Every finding on record at Lakeside Health and Wellness

Based on observation, interview and record review the facility failed to ensures a resident who was incontinent of bladder received appropriate treatment and services to prevent urinary infections and to restore continence to the extent possible for 1 of 2 residents (Resident #10) reviewed for incontinent care. The facility failed to ensure Resident #10's catheter was secured to his leg and CNA T and LVN B properly cleaned the perineal/genital areas for Resident #10 during incontinent care for a catheter. This failure could place residents at risk for urinary tract infections and trauma.Based on observation, interview and record review the facility failed to ensures a resident who was incontinent of bladder received appropriate treatment and services to prevent urinary infections and to restore continence to the extent possible for 1 of 2 residents (Resident #10) reviewed for incontinent care. The facility failed to ensure Resident #10's catheter was secured to his leg and CNA T and LVN B properly cleaned the perineal/genital areas for Resident #10 during incontinent care for a catheter. This failure could place residents at risk for urinary tract infections and trauma. Finding include: Record review of Resident #10's face sheet, dated 01/20/25, reflected a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #10's had diagnoses which included COPD (chronic lung condition that limits airflow and causes difficulty breathing), unspecified dementia (cognitive disorder that impairs memory, thinking, and judgement), and need for assistance with personal care. Record review of Resident #10's quarterly MDS, dated [DATE], reflected resident required partial/moderate assistance- helper did less than half the effort for toileting hygiene. Record review of Resident #10's significant change MDS, dated [DATE] reflected the resident required substantial/maximal assistance- helper did more than half the effort for toileting hygiene. Record review of Resident #10's care plan, revision dated 12/08/25, reflected an intervention for provide perineal care after each incontinent episode. Record review of Resident #10's order summary report, dated 01/20/25, indicated he had an order for:Catheter Care: Out put Q shift every shift for foley catheter and catheter care Q shift and PRN every shift start date of 06/02/25. Urinary Catheter 16FR,10CC. Diagnosis: Urinary retention. Dated 12/23/24.Catheter: Check that catheter is stabilized/anchored using a leg strap/stabilizer. every shift dated 06/02/25.Record review of Resident #10's December 2025 Nursing MAR indicated he received catheter care daily for the month of December 2025. During an observation on 01/19/26 at 12:30PM, Resident #10 was in his bed fetal position (severe upper and lower extremity contractures), did not have a leg strap secure device for catheter on his leg, line was taught and full of urine. Urinary catheter bag was hung on the right side of the bed, closest to the open door with a blue privacy cover. During an observation on 01/20/26 at 9:08 AM revealed Resident #10 without a catheter secure device leg strap in place.During an observation on 01/20/26 at 11:35 AM revealed Resident #10 without a catheter secure device leg strap in place. During an attempted interview on 01/19/26 at 3:15 PM Resident #10 did not respond to questions. During an interview on 01/19/26 at 3:56 PM, CNA T said she did not complete catheter care because the hospice aide had just provided care to Resident #10, and he did not have a secure device. CNA T stated she was unaware of the last time foley catheter care was completed. CNA T stated each time incontinent care was provided, catheter care should also be provided. CNA T stated the resident was at risk for urinary tract infection. CNA T reported catheter care was performed by the CNAs. CNA T stated Resident #10's catheter should have been secured to prevent injury. During an interview on 01/19/26 at 3:45 PM, LVN B said the CNAs were responsible for performing catheter care and the nurse was responsible for ensuring the care that was provided every shift and a secure device was in place. LVN B stated when she came onto shift during her morning rounds, Resident #10 did not have a secure device. LVN B stated she had not had time to place a secure device on Resident #10 catheter. LVN B stated the secure device was to ensure the foley catheter was not tugged or caused trauma to meatus. LVN B reported Resident #10 was at risk for sepsis, UTI, and worsening of the meatus because catheter care was not provided and a secure device was not in place. During an interview on 01/20/26 at 11:26 AM, CNA V revealed she was one of the aides for Resident #10 and his penis started splitting towards the end of 2025. CNA V reported the split penis to the nurse but could not recall who the nurse was. CNA V reported she had not seen any bleeding from the penis or blood in his catheter. CNA V reported she provided foley catheter care for Resident #10 and checked for a secure device. CNA V stated the secure device prevented the penis from splitting more. During an interview on 01/20/26 at 12:15 PM, Resident #10's family member stated Resident #10 did not have any injuries to his penis when he admitted to the facility, and the facility had not notified him of Resident #10 having a split penis. During an interview on 01/20/26 at 12:42 PM, RN U stated she was the previous DON for the facility from February 2025 - April 2025. RN U reported she did not remember being told about Resident #10 penis splitting. RN U reported the resident was seen by the physician for a referral to urology and a change in order. During an interview on 01/20/26 at 1:52 PM, the Hospice Nurse stated Resident #10 admitted to hospice services on November 2025, and the resident had a split penis when she admitted him to hospice but could not provide any documentation. The Hospice Nurse said to her knowledge Resident #10's penis had not worsened. The Hospice nurse reported he had the foley catheter for the entire duration of his care on hospice. The Hospice Nurse reported the CNAs from hospice did incontinent care and foley care as well. During an interview on 01/20/26 at 4:40 PM, on a phone interview the Urologist Nurse stated that he was last seen 7/28/25 and there was no documentation from the provider of a meatus penis split or any type of erosion in the visit summary. The Urologist Nurse also stated that he had been seen by the provider 3/18/25 with no documentation of any trauma or irregularities of the penis. During an interview on 01/22/26 at 9:49 AM, the NP stated she was the provider for the facility, and to her knowledge Resident #10's penis was split since 02/2025, when she started providing care to him. She could not provide any documentation revealing these findings. During an interview on 01/22/26 at 9:54 AM, LVN U revealed she was a previous employee who provided care to Resident #10. LVN U stated she was responsible for ensuring Resident #10's catheter was secured. LVN U stated Resident #10's penis was split due to long-term use of a catheter. LVN U said she was aware Resident #10 had a split penis, but she did not document it because she did not believe it was a problem. LVN U stated the splitting of the penis was prevented by the secure device and catheter care. LVN U stated Resident #10 often had UTIs (urinary tract infections) which she stated was prevented by good perineal care and hand hygiene. During an interview on 01/22/26 at 4:38 PM, the DON said she expected nursing staff to provide catheter care for Resident #10 when proving personal care needs according to orders and as needed. The DON stated she expected nursing staff to check for a secure device each time care was provided. The DON reported the aides performed catheter care, but any nursing staff could provide catheter care for Resident #10. The DON stated she was responsible for overseeing all catheters in the facility. The DON stated Resident #10 was at risk for infection and injury when catheter care was not provided and a secure device was not in place. The DON stated in-service was completed for all nursing staff annually to ensure competence of perineal care. During an interview on 01/22/26 at 5:40 PM, the Administrator said she expected foley catheter care to be provided according to orders. The Administrator stated she expected care to be provided at the time it was needed. The Administrator stated she expected Resident #10 to have a secure device in place per the physician's order and Resident #10 was at risk of UTI and breakdown. Record review of Resident #10's progress notes from January 2025-January 2026 reflected no documentation found of the resident's split penis. Record review of competency checklist, dated 12/22/2025 for CNA T revealed a check off was completed for incontinent care and foley catheter care. Record review of the facility's person care policy, revision date February 2018, reflected The purpose of this procedure or people cleanliness and comfort will be resident to prevent infections and skin irritations, and to observe the resident's skin condition.For a male resident: if the resident has an indwelling catheter, gently wash the juncture of the tubing from the urethra down the catheter about 3 inches, Gently rinse and dry the area. Document.any problems noted at the catheter-urethral junction during perineal care such as drainage, redness, bleeding, crusting, or pain. Any discharge, odor, bleeding, skin care problems or irritation, complaints of pain or discomfort.

Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 ice machine reviewed for kitchen sanitation.The facility failed to ensure the ice machine, stored in the kitchen area, was free from black and brown substances at the bottom of the bucket on 01/19/26. This failure could place residents at risk for foodborne illness. Findings included:During an observation on 01/19/26 at 11:09 a.m., the ice scoop holder located in the main area of the kitchen had a black and brown substance at the bottom of the bucket. During an observation and interview on 01/19/26 at 11:10 a.m., Dietary Aide S looked into the ice scoop holder and said she saw black and brown substances in the bottom of the bucket. She said they cleaned the ice scoop daily but was not aware that the ice scoop holder came off the wall. She said residents could get sick from what looked like dirt and rust. Dietary Aide S took the ice scoop holder and ran it through the dishwasher, and the black/brown substance was removed.During an interview on 01/22/26 at 1:29 p.m., the Dietary Manager said the kitchen staff were responsible for cleaning the ice scoop and holder. She said the cleaning schedule did not say scoop holder, but it was part of the cleaning schedule. She said the dietary aide was supposed to clean the ice scoop and ice holder daily. She said it should be washed to prevent cross-contamination.During an interview on 01/22/26 at 5:22 p.m., the DON said the kitchen staff were responsible for cleaning the ice scoop and ice scoop container. She said she was not aware of the cleaning schedule but expected it to be cleaned daily to prevent foodborne illness.During an interview on 01/22/26 at 5:52 p.m., the Administrator said she did not expect the ice container to be dirty. She said the dietary staff were responsible for ensuring the ice scoop and ice scoop container were cleaned. She said failure to keep them clean could spread germs. Record review of the facilities policy titled, General Kitchen Sanitation, dated 10/01/2018, indicated, Policy: The facility recognizes that food-borne illness has the potential to harm elderly and frail residents. All Nutrition & Food Service employees will maintain a clean, sanitary kitchen facility in accordance with the state and US food pose in order to minimize the risk of infection and foodborne illness. Procedure.#6. Clean non-food-contact surfaces of equipment at intervals as necessary to keep them free of dust, dirt, and food particles, and otherwise in a clean and sanitary condition.

Based on observation, interviews, and record review, the facility failed to ensure complete and accurate documentation for 2 of 3 residents reviewed for medical records. (Resident #10, Resident #11.)The facility failed to ensure accurate and complete documentation was entered for Resident #10, Resident #11 related to wound care. This failure could place residents at risk for inaccuracy of clinical records and decreased continuity of resident care.1. Record review of Resident #10's face sheet, dated 01/20/25, indicated he was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses COPD (chronic lung condition that limits airflow and causes difficulty breathing), unspecified dementia (cognitive disorder that impairs memory, thinking, and judgement), and need for assistance with personal care. Record review of Resident #10's MDS, dated [DATE], indicated the following pressure ulcers:(3) stage 3 pressure ulcers and (0) present upon admission.(1) stage 4 pressure ulcer and (0) s present upon admission. (1) unstageable pressure ulcer due to coverage of wound bed by slough (dead tissue) and/or eschar (dead black tissue) and (0) present upon admission. Record review of Resident #10's care plan, dated 12/08/25, revealed he had actual impairment to his left hip, right heel, right shin to provide wound care as ordered. Record review of Resident #10's order summary report dated 01/20/26, revealed orders for the following wound care:Clean left hip with wound cleanser and pat dry apply alginate calcium with silver to wound bed and cover with island dressing dated 11/20/25.Clean right heel with NS or wound cleanser and pat dry apply medihoney (ointment used for wounds) to right heel and cover with island dressing. Daily and PRN one time a day start date 12/25/25.Clean left hip with normal saline/wound cleanser, pat dry, apply hydrogel with silver (ointment used for wounds) and cover with dry dressing change every day and as needed every 24 hours as needed for unstageable change if soiled or dislodged dated 08/26/25.Cleanse left hip with normal saline/wound cleanser, pat dry, apply hydrogel with silver and cover with dry dressing every day and as needed one time a day for unstageable start date 08/27/25.Cleanse wound to right shin with normal saline and wound cleanser. Pat dry. Apply alginate calcium with silver. Cover with an abdominal pad. Secure with tube gauze daily and PRN as needed start date 12/04/25.Clean wound to right shin with NS/WC. Pat dry. Apply alginate calcium with silver. Cover with ABD pad. Secure with tube gauze daily and PRN one time a day start date 12/05/25.During an observation with the Treatment Nurse on 01/20/26 at 9:39 a.m., Resident #10 had wounds to his left hip, right shin, and right heel. Record review of weekly skin assessment, dated 12/26/25, revealed documentation of, Inner thigh being addressed via Treatment Nurse. No new skin issues noted. Resident #10 wound to the right heel, right shin, and left hip were not documented. Record review of weekly skin assessment, dated 12/30/25, revealed documentation of, No new issues noted. Has multiple wounds being treated. Resident #10 wound to the right heel, right shin, and left hip were not documented. Record review of weekly skin assessment, dated 01/06/26, revealed documentation for three wound sites with measurements and staged as follows:Left hip stage III- 0.3x0.4x0.1 Right heel stage III- 0.9x2.9x0.2Right Shin stage III- 8.0x4.3x0.1No unit of measurement was indicated. 2. Record review of Resident #11's face sheet, dated 01/21/26, indicated she was an [AGE] year-old female admitted to the facility on [DATE] with diagnoses of unspecified dementia (memory loss, impaired judgement, and reduced ability to perform activities of daily living independently), dysphagia following other cerebrovascular disease (difficulty swallowing following a stroke), muscle weakness, and need for assistance with personal care. Record review of Resident #11's quarterly MDS, dated [DATE], indicated a functional limit in range of motion of the lower extremity (hip, knee, ankle foot) impairment on both sides and used a wheelchair for mobility. Resident #11 required partial/moderate assistance with oral hygiene, toileting hygiene, shower/bathe self, upper body dressing, and personal hygiene. Resident #11 required substantial/maximal assistance with lower body dressing and putting on/taking off footwear. Resident #11's MDS indicated she was always incontinent of bowel and bladder. Resident #11's MDS indicated she had two stage III pressure ulcers and zero that were present upon admission. Record review of Resident #11's care plan, dated 12/03/25, indicated right heel stage III pressure and risk for impairment to skin integrity of the left feel related to history of impairment to left heel. Resident #11's care planned intervention was: Monitor/document location, size and treatment of skin injury. Report abnormalities, failure to heal, signs and symptoms of infection, maceration (skin breakdown due to moisture) to MD. Weekly skin assessment. Notify MD of impaired skin integrity PRN. Record review of Resident #11's order summary indicated an order for the following:Weekly skin assessment Thursday 6:00 a.m. - 6:00 p.m. complete head to toe assessment and document findings on the weekly skin observation tool with a start date of 10/09/25. Wound care consult for open area to left heel active date of 08/24/25.Wound care consult for redness to bony prominence of resident right lateral ankle active date of 07/01/25.Cleanse right heel with normal saline and wound cleanser, pat dry. Apply calcium alginate with silver. Cover with dry dressing daily and PRN for soiled displaced one time a day start date of 12/04/25.During an observation on 01/20/26 at 1:34 p.m., the Treatment Nurse performed wound care to the right heel on Resident #11. CNA H then placed pressure relieving boot back on Resident #11's heel. No care was provided for the left heel. The wound to Resident #11 heel was pink with slight clear drainage. During an interview on 01/20/26 at 1:45P p.m. the Treatment Nurse stated there was an order to perform care for the right heel only. The WC LVN stated Resident #11 wore pressure relieving boots to both feet. During an interview on 01/20/26 at 2:00 p.m., Resident #11 stated wound care was provided daily to her right heel. Resident #11 did not report any wounds to the left heel. Record review of Resident #11's weekly skin observation tool, dated 12/18/25, revealed documentation of no new skin issues noted at this time. No documentation of Resident #11 wound to the right heel. Record review of Resident #11's weekly skin observations tool, dated 12/25/25, revealed documentation of no new skin issues seen or reported. No documentation of Resident #11 wound to the right heel. Record review of Resident #11's weekly skin observation tool, dated 01/01/26, revealed documentation of a stage III pressure to the left heel with measurements of 2.0x2.1x0.1. No documentation of Resident #11 wound to the right heel. No unit of measurement was documented. Record review of Resident #11's weekly wound assessment, dated 01/15/26, revealed documentation of one right heel unstageable pressure with measurement of 1.7x2.8x0.1. Record review of Resident #11's weekly wound assessment, dated 01/22/26, revealed documentation of one right heel unstageable pressure with measurements of 1.9x2.8x0.1. Record review of Resident #11's wound evaluation and management summary, dated 12/09/25, revealed wound care physicians reported Resident #11 had wounds to her right and left heel. Documentation revealed a wound to the right heel stage III and left heel unstageable. During an interview on 01/20/26 at 9:50 a.m., LVN B stated she was responsible for completing and documenting the weekly wound assessment in the residents electronic medical record. LVN B stated the floor nurse was responsible for completing the weekly skin assessments to track changes and existing conditions. Treatment Nurse stated she documented on the wounds she was currently providing care for. LVN B reported that the wound care provider oversaw Resident #10, Resident #11 care. During an interview on 01/20/26 at 11:42 a.m., LVN B stated the floor nursing staff on duty was responsible for completing weekly skin assessments. LVN B reported that she only documents was there was a new skin condition and was not aware of the need for documentation of existing skin issues. After surveyor intervention LVN B stated she should have documented all existing skin conditions to ensure accurate documentation and tracking was done. LVN B stated the resident was at risk of missing documentation. During an interview on 01/20/26 at 1:55 p.m., the Treatment Nurse stated she completed a weekly wound report, and the floor nurse completed the weekly skin assessment. During an interview on 01/22/26 at 4:50 p.m., the DON stated she expected nursing staff to document weekly skin assessment and the wound care nurse to complete weekly wound assessment. The DON stated Resident #10 and Resident #11 were at risk of a wound undetected or worsening if accurate documentation was not available. The DON stated she was aware of previous incorrect documentation of skin assessments and stated she completed an in-service with the staff but was unaware it was still happening. During an interview on 01/22/26 at 5:44 p.m., the Administrator stated she expected skin and wound assessments to be accurately documented timely by the floor nursing staff. She expected the DON to oversee documentation of wound assessments and weekly skin. The Administrator reported an in-service regarding documentation was done on 11/13/25. Record review of system pathway #1 - Skin and Wound Management, undated, revealed:Ongoing all residents should be checked from head to toe weekly by a licensed nurse to identify any new pressure injuries or other types of skin concerns. The licensed nurse should document the results of weekly skin checks by completing a Weekly Skin Observation tool and note either: Any new identified area(s), or Updates existing current areas previously identified status, or In Section A. #2 of the tool document the following Skin intact with no new issues In between weekly head to toe skin checks conducted by a license nurse if a pressure injury, ulcer, skin breakdown or wounds was identified, the licensed nurse should: document in the resident's electronic health record progress notes, noted new area identified, include location, description, size, color, drainage and if odor present. complete the weekly skin observation tool with the date identified AND then complete a Weekly Wound Progress Report UDA as includes more descriptive details Notified the DON/ADON/Treatment nurse and the log to include, but not limited to size, stage, location, drainage, and odor. Record review of Charting and Documentation policy revision date July 2017 revealed The following information was to be documented in the resident medical record: a. Objective observations;b. Medications administered;c. Treatments or services performed;d. Changes in the resident's condition;e. Events, incidents or accidents involving the resident; andf. Progress toward or changes in the care plan goals and objectives. To ensure consistency in charting and documentation of the resident's clinical record, only community approved abbreviations and symbols may be used when recording entries in the resident's clinical records.Documentation of procedures and treatments will include care-specific details, including:a. the date and time the procedure/treatment was provided;b. the name and title of the individual(s) who provided the care;c. the assessment data and/or any unusual findings obtained during the procedure/treatment;d. how the resident tolerated the procedure/treatment;e. whether the resident refused the procedure/treatment;f. notification of family, physician or other staff, if indicated; andg. the signature and title of the individual documenting.A Weekly Skin/Wound Progress Report UDA in the resident(s) E.H.R was completed and updated weekly for any non-pressure skin condition, including Arterial Ulcers, Diabetic Neuropathy Ulcers, Venous Insufficiency Ulcers, Bruises, Skin Tears and Surgical Wounds. A Weekly Skin/Wound Progress Report UDA was completed upon any identification of pressure injury(s), ulcers and updated at least weekly and as needed with any significant change. All pressure injuries are staged according to the updated NPUAP guidelines (see Protocol 1-F). The Resident's overall care plan was completed for each site and updated with any changes to interventions.

Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of communicable diseases and infections for 5 of 6 residents (Resident #4, Resident #8, Resident #10, Resident #67, and Resident #79) reviewed for infection control. 1. The facility failed to ensure CNA E followed enhanced barrier precautions and performed proper glove while providing incontinent care to Resident #67 on 01/20/2026. 2. The facility failed to ensure CNA E did not handle linens with blood on them without gloves on 01/20/2026. 3.The facility failed to ensure CNA H performed hand hygiene while providing incontinent care for Resident #79 on 01/19/26. 4.The facility failed to have PPE signage outside Resident #8's room on 01/19/26 and 01/20/26. 5. The facility failed to ensure CNA T and LVN B used enhanced barrier precautions for Resident #10 while providing catheter care on 01/19/2026. 6. The facility failed to ensure Resident #4 had enhanced barrier precautions signage on his door and enhanced barrier precautions cart in place for staff to use. These failures could place residents at risk for cross contamination and the spread of infection.1. Record review of a face sheet dated 01/22/2026 indicated Resident #67 was a [AGE] year-old male initially admitted to the facility on [DATE] and re-admitted [DATE] with diagnoses which included dementia (loss of memory, language, problem solving and other thinking abilities that were severe enough to interfere with daily life), chronic respiratory failure with hypoxia (condition where the lungs cannot supply enough oxygen or remove enough carbon dioxide from the blood), and benign prostatic hyperplasia without lower urinary tract symptoms (overgrowth of prostate tissue blocks the flow of urine). Record review of Resident #67's Quarterly MDS assessment dated [DATE] indicated he was understood by others and understood others. The MDS assessment indicated Resident #67 had a BIMS score of 12, which indicated his cognition was moderately impaired. The MDS assessment indicated Resident #67 required partial/moderate assistance with personal hygiene and toileting hygiene, and substantial/maximal assistance with showering/bathing self. The MDS assessment indicated Resident #67 had an indwelling catheter (flexible tube inserted into the bladder to drain urine when someone cannot urinate on their own) and was frequently incontinent of bowel. Record review of Resident #67's Order Summary Report dated 01/22/2026 indicated: Catheter care every shift and as needed with a start date of 09/25/2025 Enhanced barrier precautions PPE required when performing high contact activities every shift with a start date of 09/28/2025. Record review of Resident #67's care plan revised 10/13/2025 indicated he had the potential for skin impairment to cleanse resident after incontinent episodes as needed. Resident #67's care plan indicated he had an indwelling catheter to provide catheter care every shift and as needed. Resident #67's care plan indicated he required enhanced barrier precautions related to an indwelling catheter. His care plan indicated enhanced barrier precautions should be utilized during ADLs including but not limited to providing hygiene and changing linens/briefs or when toileting. During an observation and interview on 01/20/2026 at 5:17 PM, CNA E provided incontinent care to Resident #67. Outside of Resident #67's room a sign was observed that indicated enhanced barrier precautions should be followed and there was a cart with PPE inside of it. CNA E entered Resident #67's room and put on gloves. CNA E did not put on a gown. Resident #67 had an episode of bowel incontinence. CNA E cleaned Resident #67's front perineal area and provided catheter care, turned him on his side, and then cleaned his buttocks. CNA E removed the dirty brief, applied a clean brief, while using the dirty gloves. CNA E then turned Resident #67 on his back. CNA E raised Resident #67's scrotal sac to check underneath. Resident #67 still had stool underneath his scrotal sac, so she cleaned him on top of the clean brief. CNA E proceeded to fasten the same brief. CNA E did not change her gloves prior to applying the clean brief. CNA E did not change Resident #67's brief after she finished cleaning off the stool underneath his scrotal sac. CNA E removed her dirty gloves. Resident #67's top sheet was dirty and had dried blood spots on it from the wounds to his legs. CNA E grabbed the top sheet without gloves and placed it in a bag. CNA E gathered the trash and linen bag and walked out of the room. CNA E performed hand hygiene in the hallway. CNA E said when changing a brief, gloves should be changed and hand hygiene performed when the dirty brief was removed. CNA E said new gloves should be applied when putting on the new brief. CNA E said she should have cleaned Resident #67 completely before placing a clean brief underneath him. CNA E said leaving the brief on Resident #67 after cleaning him up made the clean brief dirty. CNA E said she did not provide incontinent care as she should have because she was in a rush. CNA E said not providing incontinent care properly could result in an infection. CNA E said she should have put gloves on before touching the dirty linens. CNA E said touching dirty linens without gloves could result in cross contamination. CNA E said she was not aware Resident #67 required enhanced barrier precautions. She said there were signs outside of the residents' rooms, but it was hard to determine which resident required enhanced barrier precautions when there were two residents in the room. CNA E said enhanced barrier precautions should be followed so they did not contaminate other residents or themselves and to prevent cross contamination. During an interview on 01/22/2026 at 3:18 PM, the DON said when the CNAs provided incontinent care, they should change gloves and perform hand hygiene when they went from dirty to clean. The DON said the CNAs should ensure the residents were clean before putting on a clean brief. The DON said Resident #67 required enhanced barrier precautions, and CNA E should have worn a gown and gloves when providing incontinent care to Resident #67. The DON said dirty linens should not be touched without gloves. The DON said she monitored incontinent care by going to help on the hall at least once a shift when she was in the building. The DON said competency checks were completed, and if they saw anything wrong it was corrected, and everyone was re-educated. The DON said she had not noticed any issues with incontinent care. The DON said not following enhanced barrier precautions placed the residents at risk of not being protected from infections. The DON said not handling the linens properly was an infection control issue and placed the residents at risk of cross contamination. During an interview on 01/22/2026 at 3:38 PM, the Administrator said when the staff provided incontinent care, she expected them to follow the infection control procedures, the training they received, and to wear the proper PPE because it was important to protect the residents. The Administrator said management was responsible for ensuring the staff were providing proper incontinent care and following infection control procedures. The Administrator said not providing proper incontinent care placed the residents at risk of infection and the spread of infection. The Administrator said she expected the staff to follow the facility's infection control procedures when handling linens. The Administrator said not handling linens properly placed the residents at risk for the spread of infection. The Administrator said she expected the staff to follow enhanced barrier precautions, and management was responsible for ensuring they did this. The Administrator said not following enhanced barrier precautions could result in the spread of infection. 2. Record review of Resident #79's face sheet, dated 01/22/26, indicated she was an [AGE] year-old female, admitted to the facility on [DATE] and re-admitted on [DATE], with diagnoses which included dementia (loss of memory), stroke, anxiety (feelings of worry, fear, unease, and apprehension), and high blood pressure Record review of Resident 79's quarterly MDS assessment, dated 10/08/25, indicated Resident #79 understood and was understood by others. Resident #79's BIMS score was 13, indicating her cognition was intact. The MDS indicated Resident #79 required assistance with her ADLs, including transfers, dressing, personal hygiene, and bed mobility. The MDS indicated she was frequently incontinent of bowel and bladder. Record review of Resident #79's comprehensive care plan, dated 10/20/22, indicated Resident #79 had an ADL self-care performance deficit related to impaired balance, stroke, and limited range of motion to the right shoulder. The intervention was for two staff members to assist with toileting, turning, and repositioning in bed. During an observation on 01/19/2026 at 12:03 p.m., CNA H provided incontinent care for Resident #79. CNA H wiped Resident #79's front and then assisted to turn her on her left side without hand hygiene or changing her gloves. CNA H wiped Resident #79's buttock which contained bowel and assisted in turning Resident #79 to her back without hand hygiene or changing her gloves. CNA H then changed her gloves, washed her hands, applied a new brief, and completed care. During an interview on 01/19/26 at 12:55 p.m., CNA H said she did not perform hand hygiene or change her gloves after wiping Resident #79, front to back or when she turned her. She said she should have washed and changed her gloves from dirty to clean. She said she knew that without hand hygiene or removing dirty gloves, she could cause cross-contamination. During an interview on 01/22/26 at 2:24 p.m., LVN A said she was Resident #79's nurse. She said she expected staff to provide incontinent care to keep the residents clean. She said she expected them to practice hand hygiene and change gloves when going from dirty to clean. 3. Record review of Resident #8's face sheet, dated 11/24/25 indicated she was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses which included, pressure ulcer to the left heel stage 3 (a severe, full-thickness wound extending through the skin to the subcutaneous fat, appearing as a deep crater), right tibia fracture (a break in the main shinbone, usually caused by high-energy trauma (e.g., falls, accidents), resulting in immediate, severe pain, inability to bear weight, swelling, and potential deformity), and diabetes (a chronic disease where the body doesn't produce enough insulin or can't effectively use the insulin it produces, leading to high blood sugar levels). Record review of Resident #8's admission MDS assessment, dated 12/03/25, indicated Resident #8 understood and was understood by others. Resident #8's BIMS score was 03 which indicated his cognition was severely impaired. The MDS indicated Resident #8 required maximum assistance with his ADLs. The MDS indicated Resident #8 was occasionally incontinent of bladder and had a wound. Record review of Resident #8's comprehensive care plan, dated 12/02/25, indicated, Resident #8 had an actual impairment to his skin integrity of the L heel. The interventions were for staff to use caution during transfers and bed mobility to prevent striking arms, legs, and hands against any sharp or hard surface and weekly treatment per the doctors' orders with documentation to include measurement of each area of skin breakdown's width, length, depth, type of tissue and exudate and any other notable changes or observations. Record review of Resident #8's Physician order, dated 12/05/25, indicated to cleanse wound to left heel with Normal saline or wound cleaner. Pat dry. Apply Leptospermum Honey (medication used for wounds). Cover with dry dressing daily and as needed. Record review of Resident #8's medication administration record, dated 01/08/26 through 01/13/26, indicated enhanced barrier precautions for stage 3 pressure ulcer, left heel. Resident #8 must remain on precautions for the duration of their PPE requirements when performing high contact activities every shift for the residents' protection from potential infections. During an observation and interview on 01/19/26 at 11:35 a.m., Resident #8 was lying in his bed. Resident #8 said he had a wound. Observation revealed there was no EBP posting or a PPE cart outside his door. During an observation and interview on 01/20/26 at 10:33 a.m., the treatment nurse was about to perform wound care when CNA M walked up to the treatment nurse and asked if he needed to wear PPE (glove and gowns) since he did not have a sign posted or cart by his door. The treatment nurse said, Yes. CNA M applied a gown and gloves and helped the treatment nurse with Resident #8's wound. The treatment nurse said she did Resident #8's treatment yesterday (01/19/26) and Resident #8 did not have the EBP sign or the cart outside his room. She said Resident #8 was supposed to go home last week, so his signage and cart were removed. She said since he did not leave his signage and cart should have been put back because he had a wound and PPE (glove and gown) were required when providing care. During an interview on 01/20/26 at 1:30 p.m., CNA M said he was Resident #8's aide. He said he was not aware that Resident #8 still required PPE when providing care because his signage and cart were removed. He said he was aware of what to do if the signage and cart were outside his door but since it was not, he had not worn PPE (gown). He said he helped Resident #8 with his urinal earlier today (01/20/26) and did not wear a gown. He said without wearing the proper PPE (gown and gloves) it placed him and the resident at risk of infection. During an interview on 01/22/26 at 5:22 p.m., the DON said she expected the CNAs to perform incontinent care correctly. She said she expected staff to change their gloves between dirty to clean and use hand hygiene between glove changes. She said the ADON oversaw the infection control process. She said she thought she heard in the morning meeting (unknown date) that his wounds were healed and therefore the signage, carts and orders were removed. She said if he still had wounds then he was supposed to have signage on his door and a cart outside his door. She said staff should change gloves, practice hand hygiene, and wear proper PPE (gown and gloves) when caring for residents on EBP to prevent infection and cross-contamination. During an interview on 01/22/26 at 5:55 p.m., the Administrator said she expected all staff to use proper hand hygiene techniques between dirty and clean areas with all care. The Administrator said the nurse management were responsible for ensuring staff were trained on incontinent care, hand washing, EPB, and infection control. She said improper hand hygiene and not wearing the proper PPE (gown and gloves) could place residents at risk for cross-contamination or infection. 4. Record review of Resident #10's face sheet, dated 01/20/25, indicated he was a [AGE] year-old male admitted to the facility on [DATE] with the diagnosis COPD (chronic lung condition that limits airflow and causes difficulty breathing), unspecified dementia (cognitive disorder that impairs memory, thinking, and judgement), and need for assistance with personal care. Record review of Resident #10's MDS quarterly, dated 09/01/25, stated resident required partial/moderate assistance - helper does less than half the effort for toileting hygiene. Record review of Resident #10's MDS significant change, dated 10/13/25, stated resident required substantial/maximal assistance - helper does more than half the effort for toileting hygiene. Record review of Resident #10's care plan, revision dated 12/08/25, stated an intervention for provide perineal care after each incontinent episode. Record review of Resident #10's order summary report, dated 01/20/25, indicated he had an order for: Catheter CARE: OUT PUT Q SHIFT every shift for catheter and catheter care q shift and PRN every shift start date of 06/02/25. Urinary Catheter 16FR,10CC. Diagnosis: Urinary retention. Dated 12/23/24. ENHANCED BARRIER PRECAUTIONS: GOWNS AND GLOVES to be utilized during ADLs including but not limited to: Dressing, bathing, transferring, providing hygiene, changing linens/briefs or when toileting, care of indwelling medical devices, such as: catheter, Pressure stage 3 right heel, right shin, left hip, and/or close contact was anticipated for transfer/mobility every shift for RESIDENT PROTECTION from potential infections resident care that does not require Enhanced barrier precautions include: peripheral intravenous line (not peripheral central catheter), answering a call light, conversing with resident, providing medications that do not require high-contact. During an observation on 01/19/2026 3:36 p.m., revealed CNA T and LVN B failed to use enhanced barrier precautions for Resident #10 catheter care during perineal care provided for with an incontinent episode of bowel. CNA T and LVN B only put gloves on prior to starting care for Resident #10. CNA T failed to perform hand hygiene or hand sanitize before, during, and after care was provided. CNA T wore the same soiled gloves throughout the entire incontinent care and catheter care when her gloves were visibly soiled. During an interview on 01/19/26 at 3:56PM, CNA T said she forgot to use enhanced barrier precautions and wash her hands. CNA T stated there was a sign on the door to notify staff to use EBP for care. CNA T stated that the resident was at risk for UTI. CNA T reported that catheter care was performed by the CNAs. During an interview on 01/19/26 at 3:45PM, the LVN B said the CNAs are responsible for performing catheter care and the nurse was responsible for ensuring the care was provided every shift using enhanced barrier precautions. LVN B reported Resident #10 was at risk for sepsis and more UTIs when EBP was not used. During an interview on 01/22/26 at 4:38PM, the DON said she expected nursing staff to wear EBP when providing catheter care for Resident #10. The DON stated she expected nursing staff to check for a supply box and sign on the door each time they entered the room. The DON reported aides perform catheter care, but any nursing staff can provide care for Resident #10. The DON stated she was responsible for ensuring EBP was used with care by all direct care staff, monitoring all catheters in the building, and hand hygiene audit. The DON stated that Resident #10 was at risk of infection when catheter care was not provided using EBP with hand hygiene. The DON stated in-service was completed for all nursing staff annually to ensure competence of perineal care, hand hygiene and use of EBP. During an interview on 01/22/26 at 5:40PM, the Administrator said she expected enhanced barrier precautions to be provided according to orders. The Administrator stated that she expected Resident #10 to receive care from staff wearing EBP. The DON reported Resident #10 was at risk of UTI due to his catheter and stage 4 pressure wounds. Record review of competency checklist dated 12/2025 for CNA T revealed a check off was completed for incontinent care, catheter care, hand hygiene, and enhanced barrier precautions. 5. Record review of Resident #4's face sheet dated 01/22/26 indicated he was a [AGE] year-old male, re-admitted [DATE], with diagnoses which included end stage renal disease, anxiety, depression, and need for assistance with personal care. Record review of Resident #4's quarterly MDS assessment, dated 10/28/25, indicated he could make himself understood and he understood others. The MDS also indicated he had a BIMS score of 15 which meant he was cognitively intact. The MDS also indicated he required staff for set up or clean up assistance for all ADLs. The MDS also indicated he received hemodialysis while he was a resident. Record review of Resident #4's care plan, dated revised 01/15/25, indicated he required enhanced barrier precautions related to him being at risk for multi-drug resistant organisms due to his indwelling medical device with interventions in place to educate staff and visitors of enhanced barrier precautions, enhanced barrier precautions signs placed on resident doors, and enhanced barrier precautions supplies to be located in designated areas on the halls. Record review of Resident #4's physicians order summary report, dated 01/20/26, indicated 1) Dialysis – monitor AV shunt/fistula to left arm for thrill and bruit every shift. Notify MD/NP for any unusual/unexpected findings every shift related to end stage renal with a start date of 11/12/25 and no end date. 2) Enhanced barrier precautions: gowns and gloves to be utilized during ADLs including but not limited to: Dressing, bathing, transferring, providing hygiene, changing linens/briefs or when toileting, care of indwelling medical devices, such as: catheters, g-tubes, and PICC lines, and wound care of chronic wounds (pressure ulcers, diabetic ulcers, unhealed surgical wounds or venous stasis ulcers), and/or close contact was anticipated for transfer/mobility every shift for resident protection from infection. Resident care that does not require enhanced barrier precautions included: peripheral intravenous line (not peripheral central catheter), answering a call light, conversing with resident, providing medications that do not require high contact with a start date of 06/02/25 and no end date. During an interview on 01/22/26 at 2:49 p.m., LVN A said Resident #4 should probably have enhanced barrier precautions, but he cared for himself for most of his ADLs. LVN A said he had dialysis access (a port or catheter used for dialyzing) that nurses must care for at times. LVN A said the importance of enhanced barrier precautions was to keep infection from being passed. During an interview on 01/22/26 at 5:21 p.m., the DON said the staff should have been using enhanced barrier precautions during direct care. The DON said the charge nurse should have been using enhanced barrier precautions while assessing Resident #4's dialysis access. The DON said the Infection Preventionist (the ADON) and DON were responsible for ensuring the person protection equipment cart and the signs for enhanced barrier precautions were outside of the room. The DON said the failure placed a risk for Resident #4 having increased risk for infection and the community of the facility could be at risk if Resident #4 developed an infection. During an interview on 01/22/26 at 5:52 p.m., the Administrator said she expected the signage and the cart for enhanced barrier precautions to be placed at Resident #4's room and door if it was required and she expected everyone to adhere to the infection control policy. The Administrator said the DON and ADON were responsible for ensuring enhanced barrier precautions were placed. The Administrator said the failure placed at risk of spread of infection. Record review of the facility policy Preventing and Controlling infections, dated 1/2022, did not include enhanced barrier precautions. Record review of the facility's policy titled, Perineal Care, dated revised February 2018, indicated, The purpose of this procedure was to provide cleanliness and comfort to the resident, to prevent infections and skin irritation, and to observe the resident's skin condition.Put on gloves.For a male resident a. Wet washcloth and apply soap or skin cleansing agent. b. Wash perineal area starting with urethra and working outward c. If the resident has an indwelling catheter, gently wash the juncture of the tubing from the urethra down the catheter about three inches. Gently rinse and dry the area. d. Retract foreskin of the uncircumcised male. e. Wash and rinse urethral area using a circular motion. f. Continue to wash the perineal area including the penis, scrotum and inner thighs. g. Thoroughly rinse perineal area in same order, using fresh water and clean washcloth. h. If the resident has an indwelling catheter, hold the tubing to one side and support the tubing against the leg to avoid traction or unnecessary movement of the catheter. i. Gently dry perineum following same sequence. j. Reposition foreskin of uncircumcised male. Ask the resident to turn on his side with his upper leg slightly bent, if able. l. Rinse wash cloth and apply soap or skin cleaning agent. m. Wash and rinse the rectal area thoroughly, including the area under the scrotum, the anus, and the buttocks. n. Dry area thoroughly. 9. Discard disposable items into designated containers. 10. Remove gloves and discard into designated container. 11. Wash and dry your hands thoroughly 12. Reposition the bed covers. Make the resident comfortable. 13. Place the call light within easy reach of the resident. 14. Clean wash basin and return to designated storage area. 15. Clean the bedside stand. 16. Wash and dry your hands thoroughly. Record review of the facility's undated policy titled, Implementing the use of Enhanced Barrier Precautions in Skilled LTC Nursing Facilities, Recommendations following Enhanced Barrier Precautions for nursing home staff based on care activities.Examples of Care Activities use hand hygiene, gown, gloves (high-contact activities) providing care under clothes or dressings, providing bundled AM or PM care including oral care, dressing, bathing, grooming, taking the resident to the toilet or providing peri care, having prolonged high-contact with items in the resident's room, resident equipment, or with resident clothing or skin in the resident's room, shower room, or the therapy gym, or doing extended therapy/restorative activities, changing the linens, providing bed mobility, including rolling from side to side.

