Every finding on record at Lakeside Health & Rehabilitation

Based on resident/staff interview, facility document review and clinical record review, it was determined that the facility staff failed to maintain a safe/functional, comfortable environment for three of nine residents, Resident #2, #6 and #9. The findings include: 1.The facility staff failed to ensure a safe, comfortable temperature and functional equipment for Resident #2. Observations on the 100-200 hall found staff going to another resident hall (300-400) to obtain mechanical lift. A review of the facility's pest control logs revealed, April 2024-38 German cockroaches, May 2024-16 German cockroaches, June 3, 2024-88 German cockroaches, 6/18/24-46 German cockroaches and 7/24/24-51 German cockroaches. Resident #2 was admitted to the facility on [DATE] with diagnosis that included but were not limited to: cerebral vascular infarction, seizures, hypertension and obstructive uropathy. The most recent MDS (minimum data set) assessment, a quarterly assessment, with an ARD (assessment reference date) of 7/19/24, coded the resident as scoring a 08 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was moderately cognitively impaired. A review of the MDS Section G-functional status coded the resident as being dependent for bed mobility, transfer, dressing, bathing and hygiene; supervision for eating. A review of the comprehensive care plan with a revision date of 3/22/23, revealed, FOCUS: Resident has an ADL (activities of daily living) self-care performance deficit. INTERVENTIONS: The resident requires Mechanical Lift with 2 staff assistance for transfers. Physical assist as needed with ADL every shift. An interview was conducted on 7/30/24 at 9:45 AM with LPN (licensed practical nurse) #1. When asked about the temperature in Resident #2's room (room [ROOM NUMBER]), LPN #1 stated, it is hot in here. The air conditioning is not on. When asked if the window should be raised about 2 inches, LPN #1 stated, no, let me close it. LPN #1 unable to close the window. ASM #2, the director of nursing entered the room and assisted LPN #1 to close the window, one of them on each side of the window. ASM #2 stated, let me turn on the AC. AC was not providing cool air, ASM #2 stated, it may take a while to cool off. On 7/30/24 at 2:24 PM, went back to room [ROOM NUMBER], room was still warm with AC running highest setting. LPN #1 was asked about the room temperature, LPN #1 stated, it is warm in here. An interview was conducted on 7/30/24 at 3:45 PM with CNA (certified nursing assistant) #1, when asked about Resident #2, CNA #1 stated, his AC (air conditioning). it was not working then it was working. He would get agitated about it. There are roaches, in the facility, but we have a pest control company that comes in monthly I believe. The mechanical lift on our unit does not work so we need to borrow one from another unit. An interview was conducted on 7/31/24 at 3:00 PM with CNA #6. When asked about functioning of mechanical lifts, CNA #6 stated, we have to borrow from another unit and it sometimes delays our ability to get the residents up in a timely manner. On 8/1/24 at 10:00 AM, ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing and ASM #6, the regional director of clinical operations was made aware of the concerns. No further information was provided prior to exit. 2.The facility staff failed to ensure a safe, comfortable temperature and functional equipment for Resident #6. Observations on the 100-200 hall found staff going to another resident hall (300-400) to obtain mechanical lift. A review of the facility's pest control logs revealed, April 2024-38 German cockroaches, May 2024-16 German cockroaches, June 3, 2024-88 German cockroaches, 6/18/24-46 German cockroaches and 7/24/24-51 German cockroaches. Resident #6 was admitted to the facility on [DATE] with diagnosis that included but were not limited to: ASCVD (atherosclerotic cardiovascular disease), DM (diabetes mellitus) and RBKA (right below the knee amputation). The most recent MDS (minimum data set) assessment, a quarterly assessment, with an ARD (assessment reference date) of 6/6/24, coded the resident as scoring a 15 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was not cognitively impaired. A review of the MDS Section G-functional status coded the resident as being dependent for bed mobility, transfer, dressing, bathing and hygiene; supervision for eating. A review of the comprehensive care plan with a revision date of 9/5/23, revealed, FOCUS: Resident has an ADL (activities of daily living) self-care performance deficit related to weakness and BKA. INTERVENTIONS: The resident will be lifted and transferred with a (Hoyer mechanical lift). Staff will follow facility policy of two staff to use mechanical lifts at all times. An interview was conducted on 7/30/24 at approximately 12:00 PM with OSM (other staff member) #2, the maintenance director. When asked about the leaking ceiling, OSM #2 stated, it has been like that for a few days. I need someone with an electrical background to come in, because of all the electrical wires, you cannot go up there to fix a leak with all those wires like that. When asked if this facility is providing a safe, comfortable environment, OSM #2 stated, no. An interview was conducted on 7/30/24 at 3:45 PM with CNA (certified nursing assistant) #1, when asked about Resident #2, CNA #1 stated, his AC (air conditioning). it was not working then it was working. He would get agitated about it. There are roaches, in the facility, but we have a pest control company that comes in monthly I believe. The mechanical lift on our unit does not work so we need to borrow one from another unit. An interview was conducted on 7/31/24 at 9:00 AM with Resident #6. When asked about her concerns, Resident #6 stated, there are roaches, the ceiling tiles are out and there is a drip into a large garbage can, it has been like that for several days. We are not being got up in a time, not because of the staff but because they have to borrow the lift from another unit. An interview was conducted on 7/31/24 at 3:00 PM with CNA #6. When asked about functioning of mechanical lifts, CNA #6 stated, we have to borrow from another unit and it sometimes delays our ability to get the residents up in a timely manner. On 8/1/24 at 10:00 AM, ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing and ASM #6, the regional director of clinical operations was made aware of the concerns. No further information was provided prior to exit. 3.The facility staff failed to ensure a safe, comfortable temperature and functional equipment for Resident #9. Observations on the 100-200 hall found staff going to another resident hall (300-400) to obtain mechanical lift. A review of the facility's pest control logs revealed, April 2024-38 German cockroaches, May 2024-16 German cockroaches, June 3, 2024-88 German cockroaches, 6/18/24-46 German cockroaches and 7/24/24-51 German cockroaches. Resident #9 was admitted to the facility on [DATE] with diagnosis that included but were not limited to: quadriplegia, diabetes mellitus and morbid obesity. The most recent MDS (minimum data set) assessment, a quarterly assessment, with an ARD (assessment reference date) of 5/29/24, coded the resident as scoring a 15 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was not cognitively impaired. A review of the MDS Section G-functional status coded the resident as being dependent for bed mobility, transfer, dressing, bathing and hygiene; independent for eating. A review of the comprehensive care plan with a revision date of 12/6/23, revealed, FOCUS: Resident has limited physical mobility related to Neurological deficits, cervical disc disorder, quadriplegia, spondylosis and generalized muscle weakness. INTERVENTIONS: The resident requires a slid board for transfers to and from wheelchair to bed and may use mechanical devices as needed for transfers. The resident may use slid board for transfers and sit to stand as needed. An interview was conducted on 7/30/24 at approximately 12:00 PM with OSM (other staff member) #2, the maintenance director. When asked about the leaking ceiling, OSM #2 stated, it has been like that for a few days. I need someone with an electrical background to come in, because of all the electrical wires, you cannot go up there to fix a leak with all those wires like that. When asked if this facility is providing a safe, comfortable environment, OSM #2 stated, no. An interview was conducted on 7/30/24 at 3:45 PM with CNA (certified nursing assistant) #1, when asked about Resident #2, CNA #1 stated, his AC (air conditioning). it was not working then it was working. He would get agitated about it. There are roaches, in the facility, but we have a pest control company that comes in monthly I believe. The mechanical lift on our unit does not work so we need to borrow one from another unit. An interview was conducted on 7/31/24 at 3:00 PM with CNA #6. When asked about functioning of mechanical lifts, CNA #6 stated, we have to borrow from another unit and it sometimes delays our ability to get the residents up in a timely manner. An interview was conducted on 8/1/24 at 7:45 AM with Resident #9. When asked about her concerns, Resident #9 stated, there is a leak in the hallway from the ceiling for days, last week when we had that thunderstorm, the facility flooded. Roaches are everywhere. I use either the sit to stand to get out of bed or the mechanical lift. The staff have to go to another unit to get the equipment to get me up. Sometimes I am not able to get out of bed because the equipment has to be borrowed. On 8/1/24 at 10:00 AM, ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing and ASM #6, the regional director of clinical operations was made aware of the concerns. No further information was provided prior to exit.

