON) confirmed he was not aware of the current CDC pneumococcal vaccinations. The DON stated it was important to have an accurate policy on vaccinations to ensure the staff provided the most accurate information to residents and/or their representatives.

Based on interviews and record review the facility failed to complete Fall Risk Assessments during the admission process and post falls for two Residents (R) (R3 and R4) of three residents reviewed for falls. Findings include: 1.R3 was admitted to the facility on [DATE]. Her admitting diagnoses include, but not limited to unspecified fracture of shaft of left femur, Alzheimer's disease, fall on same level, and encounter for other orthopedic aftercare. The Brief Interview of Mental Status (BIMS) was conducted on 9/27/2024 and revealed that R3 was rarely/never understood. Review of care plan revealed that resident had falls on 9/29/2024, 10/8/2024, and 10/9/2024. Review of the medical record revealed falls occurring on 9/29/2024, 10/8/2024, and 10/09/2024. Further review revealed that there was no evidence that a Fall Risk Assessment was completed for date of admission, post fall on 9/29/2024, post fall on 10/8/2024, or post fall 10/9/2024. Further records review revealed that fall risk evaluation was completed on 10/13/2024 with a score of 22.0. The assessment category indicated High Risk. 2.R4 was admitted to the facility under the services of hospice on 10/2/2024. Her admitting diagnoses include, but not limited to chronic congestive heart failure, and osteoarthritis of left shoulder and right knee. The Brief Interview of Mental Status (BIMS) was conducted on 11/25/2024 and revealed that R4 was cognitively intact. Review of Fall Occurrence Note dated 11/24/2024 at 1:15 am revealed: While on runs heard resident screaming out for help. I entered her room and observed resident sitting on the floor next to bed. Her back was against the bed. Call light in reach. Resident sustained a skin tear to right forearm. First aid given. Resident complaining of pain to the left knee. Resident currently on hospice care. Hospice Nurse on called notified. Contacts listed as self. Review of admitting records revealed that there was no evidence that a Fall Risk Assessment was completed for date of admission. Further review of electronic medical record included a Morse Falls Risk Evaluation dated 11/24/2024 with a score of 75. The assessment tool stated that a score higher than 45 indicated a resident was at high risk for falls. An interview was conducted with Director of Nursing (DON) on 11/27/2024 at 11:30 am. She stated that fall risk assessment should be completed during initial assessment. She Confirmed that R3 and R4 did not have fall risk assessments completed during admission. She started working at this facility on 11/01/2024 and she is not aware who was responsible for fall assessment for new admissions prior 11/01/12024. Interview with LPN AA 11/27/2024 at 11:50 am confirmed that fall risk assessments should be completed during admission, even for residents with hospice services. Interview with Administrator on 11/27/2024 at 12:25 pm revealed his expectation for all nurses to complete all required assessments.

Based on record review, staff interviews, and review of facility documents titled, Facility Assessment Tool and the PBJ (payroll-based journal) Staffing Data Report, the facility failed to ensure that the facility had adequate nursing staff on the weekends. The deficient practice had the potential to affect the care provided to the 51 residents that resided in the facility. Findings include: Review of The Facility Assessment Tool dated 4/17/2024 revealed the average daily census in the facility was 57 residents. The Facility Assessment Tool documented the average hourly staffing needs per day were 36 - 48 hours for licensed nurses providing direct care, and 105 - 120 hours for nurse aides. Review of the PBJ Staffing Data Report FY (fiscal year) Quarter 2 2024 (1/1/2024 through 3/31/2024) revealed based on the data submitted, the facility triggered Excessively Low Weekend Staffing. Review of PBJ Data Hours Log, provided by the facility, for FY Quarter 2, revealed an average of 77 hours per day for nurse's aides for weekends. Interview on 7/21/2024 at 3:00 pm with the Regional Director of Clinical Operations (RDCO) and the Regional Nurse Consultant (RNC) CC revealed they were both aware of PBJ's excessively low weekend staffing received for the second quarter of 2024.