Based on observation, interview, and record review, the facility failed to provide food that was palatable and served at an appetizing temperature for 16 of 23 residents (Residents #64, #8, #50, #9, and 12 anonymous) and 1 of 1 lunch meals reviewed for palatability. The facility failed to provide palatable food served at an appetizing temperature or taste for Residents #64, #8, #50, #9, and 12 anonymous residents, who complained the food served was cold and bland. The dietary staff failed to provide food that was palatable for the lunch meal observed on 01/20/26. These failures could place residents at risk of weight loss, altered nutritional status, and diminished quality of life. Findings included: During an interview on 01/19/26 at 11:00 a.m., Resident #64 said the food was bland and boring. During an interview on 01/19/26 at 11:09 a.m., Resident #8 said the food was not good. He said the food needed more flavor. He said they needed a new cook. During an interview on 01/19/26 at 11:37 a.m., Resident #50's family member said sometimes when Resident #50 received his food, it was cold. During an interview on 01/19/26 at 12:45 p.m., Resident #9 said the food was not good and could taste better. She said the ham was salty. During an observation and interview on 01/20/26 at 1:29 p.m., the Dietitian and six state surveyors sampled a lunch tray. The sample tray consisted of meatloaf, mashed potatoes, asparagus, and Jello. The Dietitian said the sample tray that was tested did not meet her expectations with flavor or temperature. She said the food was bland and did not retain its heat coming out of the kitchen. During the sampling, the meatloaf was lukewarm. The mashed potatoes were bland and needed more salt, and the asparagus was overcooked. She said the Jello was warm and not at the correct temperature. During a confidential resident group meeting 12 residents stated the food was always cold. During an interview on 01/22/26 at 4:12 p.m., CNA E said she worked on hall 400 and the residents complained about the taste of the food at times, but mostly about the food being cold. She said she would offer them something else. During an interview on 01/22/26 at 4:23 p.m., Dietary Aide K said sometimes the staff would return trays and ask them to warm them. She said they would often fix the resident a new plate. During an interview on 01/22/26 at 4:29 p.m., LVN A said the residents complained about the food in general, about what was served more than anything else, but occasionally about the taste or being cold. She said they did not re-warm food but would get them something else. She said she would also offer supplements because she did not want a resident to lose weight. During an interview on 01/22/26 at 4:36 p.m., the Dietary Manager said she had not had complaints about the food. She said they had a resident council meeting monthly on food, and the residents had not voiced complaints. She said she talked with the dietitian who tasted the food on Tuesday (01/20/26) for lunch, and she said the food could have used more salt. She said they could not use salt because some residents had different diets. She said if the residents did not like the food, they may not eat it, which could cause weight loss. During an interview on 01/22/26 at 5:22 p.m., the DON said she had a test tray randomly but did not eat out of the kitchen regularly. She said she felt the food she tested was fine for her. She said if a resident said their food was cold, she expected staff to go to the kitchen and get a new tray. She said the residents who were not eating or eating less would be placed at risk for malnutrition and weight loss. During an interview on 01/22/26 at 5:52 p.m., the Administrator said she ate out of the kitchen weekly and did not have any concerns. She said the Dietary Manager was responsible for ensuring the food served was palatable and served at an appetizing temperature. She said failure to serve palatable food could cause weight loss. Record review of the facility's policy titled, Taking Temperature, dated 06/01/2019, indicated, Policy: The facility realizes the critical nature of serving foods at the correct temperatures to ensure the health of its residents. The facility will take and record the temperatures of all foods prior to service. Foods not at the correct temperature will be corrected or discarded, as necessary.

Based on observation, interview, and record review, the facility failed to ensure the meals served met the nutritional needs of residents for 1 of 1 meal (the lunch meal) reviewed for meal service. The facility failed to ensure [NAME] R followed the recipe for preparing ham for lunch on 01/19/26. This failure could place residents at risk for weight loss, not having their nutritional needs met, and a decreased quality of life. Findings included: During an observation on 01/19/26 at 12:12 p.m., the state surveyor noted 10 residents' lunch trays in which the ham slice appeared small. During an observation and interview on 01/19/26 at 12:56 p.m., [NAME] R said the size of the ham that was needed was documented on the dietary spreadsheet. [NAME] R looked at the spreadsheet and said it was supposed to be 3 ounces. She weighed the ham slice, and it was revealed to be 2.1 ounces. She weighed 1.5 slices of ham, and it measured 3 ounces. She said she had pre-measured the ham slice before cooking, and it weighed 3 ounces. She said she did not reweigh the ham slice after cooking. She said she should have reweighed to ensure she had the correct weight before serving. [NAME] R said she did not realize she was serving the incorrect size of ham until the surveyor's intervention. [NAME] R said she was responsible for ensuring she served the correct amount of ham, and failure to do so placed the residents at risk for receiving less food. During an interview on 01/20/23 at 5:52 p.m., the Registered Dietitian said the correct serving size should be used with all meals. The Registered Dietitian said the spreadsheet menu indicated what size serving of ham was supposed to be used. The Registered Dietitian said the Dietary Manager was responsible for ensuring the cooks followed the menu serving size. The Registered Dietitian said it was important to serve with the correct serving size to ensure the residents received the correct amount of nutrients, and not serving with the correct serving size could result in weight loss. During an interview on 01/22/26 at 1:29 p.m., the Dietary Manager said [NAME] R was supposed to serve 3 ounces of ham for the lunch menu on 01/19/26. She said cook R weighed the ham slice before cooking it but did not re-weigh the ham slice after cooking it. She said the ham shrank during the cooking phase and was not at the correct serving size. The Dietary Manager said not following the serving size or providing enough protein could cause weight loss. During an interview on 01/22/26 at 5:22 p.m., the DON said she expected the dietary staff to use the correct serving size so residents could receive the correct portions. The DON said failure to use the correct serving size placed residents at risk for not receiving the nutrition intended. The DON said the Dietary Manager was responsible for ensuring the correct serving size was used to serve the residents' meals. During an interview on 01/22/26 at 5:52 p.m., the Administrator said she expected the dietary staff to read the menu and use the correct serving size. The Administrator said the Dietary Manager was responsible for ensuring the correct serving size was used when serving the meals. The Administrator said failure to serve the correct serving size could affect the residents' overall health and well-being. During an interview with the Dietary Manager on 01/22/26 at 6:00 p.m., the facility's policy regarding following the menus was requested and not provided before exit. Record review of the facility's policy titled, Meal Service Food Handling and Preventing Contamination Reminders, dated 1/22, indicated, Procedure: Serving diet trays: B. Identify diet tray by card. C. Identify the resident and place tray within easy reach of resident. E. Replace missing items following facility policy. E (3) offer to replace or rewarm food that has become cold. Record review of the facility's policy titled, Portion Control dated 10/01/2018, indicated, Policy: The facility will use standard portion control procedures and utensils to ensure that adequate portions are served to residents. Procedure: 2. A dated copy of the daily menu extensions with portion sizes should be posted in the kitchen near the preparation and serving areas. 3. Portions for each food item should follow the specific portion sizes listed on the menus .

Based on observation, interview, and record review, the facility failed to provide pharmaceutical services, including procedures that assured the accurate acquiring, receiving, dispensing and administering of all drugs and biologicals to meet the needs of each resident and determined that drug records were in order and that an account of all controlled drugs were maintained and periodically reconciled for 3 of 5 residents (Resident #1, Resident #10, and Resident #56) reviewed for pharmacy services. 1. The facility failed to ensure there was not a delay in administering Resident #1's Debrox (medication that softens and loosens ear wax to make it easier to remove), after it was ordered on 01/16/2026. 2. The facility failed to ensure Resident #56 received 2 puffs of Combivent (medication used to treat/prevent wheezing and shortness of breath) as ordered by the physician on 01/20/2026. 3. The facility failed to ensure LVN B periodically reconciled Resident #10's morphine/diazepam suppositories (medication used for pain/anxiety). These failures could place residents at risk of not having medications available for use, medications errors, drug diversions, and inaccurate records. Findings included: 1. Record review of Resident #1's face sheet dated 01/22/2026 indicated she was an [AGE] year-old female initially admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses which included dementia (loss of memory, language, problem solving and other thinking abilities that were severe enough to interfere with daily life), chronic obstructive pulmonary disease (chronic inflammatory lung condition that affects the respiratory system), and bilateral sensorineural hearing loss (type of hearing impairment affecting both ears, often caused by damage to the inner ear or auditory nerve, and it can significantly impact communication and quality of life). Record review of Resident #1's Comprehensive MDS assessment dated [DATE] indicated she was able to understand others and others understood her. The MDS assessment indicated Resident #1 had a BIMS score of 5, which indicated her cognition was severely impaired. The MDS assessment indicated Resident #1 required partial/moderate assistance with dressing, toileting, and personal hygiene. Record review of Resident #1's Order Summary Report, dated 01/19/2026 indicated Debrox solution 6.5% instill 5 drops in both ears two times a day for cerumen (earwax) impaction for 4 days with a start date of 01/16/2026. Record review of Resident #1's January 2026 MAR indicated Debrox solution 6.5% instill 5 drops in both ears two times a day for cerumen (earwax) impaction for 4 days with a start date of 01/16/2026. The following was documented:01/16/2026: 6 PM-1 AM other/see nurses notes signed by LVN F.01/17/2026: 6AM-10 AM refused signed by LVN D.01/17/2026: 6 PM-1 AM other/see nurses notes signed by LVN F.01/18/2026: 6AM-10 AM refused signed by LVN D.01/18/2026: 6 PM-1 AM other/see nurses notes signed by LVN F.01/19/2026: 6 AM-10 AM other/see nurses notes signed by LVN C. Record review of Resident #1's Progress Notes indicated:01/16/2026 at 12:49 PM New order noted earlier for Debrox drops to start later this afternoon signed by LVN D. 01/16/2026 at 9:12 PM an order administration note for Debrox signed by LVN F did not address if Debrox was administered. 01/18/2026 at 10:35 PM an order administration note for Debrox signed by LVN F did not address if Debrox was administered. Resident #1's Progress Notes dated 01/16/2026-01/19/2026 did not further address if Debrox was administered. Record review of Resident #1's care plan with a target date of 02/17/2026 did not address the use of debrox. During an interview on 01/19/2026 at 12:00 PM, Resident #1 said she felt like her ears were stopped up, and she told the nurses she needed them cleaned and they would not do it. Resident #1 said she told the nurses a while ago. Resident #1 was not able to provide a specific date range. During an interview on 01/19/2026 at 12:06 PM, LVN C said she was aware Resident #1 complained about her ears being stopped up and needing to be cleaned. LVN C said an order for ear drops was received Friday (01/16/2026), but they had not been delivered from the pharmacy. LVN C said she had not contacted the pharmacy regarding Resident #1's ear drops. LVN C said LVN D received an order for the ear drops on 01/16/2026, and the ear drops should have been delivered the following day. LVN C said she did not work on the weekend, so she did not know why the ear drops were not delivered. LVN C said if the pharmacy did not deliver medications the following day, they should contact the pharmacy to see why it was not delivered. LVN C said a delay in receiving medications from the pharmacy resulted in the residents not being treated for their condition. During an attempted phone interview on 01/22/2026 at 11:30 AM, LVN F did not answer the phone. During an interview on 01/22/2026 at 3:25 PM, the DON said staff did not contact her over the weekend to notify her Resident #1's Debrox was not delivered from the pharmacy. The DON said when a new medication was ordered from the pharmacy, and it was not delivered the next day they should contact the pharmacy and notify her and the doctor. The DON said there were many risks associated with not administering medications in a timely manner after they were ordered, and it could effect the care the residents received. During an interview on 01/22/2026 at 3:43 PM, the Administrator said she expected medications to be ordered in a timely manner. The Administrator said administrative staff should ensure medications were ordered from the pharmacy. The Administrator said not administering medications in a timely manner after an order was received could result in a delay in the care provided During an interview on 01/22/2026 at 4:13 PM, LVN D said there was no one available to go get the Debrox from the store. LVN D said she charted Resident #1 refused the Debrox because the DON instructed her to do so. LVN D said they were having issues with the pharmacy, and the DON instructed the staff to chart refused if a medication was not delivered by the pharmacy. LVN D said the DON would deny that she told the staff to chart refused when medications were not delivered from the pharmacy. LVN D said she had to do what her boss told her to. LVN D said she did not report to the Administrator that she was instructed to chart refused when a medication was not delivered. LVN D said it was important for medications to be administered because the doctor ordered it for a reason and to make the resident's life better. During an interview on 01/22/2026 at 5:36 PM, the DON said she never told the staff to chart refused when a medication was not delivered by the pharmacy. The DON said every morning they went over the new orders to ensure medications were delivered. The DON said the pharmacy usually delivered the next day, but if there was a delay the staff should contact her and the pharmacy. The DON said she was not notified over the weekend that Resident #1 needed Debrox. The DON said Debrox was over the counter, and had she been notified she would have brought it to the facility. During an interview on 01/22/2026 at 6:06 PM, the Administrator said it was not reported to her that the DON was telling the staff to document refused when medications were not available for administration. The Administrator said the staff should not document refused for a medication that was not available, and she expected the staff to notify the pharmacy and the DON if a medication was not delivered. 2. Record review of Resident #56's face sheet dated 01/22/2026 indicated he was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses which included dementia (loss of memory, language, problem solving and other thinking abilities that were severe enough to interfere with daily life) and asthma (a condition that causes the airways to narrow and swell). Record review of Resident #56's Quarterly MDS assessment dated [DATE] indicated he was able to understand others, and he was understood by others. The MDS assessment indicated Resident #56 had a BIMS score of 15, which indicated his cognition was intact. The MDS assessment indicated Resident #56 had shortness of breath or trouble breathing with exertion and when lying flat. Record review of Resident #56's Order Summary Report dated 01/20/2026 indicated an order for Combivent 18-103 mcg/actuation inhale 2 puffs orally every 12 hours with a start date of 01/22/2025. Record review of Resident #56's care plan revised 01/07/2026 indicated he had asthma with the potential for shortness of breath and respiratory illness, and interventions included to give medications as ordered. During an observation of medication administration and an interview on 01/20/2026 at 9:07 AM, LVN B administered Resident #56's Combivent. Resident #56 only inhaled one puff of Combivent. LVN B said Resident #56 was supposed to inhale 2 puffs of the Combivent, but she was nervous and did not pay attention. LVN B said not administering the correct dose of Combivent could result in Resident #56 having an asthma flare up. During an interview on 01/22/2026 at 3:23 PM, the DON said the nurses should follow the rights of medication administration and ensure the correct dose was administered. The DON said she made random observations of medication administration, and the pharmacy consultant observed medication administration once a month. The DON said Resident #56's medication not administered as ordered could result in respiratory difficulty or the resident could be in distress. During an interview on 01/22/2026 at 3:41 PM, the Administrator said she expected the nurses to follow the policy for medication administration, and ensure the resident received the right medication and all the rights of medication administration were followed. The Administrator said management staff were responsible for ensuring the nurses were administered medications properly. The Administrator said she was not clinical, but not administering medications as ordered could result in adverse effects. 3. Record review of a face sheet dated 01/22/2026 indicated Resident #10 was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses which included dementia (loss of memory, language, problem solving and other thinking abilities that were severe enough to interfere with daily life), chronic pain syndrome (a condition where pain lasting longer than 3-6 months is accompanied by significant emotional, mental, and functional issues, such as depression, anxiety, and daily life disruption), and chronic obstructive pulmonary disease (chronic inflammatory lung condition that affects the respiratory system). Record review of Resident #10's Comprehensive MDS assessment dated [DATE] indicated he was able to understand others and others understood him. The MDS assessment indicated Resident #10 had a BIMS score of 0, which indicated his cognition was severely impaired. The MDS assessment indicated Resident #10 was dependent on staff for personal hygiene and showering/bathing self and required substantial/maximal assistance with toileting hygiene. The MDS assessment indicated Resident #10 received scheduled pain medication, and he did not receive PRN pain medication. Resident #10's MDS assessment indicated he received opioids. Record review of Resident #10's Order Summary Report dated 01/22/2026 indicated he had an order for morphine/diazepam suppository 10 mg insert 1 suppository rectally every 12 hours as needed for pain/anxiety with a start date of 01/13/2026. Record review of Resident #10's care plan revised 01/06/2026 indicated he had a terminal prognosis and was on hospice services to observe resident closely for signs of pain and administered medications as ordered. Record review of Resident #10's Medication Count Sheet indicated morphine/diazepam 10/10 suppositories insert 1 rectally every 12 hours as needed, 12 suppositories were received on 09/03/2025, and none had been administered. During an observation of the facility's medication storage room with LVN B on 01/20/2026 at 4:58 PM, Resident #10's morphine/diazepam suppositories were in the refrigerator in the medication storage room. There were 12 suppositories. LVN B said she had not been counting the morphine/diazepam suppositories every shift. LVN B said she usually counted them when she returned from being off, but she did not count them at the beginning/end of every shift because she knew the suppositories had not been messed with. LVN B said narcotics should be counted at the beginning and end of every shift. LVN B said it was important for narcotics to be counted because there could be a discrepancy, staff could misuse them, and to ensure they were charted properly so the resident was not double dosed. During an interview on 01/22/2026 at 3:28 PM, the DON said narcotics should be counted every shift, including Resident #10's morphine/valium suppositories. The DON said she monitored to ensure the staff was counting by checking the narcotic sheets to ensure they were signed. The DON said narcotics should be counted every shift to decrease the risk of drug diversion, to ensure the residents had the medications when they needed them, and to check the expiration dates of the medications. During an interview on 01/22/2026 at 3:44 PM, the Administrator said she expected the staff to count all narcotics each shift. The Administrator said management should ensure this was happening. The Administrator said not counting the narcotics each shift could result in a drug diversion or the patient could run out of medications. Record review of the facility's undated policy titled, Delivery, Receipt, and Storage of Medication, indicated, .New orders will be delivered upon the next routine delivery. Record review of the facility's policy titled, Administering Medications, revised April 2019, indicated, Medications are administered in a safe and timely manner, and as prescribed.The individual administering the medication checks the label THREE (3) times to verify the right resident, right medication, right dosage, right time and right method (route) of administration before giving the medication. Record review of the facility's policy titled, Controlled Substances, revised April 2019, indicated, The community complies with all laws, regulations, and other requirements related to handling, storage, disposal, and documentation of controlled medications. 8. Controlled substances are reconciled upon receipt, administration, disposition, and at the end of each shift.Controlled medications are counted at the end of each shift. The nurse coming on duty and the nurse going off duty determine the count together.