Based on review of facility's documentation and staff interview, it was determined that the facility failed to allow the resident to make decisions regarding his treatment for one of nine residents, Resident #1. The findings included: Resident #1 was admitted to the facility on [DATE] with diagnosis that included but were not limited to: CHF (congestive heart failure), DM (diabetes mellitus), CAD (cardiovascular disease) and CVA (cerebrovascular accident). The most recent MDS (minimum data set) assessment, an annual assessment, with an ARD (assessment reference date) of 6/7/24, coded the resident as scoring a 15 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was cognitively intact. A review of the MDS Section G-functional status coded the resident as requiring total dependence for transfer, bathing, bed mobility, dressing, hygiene and supervision for eating. A review of the comprehensive care plan dated 11/16/21 revealed, FOCUS: Cardiac disease related to DM, CAD, Presence of cardiac pacemaker, CHF and A flutter. INTERVENTIONS: Obtain vital signs as indicated; report changes to physician. Administer medication per physician orders. Administer oxygen as ordered. A review of the progress note dated 7/7/24 at 5:36 PM revealed, [AGE] year-old male resident seen at the request of nursing. Requesting to go to ER for shortness of breath. A review of the progress note dated 7/7/24 at 6:47 PM revealed, resident complained of (c/o) SOB. resident assessed. congestion noted. resident c/o fluid in chest. NP is aware. NP [NAME] recommended Chest Xray for SOB. Albuterol 3mL BID x7days. CBC, BMP for 7.8.2024. Lasix 40mg one time dose for fluid retention. resident alert and verbal. Vitals stable. A review of the progress note dated 7/7/24 at 6:47 PM revealed, Writer contacted third eye (physician tele-health after hours service). give clearance to send resident to ER. Writer contact NP about COC (change of condition) and transfer to ED. NP stated to treat in house. A review of the progress note dated 7/8/24 at 6:18 AM revealed, Resident continued to complain of congestion this shift. VS BP 167/95, 77, 18, 97.6, 99% on O2 Q 3LPM. He refused lab work this morning and Per RP, she called 911 and patient was taken to the hospital. NP aware. An interview was conducted on 7/30/24 at 2:05 PM with LPN (licensed practical nurse) #6. When asked about Resident #1, LPN #6 stated, the CNA brought to my attention that he was not feeling well, feel like he had fluid and sounded congested. I did a respiratory assessment. I called the telehealth service, took the tablet to the resident and telehealth, who ordered resident to be sent to the ED. There is a note at nurse's station: which reveals If Third Eye (telehealth) orders resident sent out, this needs to be approved by either NP or Medical Director. I called NP who asked how he was sounding and stated we are going to treat him in house. I gave him Lasix, breathing treatment, Chest x-ray ordered, CBC and CMP. I let the resident know what the NP said. I let the oncoming nurse know. My shift ends at 11:00 PM. I entered all the orders into computer. An interview was conducted on 7/31/24 at 10:35 AM with LPN #4, the unit manager. When asked if the resident requests to go to the hospital what happens, LPN #4 stated, we inform the NP and/or physician and then send the resident out to the hospital. When asked why the resident is sent out, LPN #4 stated, because it is their right. An interview was conducted on 7/31/24 at 2:38 PM with ASM (Administrative staff member) #4, the nurse practitioner (NP). When asked about residents asking to go out to the hospital, ASM #4 stated, so if they request to go to the hospital, we assess them, depending on severity see if we can manage in house. If the resident still wants to go out, they go out. We do not stop them. I believe the protocol is to notify the attending and he makes the decision. An interview was conducted on 8/1/24 at 9:35 AM with ASM #7, the medical director. When asked about residents requesting to go to the hospital, ASM #7 stated, the staff are to contact us before sending a resident out. I do not hold them against their will. It is their right to go out. I do not review every single case. On 8/1/24 at 10:00 AM, ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing and ASM #6, the regional director of clinical operations was made aware of the concerns. No further information was provided prior to exit.

Based on resident/staff interview, facility document review and clinical record review, it was determined that the facility staff failed to maintain a clean and homelike environment for three of nine residents, Resident #2, #6 and #9. The findings include: 1.The facility staff failed to ensure a safe, comfortable temperature and functional equipment for Resident #2. Observations on the 100-200 hall found staff going to another resident hall (300-400) to obtain mechanical lift. A review of the facility's pest control logs revealed, April 2024-38 German cockroaches, May 2024-16 German cockroaches, June 3, 2024-88 German cockroaches, 6/18/24-46 German cockroaches and 7/24/24-51 German cockroaches. Resident #2 was admitted to the facility on [DATE] with diagnosis that included but were not limited to: cerebral vascular infarction, seizures, hypertension and obstructive uropathy. The most recent MDS (minimum data set) assessment, a quarterly assessment, with an ARD (assessment reference date) of 7/19/24, coded the resident as scoring a 08 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was moderately cognitively impaired. A review of the MDS Section G-functional status coded the resident as being dependent for bed mobility, transfer, dressing, bathing and hygiene; supervision for eating. A review of the comprehensive care plan with a revision date of 3/22/23, revealed, FOCUS: Resident has an ADL (activities of daily living) self-care performance deficit. INTERVENTIONS: The resident requires Mechanical Lift with 2 staff assistance for transfers. Physical assist as needed with ADL every shift. An interview was conducted on 7/30/24 at 9:45 AM with LPN (licensed practical nurse) #1. When asked about the temperature in Resident #2's room (room [ROOM NUMBER]), LPN #1 stated, it is hot in here. The air conditioning is not on. When asked if the window should be raised about 2 inches, LPN #1 stated, no, let me close it. LPN #1 unable to close the window. ASM #2, the director of nursing entered the room and assisted LPN #1 to close the window, one of them on each side of the window. ASM #2 stated, let me turn on the AC. AC was not providing cool air, ASM #2 stated, it may take a while to cool off. On 7/30/24 at 2:24 PM, went back to room [ROOM NUMBER], room was still warm with AC running highest setting. LPN #1 was asked about the room temperature, LPN #1 stated, it is warm in here. When asked if this is a homelike environment, LPN #1 stated, no. An interview was conducted on 7/30/24 at 3:45 PM with CNA (certified nursing assistant) #1, when asked about Resident #2, CNA #1 stated, his AC (air conditioning). it was not working then it was working. He would get agitated about it. There are roaches, in the facility, but we have a pest control company that comes in monthly I believe. When asked if this was a homelike environment, CNA #1 stated, no, it is not. On 8/1/24 at 10:00 AM, ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing and ASM #6, the regional director of clinical operations was made aware of the concerns. No further information was provided prior to exit. 2.The facility staff failed to ensure a safe, comfortable temperature and functional equipment for Resident #6. Observations on the 100-200 hall 7/30/24-8/1/24 found a large (approximately 50 gallon) under a leak from the ceiling (two ceiling tiles removed) at the end of the nurse's station. A review of the facility's pest control logs revealed, April 2024-38 German cockroaches, May 2024-16 German cockroaches, June 3, 2024-88 German cockroaches, 6/18/24-46 German cockroaches and 7/24/24-51 German cockroaches. Resident #6 was admitted to the facility on [DATE] with diagnosis that included but were not limited to: ASCVD (atherosclerotic cardiovascular disease), DM (diabetes mellitus) and RBKA (right below the knee amputation). The most recent MDS (minimum data set) assessment, a quarterly assessment, with an ARD (assessment reference date) of 6/6/24, coded the resident as scoring a 15 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was not cognitively impaired. A review of the MDS Section G-functional status coded the resident as being dependent for bed mobility, transfer, dressing, bathing and hygiene; supervision for eating. A review of the comprehensive care plan with a revision date of 9/5/23, revealed, FOCUS: Resident has an ADL (activities of daily living) self-care performance deficit related to weakness and BKA. INTERVENTIONS: The resident will be lifted and transferred with a (Hoyer mechanical lift). Staff will follow facility policy of two staff to use mechanical lifts at all times. An interview was conducted on 7/30/24 at approximately 12:00 PM with OSM (other staff member) #2, the maintenance director. When asked about the leaking ceiling, OSM #2 stated, it has been like that for a few days. I need someone with an electrical background to come in, because of all the electrical wires, you cannot go up there to fix a leak with all those wires like that. When asked if this facility is providing a safe, comfortable and homelike environment, OSM #2 stated, no. An interview was conducted on 7/30/24 at 3:45 PM with CNA (certified nursing assistant) #1, when asked about Resident #2, CNA #1 stated, his AC (air conditioning). it was not working then it was working. He would get agitated about it. There are roaches, in the facility, but we have a pest control company that comes in monthly I believe. When asked if this was a homelike environment, CNA #1 stated, no, it is not. An interview was conducted on 7/31/24 at 9:00 AM with Resident #6. When asked about her concerns, Resident #6 stated, there are roaches, the ceiling tiles are out and there is a drip into a large garbage can, it has been like that for several days. We are not being got up in a time, not because of the staff but because they have to borrow the lift from another unit. On 8/1/24 at 10:00 AM, ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing and ASM #6, the regional director of clinical operations was made aware of the concerns. No further information was provided prior to exit. 3.The facility staff failed to ensure a safe, comfortable temperature and functional equipment for Resident #9. Observations on the 100-200 hall 7/30/24-8/1/24 found a large (approximately 50 gallon) under a leak from the ceiling (two ceiling tiles removed) at the end of the nurse's station. A review of the facility's pest control logs revealed, April 2024-38 German cockroaches, May 2024-16 German cockroaches, June 3, 2024-88 German cockroaches, 6/18/24-46 German cockroaches and 7/24/24-51 German cockroaches. Resident #9 was admitted to the facility on [DATE] with diagnosis that included but were not limited to: quadriplegia, diabetes mellitus and morbid obesity. The most recent MDS (minimum data set) assessment, a quarterly assessment, with an ARD (assessment reference date) of 5/29/24, coded the resident as scoring a 15 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was not cognitively impaired. A review of the MDS Section G-functional status coded the resident as being dependent for bed mobility, transfer, dressing, bathing and hygiene; independent for eating. A review of the comprehensive care plan with a revision date of 12/6/23, revealed, FOCUS: Resident has limited physical mobility related to Neurological deficits, cervical disc disorder, quadriplegia, spondylosis and generalized muscle weakness. INTERVENTIONS: The resident requires a slid board for transfers to and from wheelchair to bed and may use mechanical devices as needed for transfers. The resident may use slid board for transfers and sit to stand as needed. An interview was conducted on 7/30/24 at approximately 12:00 PM with OSM (other staff member) #2, the maintenance director. When asked about the leaking ceiling, OSM #2 stated, it has been like that for a few days. I need someone with an electrical background to come in, because of all the electrical wires, you cannot go up there to fix a leak with all those wires like that. When asked if this facility is providing a safe, comfortable environment, OSM #2 stated, no. An interview was conducted on 7/30/24 at 3:45 PM with CNA (certified nursing assistant) #1, when asked about Resident #2, CNA #1 stated, his AC (air conditioning). it was not working then it was working. He would get agitated about it. There are roaches, in the facility, but we have a pest control company that comes in monthly I believe. When asked if this was a homelike environment, CNA #1 stated, no, it is not. An interview was conducted on 8/1/24 at 7:45 AM with Resident #9. When asked about her concerns, Resident #9 stated, there is a leak in the hallway from the ceiling for days, last week when we had that thunderstorm, the facility flooded. Roaches are everywhere. I use either the sit to stand to get out of bed or the mechanical lift. The staff have to go to another unit to get the equipment to get me up. Sometimes I am not able to get out of bed because the equipment has to be borrowed. On 8/1/24 at 10:00 AM, ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing and ASM #6, the regional director of clinical operations was made aware of the concerns. No further information was provided prior to exit.