Based on observations and staff interviews, the facility failed to maintain the walk-in freezer in a manner to prevent ice buildup from forming on the freezer unit. This failure had the potential to contaminate food items located under the ice and place the 51 residents receiving an oral diet from the kitchen at risk of contracting a foodborne illness. The facility census was 51. Findings include: Observation of the walk-in freezer on 7/19/2024 at 8:00 am revealed ice formations hanging from the freezer unit located to the left side of the door. The ice formations ranged in size from 6 inches in diameter at the top to less than 1 inch in diameter at the floor and were observed on the shelving below the freezer unit and the freezer floor. The Certified Dietary Manager (CDM) verified the ice formation and the buildup of ice on the freezer floor. In an interview on 7/19/2024 at 8:00 am, the CDM stated the walk-in freezer had malfunctioned a while back, and the Maintenance Director and Interim Administrator were aware. She further stated an outside company had inspected the freezer, but it had not been repaired. She stated the dietary staff were aware to avoid storing food items on the shelves under the freezer unit and to use caution when walking in the freezer due to the ice formation on the floor. She further stated she had discarded numerous cases of foods due to ice formation on the foods. In an interview on 7/20/2024 at 10:05 am, the Maintenance Director stated he was aware of the ice formation in the walk-in freezer and that he manually removed the ice periodically. He further stated he thought an outside service provider had inspected the freezer before he was employed at the facility, but he was unsure what the recommendations were. He stated that the Interim Administrator was aware of the concern. In an interview on 7/20/2024 at 10:10 am, the Regional Director of Environmental Services stated he was unaware of a concern with the walk-in freezer prior to this date and that he would address the concern. In an interview on 7/20/2024 at 10:20 am, the Interim Administrator stated she was aware of the ice formation in the walk-in freezer. She stated the concern began before she became the Interim Administrator, and the Regional Director was aware of it. She stated an outside service provider had inspected the freezer, but she was unsure of the date or recommendations. In an interview on 7/20/2024 at 3:05 pm, the Maintenance Director stated he was unable to locate documentation of an outside service provider inspecting or servicing the walk-in freezer. In an interview on 7/21/2024 at 11:40 am, the Interim Administrator stated she was unable to provide documentation of a service visit for the walk-in freezer. Observation on 7/21/2024 at 3:15 pm of the walk-in freezer with the CDM revealed the freezer had ice formation hanging from the freezer unit located to the left side of the door. The ice formation extended onto the shelving and the floor. One case of pie crust located on the lower shelf was covered in ice formation, and there was ice buildup on the floor. The CDM stated staff tried to avoid placing items under the freezer unit, but there was limited space to store frozen foods. She discarded the case of pie crust and stated she had previously discarded numerous cases of foods due to ice forming on them.

Based on record review, staff interviews, and review of the facility policy titled, Quality Assurance and Performance Improvement (QAPI), the facility failed to ensure the Medical Director or an appointee of the Medical Director's attendance and participation in QAPI committee meetings, at least quarterly. Specifically, the Medical Director or their appointee was not present and did not attend three of the six QAPI committee meetings reviewed. Findings include: Review of the facility policy titled Quality Assurance and Performance Improvement (QAPI) date implemented 8/1/2023 revealed under the section titled Policy Explanation and Compliance Guidelines number two The Quality Assessment and Assurance (QAA) Committee shall be interdisciplinary and shall consist at minimum of the Director of Nursing (DON), Medical Director or his/her designee, and at least three other members of the facility's staff, at least one of which must be the Administrator, Owner, a Board Member or other individual in a leadership role, and the Infection Preventionist. Review of the QAPI committee meeting sign-in sheets, dated 7/18/2023, 8/24/2023, 9/25/2023, 11/2/2023, 1/26/2024 and 4/25/2024 revealed the medical director nor their appointee's signature was not found on the sign in sheets dated 11/2/2023, 1/26/2024 and 4/25/2024. During an interview on 7/21/2024 at 3:56 pm, the Regional Director of Clinical Operations AA revealed that the QAA committee met regularly. She confirmed that neither the Medical Director's signature nor a designee of the Medical Director's signature was on the QAPI meeting sign-in sheets for 11/2/2023, 1/26/2024, or 4/25/2024. She revealed that neither the Medical Director nor their appointee attended the meetings, nor did they have documentation otherwise.