Based on observation, interview and record review the facility failed to ensure the resident environment remained as free of accident hazards as was possible for 4of 6 residents (Residents #79, #28, #41 and #61) reviewed for accidents. 1. The facility failed to ensure 2 staff were utilized for bed mobility for Resident #79 on 01/19/26 and 01/20/26. 2. The facility failed to ensure Resident #28's disposable razor, shaving cream, and 3 bottles of liquid air freshener were not stored at the bedside. 3. The facility failed to ensure shaving cream was not stored in Residents #41and #61's bathroom. These failures could place residents at risk of injury. Findings include: 1. Record review of Resident #79's face sheet, dated 01/22/26, reflected an [AGE] year-old female who was admitted to the facility on [DATE] and re-admitted on [DATE]. Resident #79 had diagnoses which included dementia (loss of memory), stroke, anxiety (feelings of worry, fear, unease, and apprehension), and high blood pressure. Record review of Resident #79's quarterly MDS assessment, dated 10/08/25, reflected Resident #79 understood and was understood by others. Resident #79's BIMS score was 13, which indicated her cognition was intact. Resident #79 required assistance with her ADLs, which included transfers, dressing, personal hygiene, and bed mobility. Resident #79 was frequently incontinent of bowel and bladder. Record review of Resident #79's comprehensive care plan, dated 10/20/22, indicated Resident #79 had an ADL self-care performance deficit related to impaired balance, stroke, and limited range of motion to the right shoulder. The intervention was for two staff members to assist with toileting, turning, and repositioning in bed. During an observation on 01/19/26 at 12:03 p.m., revealed CNA H provided incontinent care for Resident #79. CNA H did not have another staff member to assist with bed mobility or toileting. During an interview on 01/19/26 at 12:55 p.m., CNA H said the ADON told her she should have waited to provide care for Resident #79 until she got help. She said it was hard to get everything done and wait on others when she had about 25 residents. She said she had always provided care for Resident #79 by herself. During an interview and observation on 01/22/26 at 1:43 p.m., CNA H said Resident #79 was a 1-person assist for bed mobility and toileting. She said she had been providing care for Resident #79 as a one-person assist. CNA H called over CNA L, and she said Resident #79 was a one-person assist for bed mobility and toileting. She said she provided care for Resident #79 this morning (01/22/26) by herself. Both CNAs said they knew how to take care of a resident through their care plan. CNA H looked at Resident #79's care plan on their task page and said she was a 2-person assist with bed mobility and toileting. They both said they had been providing care by themselves. They both said failure to use two staff could cause an injury to the resident such as a fall. CNA H said she would be in trouble if Resident #79 had fallen or obtained an injury while providing care by herself, since the care plan indicated Resident #79 required two staff members for bed mobility and toileting. During an interview on 01/22/26 at 2:55 p.m., the ADON said it took two staff members to get Resident #79 out of bed. The ADON said sometimes Resident #79 required two staff members on days she did not feel well. She said she preferred they used two staff members for bed mobility and toileting because of the residents' weakness. She said if the care plan said they should have two staff for bed mobility and toileting, then she expected two staff members to be there. The ADON said failure to use two staff members could cause injury to the resident, such as falls or skin tears. During an interview on 01/22/26 at 5:22 p.m., the DON said Resident #79 required two staff members to assist while providing care. She said the staff should be following the care plan, and she was responsible for ensuring they followed the care plan. She said failure to follow the care plan could lead to injury. During an interview on 01/22/26 at 5:52 p.m., the Administrator said if Resident #79 had a care plan for two staff members to assist with bed mobility and toileting, then she expected staff to follow the care plan. She said nurse management was responsible for ensuring staff were following the care plan. She said if two staff members were not providing care, they could place the resident's safety at risk. 2. Resident #28 Record review of Resident #28's face sheet, dated 01/22/26, reflected Resident #28 was a [AGE] year-old male, admitted to the facility on [DATE] with diagnoses which included atrial fibrillation (irregular, often rapid heart rate). Record review of Resident #28's quarterly MDS assessment, dated 12/30/25, reflected Resident #28 made himself understood and understood others. Resident #28's BIMS score was 14, which reflected his cognition was intact. Resident #28 required partial/moderate assistance with personal hygiene which included shaving. Record review of Resident #28's comprehensive care plan, revised on 03/28/25, reflected Resident #28 had an ADL self-care performance deficit related to activity tolerance, dementia (loss of memory, language, problem solving and other thinking abilities that were severe enough to interfere with daily life), fatigue, and impaired balance. The care plan interventions included: the resident required 1 staff assistant with personal hygiene and oral care. During an observation and interview on 01/19/26 at 2:05 p.m., Resident #28 had a disposable razor, a can of shaving gel, and a can of liquid air freshener on his bathroom countertop. Resident #28 had 2 cans of liquid air freshener, and a can shaving cream under his television stand. Resident #28's family member stated she brought these items for Resident #28. During an observation on 01/20/26 at 9:05 a.m., Resident #28 had a disposable razor, a can of shaving gel, and a can of liquid air freshener on his bathroom countertop. Resident #28 had 2 cans of liquid air freshener, and a can shaving cream under his television stand. 3. Record review of Resident #41's face sheet, dated 01/22/26, reflected Resident #41 was a [AGE] year-old female, originally admitted to the facility on [DATE] with diagnoses which included COPD (chronic inflammatory lung disease that causes obstructed airflow from the lungs). Record review of Resident #41's annual MDS, dated [DATE], reflected Resident #41 made herself understood and understood others. Resident #41 had a BIMS score of 9, which indicated her cognition was moderately impaired. Resident #41 required supervision/touching assistance with personal hygiene including shaving. Record review of Resident #41's comprehensive care plan, revised 02/23/24, reflected Resident #41 had an ADL self-care performance deficit related to impaired balance, limited ROM, and right arm contracture (shortening of muscles). The care plan interventions included: the resident required 1 staff assistant with personal hygiene. Resident #61 Record review of Resident #61's face sheet, dated 01/22/26, reflected Resident #61 was a [AGE] year-old female, originally admitted to the facility on [DATE] with diagnoses which included dementia (loss of memory, language, problem solving and other thinking abilities that were severe enough to interfere with daily life). Record review of Resident #61's comprehensive care plan, revised on 09/10/24, reflected Resident #61 had an ADL self-care performance deficit related to dementia, fatigue, and ataxia (poor muscle control). The care plan interventions included: the resident required 1 staff assistant with personal hygiene. Record review of Resident #61's quarterly MDS assessment, dated 12/30/25, reflected Resident #61 made herself understood and understood others. Resident #61 had a BIMS score of 15, which indicated her cognition was intact. Resident #61 required supervision/touching assisting with shaving. During an observation and interview on 01/19/26 at 1:10 p.m., revealed there was a can labeled shaving cream on their bathroom countertop. Residents #41 and #61 stated the shaving cream did not belong to them. During an observation on 01/20/26 at 9:15 a.m., there was a can labeled shaving cream on Resident #41's and #61's bathroom countertop. During an interview on 01/22/26 at 12:51 p.m., revealed CNA P observed the disposable razor, mouthwash, shaving cream, 3 bottles of liquid air freshener in Resident #28's room and the can of shaving cream in Residents #41 and #61's room with the state surveyor. CNA P stated all staff should be aware and observant of items that did not belong at residents' bedside. CNA P stated she never noticed the items during her rounds. CNA P stated she knew there were at least two residents who wandered the hall and this failure could potentially put residents at risk for endangerment to themselves or others. During an interview on 01/22/26 at 1:00 p.m., RN G stated all staff were responsible for ensuring items were stored properly and securely. RN G stated razors and shaving cream should be stored in the supply closet and air fresher stored in the ADON/DON office. RN G stated it was important to ensure items were not left at bedside for residents' safety. During an interview on 01/22/26 at 1:10 p.m., the MDS Coordinator stated she was responsible for angel rounds (rounds completed by staff to ensure residents and their rooms were safe) Resident #28. The MDS Coordinator stated during rounds she observed obstacles that should not be stored at the bedside. The MDS Coordinator stated to her knowledge she was unsure if air freshener and shaving cream could be stored at the bedside. The MDS Coordinator stated that her thoughts for razors were to be stored in the supply room. The MDS Coordinator stated she was told what items could or could not be stored at the bedside. The MDS Coordinator stated she did not recall seeing any items during her rounds this week. The MDS Coordinator stated, it was a human error. The MDS Coordinator stated it was important to ensure items were not left at the bedside of residents' safety. During an interview on 01/22/26 at 2:33 p.m., the BOM stated she was responsible for angel rounds for Residents #41 and #61. The BOM stated rounds were done daily and she had not seen any shaving cream on their bathroom countertop. The BOM stated the aides should keep the shaving cream stored in the supply room. The BOM stated it was important to ensure items were not left at the bedside for residents' safety. During an interview on 01/22/26 at 4:03 p.m., the DON stated shaving cream, and razors should be stored in a locked cabinet that CNAs had accessed too. The DON stated air freshener should not be in the building because the chemical was not approved for the facility. The DON stated all staff, which included angel rounds, should be monitored for things that could possibly harm a resident. The DON stated she and the Administrator were responsible for monitoring and overseeing by entering random residents' rooms and making observations. The DON stated it was important to ensure items were not left at the bedside for residents' safety. During an interview on 01/22/26 at 5:04 p.m., the Administrator stated shaving cream, and razors should be stored in a location that was secured in the shower room. The Administrator stated air freshener was not allowed in the facility. The Administrator stated she was not aware these items were stored at the resident's bedside. The Administrator stated nursing staff and angel rounds were responsible for monitoring and overseeing by daily observations. Record review of the Safety and Supervision of Residents .revised on 07/2017 reflected. Our community strives to make the environment as free from accident hazards as possible. Resident safety and supervision and assistance to prevent accidents are community-wide priorities. Individualized, Resident-Centered approach to Safety.1. Our individualized, resident-centered approach to safety addressed safety and accident hazards for individual residents.Resident Risks and Environmental Hazards.b. Safe lifting and movement of residents. f. poison control.

Based on interviews and record review, the facility failed to assist residents in obtaining routine dental services to meet the needs for 1 of 2 (Resident #61) residents reviewed for dental services. The facility did not ensure Resident #61 was provided with routine dental services related to dentures in a timely manner. This failure could place residents at risk of oral complications, dental pain, and diminished quality of life. Findings included: Record review of Resident #61's face sheet, dated 12/30/26, reflected Resident #61 was a [AGE] year-old female, originally admitted to the facility on [DATE] with diagnoses which included dementia (loss of memory, language, problem solving and other thinking abilities that were severe enough to interfere with daily life). Record review of Resident #61's order summary report, dated 01/22/26 reflected an active physician order for PRN dental care with an order date of 08/19/24. Record review of Resident #61's quarterly MDS assessment, dated 12/30/25, reflected Resident #61 made herself understood and understood others. Resident #61 had a BIMS score of 15, which indicated her cognition was intact. Resident #61 required set-up or clean-up assistance with eating. Resident #61 has not had a weight loss of 5% or more in the last month or loss of 10% or more in the last six months. Record review of Resident #61's comprehensive care plan, revised on 08/26/24, reflected Resident #61 had the potential for oral/dental problems related to edentulous (no natural teeth) status. Resident #61 stated she had upper and lower dentures but lost them prior to admission. The care plan interventions included oral care daily/PRN and notify charge nurses of oral/dental problems. Record review of Resident #61 weight summary report dated 11/13/25-01/20/26, reflected Resident #61 had not had significant weight loss in the past six months. During an interview on 01/19/26 at 12:06 p.m., Resident #61 stated, I need dentures. Resident #61 stated she told several staff members, including the social worker, about her needing dentures. Resident #61 was unable to give the exact date but stated it was last year when she told the social worker about needing dentures. Resident #61 stated not having dentures made it hard for her to chew her food. During a telephone interview on 01/21/26 at 10:15 a.m., the Customer Care Representative from the dental agency stated Resident #61 needed an alternative payor source before being seen. During a telephone interview on 01/21/26 at 3:05 p.m., Resident #61's family member stated he talked to several staff members, including the social worker, repeatedly about Resident #61 needing dentures. Resident #61's family member stated they used every excuse in the books on why she has not been seen by the dentist. During an interview on 01/21/26 at 3:05 p.m., the Social Worker stated she was responsible for sending referrals and scheduling dental services for the facility residents. The Social Worker stated she had spoken to Resident #61 and Resident #61's family member about needing dentures but could not recall the exact date. The Social Worker stated she received an email from the dental agency on 12/08/25 stating Resident #61 would not be seen due to her payor source. The Social Worker stated she did not follow up with the dental agency to get more clarity about what was needed for her to be seen. The Social Worker stated she thought the dental agency would notify Resident #61of what documents were needed but she should have notified the BOM herself to see if Resident #61 had coverage or not. The Social Worker stated it was important for the residents to be referred to the dentist because it could affect their quality of care to be able to chew and speak clearly and prevent weight loss. During an interview on 01/21/26 at 3:30 p.m., the BOM stated the Social Worker had not asked about Resident #61's payor source until 01/21/26. The BOM stated Resident #61 had a lapse of payor coverage from 06/01/25 until 07/31/25 but she renewed her coverage on 08/04/25 and was approved on 09/15/25. The BOM stated if the Social Worker had told her that there was an issue with her payor source she would have notified the dental agency herself and provided them with updated information. The BOM stated it was important for Resident #61 to be referred to the dentist because it could affect her quality of life and avoid weight loss. During an interview on 01/22/26 at 4:03 p.m., the DON stated the Social Worker was responsible for initiating the dentures replacement by starting a referral process and following up on any issues with the payor source. The DON stated Resident #61 or Resident #61's family member had not mentioned to her that Resident #61 needed dentures. The DON stated it was important to ensure the residents were referred to dental care so they could eat, communicate and prevent a decline in health. During an interview on 01/22/26 at 5:04 p.m., the Administrator stated the Social Woker was responsible for making a referral to the dental agency. The Administrator stated Resident #61 or Resident #61's family members had not mentioned to her that Resident #61 needed dentures. The Administrator stated she was not monitoring the Social Worker because for as she knew there was not a problem with residents receiving services. The Administrator stated the Social Worker would start providing a list of ancillary services and she would ensure each resident received the services that were needed. The Administrator stated it was important for the residents to receive dental services to prevent weight loss. Record review of the Dental Services, revised on 10/2016 reflected. Routine and emergency dental services are available to meet the resident's oral health services in accordance with the resident's assessment and plan of care. 1. Routine.dental services are provided to our residents through a. a contract agreement with a license dentist that comes to the facility monthly.6. Social services representatives will assist residents with appointments, transportation arrangements.

Based on observation, interview, and record review the facility failed to ensure safe and sanitary storage of resident's food items for 2 of 4 residents reviewed for personal food safety. (Residents #3 and Resident #52)The facility failed to ensure Residents #3's and Residents #52's personal refrigerator temperature logs were properly checked and documented. This failure could place the residents at risk for food borne illnesses.Findings included: 1.Record review of Resident #3's face sheet, dated 1/22/26, indicated she was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses which included PTSD (post-traumatic stress disorder), depression (a mood disorder that caused a persistent feeling of sadness and loss of interest), and anxiety (persistent, excessive worry that interferes with daily life). Record review of Resident #3's admission MDS assessment, dated 12/11/25, indicated she made herself understood and she understood others. The MDS also indicated a BIMS score of 12, which indicated she was cognitively intact. The MDS also indicated she required moderate assistance with all ADLs. During an observation on 01/19/26 at 12:03 p.m., Resident #3 was out of her room. Resident #3's refrigerator temperature log was last dated 01/14/26. During and observation and interview on 01/20/26 at 1:20 p.m., Resident #3 was lying in the bed and her refrigerator temperature log continued was last updated 01/14/26 and Resident #3 said, Oh shit, that's not good for me. During an observation on 01/22/26 at 09:32 a.m. Resident #3's refrigerator temperature log was updated through 01/23/26. 2.Record review of Resident #52's face sheet, dated 01/22/26, indicated he was a [AGE] year-old male, re-admitted to the facility on [DATE], with diagnoses which included fracture of the right femur, high blood pressure, dementia (a progressive decline in mental ability that interferes with daily life), and need for assistance with personal care. Record review of Resident #52's significant change MDS, dated [DATE], indicated he understood others and made himself understood. The MDS also indicated he had a BIMS score of 3 which meant he was severely cognitively compromised. The MDS also indicated he required total assistance for transfers, maximal assistance for toileting, dressing, bathing, and bed mobility, and supervision for eating. During an observation and interview on 01/19/26 at 11:50 a.m., Resident #52 was in bed and said he did not know how long he was in the facility. Resident #52's refrigerator had a temperature log on it and it was last checked on 1/6/2025. Resident #52 said he was unsure who logged the refrigerator temperatures. During an observation and interview on 01/22/26 at 9:55 a.m., Resident #52 was in bed and the temperature log for the refrigerator was missing. Resident #52 said he was unsure where the log was but he thought his kids checked it but he did not know for sure. During an interview on 01/22/26 at 5:19 PM the DON said the guardian angels' rounds were responsible for ensuring the temperature logs were kept in place. The DON said she was unsure of the exact staff member who had Resident #3 and Resident #52's room for rounds. The DON said the failure placed a risk for the refrigerator not maintaining the proper temperature, food spoilage, and food born illnesses if the residents consumed the food. During an interview on 01/22/26 at 5:54 p.m., the Administrator said she expected the temperature logs for all residents to be checked and logged daily. The Administrator said each member of staff on their angel rounds (rounds completed by the staff to check residents and rooms) were responsible for ensuring the refrigerators were checked. The Administrator said the failure placed residents at a risk for temperatures out of range and spoiled food which could cause residents to get very sick. Record review of the facility policy titled, Personal Refrigerators & Nourishment Rooms & Refrigerators, dated 3/1/22, indicated Objective: Residents are encouraged to bring personal and familiar belongings to their new home, such as furniture and appliances; i.e. televisions, refrigerators, etc.Guidelines Please check with the community maintenance director prior to bringing in furniture and appliances; i.e.: televisions, refrigerators, etc. to ensure it is in a safe working condition, an allowable item and to ensure there is ample room for the resident to move about in the room. If the resident chooses to have a refrigerator in their room they can use it for beverages and food that is brought into the community for the resident to consume. A staff member should place a thermometer in the refrigerator and begin to record temps to ensure the refrigerator is properly working and maintaining food at proper storage temps. During angel rounds or during the temping of the refrigerator in an attempt at culture change and assisting our residents in remaining as independent as possible, an assigned staff member is to check the refrigerator and will assist the resident in throwing away any item(s) that had appeared to have gone bad or are expired.

Based on observation, interview, and record review the facility failed to ensure all drugs and biologicals used in the facility were labeled and stored in accordance with professional standards for 1 of 4 medication carts (200 hall Nurse Medication Cart) reviewed for drugs and biologicals. The facility failed to ensure one vial of albuterol sulfate 2.5 mg/3ml (medication used for breathing treatments) and a tube of diclofenac topical gel 1% (medicated gel applied on the skin to decrease pain/inflammation) were stored properly, when they were left on top of the 200 hall Nurse Medication Cart unattended on 01/21/2026. This failure could place residents at risk of not receiving drugs and biologicals as needed, medication errors, medication misuse, and drug diversion.Findings included: During an observation and interview on 01/21/2026 starting at 4:57 PM, one vial of albuterol sulfate 2.5 mg/3ml and a tube of diclofenac topical gel 1% were on top of the 200-hall Nurse Medication Cart, unattended, on the 200 hall. Multiple staff and residents were observed in the hallway around the unattended 200 hall Nurse Medication Cart. LVN A said someone called her to take them to the dining room and she forgot to put the medications back inside the medication cart. LVN A said she should not leave medications on top of the medication cart because someone could take them. During an interview on 01/22/2026 at 3:32 PM, the DON said medications should not be left on top of the medication cart. The DON said she monitored to ensure medications were stored properly by providing education to the staff, making rounds, and watching the staff. The DON said she had not noticed any medications not stored properly. The DON said medications on top of the medication cart could result in a resident getting a hold of it or eating it or a visitor taking the medication. During an interview on 01/22/2026 at 3:45 PM, the Administrator said she expected all medications to be secured at all times. The Administrator said management staff were responsible for ensuring the staff were trained to do things properly. The Administrator said leaving medications on top of the medication cart could result in someone else taking them or having them come up missing. Record review of the facility's undated policy titled, 6. Delivery, Receipt, and Storage of Medication, indicated, .6.3. Storage of Medication.Scheduled medications should be stored in a separate locked area within the medication carts or medication room.

Based on interview and record review the facility failed to ensure residents who use psychotropic drugs receive gradual dose reductions, and behavioral interventions, unless clinically contraindicated, in an effort to discontinue these drugs for 1 of 5 residents (Resident #10) reviewed for unnecessary psychotropic drugs. The facility failed to ensure Resident #10's GDR, dated 12-25, was completed after pharmacy recommended a dose reduction. This failure could place residents at risk of receiving unnecessary psychotropic medications with possible medication side effects, adverse consequences, decreased quality of life and dependence on unnecessary medications.Record review of Resident #10 face sheet, dated 01/20/25, reflected a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #10 had diagnoses which included COPD (chronic lung condition that limits airflow and causes difficulty breathing), unspecified dementia (cognitive disorder that impairs memory, thinking, and judgement), and need for assistance with personal care. Record review of Resident #10's quarterly MDS, dated [DATE], reflected the resident had an active diagnosis of depression and the resident was currently taking the following medication by pharmacological class: antidepressant, antibiotic, opioid, and anticonvulsant. Resident #10 had a BIMS of 11, which indicated only moderate impairment. Record review of Resident #10's significant change MDS, dated [DATE], reflected the resident was currently taking the following medication by pharmacological class: antidepressant, antibiotic, opioid, and anticonvulsant. Resident #10 had a BIMS of 00, which indicated severe impairment. Record review of Resident #10's care plan, revision dated 12/08/25, reflected the resident used antidepressant medication for depression. Resident #10 had interventions listed as Monitor/document/report PRN adverse reactions to Antidepressant therapy: change in behavior/mood/cognition; hallucinations/delusions; social isolation, suicidal thoughts, withdrawal; decline in ADL ability, continence, no voiding; constipation, fecal impaction, diarrhea; gait changes, rigid muscles, balance probs, movement problems, tremors, muscle cramps, falls; dizziness, fatigue, insomnia; appetite loss, weight loss, nausea and vomiting, dry mouth, dry eyes. Record review of Resident #10's medication regimen review, dated for the time period 12/02/25 to 12/06/25, reflected the need for Resident #10's medication regimen of Lexapro 15mg daily since 6/17/25. The recommendation of initiating gradual dose reduction to: Lexapro 10mg daily. Record review of Resident #10 order summary report, dated 01/20/25, indicated he had an order for:Escitalopram Oxalate Tablet Give 15 mg by mouth one time a day for Depression related to Depression, Unspecified (F32.A) Active start 06/17/2025, with no end date. Record review of Resident #10 medication administration record, dated 01/20/26, indicated resident had received Lexapro(Escitalopram Oxalate medication used for depression) Tablet with the instructions to give 15 mg by mouth one time a day for Depression every day the month of January 2026. During an interview on 01/22/25 at 10:40 AM, the DON said she was unable to provide documentation of a GDR for Resident #10 Lexapro. During an interview on 01/22/25 at 4:36 PM, the DON said at the time he went on hospice he was no longer being seen by the nurse practitioner for psychiatric care. The DON stated at that time the facility NP should have taken over his care and monitoring timeline. The DON reported when contacting the NP, the NP stated she never took over his medication regime review. The DON reported she was responsible for ensuring the GDR process was completed and Resident #10 was at risk of being over or under medicated and having unnecessary medications. During an interview on 01/22/25 at 5:36PM, the Administrator said she expected the GDR to be considered, discussed, and policy and procedures followed. The Administrator stated the DON was responsible for ensuring this process was completed and it was done between nursing, pharmacy, and the provider. The Administrator reported the resident was at risk for adverse effects of the medication. Record review of Medication Therapy Policy, dated April 2007, reflected the following: 1. Periodically, and when circumstances are present that represent a greater risk for medication-related complications, the staff and practitioner will review the medication regimen for continued indications, proper dosage and duration, and possible adverse consequences. 2. The physician will identify situations where medications should be tapered, discontinued, or changed to another medication, for example: a. when a medication is being given in excessive doses, for excessive periods of time, without adequate monitoring, or in the absence of a valid clinical rationale; b. when the results of ongoing assessment, or the presence of clinically significant adverse consequences monitoring, suggest that a medication should be reduced or discontinued entirely; and c. when a medication is being prescribed to treat, or in anticipation of, an adverse consequence of another prescribed drug. 3. The consultant pharmacist shall review each resident's medication regimen monthly, as requested by the staff or practitioner, or when a clinically significant adverse consequence is confirmed or suspected. 4. The community shall review medication-related issues as part of its quality assurance and performance improvement committee and activities.

Based on interview and record review, the facility failed to act upon the recommendations of the pharmacist report of irregularities for 1 of 24 residents (Resident #41) reviewed for (DRR) Drug Regimen Review. The facility failed to timely implement Resident #41's signed Pharmacist Recommendation to Physician on 05/08/2025, which agreed with the pharmacy recommendation to discontinue Mag-Oxide 400 mg QAM (supplement). This failure could place residents at risk for receiving unnecessary medications at the most effective dosage.Findings included: Record review of Resident #41's face sheet, dated 01/22/26, reflected Resident #41 was a [AGE] year-old female, admitted [DATE] with diagnosis of COPD (chronic inflammatory lung disease that causes obstructed airflow from the lungs). Record review of the order summary report, dated 01/22/26, reflected an active physician's order for: Mag-Oxide 400 mg; 1 tablet by mouth one time a day for supplement with a start date of 05/02/24. Record review of Resident #41's annual MDS assessment, dated 12/27/25, reflected Resident #41 made herself understood and understood others. Resident #41 had a BIMS score of 9, which indicated her cognition was moderately impaired. Record review of the comprehensive care plan, revised on 05/26/25, reflected Resident #41 had altered cardiovascular status related to hyperlipidemia (condition defined by abnormally high levels of fats (lipids), such as cholesterol and triglycerides, in the blood), coronary artery disease (a common heart condition caused by plaque buildup that narrows or blocks the arteries supplying blood to the heart muscle), high blood pressure, and congestive heart failure (a chronic, progressive condition where the heart cannot pump enough blood to meet the body's needs a chronic, progressive condition). The care plan interventions included administer medications per MD orders. Record review of the Pharmacist Recommendation to Physician, dated 05/08/25, reflected Resident #41 had an order for Mag-Oxide 400 mg QAM. The recommendation note reflected discontinue, medication no longer necessary. The NP agreed to the recommendation and signed on 05/15/25 to discontinue medication. The order was not clarified or implemented until state surveyor intervention on 01/22/26. Record review of Resident #41's MAR, dated 01/01/26-01/31/26, reflected Resident #41 received Mag-Oxide 400 mg one time a day per the physician's orders on 01/01/26-01/22/26. During an interview on 01/22/26 at 9:50 a.m., the NP stated she expected orders to be followed. The NP stated whoever handled the GDR was responsible for discontinuing the Mag-Oxide. The NP stated she believed it was either LVN N or RN O who handled the GDR at the time of the recommendation. The NP stated the risk of not discontinuing the Mag-Oxide was elevated magnesium level which could cause heart issues. An attempted telephone interview on 01/22/26 at 10:28 a.m., with LVN N, was unsuccessful but a message was left An attempted telephone interview on 01/22/26 at 10:30 a.m., with RN O, was unsuccessful but a message was left During an interview on 01/22/26 at 4:03 p.m., the DON stated she was not employed at the time of the recommendation and could not say who was responsible for ensuring the pharmacy recommendation was implemented. The DON stated a full audit of last year's recommendation was not completed. The DON stated it was important to ensure the pharmacy recommendations were implemented to prevent electrolyte imbalance and residents did not receive unnecessary medications. During an interview on 01/22/26 at 5:04 p.m., the Administrator stated she expected the nursing staff to ensure pharmacy recommendations were implemented timely. The Administrator stated the nursing management was responsible for monitoring to ensure pharmacy recommendations were implemented. The Administrator stated she was not employed at the time of the recommendation therefore she could not say who was responsible. The Administrator stated it was important to ensure pharmacy recommendations were implemented to prevent adverse side effects. Record review of the Medication Therapy, revised on 04/2007 reflected. 1. Each resident's medication regimen shall include only those medications necessary to treat existing conditions and address significant risks. 3. All medication orders will be supposed by appropriate care processes and practices.5. The physician will identify situations where medications should be.discontinued.

Based on interview and record review the facility failed to ensure the resident had a right to secure confidential and personal medical records and privacy during medical treatments for 2 of 24 residents (Residents #28, and #10) reviewed for resident rights. 1. The facility did not ensure RN G used a secure telephonic device to communicate with the facility NP. 2. The facility failed to ensure CNA T and LVN B provided privacy when providing incontinent care to Resident #10. These failures could place residents at risk for diminished quality of life, loss of dignity and self-worth.Findings include: Record review of Resident #28's face sheet, dated 01/22/26, reflected Resident #28 was a [AGE] year-old male, admitted to the facility on [DATE] with diagnoses which included atrial fibrillation (irregular, often rapid heart rate). Record review of Resident #28's quarterly MDS assessment, dated 12/30/25, reflected Resident #28 made himself understood and understood others. Resident #28's BIMS score was 14, which reflected his cognition was intact. Record review of Resident #28's nurse's note, dated 01/07/26 completed by RN G, reflected Resident was complaining of feeling dizzy and lightheadedness. He is sitting on the side of his bed. He stated, They put a patch on my shoulder today. Upon further assessment, the resident had a nicotine patch on his right shoulder. Vitals were taken and were stable. family member at bedside. The nurse's note did not address whether the NP was notified. Record review of a text message, dated 01/07/26 at 3:39 p.m., between RN G and the facility NP reflected, Hey there. FYI. we had a med error on [Resident #28] (which included his last name). Med Aide put a nicotine patch on him! He was dizzy and lightheaded and had chills. Continuing to monitor. The facility NP did not respond to the text. During an interview on 01/21/26 at 10:49 a.m., RN G stated she was notified by Resident #28 that he did not feel good. RN G stated she went down to his room, assessed him and that was when he stated he had a patch on his shoulder. RN G stated she looked at his right shoulder and noted a nicotine patch with an initial and dated 01/07/26. RN G stated she went and got the DON and notified the NP via text using her personal cell phone. RN G stated the NP did not respond via text but called the facility and instructed her to continue to monitor. RN G stated sending a text using her personal cell phone was how she coordinated with the NP. RN G stated if the resident was in danger she would call the NP. RN G stated this failure was a HIPPA violation and put Resident #28 at risk for confidentiality of his personal medical records. During an interview on 01/22/26 at 3:39 p.m., the NP stated she would like to be notified via phone before 4:00 p.m. and after 4:00 p.m. to contact the on-call provider. During an interview on 01/22/26 at 4:03 p.m., the DON stated her expectation was RN G coordinate with the provider, however the provider requested. The DON stated it was okay for RN G to text the provider using her personal cell phone if that was what the provider requested, and RN G's phone was secured by having her screen locked. The DON stated the risk of not using a secure device to send residents information was Resident #28 PHI could be shared. During an interview on 01/22/26 at 5:04 p.m., the Administrator stated she learned RN G sent a text to the NP regarding an incident that occurred with Resident #28 using her personal cell phone after the state surveyor intervention. The Administrator stated she expected staff to either coordinate with the physician either by phone, fax or PCC. The Administrator stated nursing management was responsible for overseeing and monitoring by in-service and education. The Administrator stated the risk of not using a secure device was the release of secure information or HIPPA violation. 2. Record review of Resident #10 face sheet, dated 01/20/25, reflected a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #10 had diagnoses which included COPD (chronic lung condition that limits airflow and causes difficulty breathing), unspecified dementia (cognitive disorder that impairs memory, thinking, and judgement), and need for assistance with personal care. Record review of Resident #10's Quarterly MDS, dated [DATE], reflected the resident required partial/moderate assistance- helper does less than half the effort for toileting hygiene. Resident #10 had a BIMS of 11, which indicated only moderate cognitive impairment. Record review of Resident #10's Significant Change MDS, dated [DATE], reflected the resident required substantial/maximal assistance- helper who did more than half the effort for toileting hygiene. Resident #10 had a urinary catheter and was frequently incontinent of bowel (2 or more episodes of bowel incontinence, but at least one continent bowel movement). Despite coded BIMS score of 00 which indicates severe impairment, the resident was observed to respond to questions and verbalize feeling during interview, which indicated retained ability to communicate concerns, and suggesting a potential inconsistency between the code cognitive status and the resident demonstrated abilities. Record review of Resident #10's care plan, revision dated 12/08/25, was care planned for an ADL self-care deficit related to fatigue and impaired balance. Resident #10's care plan reflected an intervention for providing perineal care after each incontinent episode. During observation on 01/19/26 at 3:36 PM, CNA T and LVN B were observed proving incontinent care to Resident #10 without ensuring privacy by closing the door or drawing the privacy curtain. During an interview on 01/19/26 at 3:15PM Resident #10 was alert and labile (able to answer most questions but not all; resident #10 had blank stare) and not consistently able to answer all questions. Surveyor attempted to interview Resident #10 regarding the privacy curtain; however, resident was asleep and did not wake up. Reasonable expectation is that the door would be closed while perineal care is being provided. During an interview on 01/19/26 at 3:45 PM, LVN B stated when providing care, she or CNA T should have closed the door. LVN B stated Resident #10 was at risk of loss of dignity and humiliation. LVN B stated she forgot to close the door. During an interview on 01/19/26 at 3:56 PM, CNA T stated Resident #10's door did not remain shut when providing care. CNA T indicated the door did not click when closing. CNA T stated not providing privacy during care could hurt his self-esteem. During a phone interview on 01/19/26 at 4:23 PM, Resident #10 representative reported she was unsatisfied with the care her family member was receiving Resident #10's Representative stated she believed he was not being treated with respect and dignity. During an interview on 01/22/26 at 4:36 PM, the DON stated she was not aware that CNA T and LVN B performed perineal care with the door open. The DON stated she expected all staff to provide privacy when providing care. The DON claimed ultimate responsibility for ensuring resident rights. The DON stated not providing privacy placed the residents at risk of humiliation. During an interview on 01/22/26 at 5:27 PM, the Administrator stated she expected the staff honor resident rights and ensure their dignity was held. The Administrator reported all staff were responsible for ensuring resident rights and Resident #10 was at risk for his needs not being met. The Administrator stated resident rights were addressed in in-services on orientation, quarterly and as needed along with abuse and neglect. Record review of the facility's policy titled Resident Rights, last revised on 12/2016, reflected . employees shall treat all residents with kindness, respect, and dignity.1. Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to: t. privacy and confidentiality. dd. communicate in person and by mail, email and telephone with privacy.