Based on observation, resident/staff interview, facility document review, and clinical record review, it was determined the facility staff failed to report an allegation of residents receiving illegal drugs in a timely manner for two of nine residents, Resident #7 and #8. The findings include: 1.The facility failed to report an allegation of resident receiving illegal drugs resulting in hospitalization a timely manner for Resident #7. A resident requested interview was conducted on 7/31/24 at 9:00 AM with Resident #6, who has a BIMS of 15. During the interview, Resident #6 stated that two residents, Resident #7 and Resident #8 had received illegal drugs while in the facility and were no longer in the facility. Resident #6 was voicing concerns regarding resident safety with this behavior. Resident #7 was admitted to the facility on [DATE] with diagnosis that included but were not limited to cerebral infarction, CHF (congestive heart failure), PTSD (post-traumatic stress disorder) and pulmonary embolism. The most recent MDS (minimum data set) assessment, an admission assessment, with an ARD (assessment reference date) of 5/31/24, coded the resident as scoring a 15 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was not cognitively impaired. A review of the MDS Section GG-functional abilities and goals coded the resident as requiring supervision for bathing/transfer/dressing/toileting and eating. A review of the comprehensive care plan with a revision date of 6/1/24, revealed, FOCUS: Resident is appropriate for LTC (long term care) due to the need for 24/7 supervision secondary to medical diagnosis. INTERVENTIONS: The need for LTC is understood by resident and/or POA (power of attorney). Discharge plan to be discussed at comprehensive assessments. No evidence of an eINTERACT transfer form to the hospital or hospital transfer progress note. A review of the physician progress note dated 7/9/24 11:18 AM revealed, This is a [AGE] year-old female with a past medical history significant for hypertension, CVA, CHF, and other illnesses as stated in past medical history. She has been evaluated by psych while she has been here. She has had inappropriate physical contact with her visitors while here. She also has made sexually inappropriate comments towards staff members. Last week I was called to her bedside by nursing for an acute change in condition. Per nursing the patient was in the dining room and then returned to her room gasping for air. By the time I arrived with nursing to the room patient was awake but not alert. She was not following commands. She was transferred out of her wheelchair to the floor by staff members. Thankfully her blood pressure and pulse remained stable. Her respirations became shallow and less than 10. Her blood glucose was stable at 161. She began to drool and was unable to control her secretions. At one point she appeared to vomit. She was rolled to her side and suctioned. 911 was called and she was transported to the hospital for further evaluation and workup. In the ED she was found to be cocaine positive, but I do not have the full report for review. She is seen sitting up in her wheelchair in the courtyard today. A review of the progress note dated 7/12/24 at 2:14 PM revealed, Resident discharged with transportation. All belongings left with resident. Vitals within normal limits. Resident alert and orientated. Physician aware. An interview was conducted on 7/31/24 at approximately 8:00 AM with ASM #1, the administrator and ASM #2, the director of nursing. When asked about any facility event synopsis, grievances or any events related to resident illegal drug use-fentanyl was asked at the time. ASM #1 and ASM #2 stated no, there were no reports or illegal drug use, obtaining drugs through the mail or fentanyl. On 8/1/24 at 10:00 AM, ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing and ASM #6, the regional director of clinical operations was made aware of the concerns. A review of the facility's Abuse policy revealed The organization will maintain protocols and procedures to identify, correct and intervene in situations in which abuse, neglect, mistreatment is more likely to occur. This includes analysis of features of the physical environment that may make abuse and/or neglect more likely to occur, such as secluded areas of the facility. The assessment, care planning and monitoring of residents with needs and behaviors which might lead to neglect such as residents with self-injurious behaviors. No further information was provided prior to exit. 2. The facility failed to report an allegation of resident receiving illegal drugs resulting in two positive urine drug tests a timely manner for Resident #8. A resident requested interview was conducted on 7/31/24 at 9:00 AM with Resident #8, who has a BIMS of 15. During the interview, Resident #6 stated that two residents, Resident #7 and Resident #8 had received illegal drugs while in the facility and were no longer in the facility. Resident #6 was voicing concerns regarding resident safety with this behavior. Resident #8 was admitted to the facility on [DATE] with diagnosis that included but were not limited to CHF (congestive heart failure), COPD (chronic obstructive pulmonary disease), diabetes mellitus and opioid abuse with intoxication. The most recent MDS (minimum data set) assessment, an admission assessment, with an ARD (assessment reference date) of 5/31/24, coded the resident as scoring a 15 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was not cognitively impaired. A review of the MDS Section GG-functional abilities and goals coded the resident as requiring supervision for bathing/transfer/dressing/toileting and eating. A review of the comprehensive care plan with a revision date of 4/5/24, revealed, FOCUS: The resident wishes to return/be discharged to home. INTERVENTIONS: Evaluate/record the resident's abilities and strengths, with family/caregivers. Determine gaps in abilities which will affect discharge. Make arrangements with required community resources to support independence post-discharge. A review of the NP (nurse practitioner) progress note dated 6/29/24 at 7:53 PM revealed, Patient seen at the request of nursing for lab review. She is seen today at bedside. Social services were present at time of exam. I notified patient of the results of her positive drug screen. She wanted to know why her urine has amphetamines in it. She denied drug use. She stated that she only leaves the facility to go to appointments. I told her that she was seen in the parking lot behind a vehicle this week with unknown individuals. Staff had reported the suspicious behavior. Psych is following and also recommended a UDS (urine drug screen). She was given a drug contact by social services. She did sign it. ASSESSMENT AND PLAN: #Positive Drug Screen: -Positive for amphetamines and opiates, -Opiates consistent with the prescribed Percocet here, -Discussed findings with patient, -SS (social services) provided drug contract, -Discontinue Percocet, -Add prn Ibuprofen, -Will ask SS and LPC to provide resources for drug addiction. A review of the LPC progress note dated 7/8/24 at 12:00 PM revealed, Reason for Follow-up: Psychotherapy follow up: Chief Complaint / Nature of Presenting Problem: Resident has been agitated in recent weeks. She has tested positive for methamphetamines even though she is not prescribed medication this type of. Her boyfriend has been coming more recently and she has been leaving without permission to leave with him per staff. She has been more difficult to care for and her mood may be attributed to methamphetamine use. A review of the NP progress note dated 7/8/24 at 12:40 PM revealed, ASSESSMENT AND PLAN: #urine review-Positive for amphetamines. #Positive Drug Screen-Positive for amphetamines and opiates. -Opiates consistent with the prescribed Percocet here which is now discontinued until she has a clean UDS. -Discussed findings with patient. SS provided drug contract, prn Ibuprofen available, Will ask SS and LPC to provide resources for drug addiction, repeat UDS this Friday. A review of the NP progress note dated 7/10/24 at 2:15 PM revealed, ASSESSMENT AND PLAN: Discharge planning, SW attempting to find placement, Advised follow up with PCP 1-2 days and keep all f/u apts. scripts written. chart, labs and tests reviewed. Home health order placed. Discussed with social worker and staff. Positive Drug Screen: Positive for amphetamines and opiates, opiates consistent with the prescribed Percocet here which is now discontinued until she has a clean UDS. An interview was conducted on 7/31/24 at approximately 8:00 AM with ASM #1, the administrator and ASM #2, the director of nursing. When asked about any facility event synopsis, grievances or any events related to resident illegal drug use-fentanyl was asked at the time. ASM #1 and ASM #2 stated no, there were no reports or illegal drug use, obtaining drugs through the mail or fentanyl. On 8/1/24 at 10:00 AM, ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing and ASM #6, the regional director of clinical operations was made aware of the concerns. No further information was provided prior to exit.