Based on staff interviews, record review, and a review of the facility policy titled, Resident Assessment-Coordination with PASARR (preadmission screening and resident review) Program, the facility failed to submit a PASARR Level II for two of four residents (R) (R5 and R19) reviewed after a new mental illness diagnosis was added. This deficient practice had the potential to affect the appropriate level of care and services provided for R5 and R19. Findings include: A review of the facility policy titled Resident Assessment-Coordination with PASARR Program dated 2/12/2022 revealed the Policy stated, This facility coordinates assessments with the preadmission screening and resident review (PASARR) program under Medicaid to ensure that individuals with a mental disorder, intellectual disability, or a related condition receive care and services in the most integrated setting appropriate to their needs. The Policy Explanation and Compliance section stated, 6. The Social Services Director shall be responsible for keeping track of each resident's PASARR screening status and referring to the appropriate authority. 9. Any resident who exhibits a newly evident or possible serious mental disorder, intellectual disability, or a related condition will be referred promptly to the state mental health or intellectual disability authority for a level II resident review. Examples include: b. A resident whose intellectual disability or related condition was not previously identified and evaluated through PASARR. 1. A review of the electronic medical record (EMR) revealed that R5 was admitted to the facility with diagnoses including but not limited to generalized anxiety disorder, migraine, and major depressive disorder. Further review revealed a diagnosis of bipolar disorder was added on 2/1/2024. A review of the annual Minimum Data Set (MDS) dated [DATE] in section A (Identification Information) documented the resident was not currently considered by the state Level II PASRR process to have serious mental illness and/or intellectual disability or a related condition, section I (Active Diagnoses) documented bipolar disorder, and section O (Special Treatments and Programs) documented R5 did not receive psychological services. A review of the quarterly MDS dated [DATE] revealed section I (Active Diagnoses) documented bipolar disorder, and section O (Special Treatments and Programs) documented R5 did not receive psychological services. A review of the EMR revealed no documentation of psychological services in the last 12 months. A review of the EMR revealed a PASRR Level I request dated 1/7/2021 without bipolar disorder marked on the form. A further review revealed there was no re-submission for a PASRR Level I after the bipolar diagnosis was added on 2/1/2024. The facility did not have a Social Services Director (SSD). The Director of Nursing (DON) was unavailable for an interview. In an interview on 7/20/2024 at 11:30 am, the Interim Administrator verified R5 had a diagnosis of bipolar disorder dated 2/1/2024 and did not have a PASRR Level II. She stated when a resident received a serious Mental Disorder (MD) or Intellectual Disability (ID) diagnosis, the SSD was responsible for submitting for a PASRR Level II. She stated new diagnoses were discussed in the morning meetings and the SSD typically attended the meetings. The Interim Administrator further stated the facility currently did not have an SSD. In an interview on 7/20/2024 at 2:13 pm, Regional Nurse Consultant (RNC) CC stated when a resident was newly diagnosed with a serious MD or ID, the SSD should submit for a PASRR Level II. She stated new diagnoses were discussed in the morning and care plan meetings, and the SSD typically attended the meetings. She further stated the PASRR Level II was used to ensure a resident received the specialized care and services recommended and without the PASRR Level II recommendations, a resident could have adverse effects such as not receiving needed services and medication management by a specialized provider. 35062 2. A review of the Face Sheet revealed that R19 was admitted without a significant mental health diagnosis and a primary diagnosis of fibromyalgia. On 10/19/2023, the resident had a new diagnosis of panic disorder and on 2/1/2024 the resident had a new diagnosis of bipolar disorder. Review of the PASRR Level I dated 5/18/2023 revealed no primary diagnosis of dementia and no primary diagnosis of serious mental illness. Further review of the clinical record revealed no documented evidence that the resident was reevaluated related to a new diagnosis of mental illness. A review of the annual MDS dated [DATE] revealed R19 had a BIMS score of 14, indicating R19 was cognitively intact. Section A (Identification Information) documented the resident had not been evaluated by PASRR Level II. Section I (Active Diagnoses) documented anxiety disorder, depression, and bipolar disorder. Section O (Special Treatments and Programs) documented no psychological therapies or treatments were received. Review of the Physician Orders dated 7/1/2024 revealed R19 had an order for olanzapine (antipsychotic medication) 2.5 milligrams (mg) every morning and at bedtime related to bipolar disorder per psychiatry. Interview on 7/20/2024 at 2:53 pm with Regional Nurse Consultant CC revealed she was unable to locate a PASRR Level II for R19 and was unsure why the resident was not reevaluated with the new diagnosis. She indicated she attempted to contact the Social Worker who was no longer employed at this time and was unsuccessful.

Based on observations, resident and staff interviews, record review, and review of the facility policies titled Comprehensive Care Plan and Oxygen Administration, the facility failed to develop a person-centered comprehensive care plan for one of 20 sampled residents (R) (R15). This failure increased the potential for R15 not to receive treatment and/or care according to their needs. Findings include: A review of the facility policy titled Comprehensive Care Plans dated 2/12/2022 revealed the Policy Explanation and Compliance Guidelines stated, 3. The comprehensive care plan will describe, at a minimum, the following: a. The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychological well-being. A review of the facility policy titled Oxygen Administration dated 2/12/2022 revealed the Policy stated, Oxygen is administered to residents who need it, consistent with professional standards of practice, the comprehensive person-centered care plans, and the resident's goals and preferences. The Policy Explanation and Compliance Guidelines stated, 4. The resident's care plan shall identify the interventions for oxygen therapy, based upon the resident's assessment and orders, such as, but not limited to a. The type of oxygen delivery system. b. When to administer, such as continuous or intermittent, and/or when to discontinue. b. Equipment setting for the prescribed flow rates. d. Monitoring of SpO2 (oxygen saturation) levels and/or vital signs, as ordered. e. Monitoring for complications associated with the use of oxygen. A review of R15's quarterly Minimum Data Set (MDS) dated [DATE] revealed section C (Cognitive Patterns) documented a Brief Interview for Mental Status (BIMS) of 15 (indicating intact cognition), and section O (Special Treatments and Programs) documented the resident received oxygen while a resident. A review of R15's care plan revealed there was no care area, goals, or interventions for the administration of oxygen. A review of the Physician's orders revealed an order dated 6/27/2024 for oxygen via a nasal cannula (NC) at 2 liters per minute (LPM), continuous. A review of the Medication Administration Records (MARs) dated 7/2024, 6/2024, and 5/2024 revealed oxygen was documented as administered as ordered. During observation and interview on 7/19/2024 at 8:57 am, R15 was receiving oxygen via a NC at 2 LPM. She stated she wore the oxygen most of the time and only removed it during meals and showers. Observations on 7/20/2024 at 7:40 am and 7/21/2024 at 8:35 am revealed R15 was receiving oxygen via a NC at 2 LPM. The Director of Nursing (DON) was not available for an interview. In an interview on 7/21/2024 at 11:30 am, Regional Director of Clinical Operations (RDCO) AA verified there was no care plan area for oxygen administration on R15's care plan. She stated if a resident received oxygen, it should be addressed in the care plan. She further stated the MDS Coordinator was responsible for ensuring the care plan contained the current services and care provided to the resident, and the omission on the care plan was an oversight.