Based on observation, interview and record review the facility failed to treat each resident with respect, dignity and care in a manner and in an environment that promoted maintenance or enhancement of his or her quality of life, recognizing each resident's individuality and protecting and promoting the rights of the resident for 1 of 5 residents (Resident #10) reviewed for resident rights. The facility failed to ensure CNA T spoke in a manner of dignity to Resident #10These failures could place residents at risk of embarrassment, isolation, and diminished quality of life.Findings Include: Record review of Resident #10 face sheet, dated 01/20/25, reflected a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #10 had diagnoses which included COPD (chronic lung condition that limits airflow and causes difficulty breathing), unspecified dementia (cognitive disorder that impairs memory, thinking, and judgement), and need for assistance with personal care. Record review of Resident #10's Quarterly MDS, dated [DATE], reflected the resident required partial/moderate assistance- helper does less than half the effort for toileting hygiene. Resident #10 had a BIMS of 11, which indicated only moderate cognitive impairment. Record review of Resident #10's Significant Change MDS, dated [DATE], reflected the resident required substantial/maximal assistance- helper who did more than half the effort for toileting hygiene. Resident #10 had a urinary catheter and was frequently incontinent of bowel (2 or more episodes of bowel incontinence, but at least one continent bowel movement). Despite coded BIMS score of 00 which indicates severe impairment, the resident was observed to respond to questions and verbalize feeling during interview, which indicated retained ability to communicate concerns, and suggesting a potential inconsistency between the code cognitive status and the resident demonstrated abilities. Record review of Resident #10's care plan, revision dated 12/08/25, was care planned for an ADL self-care deficit related to fatigue and impaired balance. Resident #10's care plan reflected an intervention for providing perineal care after each incontinent episode. During observation on 01/19/26 at 3:36 PM, CNA T and LVN B were observed proving incontinent care to Resident #10. While the resident had an active bowel movement and passed gas, CNA T stated, Thanks, [Resident 10], in a mocking tone. During an interview on 01/19/26 at 3:15 PM, Resident #10 stated he felt ashamed' of how he was being treated. The resident further stated staff were treating me like wresting during care. Resident #10 described the way staff treated him roughly when performing perineal care but could not identify or describe the staff. Resident #10 was alert and labile (able to answer most questions but not all; resident #10 had blank stare) and not consistently able to answer all questions. Surveyor attempted to interview resident regarding the privacy curtain; however, resident was asleep and did not wake up. Reasonable expectation is that the door would be closed while perineal care is being provided. During an interview on 01/19/26 at 3:45 PM, LVN B stated the comment made by CNA was inappropriate and she would not have said that. LVN B stated when providing care, she or CNA T should have closed the door. LVN B stated Resident #10 was at risk of loss of dignity and humiliation. LVN B stated she forgot to close the door. During an interview on 01/19/26 at 3:56 PM, CNA T stated Resident #10's door did not remain shut when providing care. CNA T indicated the door did not click when closing. CNA T stated when she said Thanks it could have been taken wrong or upset Resident #10 and hurt his self esteem. CNA T stated the comment she made was inappropriate. CNA T stated that she jokes around with Resident #10. During a phone interview on 01/19/26 at 4:23 PM, Resident #10 representative reported she was unsatisfied with the care her family member was receiving Resident #10's Representative stated she believed he was not being treated with respect and dignity. During an interview on 01/22/26 at 4:36 PM, the DON stated she was not aware CNA T spoke to Resident #10 in a undignifying way. DON stated she was not aware that CNA T and LVN B performed perineal care with the door open. The DON stated she expected all staff to treat residents with dignity and respect at all times. All staff were responsible for ensuring resident rights and dignity. The DON claimed ultimate responsibility for ensuring resident rights. The DON stated the resident was at risk of humiliation. During an interview on 01/22/26 at 5:27 PM, the Administrator stated she expected the staff honor resident rights and ensure their dignity was held. The Administrator reported all staff were responsible for ensuring resident rights and Resident #10 was at risk for his needs not being met. The Administrator stated I don't think they should say that. It's not acceptable to joke with the resident. It could be taken wrong and can considered making fun and embarrass him. The Administrator stated resident rights were addressed in in-services on orientation, quarterly and as needed along with abuse and neglect. Record review of the Resident Rights policy, revised 12/2016, reflected: Employees shall treat all residents with kindness, respect, and dignity.Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the residents' right to:a dignified existence.be treated with respect, kindness, and dignity.be free from abuse, neglect, misappropriation of property, and exploitation.

Based on observation, interview and record review, the facility failed to ensure that a resident who needed respiratory care, was provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goal and preferences for 1 of 2 residents (Resident #41) reviewed for oxygen therapy. The facility failed to ensure Resident #41's oxygen concentrator filter was cleaned. This failure could place residents at risk for developing respiratory complications and a decreased quality of care.Findings include: Record review of Resident #41's face sheet, dated 01/22/26, reflected Resident #41 was a [AGE] year-old female, originally admitted to the facility on [DATE] with diagnoses which included COPD (chronic inflammatory lung disease that causes obstructed airflow from the lungs). Record review of Resident #41's comprehensive care plan, revised 08/01/23, reflected Resident #41 had COPD. The care plan interventions included: oxygen therapy per MD order. Record review of Resident #41's annual MDS assessment, dated 12/27/25, reflected Resident #41 made herself understood and understood others. Resident #41 had a BIMS score of 9, which indicated her cognition was moderately impaired. Resident #41 received oxygen therapy. Record review of the physician order report, dated 01/22/26, reflected Resident #41 had an active physician order for oxygen at 2-3 liter per minute at bedtime with a start date 09/25/25. Resident #41 had an active physician order to check oxygen filter for placement and cleanliness every night every Sunday with a start date 08/25/24. During an observation and interview on 01/19/26 at 1:08 p.m., revealed Resident #41 was sitting in her wheelchair. Resident #41's oxygen concentrator filter had a thick, grey, fuzzy material. Resident #41 stated she wore oxygen at night due to SOB. During an observation on 01/20/26 at 9:07 a.m., revealed Resident #41 was sitting in her wheelchair. Resident #41's oxygen concentrator filter had a thick, grey, fuzzy material. During an observation and interview on 01/22/26 at 1:00 p.m., RN G stated the nurse staff on Sunday nights were responsible for changing/cleaning the oxygen filter. RN G observed with the state surveyor Resident #41's oxygen filter and stated, it definitely needs to be cleaned. RN G stated it was important to ensure filters were cleaned to prevent an infection. During a telephone interview on 01/22/26 at 2:02 p.m., LVN P stated she was the 6a-6p charge nurse on 01/18/26. LVN P stated she was responsible for cleaning Resident #41's oxygen filter. LVN P stated she believed she changed the filter but could not remember for sure. LVN P stated not changing the filter put Resident #41 at risk for a respiratory infection. During an interview on 01/22/26 at 4:03 p.m., the DON stated the nurse on the 6a-6p shift on Sunday was responsible for cleaning the filter. The DON stated she monitored by daily random rounds. The DON stated there had not been any issues in the past. The DON stated it was important those tasks were completed to prevent a respiratory infection. During an interview on 01/22/26 at 5:06 p.m., the Administrator stated she expected oxygen filters to be cleaned according to the physician orders. The Administrator stated nursing management was responsible for overseeing and monitoring. The Administrator stated this failure could potentially put Resident #41 at risk for a respiratory infection. Record review of the facility's Oxygen Concentrator & Other Respiratory Equipment, revised on 02/2024 reflected .the purpose of this procedure is to guide prevention of infection associated with respiratory therapy tasks and equipment. among residents and staff. Steps in the Procedure.3. Wash external filters from oxygen concentrators every seven days with soap and water. Rinse and squeeze dry before re-inserting.

Based on interview and record review the facility failed to ensure residents received proper treatment devices to maintain vision and hearing abilities, and if necessary, assisted the residents in making appointments for 1 of 2 residents (Resident #61) reviewed for hearing devices. The facility did not ensure an appointment for an audiologist (healthcare professional specialized in hearing) for Resident #61 after she reported missing hearing aids. This failure could place residents at risk of decreased communication ability, quality of life, and/or social isolation. Findings include: Record review of Resident #61's face sheet, dated 12/30/26, reflected Resident #61 was a [AGE] year-old female, originally admitted to the facility on [DATE] with diagnoses which included dementia (loss of memory, language, problem solving and other thinking abilities that were severe enough to interfere with daily life). Record review of Resident #61's quarterly MDS assessment, dated 12/30/25, reflected Resident #61 made herself understood and understood others. Resident #61 had a BIMS score of 15, which indicated her cognition was intact. Resident #61 had adequate ability to hear and did not have hearing aide appliances. Record review of Resident #61's comprehensive care plan, revised on 01/13/26, reflected Resident #61 had a communication problem related to a hearing deficit. The care plan interventions included: anticipating, meeting needs and validating residents' message by repeating aloud. Record review of Resident #61's order summary report, dated 01/22/26 reflected an active physician order for audiological care PRN with an order date 08/19/24. During an interview on 01/19/26 at 12:06 p.m., Resident #61 stated she had two pairs of hearing aides taken from her. Resident #61 stated she told several staff members, including the social worker, about her needing hearing aids. Resident #61 was unable to give the exact date but stated it was last year when she told the social worker about needing hearing aids. Resident #61 stated not been able to hear what others were saying aggravates her. During a telephone interview on 01/21/26 at 3:05 p.m., Resident #61's family member stated he had talked to several staff members which included the social worker repeatedly about Resident #61 needing hearing aids. Resident #61's family members stated but the facility would use every excuse in the books on why she still has not been seen by the ear doctor. During an interview on 01/21/26 at 3:05 p.m., the Social Worker stated she was responsible for sending referrals to the audiologist. The Social Worker stated she had spoken to Resident #61 and Resident #61's family members about needing hearing aids but could not recall the exact date. The Social Worker stated Resident #61 stated to her that a pair of hearing aids were missing so she went to check her room and did not have any luck finding them. The Social Worker stated she spoke with an agency about Resident #61 being seen for hearing aids but did not have the document she spoke with about her hearing aids in December. The Social Worker stated she was going to start a grievance about the missing hearing aids but got interrupted. The Social Worker stated not being able to hear could affect her communicating her needs and wants. During an interview on 01/22/26 at 4:03 p.m., the DON stated the Social Worker was responsible for making the appropriate referral to the audiologist and starting a process of having the hearing aids replaced or initiated. The DON stated Resident #61 or Resident #61's family member had not mentioned to her that Resident #61 needed hearing aids. The DON stated it was important to ensure the residents were referred to an audiologist to prevent decrease quality of life and being able to hear to communicate. During an interview on 01/22/26 at 5:04 p.m., the Administrator stated the Social Woker was responsible for making a referral to the audiologist. The Administrator stated Resident #61 or Resident #61's family members had not mentioned to her that Resident #61 needed hearing aids. The Administrator stated she was not monitoring the Social Worker because for as she knew there was not a problem with residents receiving services. The Administrator stated the Social Worker would start providing a list of ancillary services and she would ensure each resident received the services that were needed. The Administrator stated it was important for the residents to receive audiologist services to prevent decreased quality of life. During an interview on 01/22/26 at 5:15 p.m., a request for the facility policy regarding audiologists was submitted to the DON. A policy regarding audiologists was not received prior to exit.

Based on interview and record review, the facility failed to ensure assessments were coordinated with Preadmission Screening and Resident Review (PASRR) program under Medicated in subpart C to the maximum extent practicable to avoid duplicative testing and effort and coordination included incorporating the recommendations from the PASARR level II determination and the PASARR evaluation report into a resident's assessment, care planning, and transitions of care for 1 of 8 residents (Resident #41) reviewed for PASRR.The facility did not ensure the correct PASRR (a preliminary assessment completed for all individuals before admission to a Medicaid-certified nursing facility to determine whether they might have a mental illness or intellectual disability) Level 1 Screening was submitted to the local authority for Resident #41 who had a diagnosis of mental illness upon admission. This failure could place residents at risk for a diminished quality of life and not receiving necessary care and services in accordance with individually assessed needs. Findings include: Record review of Resident #41's face sheet, dated 01/22/26, reflected Resident #41 was a [AGE] year-old female, originally admitted to the facility on [DATE] with diagnoses which included major depressive disorder (chronic sadness that interferes with daily life), bipolar (a disorder associated with episodes of mood swings ranging from depression lows to manic highs), anxiety (excessive worry), and personal history of other mental and behavioral disorders. Record review of Resident #41's comprehensive care plan, revised on 01/14/24, reflected Resident #41used antipsychotic medication related to schizophrenia (a condition that can make you feel detached from reality and can affect our mood) and bipolar. Record review of Resident #41's annual MDS assessment, dated 12/27/25, reflected Section A1500 asked Is the resident currently considered by the state level II PASRR process to have serious mental illness and/or intellectual disability or a related condition? This section was marked 0 which meant No. Section A.1510 Level II Preadmission Screening and Resident Review (PASRR) Conditions did not have A. Serious mental illness, B. Intellectual Disability, or C. Other related conditions checked. Resident #41 understood others and made herself understood. Resident #41 had a BIMS score of 9, which indicated her cognition was moderately impaired. Record review of a referral entity assessment dated [DATE] reflected Resident #41 had a history of depression and bipolar (chronic mental health condition characterized by extreme mood swings, alternating between emotional highs and lows). Record review of Resident #41's PASRR Level 1 Screening form, dated 09/23/21, reflected Resident #41 had no evidence or indicator of dementia or a mental illness. Record review of Resident#41's PASRR Level 1 Screening form, dated 05/25/23, reflected Resident #41 had evidence of mental illness. During an interview on 01/19/26 at 1:08 p.m., Resident #41 stated she always had a history of mental illness. During an interview on 01/22/26 at 11:19 a.m., the MDS Coordinator stated the previous MDS Coordinator was responsible for ensuring PASRR Level 1 was completed accurately. The MDS Coordinator stated a Form 1012 should have been completed to correct the inaccurate PASRR Level 1, which would determine whether to submit a new PL1 screening form for a possible PASRR positive dx. The MDS Coordinator stated it was important for the residents to be screened for PASRR to ensure they're evaluated for eligibility and services. During a telephone interview on 01/22/26 at 11:30 a.m., the MDS Consultant stated if a Level 1 was incorrect or a diagnosis was added that was not previously there, she expected a Form 1012 to be completed so the resident could be reevaluated for services. The MDS Consultant stated the previous MDS Coordinator was responsible for ensuring a Form 1012 was completed for Resident #41 when the first PASARR Level 1 was completed in 2021. The MDS Consultant stated she was not the consultant at the time of Resident #41 admission. The MDS Consultant stated it was important for residents to be screened for PASRR to ensure they're evaluated for eligibility and services. During an interview on 01/22/26 at 5:04 p.m., the Administrator stated if there was a discrepancy she would expect the MDS Coordinator to follow the appropriate steps to rectify. The Administrator stated it was important for the residents to be screened for PASRR to provide the right services. Record review of the facility's undated policy, Minimum Data Set Process, reflected . the long-term care facility follows CMS requires RAI as a policy the facility completes an MDS and codes the MDS per the RAI manual and coding is based upon clinical assessments, interviews, etc.

Based on interview and record reviews the facility failed to ensure the assessment accurately reflected the resident's status for 2 of 5 residents (Resident #3 and Resident #68) reviewed for accuracy of MDS assessments. 1) The facility failed to ensure Resident #3's MDS accurately reflected the resident was PASRR positive for mental illness. 2) The facility failed to ensure Resident's #68's MDS accurately reflected PASRR positive for mental illness.These failures could place residents at risk of not receiving the necessary care and services to prevent falls and injuries related to inaccurate MDS assessments. Findings included: 1. Record review of Resident #3's face sheet, dated 1/22/26, indicated reflected she was a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #3 had with the diagnoses which included PTSD (post-traumatic stress disorder), depression (a mood disorder that cause a persistent feeling of sadness and loss of interest), and anxiety (persistent, excessive worry that interferes with daily life). Record review of Resident #3's admission MDS assessment dated [DATE] indicated reflected she could make self understood and she understood others. The MDS also indicated she Resident #3 had a BIMS score of 12, which meant she was cognitively intact. The MDS also indicated in Section A1500: documented Resident #3 was not currently considered by the state level II PASRR process to have serious mental illness and/or intellectual disability or a related condition, which indicated she was PASRR negative. Record review of the PASRR Evaluation (level II assessment), completed on 12/15/25 indicated reflected Resident #3 was PASRR positive for mental illness. Record review of Resident #3's care plan, dated 12/15/25, indicated reflected Resident #3 was PASRR positive. 2. Record review of Resident #68's face sheet, dated 01/22/26, reflected Resident #68 was a [AGE] year-old female, originally admitted to the facility on [DATE] with diagnoses which included depression (a mood disorder that cause a persistent feeling of sadness and loss of interest), bipolar (a disorder associated with episodes of mood swings ranging from depression lows to manic highs) and anxiety (excessive worry). Record review of Resident #68's PASRR Evaluation (level II assessment), completed on 01/07/25, reflected Resident #68 met the PASRR definition of mental illness, which indicated she was PASRR positive. Record review of Resident #68's comprehensive care plan, revised on 12/10/25, reflected Resident #68 was PASRR positive for mental illness. Record review of Resident #68's annual MDS assessment, dated 01/05/26, reflected in Section A1500: Resident #68 was not currently considered by the state level II PASRR process to have serious mental illness and/or intellectual disability or a related condition, which indicated she was PASRR negative. During an interview on 01/22/26 at 11:19 a.m., the MDS Coordinator stated the MDS Consultant was responsible for completing Resident #68's annual MDS assessment and she was responsible for completing Resident #3's admission MDS assessment. The MDS Coordinator stated Resident #3's admission MDS assessment should have reflected the resident had mental illness and was positive for PASRR. The MDS Coordinator stated it was important for the PASRR status to be coded accurately to ensure the residents received the services needed. During a telephone interview on 01/22/26 at 11:30 a.m., the MDS Consultant stated she was responsible for completing Resident #68's annual MDS assessment. The MDS Consultant stated it should have been marked yes because Resident #68 was PASRR positive. The MDS Consultant stated it was a mistake on her part. The MDS Consultant stated she did an audit about two weeks, but Resident #68's annual was not done until after the audit. The MDS Consultant stated it did not affect Resident #68's care by not coding the annual MDS accurately. During an interview on 01/22/26 at 5:04 p.m., the Administrator stated she expected the MDS assessments to accurately reflect the resident's status. The Administrator stated the MDS Coordinators were responsible for accurately coding the MDS assessments and the MDS Consultant was responsible for monitoring to ensure MDS assessments were completed accurately. The Administrator stated not coding the MDS assessments correctly could affect the residents' function and diagnoses. Record review of the facility's, undated, policy Minimum Data Set Process reflected . the long-term care facility follows CMS requires RAI as a policy the facility completes an MDS and codes the MDS per the RAI manual and coding is based upon clinical assessments, interviews, etc. Record review of the RAI Manual, dated October 2025, reflected A1500: PASRR . code 1, yes: if PASRR Level II screening determined that the resident had a serious mental illness.

Based on interviews and record review the facility failed to protect the resident's right to be free from verbal abuse for 1 of 4 residents (Resident #1) reviewed for resident abuse. The facility did not ensure Resident #1 was free from abuse when CNA D was observed standing over resident, loudly talking and telling Resident #1 you tripping in response to resident's statements on 03/01/2025.This failure could place residents at risk of psychosocial harm, feeling disrespected or uncomfortable, decreased self-esteem, impaired quality of life and abuse. Findings Included: Record review of Resident #1's admission Record dated 11/18/2025 revealed an [AGE] year-old male admitted [DATE] and readmitted [DATE] with diagnoses to include cerebral infarction (a restriction of blood supply to tissues caused by a blockage that stops blood flow to part of the brain), ataxia (a neurological symptom characterized by lack of muscle coordination), bilateral osteoporosis (a disease that causes bones to become weak and brittle), hypertension (high blood pressure), and radiculopathy (compressed nerve root exiting the spine causing pain, numbness, tingling or weakness). Record review of Resident #1's comprehensive MDS dated [DATE] revealed a BIMS score of 5 indicating severe cognitive impairment. Record review of Resident #1's comprehensive MDS dated [DATE] revealed resident had no upper or lower extremity impairment, utilized a wheelchair for mobility, required supervision in eating, toileting, bathing, upper body dressing, and moderate assistance in lower body dressing, bed mobility and transfers. Record review of Resident #1's care plan, undated, viewed 11/19/25 revealed resident had a communication deficit, impaired cognitive function and thought processes with difficulty making decisions and short-term memory loss. The care plan interventions included using task segmentation to support short term memory deficits, cue, reorient and supervise resident as needed and provide consistent care to decrease confusion. An attempt to interview AP CNA D was made on 11/18/25 at 10:00 a.m. There was no answer, and surveyor was unable to leave a message. Record review of AP CNA D's written statement (undated) revealed she denied any verbal abuse directed at Resident #1. During an interview of Resident #1 on 11/19/25 at 10:57 a.m., Resident #1 denied staff verbal abuse and stated he feels safe in the facility. Record review of PIR dated 0 3/07/2025 revealed Resident #1 did not recall the incident of suspected verbal abuse.During an interview on 11/19/2025 at 10:57 a.m. with the family member of Resident #1, she stated she visits often and has never had a concern about the staff that care for him. The family member stated she recalls being notified that a staff member was observed talking loudly and inappropriately to her husband. Spouse stated she did not notice any mood or behavior changes in Resident #1. During an interview on 11/18/2025 at 2:01 p.m., CNA E stated she had worked at the facility for almost 1 year and has been trained to separate the resident from any staff member who she observed verbally abusing a resident and to notify the Administrator. CNA E stated she was aware of the concern related to Resident #1 but did not have firsthand knowledge.During an interview on 11/18/2025 at 8:10 a.m., CNA F confirmed her statement that she overheard AP CNA D talking loudly and in a very demeaning manner to Resident #1 CNA F stated she removed Resident #1 and took him to his room and then informed the nurse. Record review of CNA F's written statement dated 03/01/2025 revealed she observed what she felt were patronizing and demeaning words from CNA D towards Resident #1.During an interview on 11/19/2025 at 11:30 a.m., LVN G confirmed her statement that she overheard AP CNA D loudly talking to Resident #1 in a very condescending manner and when he was able to respond to her, AP CNA D told him he was tripping. LVN G stated that she intervened, asked AP CNA D to clock out and go home and then contacted the Abuse Coordinator. Record review of LVN G's statement dated 03/01/2025 revealed she overheard CNA D loudly speaking to Resident #1 and asked her to lower her voice and communicate more professionally with the resident. LVN G noted in her statement that CNA D was standing over Resident #1 who was in a wheelchair at the time, and she felt the tone of her voice was condescending. During an interview on 11/19/2025 at 5:01 p.m., the DON stated that she expects all staff to report any case of verbal abuse and intervene at the time of occurrence to keep the resident safe. The DON stated that all new hires receive on-boarding training for Abuse, Neglect & Exploitation and in-services are completed annually and as needed for any concern of abuse. She stated adverse effects of verbal abuse on the resident could be psychosocial wellbeing concerns, increased behaviors or alterations in mood state. The DON stated she was not employed at the facility at the time of this reported incident and has no firsthand knowledge of the incident. During an interview on 11/19/2025 at 5:29 p.m., the Administrator stated that she was not working at the time of this incident and stated that she expects staff to notify her right away of any concern of abuse. The Administrator stated that she would lead the investigation for any concerns of abuse and ensure the AP is suspended pending completion of the investigation. The Administrator stated she would ensure that a complete psychosocial assessment and follow-up are completed. The Administrator stated she is ultimately responsible for all aspects of the investigation. The Administrator stated she was not employed at the facility at the time of this reported incident and has no firsthand knowledge of the incident. Record review of the PIR dated 03/07/2025 revealed that CNA D was suspended pending investigation and CNA D verbally quit during the investigation period on 03/03/2025 and did not return to the facility or return calls from the Administrator. Record review of the facility policy titled Abuse, Neglect, and Exploitation revised on 01/08/2023 reflected, Each resident has the right to be free from abuse, mistreatment, neglect, corporal punishment, involuntary seclusion and financial abuse.

Based on interview and record review the facility failed to ensure a resident who was incontinent of the bladder and had an indwelling urinary catheter received appropriate treatment and services for 1 of 3 residents (Resident 30) reviewed for urinary catheters. The facility failed to properly anchor Resident #30's foley catheter to prevent pulling and tension of the foley catheter tubing which resulted in a tear in his penis 3.5 cm in length and an ER visit on [DATE]. This failure could place residents at risk of injury, urinary tract infections, and a decreased quality of life. Findings included: Record review of a face sheet dated [DATE] indicated Resident #30 was a [AGE] year-old male initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included chronic obstructive pulmonary disease (chronic inflammatory lung condition that affects the respiratory system), dementia (memory loss), benign prostatic hyperplasia (enlarged prostate blocks the flow of urine), and retention of urine. Record review of the Comprehensive MDS assessment dated [DATE] indicated Resident #30 was able to make himself understood and understood others. The MDS assessment indicated Resident #30 had a BIMS score of 13, which indicated his cognition was intact. The MDS assessment indicated Resident #30 required substantial/maximal assistance with eating, toileting hygiene, dressing, and partial/moderate assistance with personal hygiene. The MDS assessment indicated Resident #30 had an indwelling catheter. Record review of Resident #30's care plan with a date initiated of [DATE] indicated he had an ADL self-care performance deficit related to dementia, hemiplegia (paralysis or weakness of one side of the body), limited mobility, and stroke and required assistance of one staff for bathing, bed mobility, dressing and personal hygiene. Resident #30's care plan indicated he had an indwelling catheter related to benign prostatic hyperplasia to check the tubing for kinks each shift, monitor for signs and symptoms of discomfort on urination and frequency, monitor/document for pain/discomfort due to catheter, monitor/record/report to doctor for signs and symptoms of urinary tract infection, pain, burning, blood tinged urine, cloudiness, no output, deepening of urine color, increased pulse, increased temperature, urinary frequency, foul smelling urine, fever, chills, altered mental status, change in behavior, change in eating patterns. Record review of Resident #30's Order Summary Report dated [DATE] indicated: foley catheter care every shift and as needed with a start date of [DATE] secure catheter with leg strap with a start date of [DATE] urinary catheter with a start date of [DATE]. Record review of Resident #30's Clinical Admission completed [DATE] indicated he had a foley catheter and his skin was within the normal limits. Resident #30's Clinical Admission did not indicate any tears in his penis. Record review of Resident #30's Weekly Skin Observation completed on [DATE] and [DATE] by RN F did not indicate tears in his penis or any penile issues. Record review of Resident #30's progress notes indicated: [DATE] at 9:05 PM Responsible Party in facility to see resident earlier on tonight. Requested said nurse to assess his father. Resident noted /c (with) malodor to the groin area. His ureter was noted torn measuring 3.5cm in length (from tip of penis to shaft of penis). Foley catheter in place. Redness also noted to scrotum and inner right leg. No bleeding noted. Denies pain. No shock symptoms noted. Tear not noted fresh. Requested that [NAME] be called, which took place via conference call will both Rp/D.O.N. Resident with request of family member was sent out via ambulance to hospital. Message left via answering service for PCP regarding findings and transfer to hospital. Signed by Charge Nurse G. [DATE] at 1:32 AM Patient arrived back in facility from ER via transportation from family. Patient is stable with no complaints of any pain and is resting comfortably back in bed with call [sic] within reach. Patients family is very admit [sic] about making sure patient is changed frequently and peri care performed regularly. Patient came back with new orders from ER with Cephalexin (antibiotic) 50mg po BID for 7 days, Bacitracin (antibiotic ointment) BID to penis for 7 days, Clotrimazole antifungal cream to groin, referral for urologist for suprapubic catheter (tube that drains urine from the bladder from a small incision in the abdomen) consult. Signed by Charge Nurse Y. Record review of Resident #30's ER After Visit Summary dated [DATE] indicated reason for visit penis injury and hand injury and diagnoses of erosion of penis (breakdown of tissue at the catheter insertion site), sebaceous cyst (fluid filled lump under the skin) and tinea cruris (fungal skin infection). During an interview on [DATE] at 10:45 AM, Resident #30's family member was at his bedside. Resident #30's family member said approximately five months ago they had visited Resident #30 and noticed a bad odor. Resident #30's family member said upon inspection of Resident #30's penis and foley catheter they realized the odor was coming from his private area. Resident #30's family member said there was blood and they noticed he had a split penis. Resident #30's family member said the facility had not been providing Resident #30 foley catheter care like they were supposed to. Resident #30's family member said they spoke with the DON regarding the lack of care being provided to Resident #30 and that same night ([DATE]) Resident #30 was sent to the ER for evaluation. During an interview on [DATE] at 5:01 PM, RN F said he had provided care to Resident #30. RN F said when Resident #30 admitted to the facility he had not seen any issues with his foley catheter or penis. RN F said he remembered the incident when Resident #30 was sent to the ER for evaluation for his split penis. RN F said he remembered Resident #30's family member brought it up to the facility staff. RN F said prior to Resident #30's family member identifying the penile erosion he had performed assessments on Resident #30 and there were no issues with his penis or catheter. RN F said if a resident had penile erosion upon admission to the facility it should be documented on the skin assessments. During an attempted phone interview on [DATE] at 5:12 PM, Charge Nurse G did not answer the phone. During an attempted observation and an interview on [DATE] at 5:29 PM, Resident #30's family members were at bedside and informed the surveyor Resident #30 was deceased and they preferred not to be bothered. During an interview on [DATE] at 12:30 PM, the DON said Resident #30's family member contacted her and sent her a picture of Resident #30's penis. The DON said she called Resident #30's family member to address the situation and ensure the resident was okay. The DON said she instructed the staff to send Resident #30 to the ER for evaluation. The DON said she believed Resident #30 admitted to the facility with the penis erosion. The DON said she could not find documentation of it in Resident #30's electronic medical record. The DON said she would continue to search through Resident #30's assessments to see if it was documented (documentation that Resident #30 admitted to the facility with the penis erosion was not provided upon exit of the facility). The DON said she told Resident #30's family member the injury to his penis was probably due to the catheter strap that was securing his foley catheter was on him too tight. The DON said the staff were not giving foley catheter enough slack for when he sat up or got up to walk with therapy. The DON said the foley catheter not having enough slack was causing friction and pulling the foley catheter. The DON said the CNAs and the nurses should be ensuring residents with a foley catheter have it properly secured and that it has enough slack so it will not get pulled and to prevent injury. The DON said she believed after the incident she had done an in-service with the staff, but she was not sure. The DON said she remembered doing verbal teaching with the staff regarding Resident #30's foley catheter and ensuring it was not getting pulled. During a phone interview on [DATE] at 1:59 PM, the DON brought her cell phone to the surveyor and Resident #30's family member was on the phone. Resident #30's family member said when he noticed Resident #30's penile erosion he had freaked out because it was a traumatic thing. Resident #30's family member said a week later Resident #30 was taken to the urology clinic, and it was explained to him that penile erosion was a common thing for long-term catheter use. Resident #30's family member said upon admission to the facility Resident #30 did not have any physical signs of penile erosion. During an interview on [DATE] at 1:31 PM, the facility's policy regarding foley catheter care was requested from the Regional Compliance Nurse and not received upon exit of the facility. Record review of the CDC's Indwelling Urinary Catheter Insertion and Maintenance accessed on [DATE] indicated, .Properly secure catheters to prevent movement and urethral traction .Catheter securement devices act as an anchor to prevent tugging and pulling which can cause irritation and inflammation. When catheters are not secured in male patients, the tugging and pulling can cause pressure sores on the penis tip .