Based on staff interview, clinical record review and facility document review, it was determined the facility staff failed to meet professional standards for one of nine residents, Resident #1. The findings include: The facility staff failed to meet professional standards by assessing/monitoring Resident #1. Resident #1 was admitted to the facility on [DATE] with diagnosis that included but were not limited to: CHF (congestive heart failure), DM (diabetes mellitus), CAD (cardiovascular disease) and CVA (cerebrovascular accident). The most recent MDS (minimum data set) assessment, an annual assessment, with an ARD (assessment reference date) of 6/7/24, coded the resident as scoring a 15 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was cognitively intact. A review of the MDS Section G-functional status coded the resident as requiring total dependence for transfer, bathing, bed mobility, dressing, hygiene and supervision for eating. A review of the comprehensive care plan dated 11/16/21 revealed, FOCUS: Cardiac disease related to DM, CAD, Presence of cardiac pacemaker, CHF and A flutter. INTERVENTIONS: Obtain vital signs as indicated; report changes to physician. Administer medication per physician orders. Administer oxygen as ordered. A review of the progress note dated 7/7/24 at 5:36 PM revealed, [AGE] year-old male resident seen at the request of nursing. Requesting to go to ER for shortness of breath. A review of the progress note dated 7/7/24 at 6:47 PM revealed, resident complained of (c/o) SOB. resident assessed. congestion noted. resident c/o fluid in chest. NP is aware. NP [NAME] recommended Chest Xray for SOB. Albuterol 3mL BID x7days. CBC, BMP for 7.8.2024. Lasix 40mg one time dose for fluid retention. resident alert and verbal. Vitals stable. A review of the progress note dated 7/7/24 at 6:47 PM revealed, Writer contacted third eye (physician tele-health after hours service). give clearance to send resident to ER. Writer contact NP about COC (change of condition) and transfer to ED. NP stated to treat in house. A review of the progress note dated 7/8/24 at 6:18 AM revealed, Resident continued to complain of congestion this shift. VS BP 167/95, 77, 18, 97.6, 99% on O2 Q 3LPM. He refused lab work this morning and Per RP, she called 911 and patient was taken to the hospital. NP aware. A review of the eINTERACT (electronic Interventions to Reduce Acute Care Transfers) form, revealed the form was not started till 7/8/24 at 4:33 PM and not signed off till 7/12/24. An interview was conducted on 7/30/24 at 2:05 PM with LPN (licensed practical nurse) #6. When asked about Resident #1, LPN #6 stated, the CNA brought to my attention that he was not feeling well, feel like he had fluid and sounded congested. I did a respiratory assessment. I called the telehealth service, took the tablet to the resident and telehealth, who ordered resident to be sent to the ED. There is a note at nurse's station: which reveals If Third Eye orders resident sent out, this needs to be approved by either NP or Medical Director. I called NP who asked how he was sounding and stated we are going to treat him in house. I gave him Lasix, breathing treatment, Chest x-ray ordered, CBC and CMP. I let the resident know what the NP said. I let the oncoming nurse know. My shift ends at 11:00 PM. I entered all the orders into computer. When asked if any additional monitoring of Resident #1 was done between 7/7/24 5:36 PM and 11:00 PM, LPN #6 stated, only what I documented. An interview was conducted on 7/31/24 at 10:35 AM with LPN #4, the unit manager. When asked if there was any additional evidence of Resident #1 being monitored, such as vital signs, oxygen saturation, lung sounds from 7/7/24 5:36 PM and 7/8/24 6:18 AM, LPN #4 stated, probably on the transfer form. When told the transfer form had not been initiated till 7/8/24 at 4:33 PM and the vital signs (BP, pulse and respirations) documented on the form were timed for 7/7/24 at 6:23 PM and the oxygen saturation data was from 3/6/24 at 9:11 AM, LPN #4 stated, no, there is no additional information. On 8/1/24 at 10:00 AM, ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing and ASM #6, the regional director of clinical operations was made aware of the concerns. No further information was provided prior to exit.

Based on resident/staff interview, facility document review and clinical record review, it was determined that the facility staff failed to provide incontinence care for dependent residents for three of nine residents, Resident #3, #4 and #9. The findings include: 1.The facility staff failed to provide evidence of incontinence care for dependent Resident #3. Resident #3 was admitted to the facility on [DATE] with diagnosis that included but were not limited to: cancer, anemia and malnutrition. The most recent MDS (minimum data set) assessment, a 5-day admission assessment, with an ARD (assessment reference date) of 5/21/24, coded the resident as scoring a 13 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was not cognitively impaired. A review of the MDS Section G-functional status coded the resident as being dependent for toileting, bathing and hygiene. A review of the comprehensive care plan with a revision date of 5/22/24, revealed, FOCUS: Resident has bladder incontinence related to impaired mobility. INTERVENTIONS: Clean peri-area with each incontinence episode. The resident uses disposable briefs. A review of the May ADL record revealed missing documentation for 5/17/24 night shift and June ADL record revealed missing documentation on 6/7/24 day shift. An interview was conducted on 7/30/24 at 3:15 PM with CNA (certified nursing assistant) #2. When asked about providing incontinence care, CNA #2 stated, we are to do it every two hours. When we have 16 plus patients, you cannot get to every patient, do baths, get them up and feed them. Sometimes it does not get done every two hours. When asked where this would be documented, CNA #2 stated, on the ADL record. An interview was conducted on 7/31/24 at 6:30 AM with CNA #3. When asked about providing incontinence care, CNA #3 stated, at 4:30-5:00 AM start rounds for incontinence care. When asked where this is documented and evidence of incontinence care provided, CNA #3 stated, it is on the ADL record. On 8/1/24 at 10:00 AM, ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing and ASM #6, the regional director of clinical operations was made aware of the concerns. No further information was provided prior to exit. 2. The facility staff failed to provide evidence of incontinence care for dependent Resident #4. Resident #4 was admitted to the facility on [DATE] with diagnosis that included but were not limited to: pulmonary embolism, polyneuropathy and bipolar disorder. The most recent MDS (minimum data set) assessment, a 5-day admission assessment, with an ARD (assessment reference date) of 6/27/24, coded the resident as scoring a 14 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was not cognitively impaired. A review of the MDS Section G-functional status coded the resident as being dependent for toileting, bathing and hygiene. A review of the comprehensive care plan with a revision date of 6/22/24, revealed, FOCUS: Resident has bladder incontinence related to impaired mobility. INTERVENTIONS: Clean peri-area with each incontinence episode. The resident uses disposable briefs. A review of the June ADL (activities of daily living) record revealed missing documentation on 6/21/24 night shift and the July ADL record, missing on 7/7/24 night shift and 7/8/24 day shift. An interview with Resident #4 on 7/30/24 at 11:45 AM revealed Resident #4 stating, they do not change me like they should. I am laying in poop or urine for 6-8 hours, mostly on night shift and worse on the weekends. On 7/31/24 at 11:30 AM, Resident #4 stated, last changed at 10:00 PM on 7/30/24 and then not changed again till this morning 7/31/24 at 6:00 AM. An interview was conducted on 7/30/24 at 3:15 PM with CNA (certified nursing assistant) #2. When asked about providing incontinence care, CNA #2 stated, we are to do it every two hours. When we have 16 plus patients, you cannot get to every patient, do baths, get them up and feed them. Sometimes it does not get done every two hours. When asked where this would be documented, CNA #2 stated, on the ADL record. An interview was conducted on 7/31/24 at 6:30 AM with CNA #3. When asked about providing incontinence care, CNA #3 stated, at 4:30-5:00 AM start rounds for incontinence care. When asked where this is documented and evidence of incontinence care provided, CNA #3 stated, it is on the ADL record. On 8/1/24 at 10:00 AM, ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing and ASM #6, the regional director of clinical operations was made aware of the concerns. No further information was provided prior to exit. 3. The facility staff failed to provide evidence of incontinence care for dependent Resident #9. Resident #9 was admitted to the facility on [DATE] with diagnosis that included but were not limited to: quadriplegia, diabetes mellitus and morbid obesity. The most recent MDS (minimum data set) assessment, a quarterly assessment, with an ARD (assessment reference date) of 5/29/24, coded the resident as scoring a 15 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was not cognitively impaired. A review of the MDS Section G-functional status coded the resident as being dependent for bed mobility, transfer, dressing, bathing and hygiene; independent for eating. A review of the comprehensive care plan with a revision date of 12/6/23, revealed, FOCUS: Resident has limited physical mobility related to Neurological deficits, cervical disc disorder, quadriplegia, spondylosis and generalized muscle weakness. INTERVENTIONS: The resident requires a slid board for transfers to and from wheelchair to bed and may use mechanical devices as needed for transfers. The resident may use slid board for transfers and sit to stand as needed. A review of the May ADL (activities of daily living) record revealed missing documentation on 5/15/24 evening shift and the July ADL record, missing on 7/7/24 night shift and 7/8/24 day shift. An interview was conducted on 7/30/24 at 3:15 PM with CNA (certified nursing assistant) #2. When asked about providing incontinence care, CNA #2 stated, we are to do it every two hours. When we have 16 plus patients, you cannot get to every patient, do baths, get them up and feed them. Sometimes it does not get done every two hours. When asked where this would be documented, CNA #2 stated, on the ADL record. An interview was conducted on 7/31/24 at 6:30 AM with CNA #3. When asked about providing incontinence care, CNA #3 stated, at 4:30-5:00 AM start rounds for incontinence care. When asked where this is documented and evidence of incontinence care provided, CNA #3 stated, it is on the ADL record. An interview was conducted on 8/1/24 at approximately 7:45 AM with Resident #9. When asked about incontinence care, Resident #9 stated, they are doing the best they can with the staff they have. They cannot get to us every two hours because of being short. On 8/1/24 at 10:00 AM, ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing and ASM #6, the regional director of clinical operations was made aware of the concerns. No further information was provided prior to exit.