Based on observations, resident and staff interviews, record review, and review of the facility policies titled, Nebulizer Therapy and CPAP/BiPAP (continuous/bilevel positive airway pressure machine) Cleaning, the facility failed to ensure that respiratory supplies were stored properly for two of 21 sampled residents (R) (R14 and R27). This deficient practice increased the risks of spreading microorganisms and placed R14 and R27 at risk for respiratory infections and a diminished quality of life. Findings include: Review of the policy titled Nebulizer Therapy, date implemented 2/12/2022, documented under Care of the Equipment: 1. Clean after each use. 2. Wash hands before handling equipment. 3. Disassemble parts after every treatment. 4. Rinse the nebulizer cup and mouthpiece with sterile or distilled water. 6. Air dry on an absorbent towel. 7. Once completely dry, store the nebulizer cup and the mouthpiece in a [brand name] (re-sealable) bag. Review of the facility policy titled CPAP/BiPAP Cleaning revised 2/12/2022 documented under Policy: It is the policy of the facility to clean CPAP/BiPAP equipment in accordance with the current CDC (Centers for Disease Control and Prevention) guidelines and manufacturer recommendations in order to prevent the occurrence or spread of infections. Under Policy Explanation and Compliance Guidelines: .6. Clean mask frame daily after use with CPAP cleaning wipe or soap and water. Dry well. Cover with plastic bag or completely enclose in machine storage when not in use. 1. Review of the electronic medical record (EMR) revealed R14 was admitted to the facility with pertinent diagnoses listed as but not limited to acute chronic diastolic congestive heart failure, pleural effusion, acute respiratory failure with hypoxia (lack of oxygen), viral pneumonia, and chronic obstructive pulmonary disease (COPD). Review of R14's discharge return expected Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 6/19/2024 revealed a Brief Interview for Mental Status (BIMS) was not completed, her short-term memory was documented as ok, and her ability to make decisions regarding tasks of daily life was moderately impaired. Section GG (Functional Abilities and Goals) revealed she required substantial/maximum assistance with personal hygiene. Review of R14's care plan, initiated on 2/4/2024, indicated a focus of a potential risk for altered respiratory status related to her diagnosis of COPD. The goals included but were not limited to maintaining a normal breathing pattern. The interventions included but not limited to giving nebulizer treatments (a machine that turns liquid medicine into a mist that can be inhaled through a mouthpiece or mask) and oxygen as ordered. Review of the EMR revealed physician's orders for R14 included but were not limited to ipratropium-albuterol inhalation solution 0.5 - 2.5 milligrams (mg) per 3 milliliters (ml); inhale three ml's orally every six hours as needed for wheezing (a medication administered through a nebulizing machine used to treat lung diseases). Observations on 7/19/2024 at 10:05 am revealed a nebulizer mouthpiece lying on top of the oxygen concentrator (a machine that makes oxygen out of room air) next to R14's bed was not covered with a protective bag, and a nebulizer on top of R14's nightstand with the tubing in the second drawer of the nightstand, also not covered or in a protective bag. Observations on 7/19/2024 at 2:00 pm and 7/20/2024 at 7:45 am revealed R14's nebulizer on top of the oxygen concentrator with the mouthpiece on top of the nebulizer, uncovered and not in a protective bag, and a second nebulizer on top of R14's nightstand with the tubing in the second drawer, not covered or in a protective bag. During an observation and interview on 7/20/2024 at 1:50 pm, Regional Nurse Consultant CC verified and confirmed the nebulizer on top of the oxygen concentrator had a mouthpiece attached, and it was not covered or placed in a protective bag. She verified and confirmed the second nebulizer on R14's nightstand had tubing connected to a mask located in the second drawer of the nightstand that was not covered or stored inside a protective bag. She stated the charge nurse was responsible for ensuring the mask/mouthpiece was clean and stored inside a protective bag. She further stated the mouthpiece and mask should be cleaned and allowed to air dry and then stored in a bag. She stated the possible potential outcomes of this practice could result in residents developing respiratory and/or skin infections. 