Based on interview and record review the facility failed to ensure residents were free from abuse for 1 of 7 residents (Resident #1) reviewed for resident abuse. 1.The facility failed to ensure Resident # 1, was free from physical abuse on 04/03/2024, when CNA A used excessive rubbing force across Resident #1's chest while providing a shower which resulted in a 5 cm superficial laceration (cut or tear in the skin) across her chest at the level of the 2-3rd rib with surrounding ecchymosis (bruising), tenderness, and closed fractures of the 2nd and 3rd rib. 2.The facility failed to protect Resident #1 by not ensuring CNA A did not continue to provide care to Resident #1 after the shower room incident on 04/03/2024. The non-compliance was identified as past non-compliance. The Immediate Jeopardy began on 04/03/2024 and ended on 04/04/2024. The facility had corrected the noncompliance before the survey began. This failure could place residents at risk of physical harm, mental anguish, and/or emotional distress. The findings included: Record review of a face sheet dated 09/20/2024 indicated Resident #1 was an [AGE] year-old female admitted to the facility on [DATE] with the diagnoses of chronic respiratory failure (a condition that occurs when the lungs cannot get enough oxygen into the blood or eliminate enough carbon dioxide from the body), contracture of muscle of the left and right forearm, muscle weakness, dependence of a wheelchair, rheumatoid arthritis of hands (chronic swelling of the small joints), speech and language deficits following cerebrovascular disease (weakness on one side of the body). Record review of the quarterly MDS assessment dated [DATE] revealed Resident #1 had a BIMS score of 12, which indicated mild cognitive deficit. Resident #1 required maximum assistance for ADLs such as toileting, showering and dressing. Record review of a care plan revised on 11/09/2023 titled ADL assistance indicated Resident #1 had an ADL self-deficit and required maximum assistance with dressing, toileting and showering. The interventions for Resident #1 included: Transfer - The resident required mechanical lift - Hoyer Lift with 2 staff assistance for transfers. Record review of Incident Report dated 04/03/2024 indicated Resident #1 experienced a 1.5 x 1.5 x .5 cm laceration across her chest while in the shower room on 04/03/2024. Record review of the hospital Encounter Summary for Resident #1 dated 04/04/2024 documented the Final Diagnosis: abrasion to skin, closed fracture of multiple ribs of right side, assault. Assessment: 5 cm linear (a line) superficial laceration across anterior chest at level of 2-3rd rib. Piece of skin separated down middle of laceration, attached to right side of laceration, no jagged edges. Surrounding ecchymosis (discoloration of the skin resulting from bleeding underneath, typically caused by bruising) and tenderness. Medical Decision Making: [AGE] year-old female presents with primary history of cerebrovascular accident with residual left sided deficits (wheelchair bound at baseline) who suffered unfortunate traumatic skin tears to her chest yesterday evening at the hands of her CNA. The CNA is new, currently training, and seemingly became too aggressive while giving the patient a bath. Per patient, bath water was too hot, and she was scrubbing her too aggressively. Skin tear to middle chest noted. Chest X-Ray suggestive of Right sided rib fracture. Will clean skin tear thoroughly and apply dermabond. (skin adhesive). Of greater concern is the possibility of elder abuse. Patient and [family member] would like to discharge. Medically ready, just waiting on Social Worker for assault case. [family member] and patient would like to leave and will file report outpatient. During an interview on 09/17/2024 at 11:10 AM, Resident #1 said she reminded CNA A that she did not want her hair washed, but the CNA A did not acknowledge her. Resident #1 said CNA A proceeded to use the shower hose and sprayed the water in her face. Resident #1 repeated she did not want her hair wet because she used the salon for her hair care. CNA A squeezed soap onto Resident #1's chest area and rubbed aggressively back and forth. Resident #1 told CNA A to stop because she was hurting her. CNA A continued to rub the front of Resident #1's body aggressively. Resident #1 attempted to kick at CNA A to get CNA A away from her. CNA A turned the water back on and sprayed Resident #1 all over her face again. Resident #1 stated she was yelling for CNA A to stop. Resident #1 said that CNA C entered the shower room and Resident #1 said to CNA C, I did not want my hair wet/washed. Resident #1 said that CNA C said, no, you just don't like our color and turned and left the shower room. Resident #1 said she noticed blood on the washcloth laying on the floor and asked CNA A where the blood was coming from. CNA A never responded to Resident #1. Resident #1 said she did not recall anything that hurt besides the rubbing on her chest area with the washcloth by CNA A and the water spraying hard on her face. Resident #1 stated that LVN D entered the shower room and asked what happened. Resident #1 said CNA A was yelling, she done that to herself. Resident #1 said LVN D told CNA A to leave the shower room. Resident #1 said LVN D dried her off and put her gown on. Resident #1 said several towels that were laying on the floor were stained with blood. Resident #1 said LVN D pushed her on shower chair into the hallway where CNA A, CNA B, and CNA C were standing. Resident #1 stated CNA A was talking loudly and kept repeating, she did that to herself and pulled the shower hose out of my hand and the showerhead hit her. Resident #1 said she tried to talk but CNA A kept talking over her and interrupted her several times. Resident #1 said LVN D told the CNAs to put her back into her bed because she had to call the administrator. Resident #1 said she was scared when CNA A and CNA B placed her back in her bed. Resident #1 said she asked CNA A not to hurt her. Resident #1 said she was scared of new staff and requested not to be in the shower room with new staff. Resident #1 said she did not utilize the same shower room where the incident with CNA A happened because it made her anxious and scared to go in there. During an interview on 09/17/2024 at 11:58 AM, CNA B said she was training CNA A as a new employee to the facility. CNA A had previously worked at the facility through a staffing agency. CNA B was going to shower Resident #1, but CNA A insisted on doing the shower by herself and was arguing about it in front of Resident #1. CNA B said she did not want to argue in front of Resident #1. CNA B said everything seemed fine, and she left CNA A and Resident #1 alone in the shower room. CNA B said a different resident on the hall needed help, so she went into that resident's room. CNA B stated when she come out of the other resident's room (located closer to the nurse's desk), she heard some yelling from the shower room. CNA B said she notified LVN D of the yelling. CNA B said LVN D left the nurses' desk and headed toward the shower room. CNA B said she was in the hallway outside of the shower room when LVN D brought out Resident #1, and Resident #1 was bleeding from the chest area. CNA B said LVN D asked Resident #1 what happened, but CNA A was yelling and talked over Resident #1. CNA B said Resident #1 was bleeding from her chest area and was very upset, crying, and short of breath. CNA B said LVN D instructed her and CNA A to place Resident #1 back in the bed while she called for the ambulance due to the excessive bleeding. CNA B said Resident #1 was very quiet and scared during the transfer process. CNA B said when they were in Resident #1's room, CNA A never said anything more to Resident #1. CNA B said after CNA A left the room, she remained with Resident #1. CNA B said Resident #1 cried and told her she was so scared. CNA B said Resident #1 said she had told CNA A not to wash her hair or get her hair wet, but she continued to spray her in the face area. CNA B stated Resident #1 explained CNA A was rubbing her chest with the washcloth so hard and it was hurting her, and CNA A would not stop when she asked her to. CNA B said Resident #1 kept repeating I was so scared. CNA B stated Resident #1 always wanted her showers just not her hair washed because she used the hair salon. CNA B stated CNA A left the facility soon after the incident occurred. CNA B stated EMS took Resident #1 to the hospital. CNA B said the police came but CNA A had already left the facility at that time. CNA B said in-services for abuse and neglect and how to respond to certain behaviors such as aggression were started with the working staff the same night the incident occurred. CNA B said if a resident requested the staff to stop, the staff should honor the resident's request. CNA B said if a resident refuses care, you could ask the resident later, get assistance from another staff member to see if the resident was more open to them, notify the family and get their help but you would not continue the process because that would be abuse. CNA B said if she witnessed abuse, she would always separate the people having the altercation and be sure no contact had occurred. CNA B said she did not understand why LVN D sent CNA A back to assist with Resident #1's transfer after this incident occurred. CNA B stated that prior to Resident #1's shower she had discussed with CNA A that Resident #1 did not get her hair washed during the shower. CNA B stated she had not experienced any episodes of aggression from Resident #1 while providing care to her or giving her showers. CNA B stated Resident #1 did not refuse her showers or care. CNA B stated Resident #1 would not be able to grab or hold the showerhead hose due to the contracture (a permanent or temporary shortening of muscles, tendons, and other soft tissues that causes joint stiffen and limited movements) of her hands and limited movement. During an interview on 09/17/2024 at 2:29 PM, LVN D said she was the charge nurse for Resident #1 on 04/03/2024. LVN D said CNA B was scheduled to orient CNA A. LVN D said she was at the nurses' desk when she was alerted by CNA B that she heard yelling. LVN D said she immediately went down to the shower room and opened the door, and she saw several towels laying on the floor with blood stains. LVN D said she asked Resident #1 what happened. LVN D said Resident #1 was immediately interrupted by CNA A yelling she did that to herself repeatedly. LVN D said she told CNA A to get out of the shower room, and she dried off and dressed Resident #1. LVN D said Resident #1 was still bleeding profusely. LVN D said she rolled Resident #1 into the hallway where CNA A continued to yell out, she pulled the shower hose and the shower head hit her. LVN D said that CNA C was being mouthy about skin color but could not recall what was said. LVN D said Resident #1 said, I don't get my hair washed in the shower and you sprayed me hard. LVN D said she told two CNAs to place Resident #1 back in the bed. LVN D said she could not recall who she told because everything became a blur. LVN D said she would not have told CNA A to put Resident #1 back in bed because you would separate them to protect the resident, but it was all a blur at that point. LVN D said she had to call the administrator first and he told her to immediately remove CNA A from the facility. LVN D said she had to get CNA A from another resident's room where she was providing incontinent care and told her to leave. LVN D said that she called 911 after she attempted to steri-strip the area to prevent bleeding. LVN D said EMS examined the shower hose and shower head and did not find any type of tissue on it. LVN D said the police came and filed a report. LVN D said in-services for abuse and neglect and how to respond to certain behaviors such as aggression was completed for the staff working. Attempted telephone call on 09/17/2024 at 02:43 PM to CNA A, unable to reach or leave a message due to no voice mail had been set up. During an interview on 09/18/2024 at 10:34 AM, Resident # 1's family member stated she had received a call on the GrandPad (tablet) from Resident #1. The family member stated Resident #1 was crying during the call. Resident #1's family member stated that CNA B was in the room and had assisted Resident #1 to make the call. The family member stated that during the call she saw EMS arrive to Resident #1's room. Resident #1's family member stated when she arrived at the facility Resident #1 was in the ambulance. The family member stated she went into the facility and took pictures of the shower room, shower hose and shower head, and the blood stain towels that were on the floor. Resident #1's family member said LVN D said CNA C stated that Resident #1 and CNA A were fighting over the shower head. Resident #1 family member asked CNA C if she had observed Resident #1 and CNA A fighting, and CNA C responded no. Resident #1's family member said that CNA C said, I don't have to talk to you. Resident #1's family member said Resident #1 was interviewed multiple times by different staff at the hospital and the story never changed. Resident #1's family member said she told CNA A not to get her hair wet, but CNA A refused to listen or acknowledge her and continued and sprayed her roughly with the water. CNA A then placed a large amount of soap on Resident #1's chest area and rubbed her aggressively with a washcloth. Resident #1 's family member stated Resident #1 said she asked CNA A to stop because it hurt but CNA A did not stop and proceeded to rinse her with hot water. Resident #1 stated she tried to kick at CNA A to get away from her, but CNA A backed up and no contact was made. Resident #1's family member stated that Resident #1 had limited range of motion of her upper extremities and only uses her thumb and index finger on the left and cannot pick up anything with the right hand. Resident #1's family member stated she had provided the pictures with the time stamp from the camera in Resident #1's room to the police and the facility. Resident #1's family member stated she had also provided a detailed timeline of the events that took place in Resident #1's room from the camera pictures. Resident #1 's family member stated at 07:33 PM CNA A, CNA B, and CNA C come into Resident #1's room and got Resident #1 for her shower. Resident #1's family member further stated that at 07:55 PM on the camera, CNA A and CNA B placed a brief on Resident #1 after they transferred her back in bed. Attempted telephone call on 09/18/2024 at 11:31 AM to CNA A, unable to reach or leave a message due to no voice mail had been set up. Record review of CNA C's written witness statement dated 04/03/24 at 7:50 PM indicated, heard yelling from CNA A and she opened the door to the shower room and seen CNA A's clothes were wet and the skin tear around Resident #1's neck. CNA C asked Resident #1 what happened? But Resident #1 started yelling for me to shut up and tried to kick me. By that time, I helped CNA A roll her out of the shower room and CNA B went a got the LVN D. LVN D questioned CNA B while she (CNA C) and CNA A helped Resident #1 to bed. Then I left out to do the other patient During an interview on 09/18/2024 at 11:40 AM, CNA C said on 04/03/2024 was her first shift as the facilities employee. CNA C said she had previously worked at the facility through a staffing agency. CNA C said she heard yelling from the shower room from the hallway. CNA C said she opened the shower room door and seen CNA A and Resident #1 tugging the shower head back and forth between each other. CNA C said she saw CNA A's clothes were wet. CNA C said she did not enter the shower room. CNA C said she got LVN D because Resident #1 was yelling at her. CNA C said CNA B did not want to shower Resident #1. CNA C said CNA B told CNA A to shower Resident #1 after Resident #1 told her she did not want the black girl to shower her. CNA C said Resident #1 had refused in the hallway. CNA C said after the incident occurred in the shower room, she and CNA B put Resident #1 back in the bed and dressed her alone. CNA C said she was educated on abuse and neglect and proper reactions to aggressive behaviors. CNA C said it was important to separate and not allow any contact with the alleged victim to keep them safe from abuse. CNA C said she had never come back to the facility after the night that the incident occurred. Attempted telephone call on 09/18/2024 at 02:45 PM to CNA A, unable to reach or leave a message due to no voice mail had been set up. During an interview on 09/18/2024 at 3:00 PM, the DON stated when she arrived at the facility CNA A had already left. The DON stated Resident #1 was at the hospital. The DON stated she had examined the shower head and shower hose for bodily tissue or blood but seen no indication of either. The DON stated she was unsure who placed Resident #1 back to bed after the incident in the shower room occurred. The DON stated she had been educated on abuse and neglect after the incident as well as aggressive behaviors and how to respond. The DON stated that the perpetrator or alleged perpetrator should immediately be removed from the facility and not allowed access to residents pending the investigation to ensure no harm to the alleged victim or other resident occurs. During an interview on 09/19/2024 at 08:23 AM, the Administrator stated that he had re-enacted the scenario and agreed Resident #1 had pulled the shower hose from CNA A and caused the shower head to hit her in the chest resulting in the laceration and fracture of the ribs. The Administrator stated Resident #1 could have pulled the shower hose with the use of her one finger and limited arm movement. The Administrator said CNA A was being an ass and spraying the water crazily and Resident #1 wanted CNA A to stop. CNA A did not stop as Resident #1 had requested. The Administrator stated he had tried to get the hall camera's video as requested by the police, but the video only saves for 10 days, and he was not able to get it timely from the IT (information technology) department. The administrator stated that he was not aware that LVN D had sent CNA A back into the room to transfer Resident #1 into bed after the incident had occurred. The Administrator stated if CNA B said that she and CNA A had transferred Resident #1 back into the bed after the shower room incident then that would be true because CNA B was as honest as the day is long. The Administrator said in-services on abuse and neglect, aggressive behavior and appropriate responses, and once an alleged perpetrator is identified there should be no access to the alleged victim or any resident to prevent harm and provide safety. The Administrator said he expected all staff to follow the Abuse and Neglect Policy. The Administrator said CNA A was terminated on 04/03/2024. The Administrator said CNA C was also terminated and had not worked at the facility after the incident on 04/03/2024. The Administrator said he expected CNA A would not have provided any more resident care and left the facility immediately to prevent further possibilities of abuse. The Administrator stated CNA A and CNA C come back to the facility on [DATE] for interviews by the police department. The Administrator stated the family of Resident #1 filed charges on CNA A. Record review of grievances from January 2024 to September 2024 did not reveal any abuse concerns related to CNA A or CNA C. Record review of the facility's policy and procedure, titled Reporting Abuse and Neglect Policy, dated 2021, indicated .Our facility will protect residents from harm during investigations of abuse allegations. 1. During abuse investigations, residents will be protected from harm by the following measure: Employees accused of participating in the alleged abuse will be immediately re-assigned to duties that do not involve resident contact or will be suspended without pay until the findings of the investigation have been reviewed and a determination made by the Administrator/designee. a)Should the team member(s) be reassigned to non-resident care duties, such assignment will not be in any part of the building which the resident frequents. b)If the alleged abuse involves the resident's family member or visitor, such persons(s) will not be permitted to have unsupervised visits with the resident. c)If the alleged abuse involves another resident, please see Resident-to- Resident . The Administrator was notified on 09/19/2024 at 01:43 p.m., that a past non-compliance IJ situation had been identified due to the above failures. It was determined these failures placed Residents #1 in an IJ situation on 04/03/2024. The facility had corrected the noncompliance on 04/04/2024 by the following: - Termination of CNA A who was responsible for the abuse - Written counseling of the LVN D the education on the Abuse and Neglect Policy - Safe surveys of 15 residents in the facility - 100% staff in-service on abuse and neglect and proper responses to aggressive behaviors - QAPI sign in sheet dated 05/01/2024 completed with Administrator, DON, Infection Preventionist, Medical Director, Floor Staff Representative, and Director of Maintenance with opportunities of improvement with Abuse Policy attached. Record review of Inservice dated 04/03/2024 indicated education to all staff was completed on the Abuse and Neglect Policy, Resident Rights, and Resident's with Combative Behavior. Record review of LVN D's written counseling dated 04/04/2024. Record review of CNA A's termination notice dated 04/04/2024. Interviews on 04/20/2024 from 08:30 AM - 10:48 AM of the sampled residents (Resident #2, Resident #3, Resident #4, Resident #5, Resident #6 and Resident #7) revealed no abuse occurred. All staff interviewed (LVN E, CNA F, LVN G, LVN H, LVN J, CNA K, CNA L, CNA M, LVN N, LVN P, CNA Q, RN R, 2 ADONs, Activity Director, Social Worker, MDS Coordinator, Staffing Coordinator on 09/20/2024 08:30 AM - 10:48 AM verbalized any allegation of abuse should be reported to the administrator immediately. They verbalized understanding of the types of abuse and the facility's obligation to report abuse to HHS within 2 hours and removing the alleged perpetrator from the victim or any potential victims immediately. The noncompliance was identified as PNC. The noncompliance began on 04/03/2024 and ended on 04/04/2024. The facility had corrected the noncompliance before the survey began.

Based on interview and record review, the facility failed to implement written policies and procedures that prohibit and prevent abuse, neglect, exploitation, or mistreatment of residents for 1 of 7 residents (Resident #1) reviewed for abuse and neglect. The facility failed to implement their abuse polices by not ensuring CNA A did not continue to provide care to Resident #1 after CNA physically abused Resident #1 in the shower room on 04/03/2024. The noncompliance was identified as PNC. The Immediate Jeopardy (IJ) began on 04/03/2024 and ended on 04/04/2024. The facility had corrected the noncompliance before the survey began. This failure could place residents at risk for continued abuse and neglect due to inappropriate interventions and failure to report the allegations of abuse. Findings included: Record review of the facility's policy and procedure, titled Reporting Abuse and Neglect Policy, dated 2021, indicated .Our facility will protect residents from harm during investigations of abuse allegations. 1. During abuse investigations, residents will be protected from harm by the following measure: Employees accused of participating in the alleged abuse will be immediately re-assigned to duties that do not involve resident contact or will be suspended without pay until the findings of the investigation have been reviewed and a determination made by the Administrator/designee. a)Should the team member(s) be reassigned to non-resident care duties, such assignment will not be in any part of the building which the resident frequents. b)If the alleged abuse involves the resident's family member or visitor, such persons(s) will not be permitted to have unsupervised visits with the resident. c)If the alleged abuse involves another resident, please see Resident-to- Resident . Record review of a face sheet dated 09/20/2024 indicated Resident #1 was an [AGE] year-old female admitted to the facility on [DATE] with the diagnoses of chronic respiratory failure (a condition that occurs when the lungs cannot get enough oxygen into the blood or eliminate enough carbon dioxide from the body), contracture of muscle of the left and right forearm, muscle weakness, dependence of a wheelchair, rheumatoid arthritis of hands (chronic swelling of the small joints), speech and language deficits following cerebrovascular disease (weakness on one side of the body). Record review of the quarterly MDS assessment dated [DATE] revealed Resident #1 had a BIMS score of 12, which indicated mild cognitive deficit. Resident #1 required maximum assistance for ADLs such as toileting, showering and dressing. Record review of a care plan revised on 11/09/2023 titled ADL assistance indicated Resident #1 had an ADL self-deficit and required maximum assistance with dressing, toileting and showering. The interventions for Resident #1 included: Transfer - The resident required mechanical lift - Hoyer Lift with 2 staff assistance for transfers. Record review of the hospital Encounter Summary dated 04/04/2024 documented the Final Diagnosis: abrasion to skin, closed fracture of multiple ribs of right side, assault. Assessment: 5 cm linear (a line) superficial laceration across anterior chest at level of 2-3rd rib. Piece of skin separated down middle of laceration, attached to right side of laceration, no jagged edges. Surrounding ecchymosis and tenderness. Medical Decision Making: [AGE] year-old female presents with primary history of cerebrovascular accident with residual left sided deficits (wheelchair bound at baseline) who suffered unfortunate traumatic skin tears to her chest yesterday evening at the hands of her CNA. The CNA is new, currently training, and seemingly became too aggressive while giving the patient a bath. Per patient, bath water was too hot, and she was scrubbing her too aggressively. Skin tear to middle chest noted. Chest X-Ray suggestive of Right sided rib fracture. Will clean skin tear thoroughly and apply dermabond. (skin adhesive). Of greater concern is the possibility of elder abuse. Patient and daughter would like to discharge. Medically ready, just waiting on Social Worker for assault case. Daughter and patient would like to leave and will file report outpatient. During an interview on 09/17/2024 at 11:10 AM, Resident #1 said she reminded CNA A that she did not want her hair washed, but the CNA A did not acknowledge her. Resident #1 said CNA A proceeded to use the shower hose and sprayed the water in her face. Resident #1 repeated she did not want her hair wet because she used the salon for her hair care. CNA A squeezed soap onto Resident #1's chest area and rubbed aggressively back and forth. Resident #1 told CNA A to stop because she was hurting her. CNA A continued to rub the front of Resident #1's body aggressively. Resident #1 attempted to kick at CNA A to get CNA A away from her. CNA A turned the water back on and sprayed Resident #1 all over her face again. Resident #1 stated she was yelling for CNA A to stop. Resident #1 said that CNA C entered the shower room and Resident #1 said to CNA C, I did not want my hair wet/washed. Resident #1 said that CNA C said, no, you just don't like our color and turned and left the shower room. Resident #1 said she noticed blood on the washcloth laying on the floor and asked CNA A where the blood was coming from. CNA A never responded to Resident #1. Resident #1 said she did not recall anything that hurt besides the rubbing on her chest area with the washcloth by CNA A and the water spraying hard on her face. Resident #1 stated that LVN D entered the shower room and asked what happened. Resident #1 said CNA A was yelling, she done that to herself. Resident #1 said LVN D told CNA A to leave the shower room. Resident #1 said LVN D dried her off and put her gown on. Resident #1 said several towels that were laying on the floor were stained with blood. Resident #1 said LVN D pushed her on shower chair into the hallway where CNA A, CNA B, and CNA C were standing. Resident #1 stated CNA A was talking loudly and kept repeating, she did that to herself and pulled the shower hose out of my hand and the showerhead hit her. Resident #1 said she tried to talk but CNA A kept talking over her and interrupted her several times. Resident #1 said LVN D told the CNAs to put her back into her bed because she had to call the administrator. Resident #1 said she was scared when CNA A and CNA B placed her back in her bed. Resident #1 said she asked CNA A not to hurt her. Resident #1 said she was scared of new staff and requested not to be in the shower room with new staff. Resident #1 said she did not utilize the same shower room where the incident with CNA A happened because it made her anxious and scared to go in there. During an interview on 09/17/2024 at 11:58 AM, CNA B said LVN D instructed her and CNA A to place Resident #1 back in the bed while she called for the ambulance due to the excessive bleeding. CNA B said Resident #1 was very quiet and scared during the transfer process. CNA B said when they were in Resident #1's room, CNA A never said anything more to Resident #1. CNA B said after CNA A left the room, she remained with Resident #1. CNA B said Resident #1 cried and told her she was so scared. CNA B said Resident #1 said she had told CNA A not to wash her hair or get her hair wet, but she continued to spray her in the face area. CNA B stated Resident #1 stated CNA A was rubbing her chest with the washcloth so hard, and it was hurting her, and CNA A would not stop when she asked her to. CNA B said Resident #1 kept repeating I was so scared. CNA B said in-services for abuse and neglect and how to respond to certain behaviors such as aggression were started with the working staff the same night the incident occurred. CNA B said she did not understand why LVN D sent CNA A back to assist with Resident #1's transfer after this incident occurred. During an interview on 09/17/2024 at 2:29 PM, LVN D said she was the charge nurse for Resident #1 on 04/03/2024. LVN D said she was at the nurses' desk when she was alerted by CNA B that she heard yelling. LVN D said she immediately went down to the shower room and opened the door, and she saw several towels laying on the floor with blood stains. LVN D said she asked Resident #1 what happened. LVN D said Resident #1 was immediately interrupted by CNA A yelling she did that to herself repeatedly. LVN D said she told CNA A to get out of the shower room, and she dried off and dressed Resident #1. LVN D said Resident #1 was still bleeding profusely. LVN D said she rolled Resident #1 into the hallway where CNA A continued to yell out, she pulled the shower hose and the shower head hit her. LVN D said that CNA A was being mouthy about skin color but could not recall what was said. LVN D said Resident #1 said, I don't get my hair washed in the shower and you sprayed me hard. LVN D said she told two CNAs to place Resident #1 back in the bed. LVN D said she could not recall who she told because everything became a blur. LVN D said she would not have told CNA A to put Resident #1 back in bed because you would separate them to protect the resident, but it was all a blur at that point. LVN D said she had to call the administrator first and he told her to immediately remove CNA A from the facility. LVN D said she had to get CNA A from another resident's room where she was providing incontinent care and told her to leave. LVN D said in-services for abuse and neglect and how to respond to certain behaviors such as aggression was completed for the staff working. Attempted telephone call on 09/17/2024 at 02:43 PM to CNA A, unable to reach or leave a message due to no voice mail had been set up. During an interview on 09/18/2024 at 10:34 AM, Resident #1's family member further stated that at 07:55 PM on the camera, CNA A and CNA B placed a brief on Resident #1 after they transferred her back in bed. Attempted telephone call on 09/18/2024 at 11:31 AM to CNA A, unable to reach or leave a message due to no voice mail had been set up. Record review of the CNA C's written witness statement dated 04/03/24 at 7 :50 PM indicated, heard yelling form CNA A and she opened the door to the shower room and seen CNA A's clothes were wet and the skin tear around Resident #1's neck. CNA C asked Resident #1 what happened? But Resident #1 started yelling for me to shut up and tried to kick me. By that time, I helped CNA A roll her out of the shower room and CNA B went a got the LVN D. LVN D questioned CNA B while she (CNA C) and CNA A helped Resident #1 to bed. Then I left out to do the other patient During an interview on 09/18/2024 at 11:40 AM, CNA C said 04/03/2024 CNA C said after the incident occurred in the shower room, she and CNA B put Resident #1 back in the bed and dressed her alone. CNA C said she was educated on abuse and neglect and proper reactions to aggressive behaviors. CNA C said it was important to separate and not allow any contact with the alleged victim to keep them safe from abuse. CNA C said she had never come back to the facility after the night that the incident occurred. Attempted telephone call on 09/18/2024 at 02:45 PM to CNA A, unable to reach or leave a message due to no voice mail had been set up. During an interview on 09/18/2024 at 3:00 PM, the DON stated when she arrived at the facility CNA A had already left. The DON stated Resident #1 was at the hospital. The DON stated she had examined the shower head and shower hose for bodily tissue or blood but seen no indication of either. The DON stated she was unsure who placed Resident #1 back to bed after the incident in the shower room occurred. The DON stated she had been educated on abuse and neglect after the incident as well as aggressive behaviors and how to respond. The DON stated that the perpetrator or alleged perpetrator should immediately be removed from the facility and not allowed access to residents pending the investigation to ensure no harm to the alleged victim or other resident occurs. The DON said LVN D should have told CNA A to not provide any resident care immediately. During an interview on 09/19/2024 at 08:23 AM, the Administrator he was not aware that LVN D had sent CNA A back into the room to transfer Resident #1 into bed after the incident had occurred. The Administrator stated if CNA B said that she and CNA A had transferred Resident #1 back into the bed after the shower room incident then that would be true because CNA B was as honest as the day is long. The Administrator said in-services on abuse and neglect, aggressive behavior and appropriate responses, and once an alleged perpetrator is identified there should be no access to the alleged victim or any resident to prevent harm and provide safety. The Administrator said he expected all staff to follow the Abuse and Neglect Policy. The Administrator said CNA A was terminated on 04/03/2024. The Administrator said CNA C was also terminated and had not worked at the facility after the incident on 04/03/2024. The Administrator said he expected CNA A would not have provided any more resident care and left the facility immediately to prevent further possibilities of abuse. Record review of grievances from January 2024 to September 2024 did not reveal any abuse concerns related to CNA A or CNA C. The Administrator was notified on 09/19/2024 at 01:43 p.m., that a past non-compliance IJ situation had been identified due to the above failures. It was determined these failures placed Residents #1 in an IJ situation on 04/03/2024. The facility had corrected the noncompliance on 04/04/2024 by the following: - Termination of CNA A who was responsible for the abuse - Written counseling of the LVN D the education on the Abuse and Neglect Policy - Safe surveys of 15 residents in the facility - 100% staff in-service on abuse and neglect and proper responses to aggressive behaviors - QAPI sign in sheet dated 05/01/2024 completed with Administrator, DON, Infection Preventionist, Medical Director, Floor Staff Representative, and Director of Maintenance with opportunities of improvement with Abuse Policy attached. Record review of Inservice dated 04/03/2024 indicated education to all staff was completed on the Abuse and Neglect Policy, Resident Rights, and Resident's with Combative Behavior. Record review of LVN D's written counseling dated 04/04/2024 regarding the procedures of the Abuse and Neglect Policy. Record review of CNA A's termination notice dated 04/04/2024. Interviews on 04/20/2024 from 08:30 AM - 10:48 AM of the sampled residents (Resident #2, Resident #3, Resident #4, Resident #5, Resident #6 and Resident #7) revealed no abuse occurred. All staff interviewed (LVN E, CNA F, LVN G, LVN H, LVN J, CNA K, CNA L, CNA M, LVN N, LVN P, CNA Q, RN R, 2 ADONs, Activity Director, Social Worker, MDS Coordinator, Staffing Coordinator on 09/20/2024 08:30 AM - 10:48 AM verbalized any allegation of abuse should be reported to the administrator immediately. They verbalized understanding of the types of abuse and the facility's obligation to report abuse to HHS within 2 hours and removing the alleged perpetrator from the victim or any potential victims immediately. The noncompliance was identified as PNC. The noncompliance began on 04/03/2024 and ended on 04/04/2024. The facility had corrected the noncompliance before the survey began. The noncompliance was identified as PNC. The noncompliance began on 04/03/2024 and ended on 04/04/2024. The facility had corrected the noncompliance before the survey began.