Based on observation and staff interview, it was determined that facility staff failed to maintain resident's rooms in good repair for four of 15 resident rooms observed on the Arcadia (secured) unit. The findings include: On 02/26/24 at approximately 1:37 p.m. and on 02/27/24 at approximately 8:29 a.m., an observation of resident room [ROOM NUMBER] revealed six slats missing from the left side door of the closet. On 02/26/24 at approximately 1:42 p.m., and on 02/27/24 08:30 a.m., an observation of resident room [ROOM NUMBER] revealed a section of wallpaper measuring approximately eight inches high by eighteen inches long torn off to the left of the room window. On 02/26/24 at approximately 1:54 p.m. and on 02/27/24 at approximately 8:30 a.m., an observation of resident room [ROOM NUMBER] revealed a missing drawer front on the bottom of resident's closet. On 02/26/24 at approximately 2:01 p.m. and on 02/27/24 at approximately 8:33 a.m., an observation of resident room [ROOM NUMBER] revealed a hole in the wall behind the entrance door to the room measuring approximately two and a half inches in diameter. On 02/26/24 at approximately 2:30 p.m. and on 02/27/24 at approximately 8:45 a.m., observation of the dining room revealed six, one-foot square floor tiles in poor condition. Observation of four floor tiles in front of the dining room wall located to the left of the dining room entrance revealed they were chipped, had deep impressions, and stained with a black and brown substance. Two other tiles located in front of the cabinets revealed black and brown stained deep round impressions measuring approximately an inch and a half in diameter. Further observation of the dining room revealed a hole in the wall near the left corner of the room from the entrance door to the dining room. On 02/07/2023 at approximately 2:42 p.m., an observation of the rooms and issues listed above were conducted with OSM (other staff member) #9, director of maintenance. OSM #9 stated he was not aware of the identified concerns listed above. On 02/27/2024 at approximately 2:30 p.m., an interview was conducted with OSM (other staff member) #9, director of maintenance. OSM #9 stated that he had been working for the facility for the past two months. When asked to describe the procedure he follows for addressing items in the facility in need of repair he stated that he checks the work order in TELS (an electronic work order system that also prioritizes repairs). When asked if he conducts rounds to check on resident rooms for any repairs, he stated no. OSM #9 further stated that the facility's department heads conduct rounds each morning, inspecting the resident's room and identifying and repairs they see and enter it in TELS. On 02/28/2024 at approximately 2:20 p.m., ASM (administrative staff member) #1, administrator, ASM #2, director of nursing, ASM #3, regional director of nursing, ASM #5, director of operations and ASM #6, regional director of maintenance, were made aware of the above findings. No further information was provided prior to exit.

Based on observations, staff interviews, resident interviews, facility document review, and clinical record review, it was determined the facility staff failed to develop and/or implement the care plan for six of 49 residents in the survey sample, Residents #169, #66, #188, #166, #180 and #60. The findings include: 1.a. For Resident #169, the facility staff failed to develop the comprehensive care plan for trauma informed care. The most recent MDS (minimum data set) assessment, a quarterly assessment, with an ARD (assessment reference date) of 12/26/23, coded the resident as scoring a 15 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was not cognitively impaired. A review of the comprehensive care plan dated 6/5/23 revealed, FOCUS: At risk for psychosocial well-being problem related to pain and weakness. INTERVENTIONS: Monitor/document residents' feelings relative to unhappiness, anger. A trauma informed care plan wasn't initiated until 2/26/24 once survey began. A review of the facility's Trauma Informed Screen dated 6/5/23 revealed, Have you ever experienced a type of event that was unusually or especially frightening, horrible, or traumatic? Coded 'yes'. Physical, emotional or sexual abuse at any age? Coded 'yes'. A review of the physician order dated 9/18/23 revealed, Psychiatrist consult as needed. A review of the psychiatry note dated 8/18/23 revealed, Review of Systems: Depression: Denies sadness, tearfulness, poor sleep, poor appetite, low energy, poor concentration, guilt, lack of interest. Mania: Denies impulsivity, grandiosity, recklessness, excessive energy, decreased need for sleep, increased spending beyond means, talkativeness, racing thoughts, hypersexuality. Anxiety: Denies nervousness, palpitations, rapid breathing, nausea, headaches, hypervigilance, agoraphobia, nightmares, compulsions, syncopal attacks, restlessness, sweaty-clammy skin, diarrhea, dizziness, startles easily, panic attacks, avoidance behavior, flashbacks, tingling in hands or feet, obsessions. Diagnosis: Depression: Untreated. Exacerbated by recent adjustment to pain meds. Starting Cymbalta. Titrate dose as indicated for depression and pain. An interview was conducted on 2/26/24 at approximately 1:30 PM with Resident #169. When asked if she has had trauma, Resident #169 stated, yes. When asked if she is talking with anyone, Resident #169 stated, yes, psychiatry. An interview was conducted on 2/28/24 at 12:35 PM with OSM (other staff member) #11, the assistant director of social services. When asked to describe the trauma informed care process, OSM #11 stated, when residents are admitted to the facility, we are required to do a trauma informed screen. We ask all the questions on the screen, if they indicate they have been traumatized, we put a progress note in about the trauma, we ask the resident if they want to speak to psychiatry (psych), we inform the physician and nursing and we update the care plan. Social services do the trauma informed care plan. When asked to describe social services process for residents with a positive trauma informed care screening, OSM #11 stated, there is a joint process with nursing regarding any behaviors, nursing would be the ones to reach out to the physician if there are any behaviors. We both make sure that psych NP (nurse practitioner) sees the resident. The triggers would be on the care plan most likely. We make sure they are seen by psych on a regular basis. An interview was conducted on 2/28/24 at 1:00 PM with RN (registered nurse) #3. When asked what to describe the process for trauma informed care for residents, RN #3 stated, Well, I would have to ask my unit manager about what we would need to do for residents with trauma. I do not know. When asked if there is a care plan for trauma informed care for this resident, RN #3 stated not that they knew of. On 2/28/24 at 2:20 PM, ASM (administrative staff member) #1, the administrator, ASM #2, director of nursing, ASM #3, the regional director of nursing, ASM #5 the regional director of operations and ASM #6, the regional director of maintenance was made aware of the above concerns. A review of the facility's Comprehensive Assessments and Care Delivery Process policy, revealed, Comprehensive assessments, care planning and the care delivery process involve collecting and analyzing information, choosing, and initiating interventions, and then monitoring results and adjusting interventions. Identify overall care goals and specific objectives of individual treatments. Evaluate whether or not these treatments are accomplishing the anticipated results. Make decisions about care and treatment. Apply clinical reasoning to assessment information and determine the most appropriate interventions. Decision making leading to a person-centered plan of care includes: Selecting and implementing interventions, based on the results of the above. Monitoring results and adjusting interventions includes: Periodically reviewing progress and adjusting treatments. Continue to define or refine the objectives of specific treatments as well as overall care and services. No further information was provided prior to exit. 1.b. For Resident #169, the facility staff failed to implement the comprehensive care plan for pain management. A review of the comprehensive care plan dated 6/5/23 revealed, FOCUS: Chronic pain related to sickle cell. INTERVENTIONS: Administer analgesia medication as per orders. Notify physician if interventions are unsuccessful or if current complaint is a significant change from residents past experience of pain. A review of the physician's order dated 2/8/24 revealed, Pain assessment every shift (scale 0-10) 0=no pain 1- 3=mild 4-6=moderate 7-10=severe every shift. May use Verbal or Behavioral Pain Scale or Functional Scale. A review of the physician's order dated 2/12/24 revealed, Hydromorphone Oral Tablet 2 MG (milligram). Give 4 mg by mouth every 6 hours as needed for Pain. An interview was conducted on 2/26/24 at approximately 1:30 PM with Resident #169. When asked if she has had pain, Resident #169 stated, Yes, I have frequent pain. The