35062 2. Review of the quarterly MDS assessment dated [DATE] revealed R27 had a BIMS score of 13, indicating little or no cognitive decline. Diagnoses included but were not limited to chronic respiratory failure with hypoxia, chronic respiratory failure with hypercapnia, morbid obesity with alveolar hypoventilation, and chronic obstructive pulmonary disease. Section O (Special Treatment and Services) documented the resident uses a non-invasive mechanical ventilator. Review of the Physician Order for R27 dated 7/8/2024 revealed an order for 'name of manufacturer' BiPAP [bilevel positive airway pressure], VT (Tidal Volume) 450, Rate 20, EPAP [expiratory positive airway pressure] 6, 4L O2 [oxygen] blended at bedtime for elevated CO2 [carbon dioxide] levels. Observation on 7/19/2024 at 8:54 am revealed R27's BiPAP machine on the nightstand with mask laying directly on nightstand unbagged, with no protective covering. Observation and interview on 7/20/2024 at 11:22 am with R27 revealed a BiPAP machine laying on the nightstand with the mask directly on the nightstand, unbagged. R27 stated they assisted her with using it at night, but they never put the mask in a bag or protective covering. She was unsure if they cleaned it.

Based on record review, staff interviews, and review of the facility policy titled, Use of Psychotropic Medications, the facility failed to ensure that a psychotropic medication, with appropriate diagnoses, including antianxiety medication, was not ordered as needed (PRN) for more than 14 days unless clinically indicated for one of six residents (R) (R19) reviewed for unnecessary medications. Findings include: Review of the facility policy titled Use of Psychotropic Medication dated 8/1/2023 documented the following under Policy Explanation and Guidelines: . 9. PRN orders for all psychotropic drugs shall be used only when the medication is necessary to treat a diagnosed specific condition that is documented in the clinical record, and for a limited duration (i.e. 14 days). a. If the attending physician or prescribing practitioner believes that it is appropriate for the PRN order to be extended beyond 14 days, he or she shall document their rationale in the resident's record and indicate the duration for the PRN order. A review of the annual Minimum Data Set (MDS) dated [DATE] revealed R19 had diagnoses including but not limited to panic disorder [episodic paroxysmal anxiety] and conversion disorder with seizures or convulsions. Review of the Physician Orders for R19 revealed an order for Ativan Injection Solution 2 milligram (mg)/ milliliter (ml) (antianxiety medication), inject 1 mg intramuscularly (IM) every 4 hours as needed (PRN) for seizure with an original order date of 9/27/2023. An additional order was written for Ativan Injection Solution 2 mg/ml, inject 1 mg intramuscularly every 6 hours PRN for panic attack/seizure with an original order date of 10/18/2023 and was discontinued on 11/13/2023, with no administration. The duplicate order was identified by the pharmacist and discontinued. Review of the medication administration record (MAR) revealed R19 received the Ativan 1 mg every 4 hours as needed for seizures on 10/21/2023, 10/29/2023, 11/21/2023, 11/29/2023, 3/4/2024, 3/10/2024 and 3/12/2024. Review of Nurse's Note dated 3/4/2024 at 11:55 pm revealed resident agitated, yelling out about wanting to call her mother. Jumped out of bed and started to run. Unable to redirect. Ativan IM delivered per orders with good results. In an interview on 7/21/2024 at 2:30 pm with Regional Nurse Consultant CC, she verified R19 had an active physician's order dated 9/27/2023 for Ativan 2 mg/ml injection 1 mg every 4 hours PRN seizures, without an end/stop date for the order. She further stated the Director of Nursing (DON) reviewed resident medications monthly and should have recommended an end date for the Ativan order.