Based on observation, interview, and record review, the facility lacked supervision to prevent accident hazards and failed to ensure that an environment was free from accident hazards for 3 of 6 residents reviewed for accident hazards. (Resident #249, Resident #42, and Resident #41). 1. The facility failed to ensure safety measures were in place to prevent Resident #249 and Resident #42 from obtaining an injury from hot coffee. 2. The facility failed to implement measures to prevent other coffee spills with burns. 3. The facility failed to monitor the temperatures of hot liquids served to residents. 4. The facility failed to identify residents at risk for coffee burns. 5. The facility failed to ensure Resident #249 and Resident #41 had new fall interventions implemented with each subsequent fall. An Immediate Jeopardy (IJ) situation was identified on 09/14/23. While the IJ was removed on 09/15/23 at 6:47 p.m., the facility remained out of compliance at a severity level of actual harm with a scope of pattern due to the facility's need to evaluate the effectiveness of the corrective systems. These failures could place residents at risk for diminished quality of life, accidents, and injury. Findings included: 1.Record review of Resident #249's face sheet, dated 09/05/23 indicated Resident #249 was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses which included heart failure (a condition that develops when your heart doesn't pump enough blood for your body's needs), dementia (the loss of cognitive functioning - thinking, remembering, and reasoning), and anxiety (feelings of nervousness, panic and fear). Record review of Resident #249's quarterly MDS assessment, dated 06/15/23, indicated Resident #249 was understood and usually understood others. Resident #249's BIMs score was 11, which indicated she was moderately cognitively impaired. Resident #249 required total assistance with bathing, extensive assistance with toileting, personal hygiene, transfer, dressing, bed mobility, and set-up assistance with eating. Record review of Resident #249's comprehensive care plan dated 09/16/22 indicated Resident #249 had an ADL self-care performance deficit related to activity intolerance and limited mobility. The interventions of the care plan were for staff to provide Resident #249 with assistance with eating and personal hygiene. Resident #249's care plan failed to address how many staff were needed to assist with eating prior to 06/07/23. Record review of Resident #249's file revealed a hot liquid assessment had not been completed. Record review of the coffee machine temperature log indicated start date of 09/11/23. Record review of Resident #249's incident report dated 08/15/23 at 6:30 a.m., revealed Resident #249 spilled coffee on her lap and had redness to both of her inner and top thighs. No swelling or tenderness to the area. Silvadene cream was applied to the area. Resident #249's clothes were changed and she was assisted back to the dining room. Hospice was notified. Record review of Resident #249's nurse note dated 08/15/23 at 5:40 a.m., signed by LVN N revealed LVN N was notified that Resident #249 had spilled her coffee onto her lap and had redness noted on both of her thighs (inner and top) area. No swelling or tenderness to the area. Silvadene was applied to the area. Resident #249's clothes were changed and she was assisted back to the dining room. Hospice was notified and the hospice nurse said she would notify the family and the physician. Record review of Resident #249's nurse's note dated 08/15/23 at 5:40 a.m., did not indicate any notification to the physician, nurse managers, or administrator. During an observation and interview on 9/11/23 at 3:58 p.m., the dietary manager obtained a cup from the cabinets and coffee temped the coffee in the dining room. The coffee temperature was 160 degrees F. The dietary manager said she does temp the coffee daily but does not log the temperatures. There were 6 residents sitting at the dining table closest to the coffee machine. During an interview on 09/13/23 at 4:54 p.m., LVN N said she was notified by an unknown staff member that Resident #249 had spilled coffee on herself. She said she went to assess Resident #249 and noted redness to both the inner and top thighs. LVN N said she applied Silvadene cream, changed Resident #249's clothes, and assisted her back to the dining room. LVN N said she did not notify the physician but she knew Silvadene was for burns, so she applied the cream. LVN N said she should have notified the physician but she did not. LVN N said she does not recall notifying the administrator about the burn on Resident #249 but believed she notified the DON. During an interview on 09/14/23 at 8:41 a.m., the administrator said he does not report burns unless they were major burns. He said the nursing department would have weekly meetings and if the DON felt something was not a significant event (such as an unknown injury), then she would not notify him. The administrator said he was not aware of Resident #249's coffee burn which occurred on 08/15/23 therefore he could not speak of any injuries or not. During an interview on 09/14/23 at 10:43 a.m., the facility NP said he does not recall receiving a call about Resident #249's burn. He said if any resident had a wound or skin issues, he would have the facility staff call the wound care physician. During an interview on 09/14/23 at 11:15 a.m., the facility wound care doctor said he was unaware of any staff calling him about a burn. He said if they had called, he would have instructed them to wipe the area with a cool towel to stop the burning and then apply Silvadene cream. During an interview on 09/15/23 at 12:16 p.m., the ADON said they were supposed to do a hot liquid assessment on admission and quarterly. She said they were important for the safety of residents who drink coffee. The ADON said the hot liquids were part of the required UDAs (Assessments and Evaluations) and was a team effort between her and the DON to complete. She said the coffee pots were only on during meal service and were supposed to be monitored by nursing staff. The ADON said she was unaware if any interventions were put into place after Resident #42 and Resident #249 obtained burns from the hot coffee. She said they now have things in place to prevent further coffee injuries. During an observation and interview on 09/15/23 at 1:06 p.m., observed coffee pots were still on in the dining room. Housekeeper DD came into the dining room and verified by pulling the coffee level down with the coffee dispensed. He said as far as he knew the coffee stayed on all the time and residents were allowed to get coffee at any time. During an interview on 09/15/23 at 1:40 p.m., the DON said hot liquid assessments were supposed to be done on admission and quarterly. The DON said she was responsible for ensuring the hot liquid assessment had been completed. She said prior to today (09/15/23) they did not have a plan in place to ensure staff were completing the hot liquid assessments. She said the hot liquid assessment was done to ensure residents who drank coffee or hot liquids were safe. During an interview on 09/15/23 at 7:01 p.m., the administrator said he was unaware of how often hot liquid assessments needed to be completed. He said during this survey process he realized that some of the UDAs had not been triggering as they should. He said they educated Resident #42 about her coffee spill but were unaware of any interventions put in place for Resident #249 coffee spill. He said they have implemented staff going up and down the hallways monitoring during mealtimes and alerting nurses if any concerns. He said they have completed the hot liquid assessments and educated staff on hot coffee spills. The administrator said since they had completed the hot liquid assessments, he felt the residents were safer. 45810 2. Record review of Resident #42's face sheet dated 09/14/23 indicated she was a [AGE] year-old female who was admitted to the facility on [DATE] with the diagnoses of fractured left shoulder and arm, high blood pressure, kidney failure, anxiety, and depression. Record review of Resident #42's MDS dated [DATE] indicated she had a BIMS score of 15 which indicated she was cognitively intact. The MDS also indicated she required supervision of 1 person with bed mobility, transfers, eating, and toileting. Record review of Resident #42's care plan initiated on 08/11/23 indicated she had actual impairment to skin integrity of the right upper thigh related to a burn due to coffee spill with interventions to avoid scratching, keep hands, and body parts from excessive moisture, and to monitor, document, report as needed. Record review of Resident #42's incident report dated 08/10/23 indicated she was in the dining room attempting to carry coffee for herself and 2 other residents when she dropped the cups of coffee causing it to spill on her right upper thigh. Record review of Resident #42's hot liquid screening dated 09/15/23 after surveyor intervention indicated she may have hot liquid as served without safety measures. During an interview on 09/11/23 at 04:23 PM Resident #42 said she remembered spilling coffee on her. She said that she was in the dining room on that day, and she just dropped the coffee on her. Resident #42 said the coffee was always self-serve. She said she had not had any other issues with coffee outside of that incident on 08/10/23. During an interview on 09/14/23 at 08:42 AM the DON said she was aware of Resident #42's coffee burn. She said Resident #42 went to the coffee pot and attempted to carry 3 cups of coffee and spilled the coffee before anyone could get to her. The DON said there was some redness on her right upper thigh, and it was gone within 2 hours of the assessment. She said Resident #42 told her she was fine. The DON said no residents were allowed to get coffee on their own. She said Resident #42 retrieved cups from under the cabinet. The DON said the facility started monitoring to ensure the residents did not get into the coffee themselves, but it was not documented. The DON said the coffee pot was turned off at certain times of the day so that it was not hot, and the nurses and aides were made aware to monitor, but no documentation. She said she thought In-services were provided at that time but would look for them. The DON said the Administrator monitors incidents, so he was aware of the coffee burn incident. She does not know if the kitchen checks the coffee daily, but the coffee had a regulator, so the temperatures of the coffee did not fluctuate. The DON said hot liquid assessments were supposed to be completed and the purpose of the assessment was to promote safety with hot liquids. With the assessments not being completed it placed residents at risk for unsafe coffee. During an interview on 09/15/23 at 12:37 PM the ADON said the hot liquid assessments were to be completed on admission and quarterly. The ADON said the assessments were important because a lot of residents like coffee and the assessments are needed for the resident's safety. She said the DON and ADON were responsible for ensuring they were completed. She said Resident #42 let everyone know about the incident with her coffee spill. The ADON said the incident for the coffee was placed in the nurse's note and the nurse aides were also notified by word of mouth. She said the dietary staff were responsible for checking the temperatures of the coffee. The ADON said 160 was too hot for coffee. The ADON said at the time of the burn incident on 08/10/23 the facility provided education to the resident and the staff but not documented. She said the residents were not allowed to make their own coffee. The ADON said they made sure that there were staff members in the dining room when residents started to come into the dining room. She said the nurses and nurse aides were responsible for monitoring when the first resident came into the dining room. The ADON said the coffee pot does not always stay on, but the coffee pot is turned on at the time of meal service. 33249 3. Record review of Resident #249's quarterly MDS assessment, dated 06/15/23, indicated Resident #249 was understood and usually understood others. Resident #249's BIMs score was 11, which indicated she was moderately cognitively impaired. Resident #249 required total assistance with bathing, extensive assistance with toileting, personal hygiene, transfer, dressing, bed mobility, and set-up assistance with eating. Record review of Resident #249's comprehensive care plan, dated 06/07/23 indicated Resident #249 had an actual fall on 5/20/23,05/21/23, and 06/02/23. The interventions of the care plan were for staff to determine and address causative factors of the fall, lock the wheelchair beside the bed even when the resident was not in her wheelchair, provide activities that promote exercise and strength building, provide nonskid socks at bedtime, and continue interventions on the at-risk plan. Record review of Resident #249 falls revealed she had a fall on 06/28/23, 07/24/23, 07/25/23, and 08/19/23. No injuries were noted from unwitnessed falls on 06/28/23, 07/24/23 and 07/25/23. Resident #249 had a witnessed fall on 08/19/23 at 12:20 pm and obtained an abrasion to her forehead, a small hematoma to mid-forehead, and a minor abrasion to her right knee. Record review of Resident #249 nurse notes dated 08/19/23 at 12:20 pm documented by the DON indicated, that Resident #249 was sitting at the nurses' station with RN CC and leaned forward and fell out of her wheelchair causing an abrasion to her forehead, a small hematoma to mid-forehead, and a minor abrasion to her right knee. During an interview on 09/13/23 at 11:03 p.m., RN R said when a resident had a fall they would fill out several forms on the computer, start neuros, notify the family and physician. She said if a resident required an immediate intervention such as fall mats, low bed, or nonskid socks then the nurses would put those things in place otherwise the nursing managers would put an intervention in place. During an interview on 09/15/23 at 12:16 p.m., the ADON said she had never attended a care plan meeting. She said when a resident had a fall the nurses would assess for any changes and notify the DON, family, and the physician. She said the nurses would put interventions if needed in the plan of care or risk management in the computer system. The ADON said without interventions in place they could fall again. During an interview on 09/15/23 at 8:17 PM the MDS nurse said the last care plan related to falls for Resident #249 was 06/02/23. She said she was unaware why her fall care plan had not been updated. The MDS nurse said she and the interdisciplinary team met weekly and everyone played a part in updating care plans. The MDS nurse said she was ultimately responsible for ensuring care plans had been updated and residents had interventions after each fall. The MDS nurse said the care plan should be updated for continuity of care. During an interview on 09/15/23 at 1:40 p.m., the DON said the nurses were responsible for updating the care plan and putting interventions in place. She said they were supposed to put interventions in the UDAs or plan of care. The DON said she reviewed care plans in their meetings and could not say why Resident #249's care plan had not been updated after each fall. The DON said when a resident had a fall, intervention should be implemented to prevent further falls. During an interview on 09/15/23 at 7:01 p.m., the administrator said he knew things should be care planned but was unaware if Resident #249 had falls care planned. He said Resident #249 was at risk for falls. The administrator said nursing was responsible for ensuring care plans were updated as needed. He said care plan updates were important because they were a part of the resident's care and could potentially prevent other falls. 4) Record review of a face sheet dated 9/13/2023 indicated Resident #41 was a [AGE] year-old female who was admitted on [DATE] with the diagnosis of dementia, muscle wasting and atrophy (loss of muscle) to right lower leg, muscle wasting and atrophy to left lower leg, and generalized muscle weakness. Record review of an Annual MDS dated [DATE] indicated Resident #41 was usually understood and usually understands. The MDS indicated Resident #41's BIMS score was 3 indicating severe cognitive deficiet. The MDS indicated Resident #41 required limited assistance of one staff with bed mobility, transfers, dressing, toielting, and personal hygiene. The MDS indicated Resident #41 required supervision of one staff with walking in the room, and walking in the cooridor. The MDS indicated Resident #41 had one fall with an injury (except major). Record review of a comprehensive care plan dated 9/20/2023 indicated Resident #41 had an ADL deficit and required transfer assistance of one staff and she required use of a wheelchair for locomotion. The care plan indicated Resident #41 was at risk for falls related to confusion, incontinence, and psychoactive medications the goal was Resident #41 would not sustain a serious injury. The intervention noted indicated Resident #41's call light would be within reach and ensure the bed was locked in the lowest position. The comprehensive care plan dated 4/19/2023 and revised on 8/08/2023 indicated Resident #41 had falls on 4/19/2023, 4/20/2023, 6/21/2023, 6/28/2023, and 8/3/2023. The goal of the care plan was Resident #41 would resume normal activities without further incident. The care plan interventions implemented on 4/19/2023 monitor and report as needed changes in mental status, new onset of confusion, sleepiness, agitation, and inability to maintain posture, implement neurological checks per facility protocol, provide activities to promote exercise and strength when possible, and a physical therapy consult. The care plan failed to mention interventions implemented for falls occurring after 4/19/2023. Record review of facility incident reports provided for 4/19/2023 - 8/31/2023 indicated: *4/19/2023 LVN N documented she was called to the nurses' station where Resident #41 was found face down on the floor. Resident #41's injuries included a hematoma below the left knee, a bruise forming on her forehead, and abrasion and swelling of her nose. The incident report indicated Resident #41's pain was rated at a 9 out of 10. Resident #41 was sent to the emergency room . The incident report indicated Resident #41 was oriented. The incident report indicated predisposing physiological factors were confusion, gait imbalance, and impaired memory. The incident report indicated the predisposing situation factor was ambulating without assistance. The incident and accident report provided failed to mention any interventions implemented for Resident #41. *4/20/2023 LVN N documented she was informed Resident #41 fell to her knees in the hallway. The incident indicated Resident #41's injury was an abrasion to her left knee. The incident report indicated Resident #41's mental status was oriented. The incident report indicated Resident #41's predisposing factors were confusion, gait imbalance, and impaired memory. The incident report indicated the predisposing situation factors included ambulating without assistance. The incident report provided failed to mention any interventions implemented for Resident #41. *6/21/2023 LVN N documented Resident #41 was ambulating in the hallway with this nurse and Resident #41 tripped while walking. The incident report indicated she was assisted to a wheelchair, then her reclining chair, and was found to have no injuries. The incident report indicated Resident #41's mental status was oriented to person, place, and situation. The incident report indicated Resident #41 predisposing factors were drowsy, and gait imbalance. The incident report provided failed to mention any interventions implemented for Resident #41. *6/27/2023 LVN O documented Resident #41 was standing at the nurses' station and lost her balance. The incident report indicated Resident #41 fell and landed on her left shoulder and hit her left temporal area. The incident report indicated Resident #41 was crying and complained of pain rated at an 8 out of 10 and was hurting all over. The incident report indicated Resident #41 was sent to the emergency room . The incident report indicated Resident #41's mental status was oriented to person only. The incident report indicated Resident #41's predisposing physiological factors included confusion, current UTI, gait imbalance, and impaired memory. The incident report indicated Resident #41's predisposing situation included ambulating without assistance. The incident report provided failed to mention any interventions implemented for Resident #41. *8/03/2023 at 11:25 a.m., LVN N documented Resident #41 was being assisted up from the floor in the hallway by 4 staff members to a wheelchair. The incident report indicated Resident #41 had an abrasion and bruising to her left knee. The incident report indicated Resident #41 had an x-ray ordered. The incident report indicated Resident #41 was oriented. The incident report indicated Resident #41's predisposing physiological factors included gait imbalance and impaired memory. The incident report indicated Resident #41's predisposing situation factors included ambulating without assistance. The incident report provided failed to mention any interventions implemented for Resident #41. *8/31/2023 at 2:26 p.m., LVN O documented Resident #41 was found lying on the floor on multiple blankets by the cleaning staff. Resident #41 was asked if she fell , and she replied yes. The incident report indicated Resident #41's family was asked to review the camera footage to evaluate if Resident #41 fell but the family indicated Resident #41 was not in view of the camera. The incident report indicated Resident #41 had no injuries. The incident report indicated Resident #41's mental status was oriented to person only. The incident report indicated Resident #41's predisposing physiological factor was confusion. The incident report indicated Resident #41's predisposing situation factors included ambulating without assistance and being a wanderer. The incident report failed to mention any interventions implemented for Resident #41. *8/31/2023 at 8:30 p.m., LVN O documented Resident #41 was found on the floor attempting to cover herself with a blanket. The incident report indicated Resident #41 was unable to describe how she ended up on the floor. The incident report indicated Resident #41 had no injuries. The incident report indicated Resident #41's predisposing factors included she had confusion. The incident report indicated Resident #41's predisposing situation was ambulating without assistance, and she was a wanderer. Record review of a Fall Interventions in-service dated 5/15/2023 provided by the DON indicated: *Universal fall precautions: Universal fall precautions are called universal because they apply to all patients regardless of fall risk. Universal fall precautions revolve around keeping the patient's environment safe and comfortable. *Familiarize the patient with the environment *Have the patient demonstrate call light use. *Maintain call light within reach. *Keep the patient's personal possessions within patient safe reach. *Have sturdy handrails inpatient bathrooms, room, and hallway. *Place the hospital bed in low position when a patient is resting in bed; raise bed to a comfortable height when the patient is transferring out of bed. *Keep hospital bed brakes locked. Keep wheelchair wheel locks in locked position. *Keep nonslip, comfortable, well-fitting footwear on the patient. *Use night lights or supplemental lighting. *Keep floor surfaces clean and dry. Clean up all spills promptly. *Keep patient care areas uncluttered. *Follow safe patient handling practices. *Involve resident/patient/family to discuss appropriate interventions. *Anticipate toileting needs and incontinence management. *Use of positioning devices; frequent change in position. *Keep personal items within reach. *Manage behavior symptoms by knowing *Diversional activity program of resident/patient preference *Verify transfer code and safety measures by looking on the CNA care Kardex in the computer system. Record review of a fall risk evaluation dated 9/08/2023 indicated Resident #41 has had 3 or more falls in the past three months, she had intermittent confusion, ambulatory and continent, no dropping of the blood pressure from lying to standing and her vision was adequate. The fall risk indicated she had had no changes in condition during the last 14 days and no recent hospitalization s, her gait was normal, and takes 3-4 medications. 5. Risk of falls area had no focus, no goal and no interventions marked. Section Clinical Suggestions there were no options coded. The fall risk assessment copy did not indicate the assessor. During an interview on 9/14/2023 at 9:10 a.m., CNA B said she was unaware of Resident #41 having a history of falls. CNA B said she was not aware of any fall prevention interventions for Resident #41. CNA B said she was assigned to care for Resident #41. During an interview on 9/15/2023 at 12:15 p.m., the ADON said the fall process included: after a fall the nurse completes an assessment including vital signs, neurological checks initiated and a pain assessment. The ADON said the nurse managers were notified. The ADON said interventions were implemented and placed in the Kardex POC (Point of Care) system such as a fall mat. The ADON said the fall care plan should reflect interventions with each fall. The ADON said implementing fall interventions after falls could prevent other falls. The ADON said Resident #41 was a high fall risk. The ADON said the interventions were monitored through rounds. During an interview on 9/15/2023 at 1:57 p.m., the DON said the fall process included the nurses completing a physical assessment, completing the risk assessment report, notification of the family, doctor, and management nurses. The DON said with fractures or head injuries both the administrator and she was notified. The DON said new interventions were placed in the care plan, the point of care (Kardex) and through broad stream in-servicing. The DON said Resident #41 was a high fall risk. During an interview on 9/15/2023 at 7:08 p.m., the Administrator said when a resident had a fall, he expected an incident report to be completed, to determine if the result of the fall was a physical change. The Administrator said the care plan should be updated by the nurses. The Administrator said sometimes being creative was required to implement new interventions. The Administrator said Resident #41 was a fall risk. Record review of a Falls Clinical Protocol dated March 2018 indicated: 1. They physician will help identify individuals with a history of falls and risk factors for falling c. While many falls are isolated individual incidents, a few individuals fall repeatedly. Those individuals often have an identifiable underling cause. 2. In addition, the nurse shall assess and document/report the following: g. frequency and number of falls since last physician visit; i . All current medications, especially those associated with dizziness or lethargy. 3.b. After a first fall, the staff (and physician, if possible) should watch the individual rise from a chair without using his or her arms, walk several paces, and return to sitting. If the individual has no difficulty or unsteadiness, additional evaluation may not be needed. If the individual has difficulty or is unsteady in performing this test, additional evaluation should occur. 4.a. Falls often have medical causes; they are not just a nursing issue. Cause Identification: 1. For an individual who has fallen, the staff and practitioner will begin to try to identify possible causes within 24 hours of the fall. 3. The staff and physician will continue to collect and evaluate information until either the cause of the falling is identified, or it is determined that the cause cannot be found or is not correctable. Monitoring and Follow-Up: 2. The staff and physician will monitor and document the individual's response to interventions intended to reduce falling or the consequences of falling. 4. If the individual continues to fall, the staff and physician will re-evaluate the situation and reconsider possible reasons for the resident's falling (instead of, or in addition to those that have already been identified) and also reconsider the current interventions. 5. As needed, and after an appropriately thorough review, the physician will document any uncorrectable risk factors and underlying causes . Record review of a Falls and Fall Risk, Managing policy dated March 2018 indicated based on previous evaluations and current data, the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling. Monitoring Subsequent Falls and Fall Risk 1. The staff will monitor and document each resident's response to interventions intended to reduce falling or the risks of falling. 4. If the resident continues to fall, staff will re-evaluate the situation and whether it is appropriate to continue or change current interventions. As needed, the attending physician will help the staff reconsider possible causes that may not previously have been identified. Record review of facility policy, Food Holding dated June 1, 2019, indicated, To ensure that all food served by the facility is of good quality and safe for consumption all food will be held and served according to the state and US food code and HACCP guidelines. A food sample temperature chart reveals coffee should be between 160 and 180 degrees. This was determined to be an Immediate Jeopardy (IJ) situation on 09/14/23 at 2:14 p.m. The Administrator was notified. The Administrator was provided with the IJ template on 09/14/23 at 2:24 a.m. and requested a Plan of Removal (POR). The Plan of Removal (POR) was accepted on 09/15/23 at 4:20 p.m. and indicated the following: Immediate action: Facility failed to implement measures to prevent other coffee spills with burns. 1. Resident #249 was admitted on [DATE] with diagnoses of dementia, anxiety, and heart failure. 2. Resident #42 was admitted on [DATE] with the diagnoses of Dementia, anxiety, hypertension, and depression. 3. All residents will have a hot liquid screening tool completed by the nursing admin to be completed. Completion Date: 9/14/2023 4. Residents identified at risk will have relevant adaptive devices (lids, vinyl apron, [NAME] cups, etc.) initiated based on hot fluid screening tool completed on 09/15/2023. Staff to document in E.H.R. when resident refuses to use relevant adaptive devices. Completion Date: 9/15/2023 5. Newly admitted /readmitted residents will have hot liquid screening tool completed at time other admission/readmission assessments are being completed and if identified at risk and any relevant adaptive equipment within 24 hours. 6. Care plans will be updated by the Facility MDS Nurse and Regional Support MDS nurse as needed to reflect any changes in hot liquid status based on new hot liquid screening conducted 09/15/2023. Completion Date: 9/15/2023 7. In-service initiated for hot liquid by nursing administration (DON, ADON, MDS Nurse) and staff (Lic. And non-lic. Direct Care staff, Therapy, Dietary) will be in-serviced prior to the next scheduled shift starting 9/15/2023. Policy includes steps to do when Hot Liquid Spill Occurs, from resident skin check, to temping the liquid/food item, to completing a Hot Liquid Screening Tool (PCC UDA), to updating care plan, Nutrition management adding relevant adaptive item if need identified.