pain medication is late, it is not given on time and my pain level is high due to my sickle cell. The medical record documented on the February 2024 MAR (medication administration record), the above medication. The Hydromorphone 4mg was documented as given on the following dates and times: -2/12/24 5:02 PM pain level 8 -2/13/24 12:07 AM pain level 7 -2/13/24 6:30 AM pain level 7 -2/13/24 2:30 PM pain level 8 -2/13/24 8:30 PM pain level 8 -2/14/24 3:00 AM pain level 8 -2/14/24 9:15 AM pain level 8 -2/14/24 5:16 PM pain level 7 -2/15/24 12:41 AM pain level 7 -2/15/24 6:49 AM pain level 7 -2/16/24 2:35 AM pain level 7 -2/16/24 8:30 AM pain level 7 -2/17/24 12:35 AM pain level 7 -2/17/24 9:54 AM pain level 7 -2/18/24-2/21/24 pain medication given every six hours however, pain rating was 7-9 -2/22/24 12:03 AM pain level 7 -2/22/24 6:31 AM pain level 8 -2/22/24 6:56 PM pain level 8 -2/23/24 11:36 AM pain level 6 -2/24/24 1:11 PM pain level 9 -2/24/24 7:13 PM pain level 6 -2/25/24 1:13 AM pain level 7 -2/25/24 8:29 AM pain level 8 -2/25/24 9:15 PM pain level 6 -2/26/24 3:15 AM pain level 7 -2/26/24 9:47 AM pain level 8 -2/26/24 11:00 PM pain level 9 -2/27/24 5:20 AM pain level 8 -2/27/24 12:33 PM pain level 9. An interview was conducted on 2/28/24 at 1:00 PM with RN (registered nurse) #3. When asked if the resident was only scheduled narcotics as needed and continued to have pain levels of 7-9 to describe what she would do. RN #3 stated, Well the pain medication was not taking care of the resident's pain, so I would call the physician to let them know we needed to either schedule the narcotics, change the frequency or change the narcotic. When asked why this would be done, RN #3 stated, to keep the residents as pain free as possible and because it is a nursing responsibility. When asked if the care plan for pain management was being followed for this resident, RN #3 stated, No, it is not. An interview was conducted on 2/28/24 at 1:15 PM with LPN (licensed practical nurse) #1. When asked to describe a pain management program, LPN #1 stated, to administer the pain medications ordered for the resident in the manner of which they are ordered. When asked if the resident's pain level is not controlled with the medication are there any additional steps taken, LPN #1 stated, Yes, I would call the doctor to inform him the medication was not working and to get additional orders. When asked if the care plan for pain management was being followed for this resident, LPN #1 stated, No, it is not. On 2/28/24 at 2:20 PM, ASM (administrative staff member) #1, the administrator, ASM #2, director of nursing, ASM #3, the regional director of nursing, ASM #5 the regional director of operations and ASM #6, the regional director of maintenance was made aware of the above concerns. No further information was provided prior to exit. 2. For Resident #66, the facility staff failed to implement the comprehensive care plan for a hand splint. The most recent MDS (minimum data set) assessment, a quarterly assessment, with an ARD (assessment reference date) of 12/14/23, coded the resident as scoring a 15 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was not cognitively impaired. A review of the MDS Section GG-functional abilities and goals coded the resident as being totally dependent for dressing, personal hygiene and bathing. A review of the comprehensive care plan dated 11/4/22 revealed, FOCUS: Alteration in musculoskeletal status r/t contracture of left hand. INTERVENTIONS: Assist the resident with the use of supportive devices (left hand splints) as recommended. A review of the physician orders dated 7/18/23 revealed, Left hand resting splint. Nursing to place left hand splint one time a day for Left hand contracture-night shift. An interview was conducted on 2/26/24 at approximately 1:50 PM with Resident #66. When asked if she had any assistive devices, Resident #66 stated, Yes, there is a splint for my left hand. I am to wear it at night but since I have moved to this unit, the staff do not put it on consistently at night. A review of Resident #66's medical record evidenced transfer to the unit 1/12/24. A review of the January and February 2024 ADL (activities of daily living) record revealed, Dressing: How resident puts on, fastens and takes off all items of clothing, including donning/removing a prosthesis or TED hose and was missing documentation on 1/21/24, 2/8/24, 2/14/24, 2/18/24 and 2/25/24. An interview was conducted on 2/27/24 at 6:15 AM with night shift CNA (certified nursing assistant) #1. When asks to describe the process with a resident who wears a splint, CNA #1 stated, they know what shift they are to apply it, they check the skin of the resident for any breaks or issues to report to the nurse and then document it in the medical record. When asked where it is documented, CNA #1 stated, it is on the ADL record under dressing. When asked if that is where you would find evidence that the splint was applied, CNA #1 stated yes. An interview was conducted on 2/27/24 at 6:30 AM with night shift CNA #2. When asked to describe the process with a resident who wears a splint, CNA #2 stated, they check the resident's skin, apply it and make sure the resident is comfortable with it. They document this on their records under dressing. When asked if that is where you would find evidence that the splint was applied, CNA #2 stated yes, this is where it would be. An interview was conducted on 2/28/24 at 1:00 PM with RN (registered nurse) #3. When asked if the care plan for supportive devices was being followed for this resident, RN #3 stated, no, it is not. On 2/28/24 at 2:20 PM, ASM (administrative staff member) #1, the administrator, ASM #2, director of nursing, ASM #3, the regional director of nursing, ASM #5 the regional director of operations and ASM #6, the regional director of maintenance was made aware of the above concerns. No further information was provided prior to exit. 42106 3. For Resident #188 (R188), the facility staff failed to implement the comprehensive care plan in November 2022 to provide consistent incontinence care. On the most recent MDS (minimum data set), an admission assessment with an ARD (assessment reference date) of 10/28/2022, the resident was assessed as requiring extensive assistance from one person for toileting and being frequently incontinent of bowel and bladder. The comprehensive care plan for R188 documented in part, Urinary Bowel incontinence as evidenced by muscle weakness related to disease process and physical limitations. Date Initiated: 10/21/2022 . Under Interventions it documented in part, . Provide incontinent care as needed. Date Initiated: 10/24/2022 . Review of the ADL (activities of daily living)-Toileting documentation for 11/1/2022- 11/30/2022 failed to evidence incontinence care provided to R188 on the following dates: day shift on 11/3/2022, 11/8/2022, 11/13/2022 and 11/15/2022, and on evening shift on 11/8/2022. On 2/28/2024 at 9:14 a.m., an interview was conducted with LPN (licensed practical nurse) #5, MDS coordinator. LPN #5 stated that the purpose of the care plan was to alert staff of the resident's needs and it alerted the nurse and the CNA (certified nursing assistant) of the care needs. She stated that the care plan should be implemented because they wanted to make sure they were following the resident's care needs and doctors orders. On 2/28/2024 at 9:26 a.m., an interview was conducted with LPN #6 who stated that the purpose of the care plan was to ensure the resident was cared for correctly. She stated that the care plan should be implemented to ensure the resident was taken care of and everyone followed the care plan. On 2/28/2024 at 9:45 a.m., an interview was conducted with CNA (certified nursing assistant) #6. CNA #6 stated that incontinence care was provided every two hours and documented in the computer. She stated that they documented the care they provided in the resident's record to evidence that it was done. On 2/28/2024 at 12:47 p.m., an interview was conducted with CNA #9. CNA #9 stated that the care they provided to residents was documented in the ADL documentation. She stated that they documented if a resident refused care and notified the nurse. The facility policy Comprehensive Assessment and the Care Delivery Process documented in part, .Comprehensive assessments, care planning and the care delivery process involve collecting and analyzing information, choosing, and initiating interventions, and then monitoring results and adjusting interventions . On 2/28/2024 at 2:18 p.m., ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing, ASM #3, the regional director of nursing, ASM #5, the director of operations, and ASM #6, the regional director of plant services were made aware of the concern. No further information was provided prior to exit. 4. For Resident #166 (R166), the facility staff failed to implement the comprehensive care plan to administer medications as ordered. On the most recent MDS (minimum data set) assessment, an annual assessment, with an ARD (assessment reference date) of 1/11/2024, the resident scored an 15 out of 15 on the BIMS (brief interview for mental