Based on observations, staff interviews, and review of the facility policy titled, Medication Storage, the facility failed to maintain medications in a locked and secure environment when not under direct supervision of the nurse for one of two medication carts (the 300 Hall cart). This failure placed residents, staff, and visitors at risk of having unauthorized access to residents' medications. Findings include: Review of the facility policy titled Medication Storage date implemented 2/12/2022 revealed under Policy: It is the policy of this facility to ensure all medications housed on our premises will be stored in the pharmacy and/or medication rooms according to the manufacturer's recommendations and sufficient to ensure proper sanitation, temperature, light, ventilation, moisture control, segregation, and security. Under the section titled Policy Explanation and Compliance Guidelines and subsection General Guidelines letter C revealed during medication pass, medications must be under the direct supervision of the person administering the medications or locked in the medication storage area/cart. An observation on 7/20/2024 at 9:17 am revealed Registered Nurse (RN) DD left the medication cart on the 300-hall locked with five medication cards containing medications, on top of the cart unattended while she went to the medication room to retrieve another medication needed. She returned to the medication cart at 9:21 am. An interview on 7/20/2024 at 9:21 am with RN DD, she verified and confirmed she left five medication cards with medications in them on top of the medication cart unattended while she went to the medication room to retrieve another medication needed. She stated she should not have done that. She further revealed that she should have locked the medication up in the cart prior to leaving the cart and she did not have an excuse for what she did because she knew she should not leave medication on a cart unattended for any length of time. An interview on 7/20/2024 at 1:50 pm with Regional Nurse Consultant CC revealed that the expectation was for the nurses to know that medications were to be locked in the cart unless the nurse was in attendance to the medications. She further stated if the nurse must leave the cart to attend to anything else, the expectation was that the medication be locked in the cart. She stated the possible outcome of not locking medication in the cart and leaving it unattended could be that a resident could remove the medication from the cart and possibly take them and have an adverse reaction to the medication.

Based on observations, staff interviews, record review, and review of the facility policy titled, Clean Dressing Change, the facility failed to ensure hand hygiene was performed during wound care for one of five residents (R) (R1) with pressure ulcers. The deficient practice had the potential to place the resident at risk for medical complications, unmet needs, and a diminished quality of life. Findings include: Review of the facility policy titled Clean Dressing Change, date implemented 2/12/2022, revealed the policy of the facility was to provide wound care in a manner to decrease potential for infection and/or cross contamination. The subsection titled Policy Explanation and Compliance Guidelines revealed number 14 stated, Wash hands and put on clean gloves. A review of the electronic medical record (EMR) revealed R1 was admitted to the facility with pertinent diagnoses including but not limited to pressure ulcer of the sacral region, stage IV. Review of R1's quarterly Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 4/2/2024 revealed a Brief Interview for Mental Status (BIMS) of 11, which indicates R1 had moderate cognitive impairment. Section GG (functional status) revealed R1 was dependent on staff for dressing, bathing, and toileting. Section H (Bladder and Bowel) revealed R1 was always incontinent of bladder and bowel. Review of R1's care plan initiated on 4/9/2924 indicated a focus of the potential to develop pressure ulcers related to a history of wounds. Goals included but not limited to R1 would be free of preventable skin breakdown. Interventions included but not limited to check frequently for wetness and soiling and provide incontinence care as needed, provide wound care per physician's order, keep dressing clean, dry and intact, and change dressing as needed for soiling. Review of the EMR revealed physician's orders for R1 included but was not limited to clean sacral wound with wound cleanser, fill wound bed with 4x4 gauze soaked with Dakins solution (a topical antiseptic used to treat and prevent infections in wounds, skin, and tissue) with a protective moister absorbent dressing daily and as needed until resolved. Observations made on 7/20/2024 at 10:15 am of wound care performed by Licensed Practical Nurse (LPN) HH with Certified Nursing Assistant (CNA) II assisting revealed LPN HH set up supplies needed for wound care on a table with a barrier after cleaning the table. She performed hand hygiene and donned (put on) gloves, then removed the dressing from R1's sacrum. She removed her gloves and performed hand hygiene, then donned clean gloves. She proceeded to cleanse the wound with gauze soaked with wound cleanser, cleaning from the inside to the outer edges of the wound with a circular motion. Once she completed cleansing the wound she then, without performing hand hygiene or changing gloves, began to pack the wound with gauze soaked in Dakin's solution, and covered the wound with an absorbent foam border dressing. The dressing was dated and initialed by the nurse and all disposable items including the soiled dressing were removed. In an interview on 7/10/2024 at 10:30 am, LPN HH confirmed she did not change her gloves or perform hand hygiene between cleansing the sacral wound and applying Dakin's soaked packing in the wound bed. She stated she should have stopped after cleaning the wound, removed her gloves, performed hand hygiene, donned clean gloves, applied the Dakins-soaked packing in the wound bed, and covered the wound with an absorbent foam border dressing. An interview on 7/20/2024 at 4:05 pm with the Regional Nurse Consultant CC revealed that her expectation was that the nurse who was performing wound care knew when gloves were contaminated and to perform hand hygiene and don clean gloves prior to packing a clean dressing on a wound. She stated this practice could potentially result in a wound infection.