Based on observations, interviews, and record reviews the facility failed to provide specialized rehabilitative services such as but not limited to physical therapy, speech-language pathology, occupational therapy, respiratory therapy, and rehabilitative services for mental illness and intellectual disability, or services of a lesser intensity as set forth at S483.120(c) for 14 of 15 residents (Resident #33, Resident #28, Resident #6, Resident #8, Resident #100, Resident #17, Resident #45, Resident #149, Resident #15, Resident #2, Resident #41, Resident #27, Resident #12, and Resident #99) for residents observed for specialized rehabilitative services. The facility failed to provide Resident #33 with physician ordered physical therapy from the admitted [DATE]. The facility failed to provide Resident #99 with physician ordered physical therapy from the admitted [DATE]. The facility failed to implement Resident #99's physical therapy evaluation recommendations of 5 times weekly for 4 weeks. The facility failed to ensure therapy services were provided as ordered for Resident #33, Resident #28, Resident #6, Resident #8, Resident #100, Resident #17, Resident #45, Resident #149, Resident #15, Resident #2, Resident #41, Resident #27, Resident #12, and Resident #99 consistently from [DATE] until [DATE]. These failures resulted in an identification of an Immediate Jeopardy (IJ) on [DATE] at 9:10 AM. While the IJ was removed on [DATE] at 2:59 PM, the facility remained out of compliance at potential harm that is not immediate jeopardy with a scope identified as a pattern due to the facility's need to complete in-service training, daily validation of physical therapy staff, weekly monitoring of staff knowledge of the abuse and neglect policy and evaluate the effectiveness of the corrective systems. These failures could place residents who had orders for physical therapy at risk of not having their rehabilitation needs met and possibly resulting in serious impairment likely to occur as a result of decline in physical abilities. Findings included: 1.Record review of Resident #33's face sheet dated [DATE] indicated she was a [AGE] year-old female who admitted to the facility on [DATE] with the diagnoses of fracture of left femur, falls, anxiety, high blood pressure, and pain. Record review of Resident #33's MDS dated [DATE] indicate she had a BIMS score of 13 which meant she had mildly impaired cognition. The MDS also indicated that Resident #33 required limited assist of 1 staff for bed mobility, dressing, and toileting, limited assist of 2 staff for transfers, and extensive assist of 1 staff for bathing. The MDS also indicate Resident #33 had 0 minutes of physical therapy in the last 7days. Record review of Resident #33's physician orders dated [DATE] indicated the order for PT to evaluate and treat that started on [DATE]. Record review of Resident #33's care plan last revised on [DATE] indicated she had ADL self-performance deficit with a goal to improve current level of function and an intervention to have therapy services as indicated. Record review of Resident #33's therapy notes dated [DATE]-[DATE] indicated resident only had a physical therapy evaluation and plan of treatment on [DATE] and no other treatments until after surveyor intervention on [DATE], [DATE] and [DATE]. During an interview on [DATE] at 06:15 PM the Administrator said the facility did not have a policy on therapy services, but he had a therapy services agreement. During an observation and interview on [DATE] 10:47 AM Resident #33 was lying in bed. She said she was unaware the facility did not have a physical therapist but had expected to receive physical therapy services when she agreed to come to the facility. She said she had been completing some type of therapy. During an interview on [DATE] at 02:40 PM the Director of Rehab said she had been the Director of Rehab since January of 2023. She said she was responsible for staffing the physical therapists in the facility. The Director of Rehab said the physical therapist last hired had been out of the facility since [DATE]. She said [DATE] was supposed to be the first date of work but his licensed were expired. The Director of Rehab said the physical therapist worked [DATE], and [DATE], and missed work on [DATE], related to medical issues. The Director of rehab said residents who had physical therapy orders were evaluated by a telehealth physical therapist and they had a prn PT that was supposed to come in, but never came. She said none of the residents with physical therapy orders had been seen for physical therapy treatment. She said she had text several workers that said they would come in to work as physical therapist but did not show on the day they were scheduled to treat. The Director of Rehab said she had talked to her boss, the Regional Director of operations, repeatedly to notify her that there had been no physical therapist in the building. She said the facility held a level of care meeting weekly with the regional director of operations included on the call. She said in that meeting the therapy minutes were discussed. She said she talked to the administrator about the problem several times and he was aware of the facility not having a physical therapist. The Director of Rehab said when residents had admitted to the facility it was not discussed that the facility did not have a physical therapist in the facility to treat when services were ordered. She said it was important for the residents to receive the physical therapy treatments if ordered to ensure they reach their rehabilitation goals. The Director of Rehab said residents not receiving therapy they had ordered could have caused continued weakness or gait problems. She said she did not think they would decline because she was provided extra occupational therapy when she treated residents. She said she did not see the difference in the resident getting PT and OT except the treatment plan. The Director of Rehab said the occupational therapists treat the residents daily. She said she saw the facility not having a physical therapist as a failure but not in failure in treatment. When asked why she thought that she had been notifying her boss and the administrator of the lack of a physical therapist, they never assisted in getting a physical therapist in the facility, on [DATE] after surveyor intervention, the facility had a physical therapist that came in the building to treat all residents with physical therapy orders, She started to get upset and cry and said she did not know. During an interview on [DATE] at 03:09 PM the Regional Director of Operations said the facility had had a physical therapist periodically. She said the full-time physical therapist had an un-foreseen diagnosis and been out of the building since [DATE]. She said Telehealth were performed for evaluations on residents that had orders for physical therapy. The Regional Director of Operations said she was made aware on [DATE] of there being residents who had not received further treatments. She said the Director of Rehab notified her by phone. The Regional Director of Operations said the Director of Rehab had notified her about call-ins in august but not since [DATE]. She said she did not know no residents with physical therapy ordered were not receiving physical therapy. She said with the resident not getting physical therapy as ordered, if could have caused a negative effect on their mobility and bed mobility. The Regional Director of Operations said she spoke with the facility administrator today about the issues. She said the Director of Rehab was responsible for staffing the physical therapy in facility, and she did not have a monitoring tool to ensure the ordered therapy was staffed and being completed. The Regional Director of Operations said the facility held weekly calls where she was aware that physical therapy did not have a full-time physical therapist, but as a regional she did not always attend the meetings about the visits. She said the facility did not communicate to the residents and families as they admitted that they could not provide physical therapy services. During an interview on [DATE] at 03:46 PM the DON said she said she was not aware that the facility did not have a physical therapist in the building. She said she thought the physical therapist telehealth were being completed for evaluations when they received new physician orders for physical therapy, and a physical therapy assistant was completing the in-house treats. The DON said she just found out when the administrator notified her of the investigations on [DATE]. The DON said it was important for the residents to receive the physical therapy services if they have orders. She said the risk to the residents not receiving the physical therapy treatments as ordered was decreased mobility, weight loss, or an exacerbation of what the residents had admitted to the facility for. The DON said the rehab company was responsible for ensuring the physical therapist was in the facility as scheduled to treat all residents with physical therapy orders. She said she did not attend any of the meetings that therapy had for level of care or to discuss minutes in therapy. During an interview on [DATE] at 07:00 PM the Administrator said he expected the therapy services to be provided. He said the Director of Rehab was responsible for ensuring the residents with Physical therapy orders receive the treatment ordered and would expect every day a validation to ensure the therapy was provided and to be continued as a component in their morning clinical meetings. The risk to the resident was a risk for time delay in healing. The Administrator said as a non-clinician he could not say the physical mobility would have a declined, but he could say that the residents could be more upset by not receiving the therapies ordered. 33249 2.Record review of a face sheet dated [DATE] indicated Resident #99 was an [AGE] year-old female who admitted on [DATE] with the diagnoses of wedge compression fracture of the third lumbar vertebra (fracture of the lower spine), heart failure, and a heart attack. Record review of the Baseline Care Plan dated [DATE] indicated in the summary section Resident #99 admitted to the facility for therapy and skilled nursing care. The baseline care plan summary also indicated Resident #99's plan was to discharge home at prior level of functioning with home health services. Record review of consolidated physician orders dated [DATE] indicated Resident #99 was ordered on [DATE] physical therapy to evaluate and treat as indicated. Record review of the Admission MDS dated [DATE] indicated Resident #99 was understood and understands others. The MDS indicated Resident #99's BIMS score was 10, indicating her cognition was moderately impaired. The MDS indicated Resident #99 was extensive assistance of two staff for bed mobility, and transfers. Resident #99 required extensive assistance of one staff for dressing, toileting, bathing, and personal hygiene. The MDS indicated Resident #99 did not receive any minutes of physical therapy and received 38 minutes of occupational therapy over the last 7 days. Record review of a Physical Therapy Evaluation and Treatment indicated Resident #99 was evaluated for on [DATE] for the start of the certification period of [DATE] - [DATE]. The physical therapy evaluation indicated Resident #99 had compression fractures of her lower back, lack of coordination, abnormal gait and mobility and muscle weakness. The evaluation indicated Resident #99 would receive physical therapy 5 times a week for 4 weeks. The goal of the physical therapy plan indicated Resident #99 would be able to return home. The physical therapy plan indicated Resident #99 demonstrated good rehab potential as evidenced by the ability to follow multi-step directions. During an observation and interview on [DATE] at 12:45 p.m., Resident #99 was eating her noon meal. Resident #99 said she had not had physical therapy since she arrived. Resident #99 said she was walking before her admission. Resident #99 said she could not walk now. During an interview on [DATE] at 10:59 a.m., Resident #99's family member indicated Resident #99 had admitted to the facility specifically for physical therapy. Resident #99's family member further said they chose this facility because they accepted her insurance as the payor source. The family member said she had gone to the Administrator; then the DON and she sent me to the SW with no resolution as to why the resident had just laid there with no physical therapy. Resident #99's family member said she was so upset she discharged Resident #99 and took her to a hospital her physician advised an hour away from the facility. During an interview on [DATE] at 3:44 p.m., the DOR said the physical therapist assistant had not worked since [DATE]. The DOR said she has had a physical therapist sporadically but not on regular basis. The DOR said she had reached out to the RDO of the therapy group and had not had the position filled. The DOR said she provided occupational therapy which overlapped with the physical therapy. The DOR said she had not provided the recommended physical therapy as the physical therapist indicated was needed for Resident #99 to reach her goals. The DOR said the Administrator and the RDO of the therapy company was aware there was not a physical therapist to provide treatments. During an interview on [DATE] at 12:15 p.m., the ADON said she was unaware the residents with ordered physical therapy was not receiving the physical therapy. The ADON said she could not say if a resident would have a negative outcome due to not receiving physical therapy, but she indicated a resident would have to stay longer in the nursing facility to meet their goals. During an interview on [DATE] at 1:40 p.m., the DON said she was not notified of not having a physical therapist on site to provide physician ordered therapy treatment. The DON said neglect could be not providing services. The DON said abuse and neglect could continue without prevention and investigation. During an interview on [DATE] at 7:15 p.m., the Administrator said he had reviewed the residents who had not received their ordered therapy and had found no residents had suffered a decline in their function. The Administrator said but if it had been him who had not received the ordered physical therapy he would have been upset as well. The Administrator said he was expected to follow the facility policies. The Administrator said to always put the residents first by abiding by the abuse policy. The Administrator said when the abuse policy was not followed there was a risk for the resident not to be advocated for. 3. Record review of the face sheets and physical therapy evaluations and treatments for the residents on service the month of [DATE] and [DATE] indicated: Resident #33 admitted to the facility on [DATE] and had a physical therapy evaluation completed on [DATE] with a certification period of [DATE]-[DATE] which indicated resident was supposed to have physical therapy treatments 5 times a week for 4 weeks and received no physical therapy treatments until after surveyor intervention on [DATE] by PT W, [DATE] by PT W and [DATE] by PTA XX . Resident #28 admitted to the facility on [DATE] and had a physical therapy evaluation completed on [DATE] with a certification period of [DATE]-[DATE] which indicated resident was supposed to have physical therapy treatments 5 times a week for 4 weeks and received 3 treatments of physical therapy on [DATE] by PT W, [DATE], and [DATE] by PTA YY. Resident #6 readmitted to the facility on [DATE] and facility had an order for physical therapy evaluation, but no evaluation nor treatments were found. Resident #8 readmitted to the facility on [DATE] and had a physical therapy evaluation completed on [DATE] with a certification period of [DATE]-[DATE] which indicated resident was supposed to have physical therapy treatments 5 times a week for 4 weeks and received 1 treatment on [DATE] and 1 treatment after surveyor intervention on [DATE] by PT W. Resident #100 admitted to the facility on [DATE] and had a physical therapy evaluation completed on [DATE] with a certification period of [DATE]-[DATE] which indicated resident was supposed to have physical therapy treatments 5 times a week for 4 weeks and received 1 treatment after surveyor intervention on [DATE] by PT W. Resident #17 readmitted to the facility on [DATE] and had a physical therapy evaluation completed showed incomplete and resident received 1 treatment after surveyor intervention on [DATE] PT W. Resident #45 admitted to the facility on [DATE] and had a physical therapy evaluation completed on [DATE] with a certification period of [DATE]-[DATE] which indicated resident was supposed to have physical therapy treatments 5 times a week for 4 weeks and received 1 treatment after surveyor intervention on [DATE] by PT W. Resident #99 admitted to the facility on [DATE] and discharged AMA on and had a physical therapy evaluation completed on [DATE] with a certification period of [DATE]-[DATE] which indicated resident was supposed to have physical therapy treatments 5 times a week for 4 weeks and received no therapy treatments Resident #149 admitted to the facility on [DATE] and had a physical therapy evaluation completed on [DATE] with a certification period of [DATE]-[DATE] which indicated resident was supposed to have physical therapy treatments 5 times a week for 4 weeks and received 1 physical therapy treatment after surveyor intervention on [DATE] by PT W. Resident #15 admitted to the facility on [DATE] and had a physical therapy evaluation completed on [DATE] with a certification period of [DATE]-[DATE] which indicated resident was supposed to have physical therapy treatments 3 times a week for 30 days and received physical therapy treatments twice weekly on [DATE], [DATE] by PTA ZZ, [DATE], [DATE] by PTA YY, [DATE], [DATE] by PTA BBB, [DATE], [DATE], and [DATE] by PT W after surveyor intervention. Resident #2 admitted to the facility on [DATE] and had a physical therapy evaluation completed on [DATE] with a certification period of [DATE]-[DATE] which indicated resident was supposed to have physical therapy treatments 5 times a week for 4 weeks and received 4 physical therapy treatments on [DATE], [DATE] by PT W, [DATE],[DATE] by PTA YY, and 1 treatment after surveyor intervention on [DATE] by PT W. Resident #41 admitted to the facility on [DATE] and had a physical therapy evaluation completed on [DATE] with a certification period of [DATE]-[DATE] which indicated resident was supposed to have physical therapy treatments 3 times a week for 30 days and received no physical therapy treatments. Resident #27 admitted to the facility on [DATE] and had a physical therapy evaluation completed on [DATE] with a certification period of [DATE]-[DATE] which indicated resident was supposed to have physical therapy treatments 5 times a week for 4 weeks and received 5 physical therapy treatments on [DATE] by PT W, [DATE], [DATE] by PTA BBB, [DATE], [DATE] by PTA YY and 1 treatment after surveyor intervention on [DATE] PT W. Resident #12 admitted to the facility on [DATE] and had a physical therapy evaluation completed on [DATE] with a certification period of [DATE]-[DATE] which indicated resident was supposed to have physical therapy treatments 3 times a week for 4 weeks and received 3 physical therapy treatments on [DATE] by PT W, [DATE], [DATE] by PTA YY, and 1 treatment after surveyor intervention on [DATE] by PT W. Record review of the Therapy Services Agreement for Lakeside Health and Wellness dated [DATE] indicated This Therapy Services Agreement (Agreement) is made by and between . 1. Services: a. Therapy and Related Services . i.physical, occupational, and speech therapy services, including clinical supervision of such services, in accordance with physician's orders and the applicable plan of care ii.clinical oversight, subject to Customer's direction, of (A) overall caseload and documentation support and (B) focused clinical communication, including interaction with local referral sources . The Administrator was notified on [DATE] at 10:35 AM that an Immediate Jeopardy situation was identified due to the above failure. The Administrator was provided the Immediate Jeopardy template on [DATE] at 10:41 AM. The facility's Plan of Removal was accepted on [DATE] at 07:27 AM and included: 825 - The facility failed to provide the services of physical therapy. Resident #33 admitted to the facility with a repaired femur fx on [DATE].Physical therapy was ordered on [DATE] and no services were provided. Resident #99 admitted to the facility on [DATE] with orders to receive physical therapy. Facility failed to provide physical therapy to residents #33 and #99. This failure has the potential to affect all residents with orders for physical therapy. 1. Resident #99 discharged AMA to hospital. Resident #33 was immediately assessed for any negative outcome as a result of not having physical therapy. 2. All residents with orders for physical therapy evaluated by licensed physical therapist, in-person on [DATE]. 3. All residents with orders for physical therapy to begin face-to-face treatments as ordered by licensed physical therapy staff as of [DATE]. 4. Contract Rehab provider to provide schedule of in-person physical therapy coverage over the next 30 days. Additional oversight hired that is licensed P.T. as of ,d+[DATE] to start to validate contractor has physical therapist in building and will subcontract to provide therapy backup. 5. Continuous physical therapy staff presence in facility will be validated and monitored by administrator daily. 6. IF no physical therapists occurs (not available to treat), facility will not admit residents with physical therapy orders until a physical therapists is available to treat. 7. Continuous Presence of in-person physical therapy will be reviewed monthly with medical director at facility QAPI meeting. Facility had the responsibility to protect residents from neglect that could cause regression and decline in ADL function. 1. All residents with orders for physical therapy to begin face-to-face treatments as ordered by licensed physical therapy staff as of [DATE]. 2. Contract Rehab provider to provide schedule of in-person physical therapy coverage over the next 30 days. Additional oversight hired that is licensed P.T. as of ,d+[DATE] to start to validate contractor has physical therapist in building and will subcontract to provide therapy backup. 3. Continuous physical therapy staff presence in facility will be validated and monitored by administrator daily. On [DATE] the surveyor confirmed the facility implemented their plan of removal sufficiently to remove the Immediate Jeopardy (IJ) by: Record review of face-to-face physical therapy treatments performed for all residents who had physical therapy orders completed on [DATE] by a licensed physical therapist. Record review of the [DATE] and the [DATE] schedule which included a physical therapist assistant to treat Monday through Friday. Interviews of staff on [DATE] between 10:47 AM and 02:55 PM (Dietary Manager, CNA EE, LVN FF, LVN GG, RN G, Housekeeping Supervisor, Dietary Cook HH, CNA II, Social Worker, Comfort aide S, RN F, Dietary Cook P, CNA JJ, RN DD, LVN N, LVN LL, ADON, Maintenance Manager, Administrator, DON, MDS Nurse, CNA MM, Housekeeping aide KK, Activity Director, RN NN, Dietary aide OO, LVN O, CNA T, Marketing Director, Housekeeping aide PP, Housekeeping aide QQ, Business Office Manager, RN Q, People Operations, Receptionist, Staffing Coordinator AA, MA C, Rehab Director, Regional Director of Operations, COTA RR, PTA SS) were performed. During the staff interviews the staff were able to correctly identify the types of abuse and neglect definition. The staff were able to indicate who the Abuse coordinator was as well as when and who to report abuse and neglect. During an interview with the Administrator on [DATE] at 01:10 PM he said that he had measuress in place to monitor and validate to ensure there were therapists in the facility daily to ensure ordered treatments were completed. During an observation on [DATE] at 02:30 PM PT VV was in the therapy gym providing treatments. On [DATE] at 02:59 PM, the Administrator was informed the IJ was removed; however, the facility remained out of compliance at potential harm that is not immediate jeopardy with a scope identified as a pattern due to the facility's need to complete daily validation of physical therapy staff by the Administrator and to evaluate the effectiveness of the corrective systems.

Based on interviews, and record review, the facility failed to be administered in a manner that enabled it to use its resources effectively and efficiently to maintain the highest practicable well-being for 48 of 48 residents reviewed. The administrator failed to follow the abuse and neglect policy. The administrator failed to collaborate with the regional director of the rehab company to ensure therapy services were provided as ordered. The administrator failed to monitor the director of rehab services to ensure the proper staff were available to provide physical therapy as ordered by the physician. The IP failed to ensure interventions were put in place to prevent an increase in UTIs. An Immediate Jeopardy (IJ) situation was identified on 09/14/23. While the IJ was removed on 09/15/23 at 6:47 p.m., the facility remained out of compliance at a severity level of actual harm with a scope of pattern due to the facility's need to evaluate the effectiveness of the corrective systems. These failures could place residents at an increased risk for abuse, further abuse, increased anxiety, emotional distress, depression, neglect, and retaliation. Findings included: 1.Record review of physical therapy orders for Residents #99, # 33, #28, #6, #17, 170, #45, #149, #15, #2, #41, #27 and #12 were reviewed and they were not receiving therapy as ordered. During an interview on 9/12/2023 at 3:44 p.m., the DOR said the physical therapist assistant had not worked since July 31, 2023. The DOR said she has had a physical therapist sporadically but not regularly. The DOR said she had reached out to the RDO of the therapy group and had not had the position filled. The DOR said she had not provided the recommended physical therapy as the physical therapist indicated was needed for Resident #99, # 33, #28, #6, #17, 170, #45, #149, #15, #2, #41, #27 and #12 to reach their goals. The DOR said the Administrator and the RDO of the therapy company were aware there was not a physical therapist to provide treatments. During an interview on 09/12/23 at 4:55 p.m., the administrator said he was aware physical therapy had a staffing issue at some unknown point but thought it was resolved. During an interview on 09/13/23 at 03:09 PM the Regional Director of Operations said the facility had had a physical therapist periodically. She said the full-time physical therapist had an un-foreseen diagnosis and been out of the building since August 15, 2023. She said Telehealth were performed for evaluations on residents that had orders for physical therapy. The Regional Director of Operations said she was made aware on 09/12/23 of there being residents who had not received further physical therapy by the Director of Rehab. The Regional Director of Operations said the Director of Rehab had notified her about call-ins in august but not since 9/1/23. She said she did not know no residents with physical therapy ordered were not receiving physical therapy. She said the Director of Rehab was responsible for staffing the physical therapy in facility. The Regional Director of Operations said the facility held weekly calls where she was aware that physical therapy did not have a full-time physical therapist, but as a regional, she did not always attend the meetings about the visits. She said with the residents not getting physical therapy as ordered, if could have caused a negative effect on their mobility and bed mobility. 2.Record review of the facility's quality assessment and assurance process for UTIs dated 05/12/23, revealed a performance improvement process was put into place on 05/12/23 and no other updates were put in place until mentioned by the surveyor on 09/14/23. During an interview on 09/15/23 at 12:16 p.m., the ADON said when she identified the facility had an increase of UTIs back in May 2023, they started doing random peri-care checkoffs and hand washing. She said she did notice some decrease in the number of UTIs and felt her plan of action was effective. She said she tried to update the infection log daily but at least weekly. She said she did notice last month (August 2023) had an increase in UTIs. She said she had not implemented anything on paper but had started doing peri care, handwashing, and verbal communication with staff. She said she was responsible for ensuring staff was following the infection control policy. She said part of her process as the infection preventionist was to review the UA results, look to see if they meet the Mcgeers criteria (used for retrospectively counting true infections, to meet the criteria for definitive infection, more diagnostic information (e.g., positive laboratory tests) is often necessary), and educate facility staff and hospice as needed. She said it was important to push fluids and perform good peri care and handwashing to prevent UTIs. Record review of the Therapy Services Agreement for [facility] Health and Wellness dated 02/16/2021 indicated This Therapy Services Agreement (Agreement) is made by and between . 1.Services: a. Therapy and Related Services .i.physical, occupational, and speech therapy services, including clinical supervision of such services, in accordance with physician's orders and the applicable plan of care ii.clinical oversight, subject to Customer's direction, of (A) overall caseload and documentation support and (B) focused clinical communication, including interaction with local referral sources . Record review of the Resident Abuse and Neglect Policy section H. RECOGNIZING SIGNS AND SYMPTOMS OF ABUSE/NEGLECT dated 2021 indicated, Our Facility will not condone any form of resident abuse or neglect. To aid in abuse prevention, all team members are to report any signs and symptoms of abuse/neglect to their supervisor or to the Director of Nursing immediately. The following are some examples that include but are not limited to and may be abuse/neglect signs and symptoms that should be promptly reported to determine if they meet the current state/federal reporting requirements. All suspicions shall be reported . Record review of the Resident Abuse and Neglect Policy section L. STAFF RESPONSIBLE FOR COORDINATING/IMPLEMENTING ABUSE PREVENTION dated 2021 indicated, The Administrator Facility Abuse Coordinator assumes the responsibility for the overall coordination and implementation of our community's abuse prevention program policies and procedures. POLICY INTERPRETATION AND IMPLEMENTATION The Administrator has the overall responsibility for coordination and implementation of our Facility's abuse prevention program policies and procedures . Record review of facility policy, Infection Control dated August 2016, indicated The infection prevention and control program is a facility-wide effort involving all disciplines and individuals and is an integral part of the quality assurance and performance improvement program. 2. The elements of the infection prevention and control program consist of coordination/oversight, policies/procedures, surveillance, data analysis, antibiotic stewardship, outbreak management, prevention of infection, and employee health and safety. 1. Coordination and Oversight. a. The infection prevention and control program is coordinated and overseen by an infection prevention specialist (infection preventionist). c. The infection prevention and control committee is responsible for reviewing and providing feedback on the overall program. Surveillance data and reporting information is used to inform the committee of potential issues and trends. Some examples of committee reviews may include: 7. Prevention of Infection a. Important facets of infection prevention include: (I) identifying possible infections or potential complications of existing infections; (2) instituting measures to avoid complications or dissemination.3) educating staff and ensuring that they adhere to proper techniques and procedures. (4) enhancing screening for possible significant pathogens. This was determined to be an Immediate Jeopardy (IJ) situation on 09/14/23 at 2:14 p.m. The Administrator was notified. The Administrator was provided with the IJ template on 09/14/23 at 2:24 a.m. and requested a Plan of Removal (POR). The Plan of Removal (POR) was accepted on 09/15/23 at 4:20 p.m. and indicated the following: Immediate action: The facility failed to ensure it was administered in a manner that enables it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. 1. Administrator to receive Abuse and Neglect education/in-service to be provided to on 9/13/2023 by Director of Resident Care & Education (RN Regional). Completion Date: 9/13/2023 2. Director of Resident Care & Education (RN Regional) to perform weekly random Q&A validation on what constitutes neglect, and examples of abuse and neglect. Findings will be shared with the SVP of Operations (Supervisor of Administrator) 3. Regional Rehab Director (contracted provider), Subcontractor Therapy Oversight PT to review with Administrator therapy staffing schedule weekly. The schedule will be shared with SVP of Operations (Supervisor of Administrator). 4. SVP of Operations in-serviced Administrator & DON on the oversight by SVP Operations and by Therapy subcontractor. Completion Date: 9/14/2023 5. DOR (Dir. of Rehab) to inform Administrator daily re: physical therapy discipline onsite and no later than noon, to allow a backup plan to be put in motion of notifying Regional Rehab Dir. and the Subcontractor Oversight Therapist. 6. In Weekly Clinical Care (SOC) meetings DOR to report changes in therapy frequency treatment plans and let DON and Administrator know if this differs from order and goals and if rationale is documented in resident E.H.R. 7. Continuous Presence of in-person physical therapy will be reviewed monthly with medical director at facility QAPI meeting. 8. DON/ADON to review residents with UTI's and MDS nurse(s) to update/revise care plans with interventions and update orders as needed to reduce potential for re-occurrence. Completion Date: 9/15/2023. During interviews and record reviews on 09/15/2023 from 4:20 p.m. until 6:40 p.m., the surveyors confirmed the facility implemented their plan of removal sufficiently to remove the IJ. Record review of in-service abuse, neglect, and reporting with administration staff dated 09/13/23. Record review of therapy schedule for September and October 2023 revealed they had a physical therapist scheduled. Record review of rehab reporting requirements dated 09/14/23 starting 09/15/23, signed by SVP administrator, facility administrator, and DON. Record review of care plans for 3 residents with current UTIs all updated 09/14/23 for Resident #11, #14, and #26. During an interview on 09/15/23 at 3:00 p.m., the ADON said she had been trained on the infection control process by the regional nurse which included a PowerPoint overview about infection and the process for infection control meeting and things needed to be done to prevent further infections. During an interview on 09/15/23 at 4:40 p.m., the director of rehab said she was to report her staffing to the administrator daily by noon. She said if someone were to call in sick, she would notify her regional director or designate. She said she would be attending standards of care (SOC) meetings weekly and if there had been a change in therapy such as missed visits, or a resident refusing therapy, she needed to have justification and notify the administrator. She said she had given the administrator a tentative schedule through October 2023. During a telephone interview on 09/15/23 at 6:18 p.m., the regional nurse said she would be doing weekly Microsoft team calls with the facility and asking questions about what abuse is, who is the abuse coordinator, and what were examples of abuse and neglect. She said staff could use their phones or facility computers. She said she had a Microsoft team meeting this morning (09/15/23) about abuse and infection control issues. During an interview on 09/15/23 at 6:41 p.m., the administrator said as part of their plan of removal he would be receiving updates on therapy services daily. He said he would be attending all meetings to ensure things were not missed. He said it was important to receive therapy as ordered and he was responsible for ensuring residents were receiving therapy as ordered. He said he had training on reporting, and he said everything he was supposed to report would be reported and investigations. The administrator said the risk to the resident was for the resident not being advocated for and placed them at risk for abuse and neglect to continue. On 09/15/2023 at 6:47 p.m., the Administrator was informed the IJ was removed; however, the facility remained out of compliance at a severity level of actual harm that was not in immediate jeopardy with a scope identified as pattern due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems.