status) assessment, indicating the resident was cognitively intact for making daily decisions. On 2/26/2024 at 1:52 p.m., an interview was conducted with R166 who stated that they took pain medication and often their medications were given later than they were scheduled. R166 stated that this frustrated them and they never knew when they were able to get their medications, especially on the weekends. The comprehensive care plan for R166 documented in part, The resident has hypertension (HTN) r/t (related to) lifestyle choices. Date Initiated: 04/12/2023. Under Interventions it documented in part, .Give anti-hypertensive medications as ordered. Monitor for side effects such as orthostatic hypotension and increased heart rate (Tachycardia) and effectiveness. Date Initiated: 04/12/2023 . The physician orders for R166 documented in part, - Gabapentin Oral Capsule 300 MG (milligram). Give 1 capsule by mouth three times a day for neuropathy. Order Date: 08/22/2023 . - Metoprolol Tartrate Oral Tablet 25 MG. Give 1 tablet by mouth two times a day for hypertension. Order Date: 08/22/2023 . The eMAR (electronic medication administration record) for R166 dated 2/1/2024-2/29/2024 documented the Gabapentin oral capsule 300 mg scheduled to be administered at 9:00 a.m., 1:00 p.m. and 8:00 p.m. The eMAR further documented the Metoprolol Tartrate oral capsule 25 mg scheduled to be administered at 8:00 a.m. and 8:00 p.m. Review of the Medication Admin (administration) Audit Report for R166 dated 2/1/24-2/27/24 documented the following: - On 2/2/24: The scheduled 8:00 a.m. Metoprolol given at 11:02 a.m., and the scheduled 9:00 a.m. Gabapentin given at 11:06 a.m. - On 2/4/24: The scheduled 8:00 a.m. Metoprolol given at 12:27 p.m., and the 9:00 a.m. scheduled Gabapentin given at 2:14 p.m. - On 2/9/24: The scheduled 8:00 a.m. Metoprolol given at 10:02 a.m. - On 2/10/24: The scheduled 8:00 a.m. Metoprolol given at 10:49 a.m. and scheduled 9:00 a.m. Gabapentin given at 10:49 a.m. - On 2/11/24: The scheduled 9:00 a.m. Gabapentin given at 10:54 a.m. and the 8:00 p.m. Gabapentin and Metoprolol given at 10:26 p.m. - On 2/16/24: The scheduled 8:00 p.m. Gabapentin and Metoprolol given at 9:46 p.m. - On 2/18/24: The scheduled 8:00 a.m. Metoprolol given at 9:51 a.m. - On 2/20/24: The scheduled 8:00 a.m. Metoprolol given at 10:07 a.m. and the scheduled 9:00 a.m. Gabapentin given at 10:07 a.m. The nurses notes for R166 failed to evidence documentation regarding the late administration of the medications listed above or notification of the physician for the late administration. On 2/28/2024 at 9:14 a.m., an interview was conducted with LPN (licensed practical nurse) #5, MDS coordinator. LPN #5 stated that the purpose of the care plan was to alert staff of the resident's needs and it alerted the nurse and the CNA (certified nursing assistant) of the care needs. She stated that the care plan should be implemented because they wanted to make sure they were following the resident's care needs and doctors orders. On 2/28/2024 at 9:26 a.m., an interview was conducted with LPN #6 who stated that the purpose of the care plan was to ensure the resident was cared for correctly. She stated that the care plan should be implemented to ensure the resident was taken care of and everyone followed the care plan. LPN #6 stated that medications were administered within an hour before or an hour after the scheduled time. She stated that this was done because it was the physician's order and they were supposed to follow them. She stated that if medications were given outside of the scheduled timeframe window, they notified the physician to ask them if it was alright to give the medication late or hold it. She stated that this should be documented in the nurses notes. On 2/28/2024 at 10:18 a.m., an interview was conducted with RN (registered nurse) #3 who stated that medications were administered within an hour before or after the scheduled time. She stated that this was because there were a lot of residents to give medication to and the timeframe allowed them time to manage the medication administration within that window. She stated that if medications were not administered within the one hour before or after window, they notified the physician that the medication was not given at the scheduled timeframe and let the responsible party know. She stated that the physician gave an order whether to give the medication or not and this should be documented in the nurses notes. On 2/28/2024 at 2:18 p.m., ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing, ASM #3, the regional director of nursing, ASM #5, the director of operations, and ASM #6, the regional director of plant services were made aware of the concern. No further information was provided prior to exit. 49369 5. For Resident #180 (R180), the facility staff failed to develop a comprehensive care plan for oxygen use. R180 was admitted to the facility on [DATE] with diagnosis of acute respiratory failure with hypoxia and a history of COVID-19. On 2/27/24 03:28 p.m. Resident #180 was observed with oxygen in use via nasal cannula at 3 liters per minute. A review of R180's clinical record revealed physician orders dated 2/09/24 for oxygen at 2 liters continuously via nasal cannula every shift. A review of R180's care plan failed to reveal evidence of oxygen use. On 2/28/2024 at 9:14 a.m., an interview was conducted with LPN (licensed practical nurse) #5, MDS (minimum data set) coordinator. LPN #5 stated that the purpose of the care plan was to alert staff of the resident's needs, and it alerted the nurse and the CNA (certified nursing assistant) of the care needs. She stated that the care plan should be implemented because they wanted to make sure they were following the resident's care needs and doctors' orders. On 2/28/2024 at 9:26 a.m., an interview was conducted with LPN #6 who stated that the purpose of the care plan was to ensure the resident was cared for correctly. She stated that the care plan should be implemented to ensure the resident was taken care of and everyone followed the care plan. On 2/28/24 at 2:19 p.m., ASM (administrative staff member) #1, the administrator, and ASM #2, the director of operations, ASM #3, the regional director of nursing, ASM#5, the director of operations, and ASM #6, the director of maintenance were made aware of these concerns. No further information was provided prior to exit. 29125 6. For Resident #60, the facility staff failed to implement the comprehensive care plan to administer oxygen per the physician's order. A review of the comprehensive care plan revealed one dated 11/12/22 for The resident has altered cardiovascular status related to hypertension. This care plan included an intervention dated 11/29/22 for Give oxygen as ordered by the physician. In addition, the comprehensive care plan included one dated 11/12/22 for The resident has altered respiratory status/Difficulty Breathing r/t (related to) Respiratory Failure with hypoxia, HX (history of) PE (pulmonary embolism). This care plan included an intervention dated 11/12/22 for Provide oxygen as ordered. A review of the clinical record revealed a physician's order dated 1/28/24 for Oxygen at 2 liters via nasal cannula every shift for SOB (shortness of breath). On 2/26/24 at 1:18 PM, an observation was made of Resident #60. The oxygen rate was set at 1.5 liters per minute as evidenced by the 1.5 liter mark was set across the center of the ball in the flowmeter. A review of the facility's oxygen concentrator user manual, page 28, documented, To properly read the flowmeter, locate the prescribed flowrate line on the flowmeter. Next, turn the flow knob until the ball rises to the line. Now, center the ball on the L/min (liters per minute). line prescribed. The figure drawing that demonstrated this indicated the ball in the flowmeter was positioned so that the line for the flow rate passed across the center of the ball. On 2/27/24 at 2:54 PM an interview was conducted with LPN #4 (Licensed Practical Nurse) who stated that the oxygen rate is set by the line for the liter mark goes across the middle of the ball on the flowmeter. She stated that if it was set for 1.5 liters and the order was for two liters, then it was not being administered as ordered. When asked if the care plan documented to administer the oxygen as ordered, then was the care plan followed, she stated that it was not. When asked what was the purpose of the care plan, she stated that it was to guide the care of the resident. The facility policy, Comprehensive Assessments and the Care Delivery Process documented, Comprehensive assessments will be conducted to assist in developing person-centered care plans .9. Apply clinical reasoning to assessment information and determine the most appropriate interventions. 10. Decision making leading to a person-centered plan of care includes: a. Selecting and implementing interventions, based on the results of the above On 2/27/24 at 4:30 PM, ASM #1 (Administrative Staff Member) the Administrator and ASM #2 the Director of Nursing were made aware of the findings. No further information was provided by the end of the survey.