Based on observation, record review, staff and resident interviews, and review of the facility policy titled Comprehensive Care Plan, the facility failed to follow the person-centered care plan to ensure pain interventions were implemented during wound care for one resident (R) (#43), resulting in harm to the resident, of 30 sampled residents. Findings include: A review of the facility policy, Comprehensive Care Plans, implemented 2/1/22, revealed the facility would implement a comprehensive person-centered for each resident, consistent with resident rights, to meet each resident medical and nursing needs. Review of the Minimum Data Set (MDS) Quarterly assessment dated [DATE], Section - C -Cognition, revealed a Brief Interview for Mental Status (BIMS) score of 15, indicating cognition intact. Section M-Skin Conditions revealed R#43 had a surgical wound and received surgical wound care. Section O-Special Treatments and Programs revealed R#43 received Hospice care. Section J-Health Conditions revealed R#43 was on a scheduled pain regimen and pain was reported her pain as frequent in nature. Section N-Medications revealed R#43 received opioids for the last seven days of the assessment period. A review of R#43's care plan entitled, Hospice Services, initiated 11/11/21, revealed pain medications would be administered as ordered and observed for effectiveness. A review of R#43's care plan entitled, Pain, initiated 1/29/22, revealed analgesics should be administered prior to treatment or care as indicated. Staff should anticipate the resident's need for pain relief and respond immediately to any complaint of pain. Further review revealed an evaluation of the pain intervention's effectiveness should be reported to the MD (Medical Doctor) if observed ineffective. Additionally, staff would plan pain management before treatments to ensure maximum comfort and provide unhurried care. During an observation on 5/21/22 at 6:07 p.m. of the 200 hall, groans were heard coming from R#43's room. Upon entry to the room, R#43 was positioned on her right side. Registered Nurse (RN) DD was behind the resident, and the Licensed Practical Nurse (LPN) FF assisted in positioning the resident on her side. R#43 was screaming, it hurts, please stop. RN DD stated she was done and only needed to apply the bandage to the wound. During an interview with R#43 on 5/21/22 at 6:07 p.m., she stated her pain was a 12 out of 10. RN DD did not pre-medicate or assess her pain before the wound treatment. R#43 explained that she told RN DD that she was in pain, but RN DD did not stop the treatment or ask her if she wanted her to stop. During an interview with RN DD on 5/21/22 at 6:08 p.m., she stated she had worked at the facility since September 2021. RN DD stated that R#43 was on routine pain medications, but she was unsure when R#43 had received her pain medication. RN DD acknowledged she did not know what pain medication or dosage R#43 received before she began her treatment. RN DD explained she did not stop the wound care when R#43 told her to stop because it was towards the end of her shift, and she wanted to ensure the treatment was done before leaving for the day. She added it was important for R#43 to have the wound treatment due to the nature of the wound. RN DD confirmed that R#43 was screaming in pain and stated she should have stopped the treatment and addressed her pain before continuing with the treatment. A review of the Nursing Progress Notes dated 5/21/22 at 7:00 p.m. revealed that while performing wound care, R#43 was yelling out in pain at the onset of positioning and wound care. R#43 continued to vocalize her pain until the completion of the treatment. Per the note, R#43 was not offered or administered additional pain medication during the treatment. Cross refer to F697.

Based on observation, record review, staff and resident interviews, and review of facility policy titled Pain Management, the facility failed to stop and address one resident's expression of severe pain during a wound treatment, resulting in harm for resident #43, of 30 sampled residents. Findings include: A review of the facility policy, Pain Management, implemented 2/2/22, revealed the facility would recognize circumstances and situations when a resident's pain could be anticipated. Per the policy, the facility would manage or prevent pain with the comprehensive plan of care, professional standards of practice, and the resident's preferences. Continued review revealed interventions for pain management would be incorporated into the comprehensive care plan and would address specific pain management needs or goals. Pharmacological interventions included reviewing clinical conditions which might require several analgesics and/or adjuvant medications, and facility staff would notify the practitioner if the resident's pain was not controlled with the ordered medications. A medical record review revealed that R#43 was admitted on [DATE] with a past medical history of [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Minimum Data Set (MDS) Quarterly assessment dated [DATE], Section - C -Cognition, revealed a Brief Interview for Mental Status (BIMS) score of 15, indicating cognition intact. Section M-Skin Conditions revealed R#43 had a surgical wound and received surgical wound care. Section O-Special Treatments and Programs revealed R#43 received Hospice care. Section J-Health Conditions revealed R#43 was on a scheduled pain regimen and pain was reported her pain as frequent in nature. Section N-Medications revealed R#43 received opioids for the last seven days of the assessment period. A review of R#43's comprehensive person-centered care plan entitled, Pain, initiated 1/29/22, revealed analgesics should be administered prior to treatment or care as indicated. Staff should anticipate the resident's need for pain relief and respond immediately to any complaint of pain. Further review revealed an evaluation of the pain intervention's effectiveness should be reported to the MD (Medical Doctor) if observed ineffective. Additionally, staff would plan pain management before treatments to ensure maximum comfort and provide unhurried care. A review of the Physician Orders for R#43 revealed the following: 3/27/22 - admitted to Hospice. 