Based on observation, interview, and record review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent hospitalization related to infections for 1 of 13 residents reviewed (Resident #16) for urinary tract infection (an infection in any part of the urinary system) and 4 of 6 residents reviewed for (Resident #250, Resident #17, Resident#35 and Resident #9) infection control practices. *The facility had 13 urinary tract infections for the month of [DATE]. 7 of 13 residents had Escherichia coli (E. coli- bacteria in urine) in their urine culture and Resident #16 was admitted to the hospital with sepsis(a serious condition that happens when the body's immune system has an extreme response to an infection) for UTI's. *The facility failed to provide employee in-services related to handwashing, peri-care, and/or catheter care. *The facility failed to ensure the agency staff were competent with peri-care, handwashing, and/or catheter *The IP failed to ensure the hospice services were following antibiotic stewardship. *Agency CNA A failed to perform hand hygiene and change her gloves while providing incontinent care to Resident #250. *Agency CNA B failed to perform hand hygiene and change her gloves while providing incontinent care to Resident #17. *CNA M failed to perform proper incontinent care for Resident #35. *CNA TT failed to perform proper incontinent care for Resident #9. An Immediate Jeopardy (IJ) situation was identified on [DATE]. While the IJ was removed on [DATE] at 6:47 p.m., the facility remained out of compliance at a severity level of actual harm with a scope of pattern due to the facility's need to evaluate the effectiveness of the corrective systems. These deficient practices could place residents at risk for infection and hospitalization . Findings included: 1.Record review of Resident #16's face sheet, dated [DATE] indicated Resident #16 was an [AGE] year-old female admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included Bipolar (a mental illness that causes unusual shifts in a person's mood, energy, activity levels, and concentration), dementia (the loss of cognitive functioning - thinking, remembering, and reasoning), and hypertension (high blood pressure). Record review of Resident #16's significant change in status MDS assessment, dated [DATE], indicated Resident #16 was understood and usually understood others. Resident #16's BIMs score was 01, which indicated she was cognitively severely impaired. Resident #16 required extensive assistance with toileting, personal hygiene, transfer, dressing, bed mobility, limited assistance with bathing, and set-up assistance with eating. The MDS indicated she had a UTI in the last 30 days. Record review of Resident #16's comprehensive care plan, dated [DATE] indicated Resident #16 had an ADL self-care performance deficit related to confusion, dementia, and fatigue. activity intolerance and limited mobility. The interventions of the care plan were for staff to provide assistance with toilet use. Record review of Resident #16's hospital records dated [DATE] revealed a diagnosis of UTI with sepsis (occurs when your body has a life-threatening response to an infection). During an interview on [DATE] at 9:19 a.m., RN Q said he had noticed Resident #16's urine with an odor and dark in color and increased agitation. He said he had obtained an order to collect a urine sample on [DATE]. He said Resident #16 had a severe UTI and ended up in the hospital. He said she was placed on hospice service when she returned from the hospital. Record review of the facility's [DATE] monthly infection control data log revealed 13 residents who had UTIs of which 7 who had E. coli. Residents #1, #3, #11, #13, #27 and #199. Resident #16 was sent to the hospital on [DATE] with sepsis. Record review of in-service dated [DATE] revealed infection control: handwashing must be performed prior to starting and when finished with any task with residents, e.g.: peri care. Record review of the facility's quality assessment and assurance process for UTIs dated [DATE] revealed a performance improvement process was put into place on [DATE] and no other updates were put in place until mentioned by the surveyor on [DATE]. During an interview on [DATE] at 10:43 a.m., the facility NP said he knew the facility had quite a few UTIs last month but was not aware of how many. He said he had 3 more today ([DATE]). He said he recalled the facility asking for a UA for Resident #16. He said he gave orders for an antibiotic but was waiting on the culture to ensure he had her on the proper antibiotics. He said but before he could get the culture results back Resident #16 was admitted to the hospital on the ICU floor with sepsis and encephalopathy. He said sepsis was caused by an infection in the body. The facility NP said he was not sure what the facility had in place to prevent UTIs but said hygiene, nutrition, good peri care, and hydration played an important part in preventing UTIs. During a phone interview on [DATE] at 1:53 p.m., the medical director said he was not aware of all the UTIs the facility had last month. He said the facility usually notified the NP because he made rounds and would update him as needed. He said he was aware Resident #16 was in the hospital for sepsis and other comorbidities. He said she expired this morning ([DATE]). He said when a person becomes septic it could become a life-threatening medical situation because of the infection in a person's body. During an interview on [DATE] at 12:16 p.m., the ADON (who was the IP) said when she identified the facility had an increase of UTIs back in [DATE], they started doing random peri-care checkoffs and hand washing. She said she did notice some decrease in the number of UTIs and felt her plan of action was effective. She said she tried to update the infection log daily but at least weekly. The ADON said she was supposed to have her infection report completed by the 11th of each month. She said she did notice last month ([DATE]) had an increase in UTIs. She said she had not implemented anything on paper but had started doing peri care, handwashing, and verbal communication with staff. She said she was responsible for ensuring staff was following the infection control policy. She said nurse management had started doing peri care and handwashing check-offs Monday through Friday and increasing hydration. The ADON indicated the Hospice providers provide the facility with the prescribed antibiotic orders and did not report them to her. The ADON said the hospice providers treated according to signs and symptoms and did not obtain laboratory analysis. She said part of her process as the infection preventionist was to review the UA results, look to see if they meet the Mcgeers criteria (used for retrospectively counting true infections, to meet the criteria for definitive infection, more diagnostic information (e.g., positive laboratory tests) is often necessary), and educate facility staff and hospice as needed. She said it was important to push fluids and perform good peri care and handwashing to prevent UTIs. During an interview on [DATE] at 1:40 p.m., the DON said sepsis was a serious condition. She said the ADON was responsible for the infection control system. She said the ADON updated the infection control log at least weekly, but they talked about the residents who were placed on the infection log daily. The DON said it was important to update the infection control log so they could track and trend residents who had infections. She said when they noticed a pattern, they would implement an intervention as a team. During an interview on [DATE] at 3:00 p.m., the ADON said she had been trained on the infection control process by the regional nurse which included a PowerPoint overview about infection and the process for infection control meeting and information needed to be done to prevent further infections. During an interview on [DATE] at 7:01 p.m., the administrator said he expected nurses to inform the physician of any UA results and for the physician to prescribe whatever medication was needed. He said the DON and IP nurse should ensure UTIs were monitored and treated. He said residents who had UTIs should have good nutrition, increased fluids, and good peri care provided. He said it was important to track and trend infections to get to the root cause of infections. He said he was aware a diagnosis of sepsis was dangerous and could be life-threatening. 46928 2. Record review of a face sheet dated [DATE] indicated Resident #250 was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses which included encephalopathy(brain disease, damage, or malfunction), type 2 diabetes mellitus (a chronic condition that affects the way the body processes blood sugar), and unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety (loss of memory, language, problem-solving and other thinking abilities that were severe enough to interfere with daily life). Record review of the baseline care plan dated [DATE] indicated Resident #250 required one person assistance with personal hygiene, toilet use, dressing, and bathing. Resident #250's baseline care plan indicated he was always incontinent of bowel and bladder. Record review of Resident #250's electronic health record on [DATE] indicated he did not have a completed MDS assessment. During an observation and interview on [DATE] starting at 3:50 PM, Agency CNA A put on gloves and cleaned Resident #250's front genital area. Agency CNA A did not perform hand hygiene prior to putting on gloves to begin providing resident care. After Agency CNA A cleaned Resident #250's front genital area, she turned him on his side, and wiped his buttocks clean because he had had a small bowel movement. Agency CNA A then applied the clean brief and fastened it. Agency CNA A did not change gloves or perform hand hygiene prior to applying the clean brief. Agency CNA A with the dirty gloves repositioned Resident #250 in his bed and covered him up. After this, Agency CNA A grabbed Resident #250's remote control with the dirty gloves and adjusted the bed for him. Agency CNA A removed her gloves and took the trash out of the room and disposed of it. Agency CNA A did not perform hand hygiene after removing her gloves. Agency CNA A said she did not perform hand hygiene prior to the start of care, after removing her gloves, and after providing care because she forgot about that part. Agency CNA A said it was important to perform hand hygiene before and after patient care and after removing her gloves to prevent the spread of germs. Agency CNA A said she had not been checked off on incontinent care. Agency CNA A said not changing her gloves could cause the spread of infection and lead to urinary tract infections with E. Coli. Agency CNA A said she was responsible for providing proper incontinent care and performing hand hygiene. was her first day at this facility. Agency CNA A said she was not a facility employee. Agency CNA A said she was agency staff and today. 3. Record review of a face sheet dated [DATE] indicated Resident #17 was a [AGE] year-old female initially admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses which included cellulitis of the left lower limb (bacterial infection of the skin to the left lower leg), type 2 diabetes mellitus without complications (a chronic condition that affects the way the body processes blood sugar), and malignant neoplasm of the endometrium (cancer that originated in the uterus). Record review of the care plan with the date initiated of [DATE] indicated Resident #17 had an ADL self-care performance deficit and required assistance of 1 staff for personal hygiene and assistance of 2 staff for toileting. Record review of the comprehensive MDS assessment dated [DATE], indicated Resident #17 was able to make herself understood and understood others. The MDS assessment indicated Resident #17 had a BIMS of 13, which indicated her cognition was intact. The MDS assessment indicated Resident #17 required extensive assistance with bed mobility, transfers, dressing, toilet use, and personal hygiene. During an observation and interview on [DATE] at 10:54 AM, Agency CNA B provided incontinent care to Resident #17. Agency CNA B did not wash her hands prior to providing incontinent care. Agency CNA B applied gloves and took off Resident #17's brief. Agency CNA B cleaned Resident #17's front genital area and turned Resident #17 on her side. Agency CNA B cleaned Resident #17's buttocks because she had a bowel movement and applied a clean brief. Agency CNA B did not change gloves or perform hand hygiene prior to applying the clean brief on Resident #17. Agency CNA B applied barrier cream to Resident #17's buttocks with her dirty gloves. Agency CNA B took off her gloves and put on new gloves. Agency CNA B did not perform hand hygiene prior to putting on the new gloves. Agency CNA B finished fastening Resident #17's brief. Agency CNA B took off her gloves and washed her hands. Agency CNA B said she did not perform hand hygiene prior to the start of care and in between glove changes because she was nervous. Agency CNA B said she should have changed gloves and performed hand hygiene prior to applying the clean brief. Agency CNA B said she did not do it because she was nervous and forgot. Agency CNA B said it was important to perform hand hygiene while providing incontinent care and to change gloves to prevention cross-contamination. Agency CNA B said she was checked off on incontinent care that morning by the Staffing Coordinator. Agency CNA B said she was agency staff not a facility employee. During an interview on [DATE] at 12:13 PM, the ADON said she expected incontinent care to be done correctly. The ADON said she expected the CNAs to perform hand hygiene before and after providing incontinent care, to change their gloves when going from dirty to clean, and in between glove changes. The ADON said not performing incontinent care correctly or hand hygiene could lead the resident to obtain a urinary tract infection and E. coli (bacteria commonly found in stool). The ADON said everyone was responsible for ensuring incontinent care was being performed correctly. During an interview on [DATE] at 01:37 PM, the DON said she expected incontinent care to be performed as per policy. The DON said she expected the CNAs to perform hand hygiene before and after providing incontinent care, to change their gloves when going from dirty to clean, and in between glove changes. The DON said not performing incontinent care correctly could lead to infection control issues. During an interview on [DATE] at 06:51 PM, the Administrator said he expected the clinical department to follow their policy when providing incontinent care. The Administrator said he expected the CNAs to perform hand hygiene before and after incontinent care and change their gloves after going from dirty to clean if that was what the policy indicated. The Administrator said he presumed infection could happen if improper incontinent care or hand hygiene were performed. 33249 4. Record review of a face sheet dated [DATE] indicated Resident #9 was an [AGE] year-old female who was admitted on [DATE] and readmitted on [DATE] with the diagnoses of high blood pressure and anxiety. Record review of an MDS dated [DATE] indicated Resident #9. The MDS was not scored for the BIMS score. The MDS indicated Resident #9 required extensive assistance for toileting and personal hygiene. Record review of the comprehensive care plan dated [DATE] and revised on [DATE] indicated Resident #9 was incontinent of bowel and bladder. The goal was Resident #9's risk for septicemia was minimized via prompt recognition and treatment of symptoms of a UTI. The interventions included clean peri-area with each incontinence episode, and monitor/document for s/sx UTI. During an observation and interview on [DATE] at 10:44 a.m., CNA TT and CNA M both washed their hands prior to care. The brief was removed downward. CNA M wiped one wipe on the left side and one wipe on the right side and one wipe down the middle of Resident #9's perineal area. CNA M did not cleanse the labia majora and labia minora. Resident # 9 was rolled to the right and she was cleansed on the buttocks three times wiping toward the perineal area instead of away. CNA M said she had wiped Resident #9 the wrong direction, wiping towards the perineal area. CNA M said she did not open Resident #9's labias to cleanse them. CNA M said not cleansing the labias and not wiping in the wrong direction could cause infections. Record review of an undated CNA Profieciency Check Off Perineal Care indicated CNA TT was proficient in the skill of incontinent care. During an interview on [DATE] at 12:15 p.m., the ADON said she had done random check offs for pericare. The ADON said pericare should be done properly by wiping the resident from front to back only. The ADON said she checked the CNAs off on pericare using a manikin as well on residents. The ADON said pericare should be done properly in order to prevent infections. The ADON said she had not provided written in-services for handwashing and incontinent care. During the interview the ADON was asked to provide the skills check off for CNA M but one was not provided. During an interview on [DATE] at 1:40 p.m., the DON she expected incontinent care to be performed according to the check offs. The DON said the check offs had every step to ensure the task was completed correctly. The DON said she expected the incontinent care to be performed from front to back and to open the labia for cleansing. During an interview on [DATE] at 6:51 p.m., the Administrator said he expected the clinical department to follow the policy and procedures related to incontinent care. The Administrator said expected CNAs to change gloves to ensure universal precautions were met. The Administrator said the DON was responsible for ensuring incontinent care was performed correctly 5. Record review of a face sheet dated [DATE] indicated Resident #35 was an [AGE] year-old female who admitted on [DATE] with the diagnoses of diabetes, and high blood pressure. Record review of an Annual MDS indicated Resident #35 understands and was understood. The MDS indicated Resident #35 had a BIMS score of 15 indicated her cognition was intact and had no memory problems. The MDS indicated Resident #35 required extensive assistance of two staff with toileting, and extensive assistance of one staff for personal hygiene. Record review of the comprehensive care plan dated [DATE] indicated Resident #35 required assistance with her ADLs. The MDS indicated Resident #35 required 1 staff assistance with personal hygiene. During an observation and interview on [DATE] at 10:56 a.m., CNA M washed her hands prior to beginning care. CNA TT washed her hands. CNA TT opened Resident #35's brief and rolled the brief down. CNA TT wiped down once on the left side and once down the right side and once down the middle. CNA TT failed to open the labias majora and cleanse the labias minora. CNA TT assisted Resident #35 to roll to the right. CNA TT then wiped the buttocks three times from front to back using a different wipe for each cleaning wipe. CNA TT said she failed to properly cleanse the labia areas. CNA TT said not cleaning the labias well could cause infections. Record review of the facility's policy titled, Handwashing/Hand Hygiene, revised [DATE], indicated, This facility considers hand hygiene the primary means to prevent the spread of infections . 2. All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors . 7. Use an alcohol-based hand rub containing at least 62% alcohol; or, alternatively, soap (antimicrobial or non-antimicrobial) and water for the following situations: a. Before and after coming on duty; b. Before and after direct contact with residents . d. Before performing any non-surgical invasive procedures; e. Before and after handling an invasive device (e.g., urinary catheters, IV access sites) . h. Before moving from a contaminated body site to a clean body site during resident care; i. After contact with a resident's intact skin; j. After contact with blood or bodily fluids . m. After removing gloves . The use of gloves does not replace hand washing/hand hygiene. Integration of glove use along with routine hand hygiene is recognized as the best practice for preventing healthcare-associated infections Record review of a Perineal Care policy and procedure dated February 2018 indicated the purpose of this procedure was to provide cleanliness and comfort to the reisdent, to prevent infections and skin irraitiation, and to observe the resident's skin condition. Steps in the Procedure 8. a. Wet washcloth and apply soap or skin cleansing agent. b. Wash perineal area, wiping from front to back. 1. Seperate the labia and wash downward from front to back. (if the rsidnet has an indewelling catheter, gently wash the juncture of the buting from the urethra down the catheter about 3 inches. Gently rinse and dry the area). c. Ask the residen to turn on hers [NAME] with her top leg slightly bent, if able. d. Rinse the wash cloth and apply soap or skin cleansing agent. e. Wash the rctal area thoroughly, wiping from the base of the labia towards and extending over the buttocks. f. Rinse and dry thoroughly. 10 Remove gloves and discared into designated container. The policy does not mention any other glove changes. Record review of facility policy, Infection Control dated [DATE], indicated The infection prevention and control program is a facility-wide effort involving all disciplines and individuals and is an integral part of the quality assurance and performance improvement program. 2. The elements of the infection prevention and control program consist of coordination/oversight, policies/procedures, surveillance, data analysis, antibiotic stewardship, outbreak management, prevention of infection, and employee health and safety. 1.Coordination and Oversight a. The infection prevention and control program is coordinated and overseen by an infection prevention specialist (infection preventionist). c. The infection prevention and control committee is responsible for reviewing and providing feedback on the overall program. Surveillance data and reporting information is used to inform the committee of potential issues and trends. Some examples of committee reviews may include: (2) whether antibiotic usage patterns need to be changed because of the development of resistant strains. (3) whether information about culture results or antibiotic resistance is transmitted accurately and in a timely fashion; and (4) whether there is appropriate follow-up of acute infections. d. The committee meets regularly, at least quarterly, and consists of team members from across disci plines, including the Medical Director. 5. Data Analysis a. Data gathered during surveillance is used to oversee infections and spot trends. b. One method of data analysis is by manually calculating the number of infections per 1000 resident days as follows: ( I) The infection preventionist collects data from the nursing units, and categorizes each infection by body (2)To adjust for differences in bed capacity or occupancy on each unit, and to provide a uniform basis for comparison, infection rates can be calculated as the number of infections per I 000 patient days(a patient day refers to one patient in one bed for one day), both for each unit and for the entire facility; (3) Monthly rates can then be plotted graphically or otherwise compared side-by-side to allow for trend comparison; and 7. Prevention of Infection a. Important facets of infection prevention include: (I) identifying possible infections or potential complications of existing infections; (2) instituting measures to avoid complications or dissemination. (3) educating staff and ensuring that they adhere to proper techniques and procedures. (4) enhancing screening for possible significant pathogens. On [DATE] at 2:14 p.m. the Administrator was notified an Immediate Jeopardy (IJ) situation was identified due to the above failures. The Administrator was provided with the IJ template on [DATE] at 2:24 a.m. and requested a Plan of Removal (POR). The Plan of Removal (POR) was accepted on [DATE] at 4:20 p.m. and indicated the following: Immediate action: The facility failed to provide employee in-services related to handwashing, peri-care, and/or catheter. 1. DON to conduct 1:1 in-service and skills validation with CNA-A. Completion Date: [DATE]. 2. Nursing administration (DON, ADON) to conduct in-service and competency checkoff with all direct care staff and agency staff currently working in building on re: handwashing, peri-care and catheter care starting [DATE] and Complete Date; [DATE]. 3. Agency staff will have skills competency completed prior to start of next shift start on [DATE] and ongoing due to potential for different agency staff scheduled. 4. Nursing administration (DON) & Dir. of Resident Care Services & Education (regional RN) to provide power point training Incontinent Care Without Contamination to include how to perform step by step with pictures (male & female) and checklist on performing incontinent care to staffing agency to provide to agency staff and facility to provide power point training at Nurses station to review prior to start of shift for any future agency assigned to provide care within the facility. Completion Date: [DATE] 5. Dir. of Resident Care Services & Education (Regional RN) to complete in-service with Hospice Agency Lead RN re: antibiotic stewardship and partnering with facility on ABT Stewardship. Completion Date: [DATE]. 6. Dir. of Resident Care Services & Education (Regional RN) reviewed current residents with active UTI (3), E.H.R. orders were reviewed for treatment interventions and Care plans and POC tasks updated by Regional MDS nurse for interventions to reduce potential for re-occurrence. Any of residents listed in August of the (13) and Sept. (3) with completion of ABT's will be reviewed as well for treatment interventions and Care plans and POC tasks updated. Ongoing monitoring of other residents to occur in weekly clinical review meeting DON, MDS Nurse and ADON has with Dir. of Resident Care Services & Education (Regional RN). Completion Date: [DATE] On [DATE]the surveyors confirmed the facility implemented their plan of removal sufficiently to remove the IJ by: Interviews on [DATE] from 4:20 p.m. to 6:40 p.m., on all three shifts (2p-10p, 6a-2p, & 2p-10p) with the administrator, DON, ADON, LVN O, LVN U, MA C, CNA U, CNA X, CNA Y, and CNA W revealed they had completed in-services on hand washing, peri-care with or without a catheter, and Hoyer lift. Staff were able to verbally explain how they should wash their hands, how to perform proper peri care, and how to safely transfer a resident who requires a Hoyer lift for transfers. Record review of CNA A one-on-one in-service and skills validation for proper peri care dated [DATE]. Record review of in-service dated [DATE] on handwashing, peri care, and catheter care. Record review of the orientation document dated [DATE] over hand washing, peri-care with or without a catheter, and Hoyer lift was signed by 4 (CNA U, CNA X, CNA Y, and CNA W) agency staff on duty on [DATE] during the 2p-10p shift. Record review of a updated PowerPoint on hand washing, peri care, incontinent care without contamination, skin care, and peri care on males and females with or without catheters signed by (7) ,d+[DATE] staff/agency on [DATE]. (LVN O and LVN U (2p-10p),1 MA: MAC (6a-2p), 4 CNAs CNAU, CNAX, CNAY, and CNAW). Record review of an in-service dated [DATE] related to antibiotic stewardship policy, Mcgeers criteria, antibiotic prescribing, infection control policy and procedure , and interventions to initiate when trending was identified was signed by hospice RN Z. Record review of in-service dated [DATE] given by the corporate nurse via Microsoft Teams or verbally was signed by the DON, ADON, MDS, RN Q, RN R, RN CC, RN D, LVN F, LVN BB, LVN O, LVN U, and LVN N related to antibiotic stewardship policy, Mcgeers criteria, antibiotic prescribing, infection control policy and procedure, and interventions to initiate when trending was identified. During a phone interview on [DATE] at 6:18 p.m., the corporate nurse said did an education with the DON/nurse managers and hospice this morning via TEAMS. She said the first part of the in-service was ABT stewardship, tracking and trending education, a new map and how to color code so they can see issues more easily, monitoring the infection control log daily, weekly and monthly, and looking to see if they meet McGeer's criteria, education on what kind of things they would do for trends, such as check-offs on hand hygiene and peri care and explained to hospice nurses about assessing signs and symptoms. She said the 2nd part involved the DON, infection preventionist, and nursing and it included glove changes, male and female care, with or without a catheter and procedure of incontinent care. She said the facility should have copies of everything she went over. The cooperate RN said the contracted agencies were aware of their expectations. On [DATE] at 6:47 p.m., the Administrator was informed the IJ was removed; however, the facility remained out of compliance at a severity level of actual harm that was not in immediate jeopardy with a scope identified as pattern due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems.

Based on observation, interview and record review, the facility failed to provide pain management consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for 1 of 5 residents (Resident #3) reviewed for pain management. The facility did not develop and implement interventions to manage pain for Resident #3. The resident was not assessed and the physician was not notified when Resident #3 yelled out in pain when care was provided. Staff reported the resident had been expressing pain during care for the past 2 months. The resident did not receive medications as ordered for pain and there was no care plan for the pain. This failure could place residents at risk of not receiving necessary pain, discomfort and decreased quality of life. Findings include: Review of Resident #3's admission record (face sheet) revealed he was a [AGE] year-old male who was admitted into the facility on [DATE]. Review of Resident #3's MDS dated [DATE] revealed his cognitive skills for daily decision making was severely impaired, he did not reject care, he required extensive assistance of 2 person physical assist for bed mobility, transfers, dressing toileting and personal hygiene and that he was totally dependent for bathing. The MDS also revealed Resident #3 did not receive scheduled pain medication regimen, he had not received as needed medication or was offered and declined, he did not receive non-medical intervention for pain, and it revealed there was no pain present for Resident #3. Review of Resident #3's care plan with a completed date of 8/11/2021 revealed there was no care plan for pain. Review of Resident #3's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Additional orders were as follows: -There was an order dated 10/14/2021 cleans the wound of the sacrum with normal saline, pat dry and apply Santyl ointment and calcium alginate and a dressing daily. -There was an order date of 5/12/2021 for [MEDICATION(S)] 50 mg every 6 hours as needed for moderate and severe pain. There was an order to monitor pain every shift and if pain was noted it was to be charted in the nursing notes along with the interventions and treatments used and the effectiveness of it. There was no current order for Resident #3 to be administered Tylenol or [MEDICATION(S)]. Review of Resident #3's Nursing MAR dated September 1, 2021 - September 30, 2021 and Nursing MAR dated October 1, 2021 - October 31, 2021 revealed no order for Tylenol or [MEDICATION(S)]. The only medication listed on the Nursing MARs for pain was [MEDICATION(S)] 50 mg every 6 hours as needed for moderate and severe pain. There was no documentation that [MEDICATION(S)] was administered to Resident #3 from 9/1/2021 - 10/20/2021. The Nursing MAR revealed a section to monitor and assess Resident #3 for pain every shift and the pain level documented from 9/1/2021 - 10/20/2021 was 0. Review of Resident #3's Progress Notes for September 2021 and October 2021 revealed no documentation that the resident experienced, verbalized or exhibited pain. During observation on 10/19/2021 at 11:50 a.m., CNA A and CNA B provided incontinent care to Resident #3. CNA B lowered the head of the resident's bed and when he started reclining backwards Resident #3 yelled out Oh, you are hurting me, you are hurting me. CNA B replied Sorry, sorry we know, we know and they continued providing incontinent care and repositioning the resident. When CNA A and CNA B turned the resident onto his right side and he yelled Oh, oh, oh out loud and CNA B replied, You would think we were killing him. During incontinent care they rolled Resident #3 from left to right to apply the adult brief and when they rolled the resident from left to right he was moaning and groaning and he yelling out Oh, Oh, Oh and CNA B replied It's ok, I got you to Resident #3. During an interview on 10/19/2021 at 11:55 a.m., CNA B said Resident #3 would moan, groan and complain of pain every time they turned and repositioned him and every time, they provided him care. She stated that when Resident #3 would moan and groan and complain of pain during care they would just continue with care and try to talk him through it. CNA B stated that they would notify the nurses that Resident #3 complained of pain during care, but they were unsure what was done after they reported it. On 10/19/2021 at 2:10 p.m., an attempt was made to interview Resident #3, but due to his cognitive status he was unable to be interviewed. During observation on 10/19/2021 at 1:59 p.m., LVN D performed wound care to Resident #3's sacrum wound and ADON C assisted her. LVN D lowered the head of the bed and Resident #3 yelled out It hurt, it hurt and LVN D responded to him and said ok but she continued lowering the bed and did not stop. ADON C rolled the resident onto his left side and he moaned and groaned when she rolled him and ADON C's response to him was I know, I know and the resident then said, you keep on hurting me. ADON C and LVN D continued with treating the residents wound to his sacrum. ADON C turned Resident #3 over more onto his left side so that LVN D could apply the dressing to his sacrum and Resident# 3 moaned and groin from pain. ADON C's reply to Resident #3 at that time was I know, I know, but they continued providing care to the resident. Once the wound care was complete they repositioned the resident onto his back ADON C and LVN D opened the residents legs and placed a pillow between the residents legs and the resident yelled out that hurts and ADON C replied I am sorry. During an interview on 10/19/2021 at 2:05 p.m., ADON C said Resident #3 has been moaning, groaning and complaining of pain when care was provided to him since she started at the facility on August 15, 2021. She said she did not believe Resident #3 was in pain and she believed that it was more of a behavioral response. ADON C said in order to assess and identify pain they look for moaning, groaning, facial grimacing and actual complaint of pain and since Resident #3 expressed moaning and groaning and complained of pain then they should have stopped providing care and medicated and assessed him. She said they are so used to Resident #3 moaning and groaning and complaining of pain that they fail to stop, assess and medicate, and they just continue with providing the care. ADON C stated, that during care last week he was telling the staff to just let him die. She said the resident had an order for [MEDICAL RECORD OR PHYSICIAN ORDER] #3 Tylenol and [MEDICATION(S)] instead of the [MEDICATION(S)] because he did not think the [MEDICATION(S)] worked as well as the Tylenol and [MEDICATION(S)]. She said she had not consulted or notified the physician or nurse practitioner regarding Resident 3's pain. ADON C also stated that she thought that LVN D had premedicated Resident #3 with pain medication prior to wound care. During an interview on 10/19/2021 at 2:15 p.m., LVN D said that she has observed and was told that Resident #3 would moan and groan and yell out anytime he's touched. She denied medicating the resident for pain and she said she had not consulted with the physician or the nurse practitioner regarding resident #3 moaning, groaning or complaint of pain during care. During a telephone interview on 10/19/2021 at 3:43 p.m., LVN E said that she worked double weekends at the facility every weekend and during those times she was the nurse that cared for Resident #3. She stated that every time they moved Resident #3 or provided care to him, he would complain of pain, he would tell them that they were hurting him, and he would ask them to leave him alone. She stated that she spoke with the resident's family member last weekend about him moaning, groaning and complaining of pain when care was provided, and the family member told her to medicate the resident with [MEDICATION(S)] and Tylenol. She said she medicated the resident with the Tylenol and [MEDICATION(S)] as the family member requested. She stated the Tylenol and [MEDICATION(S)] was not effective with controlling Resident #3's pain because he would still yell out in pain when his legs were moved. She denied consulting with the physician or the nurse practitioner regarding Resident #3's pain. During an interview on 10/20/2021 at 11:15 a.m., DON said Resident #3's family member was very involved in his care and she denied the facility speaking with the family member regarding pain management for the resident. She said due to Resident #3's cognitive status the nurses and staff should rely on his verbal and body expressions to assess and determine his pain. She denied knowing that Resident #3 exhibited pain during care and that it was not treated. She stated that if Resident #3 was moaning and groaning and verbally complaining of pain during care then the staff should have stopped care and the resident should have been assessed and medicated. The DON reviewed the Nursing MAR and physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . DON also verified that there was no order for Tylenol or [MEDICATION(S)] and the nursing staff administered the Tylenol and [MEDICATION(S)] to the resident without an order. She stated that it was the nurse's responsibility to assess Resident #3's pain, document any interventions that were done to relieve the pain, and to consult with the physician regarding his pain and to obtain an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . She stated the process for MD notification was that the nurses would contact the nurse practitioner first and if he was unavailable the nurses were supposed to contact the medical director. During a telephone interview on 10/20/2021 at 12:50 p.m., Resident #3's family member said last month he observed his father lying in bed grimacing and he looked uncomfortable. He said at times when he was at the facility and his father complained of a headache, he complained of knee pain and other times he noticed his father looked uncomfortable. He said on occasions he would assist the staff with moving his father up in bed and during that time his father would moan and groan. He said each time he observed his father be in pain he asked the nurse to medicate his father with Tylenol and [MEDICATION(S)]. He said he was aware that his father had [MEDICATION(S)] ordered as needed for pain, but he did not think the [MEDICATION(S)] would be effective for pain. He said he was very involved in his father's care and he denied the facility consulting with him regarding pain management for his father. He stated that he thought routine pain management would be a good idea; however, he wanted the routine pain management to be [MEDICATION(S)] and Tylenol with [MEDICATION(S)] as needed. During an interview on 10/20/2021 at 1:19 p.m., CNA B said that Resident #3 started complaining of pain during care last month. She stated that she would inform the nurse on duty that the resident complained of pain, but she was unsure what was done after she reported it. During an interview on 10/20/2021 at 1:50 p.m., LVN F stated that she was MDS and care plan nurse. She stated that on 10/13/2021, she worked as medication nurse in the facility and Resident #3's family member came to her and reported that the resident was in pain and the family member requested she medicate the resident with [MEDICATION(S)] and Tylenol. She said she medicated the resident as requested. She reviewed the October physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . She stated that she must have failed at looking at the order and since she's friends with the family member, she just took his word regarding the resident having an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . She confirmed no pain assessment or medication administration for pain was documented when he exhibited pain. She also verified there was no care plan for the pain. LVN F also stated that she believed that Resident #3's moaning, groaning and complaint of pain is more of a behavioral problem other than him experiencing actual pain. During an interview and record review on 10/20/2021 at 2:12 p.m., the DON stated that the facility did not have standing orders for medications for residents in general population. She reviewed Resident #3's physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . She stated that no medication should be administered without a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . During a telephone interview on 10/22/2021 at 9:05 a.m., nurse practitioner said he went to the facility on ce a week on Thursdays and he denied the staff consulting with him regarding Resident #3 moaning, groaning or complaints of pain during care. Record Review of facilities Pain policy with a revision date of March 2018 revealed the following: - 1. The physician and staff will identify individuals who have pain or who are at risk for having pain. - 2. The nursing staff will assess each individual for pain upon admission to the facility, at the quarterly review, whenever there is a significant change in condition, and when there is onset of new or worsening of existing pain. - 3. The staff and physician will identify the characteristics of pain such as location, intensity, frequency, pattern and severity - 4. The nursing staff will identify any situations or interventions where an increase in the residents' pain may be anticipated; for example, wound care, ambulation, or repositioning Record review of the facilities Administering Medications policy with a revision date of April 2019 revealed . medications are administered in accordance with prescriber orders.