3/28/22 - acetaminophen 650 milligrams (mg) to be inserted rectally every six hours for pain or fever as needed. 5/12/22 - Naproxen 250 mg to be given by mouth every 12 hours for pain for 14 days. 5/19/22 - [MEDICATION(S)] 8 mg to be taken by mouth every six hours for pain. A review of the facility, Administrative History Report, dated 5/21/22, revealed that Registered Nurse (RN) DD administered R#43's wound care. A review of the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] During an observation on 5/21/22 at 6:07 p.m. of the 200 hall, groans were heard coming from R#43's room. Upon entry to the room, R#43 was positioned on her right side. RN DD was behind the resident, and the Licensed Practical Nurse (LPN) FF assisted in positioning the resident on her side. R#43 was screaming, it hurts, please stop. RN DD stated she was done and only needed to apply the bandage to the wound. During an interview with R#43 on 5/21/22 at 6:07 p.m., she stated her pain was a 12 out of 10. RN DD did not pre-medicate or assess her pain before the wound treatment. R#43 explained that she told RN DD that she was in pain, but RN DD did not stop the treatment or ask her if she wanted her to stop. During an interview with RN DD on 5/21/22 at 6:08 p.m., she stated she had worked at the facility since September 2021. RN DD stated that R#43 was on routine pain medications, but she was unsure when R#43 had received her pain medication. RN DD acknowledged she did not know what pain medication or dosage R#43 received before she began her treatment. RN DD explained she did not stop the wound care when R#43 told her to stop because it was towards the end of her shift, and she wanted to ensure the treatment was done before leaving for the day. She added it was important for R#43 to have the wound treatment due to the nature of the wound. RN DD confirmed that R#43 was screaming in pain and stated she should have stopped the treatment and addressed her pain before continuing with the treatment. During an interview with LPN FF on 5/21/22 at 6:09 p.m., she acknowledged she heard R#43 moaning and crying due to pain during the treatment. LPN FF stated she encouraged R#43 to hold and squeeze her hand during the treatment. LPN FF acknowledged she did not check to see if there was a medication they could give R#43. During an interview with Charge Nurse (RN) EE on 5/21/22 at 6:14 p.m., he stated his expectation of RN DD would have been to stop the treatment and check for a PRN pain medication. RN EE explained that after a resident is medicated, his expectation is for the nurse to wait an appropriate time for the pain medications to work and reassess the resident's pain before proceeding with treatment. RN EE explained that R#47 is in Hospice. If no PRN medication were available for R#47, he would expect the nurse to call the Hospice nurse to explain the resident is in pain during the treatment and get an order for [MEDICAL RECORD OR PHYSICIAN ORDER] An observation of RN EE on 5/21/22 at 6:13 p.m. revealed the nurse evaluating R#43's pain. She stated her pain rating was an 8 out of 10. RN EE told R#43 he would call about getting her something for her pain. During a follow-up interview with R#43 on 5/21/22 at 6:30 p.m., she reported her pain level was 8 out of 10. She indicated she was in pain but stated it lessened since the wound treatment stopped. R#43 explained that she told RN DD that she was in pain as soon the wound treatment began, and she asked her to stop. She could not remember what RN DD said in response to asking her to stop because she was in too much pain to recall the conversation. She only remembered that RN DD did not stop. She explained that there had been times she had asked a nurse to stop during the treatments, and they would stop and give her something for pain and come back later. She stated it helped when she was given something for pain, and the treatment wouldn't hurt as badly. She said that sometimes the nurses don't stop when she asks them to. A review of the Nursing Progress Notes dated 5/21/22 at 7:00 p.m. revealed that while performing wound care, R#43 was yelling out in pain at the onset of positioning and wound care. R#43 continued to vocalize her pain until the completion of the treatment. Per the note, R#43 was not offered or administered additional pain medication during the treatment. During a telephone interview with Hospice nurse (RN) GG on 5/22/22 at 2:34 p.m., she stated it is her expectation for facility nursing staff to call the on-call Hospice nurse if a resident is experiencing pain and requires a PRN pain medication. RN GG explained that it is not uncommon to have facility nurses call the on-call Hospice nurse for residents' needs. She added that Hospice nurses are available 24 hours a day and seven days a week to provide support to their Hospice clients. During an interview with the DON on 5/22/22 at 3:47 p.m. she stated it was her expectation of the nursing staff to properly medicate residents for pain prior to any treatments. She added that if there is no PRN medication for pain, she expected the nurse to call the MD. If a patient is on Hospice, the nurse could also call Hospice for a PRN medication. She explained that if a resident told a nurse to stop a treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . She said that nurses should be assessing for pain before, during, and after all treatments. She stated any changes in condition should be reported to her in case a resident's plan of care needed to be adjusted.