Based on observations, staff interviews, resident interviews, facility document review, and clinical record review, it was determined the facility staff failed to provide evidence of ADL (activities of daily living) care for three of 49 residents in the survey sample, Residents #487, #188 and #553. The findings include: 1. For Resident #487, the facility staff failed to provide evidence of ADL care; specifically incontinence care and dressing. The most recent MDS (minimum data set) assessment, a quarterly assessment, with an ARD (assessment reference date) of 5/26/23, coded the resident as scoring a 01 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was severely cognitively impaired. A review of the MDS Section GG-functional abilities and goals coded the resident as being moderate assist for dressing, personal hygiene and bathing. A review of the comprehensive care plan dated 9/16/22 revealed, FOCUS: ADL Self-care deficit related to impaired mobility and general weakness. Urinary Bowel incontinence. INTERVENTIONS: Assist to bathe/shower as needed. Assist with daily hygiene, grooming, dressing, oral care and eating as needed. At established toileting times, ask if toileting is needed and remind patient that it is time to use toilet. Check at least every 2 hours for incontinence. Wash, rinse and dry soiled areas. A review of the April 2023 ADL record revealed missing documentation for incontinence care on the following dates: day shift-4/3, 4/4, 4/9, 4/11 and 4/14; evening shift-4/1, 4/15, 4/19, 4/21; and night shift 4/10, 4/15, 4/16 and 4/20. A review of the April 2023 ADL record revealed missing documentation for dressing on the following dates: 4/3, 4/4, 4/9, 4/11 and 4/14. A review of the May 2023 ADL record revealed missing documentation for incontinence care on the following dates: day shift-5/21; evening shift-5/1, 5/5, 5/6, 5/8, 5/9, 5/10, 5/13, 5/15, 5/21, 5/24, 5/27, 5/28; and night shift-5/1, 5/7, 5/9, 5/13, 5/16 and 5/29. A review of the May 2023 ADL record revealed missing documentation for dressing on the following date: 5/21. A review of the June 2023 ADL record revealed missing documentation for incontinence care on the following dates: day shift-6/6, 6/9 and 6/18; evening shift-6/5, 6/6, 6/7, 6/26; and night shift-6/4. A review of the June 2023 ADL record revealed missing documentation for dressing on the following dates: 6/6, 6/9, and 6/18. An interview was conducted on 2/27/24 at 6:15 AM with night shift CNA (certified nursing assistant) #1. When asked the process for incontinence care, CNA #1 stated, they round every two hours and change them unless they call them before the two hours is up. An interview was conducted on 2/28/24 at 9:50 AM with CNA #6. When asked the process for incontinence care, CNA #6 stated, rounds are every two hours and then they document incontinence care in PCC (point click care), CNA #6 stated, That is how we evidence care is given by our documentation. On 2/28/24 at 2:20 PM, ASM (administrative staff member) #1, the administrator, ASM #2, director of nursing, ASM #3, the regional director of nursing, ASM #5 the regional director of operations and ASM #6, the regional director of maintenance was made aware of the above concerns. A review of the facility's Incontinence Care policy revealed, Based on the resident's comprehensive assessment, all residents that are incontinent will receive appropriate treatment and services. Residents that are incontinent of bladder or bowel will receive appropriate treatment to prevent infections and to restore continence to the extent possible. No further information was provided prior to exit. 42106 2. For Resident #188 (R188), the facility staff failed to provide consistent incontinence care in November 2022. On the most recent MDS (minimum data set), an admission assessment with an ARD (assessment reference date) of 10/28/2022, the resident was assessed as requiring extensive assistance from one person for toileting and being frequently incontinent of bowel and bladder. Review of the ADL (activities of daily living)-Toileting documentation for 11/1/2022- 11/30/2022 failed to evidence incontinence care provided to R188 on the following dates: -day shift on 11/3/2022, 11/8/2022, 11/13/2022 and 11/15/2022, and on evening shift on 11/8/2022. The comprehensive care plan for R188 documented in part, Urinary Bowel incontinence as evidenced by muscle weakness related to disease process and physical limitations. Date Initiated: 10/21/2022 . Under Interventions it documented in part, . Provide incontinent care as needed. Date Initiated: 10/24/2022 . On 2/28/2024 at 9:45 a.m., an interview was conducted with CNA (certified nursing assistant) #6. CNA #6 stated that incontinence care was provided every two hours and documented in the computer. She stated that they documented the care they provided in the resident's record to evidence that it was done. On 2/28/2024 at 12:47 p.m., an interview was conducted with CNA #9. CNA #9 stated that the care they provided to residents was documented in the ADL documentation. She stated that they documented if a resident refused care and notified the nurse. The facility policy Activities of Daily Living (ADLs) documented in part, POLICY: Residents will be provided with care, treatment, and services as appropriate to maintain or improve their ability to carry out activities of daily living (ADLs). Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene . Elimination (toileting); i. Residents shall be assisted with toileting as needed. ii. Residents who are incontinent of bladder or bowel, will be provided care in a timely manner . On 2/28/2024 at 2:18 p.m., ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing, ASM #3, the regional director of nursing, ASM #5, the director of operations, and ASM #6, the regional director of plant services were made aware of the concern. No further information was provided prior to exit. 49369 3. For Resident #553 (R553), the facility staff failed to provide a scheduled shower from 5/18/23 through 5/23/23 and from 5/30/23 through 6/5/23. On the most recent MDS (minimum data set), with an ARD (assessment reference date) of 9/21/23 the resident scored 15 out of 15 on the BIMS (brief interview for mental status), indicating the resident was cognitively intact for making daily decisions. Section G coded R1 as requiring extensive assistance of one staff with bathing. A review of R553's ADL (activities of daily living) records and shower sheets revealed the resident was scheduled for bathing every Wednesday, Saturday and as needed. Further review of the ADL records revealed that R553 received a shower on 5/29/23, but failed to evidence showers from 5/18/23 through 5/23/23 (six days) and from 5/30/23 through 6/5/23 (seven days).The ADL records documented. N/A. On 2/28/24 at p.m., CNA (certified nursing assistant) #3 was interviewed. She stated that resident should get showers two times a week, either morning or evenings. They have a shower sheet that nurses check after the CNAs are done. After that their unit managers must approve them as well. After that she records it in the computer. She also stated that if a resident refuses she will document why, and that on their kiosk there is a button that says refusal they use for this situation. She states that she is unsure what NA means, and that it could possibly mean that the resident is not in the room, or they have an appointment. On 2/28/24 at 10:06 a.m., LPN (licensed practical nurse) # 4, the unit manager, was interviewed. She stated that she did work with R553 and that R553 would refuse showers due to her leg. She also stated that the staff were supposed to be documenting refusals, but now that she is unit manager, they have a process in place. They fill out a shower sheet for each resident and if the resident refuses the nurse must sign off on it and call the RP (responsible party). First the nurse will go in and then the unit manager will go in and see the reason for refusal. She added: We are still working on it. On 2/28/24 at 2:19 p.m., ASM (administrative staff member) #1, the administrator, and ASM #2, the director of nursing, ASM #3, regional director of nursing, ASM#5, the director of operations, and ASM #6, the regional director of maintenance were made aware of these concerns. The facility policy, Activities of Daily Living, was reviewed. It revealed in part, Residents will be provided with care, treatment and services as appropriate to maintain or improve their ability to carry out activities of daily living (ADLs). Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene Each resident shall receive tub or shower baths as often as needed, but not less than twice weekly or as required by state law. Resident's preference and/or whose medical conditions prohibit tub or shower baths shall have a sponge bath daily. No further information was presented prior to exit.

Based on staff and resident interview, facility document review and clinical record review, it was determined the facility staff failed to evidence a complete pain management program for one of 49 residents in the survey sample, Residents #169. The findings include: The facility staff failed to provide a pain management program in accordance with professional standards of practice and the goals and preferences of Resident #169. Resident #169 was admitted to the facility on [DATE] with diagnosis that included but were not limited to sickle cell disease, anemia and CKD (chronic kidney disease). The most recent MDS (minimum data set) assessment, a quarterly assessment, with an ARD (assessment reference date) of 12/26/23, coded the resident as scoring a 15 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was not cognitively impaired. A review of the comprehensive care plan dated 6/5/23 revealed, FOCUS: Chronic pain related to sickle cell. INTERVENTIONS: Administer analgesia medication as per orders. Notify physician if interventions are unsuccessful or if current complaint is a significant change from residents past experience of pain. A review of the physician's order dated 2/8/24 revealed, Pain assessment every shift (scale 0-10) 0=no pain 1- 3=mild 4-6=moderate 7-10=severe every shift. May use Verbal or Behavioral Pain Scale or Functional Scale. A review of the physician's order dated 2/12/24 revealed, Hydromorphone Oral Tablet 2 MG (milligram). Give 4 mg by mouth every 6 hours as needed for Pain. An interview was conducted on 2/26/24 at approximately 1:30 PM with Resident #169. When asked if she has had pain, Resident #169 stated, Yes, I have frequent pain. The pain medication is late, it is not given on time and my pain level is high due to my sickle cell. The medical record documented on the February 2024 MAR (medication administration record), the above medication. The Hydromorphone 4mg was documented as given on the following dates and times: -2/12/24 5:02 PM pain level 8 -2/13/24 12:07 AM pain level 7 -2/13/24 6:30 AM pain level 7 -2/13/24 2:30 PM pain level 8 -2/13/24 8:30 PM pain level 8 -2/14/24 3:00 AM pain level 8 -2/14/24 9:15 AM pain level 8 -2/14/24 5:16 PM pain level 7 -2/15/24 12:41 AM pain level 7 -2/15/24 6:49 AM pain level 7 -2/16/24 2:35 AM pain level 7 -2/16/24 8:30 AM pain level 7 -2/17/24 12:35 AM pain level 7 -2/17/24 9:54 AM pain level 7 -2/18/24-2/21/24 pain medication given every six hours however, pain rating was 7-9 -2/22/24 12:03 AM pain level 7 -2/22/24 6:31 AM pain level 8 -2/22/24 6:56 PM pain level 8 -2/23/24 11:36 AM pain level 6 -2/24/24 1:11 PM pain level 9 -2/24/24 7:13 PM pain level 6 -2/25/24 1:13 AM pain level 7 -2/25/24 8:29 AM pain level 8 -2/25/24 9:15 PM pain level 6 -2/26/24 3:15 AM pain level 7 -2/26/24 9:47 AM pain level 8 -2/26/24 11:00 PM pain level 9 -2/27/24 5:20 AM pain level 8 -2/27/24 12:33 PM pain level 9. An interview was conducted on 2/28/24 at 1:00 PM with RN (registered nurse) #3. When asked if the resident was only scheduled narcotics as needed and continued to have pain levels of 7-9 to describe what she would do. RN #3 stated, Well the pain medication was not taking care of the resident's pain, so I would call the physician to let them know we needed to either schedule the narcotics, change the frequency or change the narcotic. When asked why this would be done, RN #3 stated, to keep the residents as pain free as possible and because it is a nursing responsibility. When asked if the care plan for pain management was being followed for this resident, RN #3 stated, No, it is not. An interview was conducted on 2/28/24 at 1:15 PM with LPN (licensed practical nurse) #1. When asked to describe a pain management program, LPN #1 stated, to administer the pain medications ordered for the resident in the manner of which they are ordered. When asked if the resident's pain level is not controlled with the medication are there any additional steps taken, LPN #1 stated, Yes, I would call the doctor to inform him the medication was not working and to get additional orders. When asked if the care plan for pain management was being followed for this resident, LPN #1 stated, No, it is not. On 2/28/24 at 2:20 PM, ASM (administrative staff member) #1, the administrator, ASM #2, director of nursing, ASM #3, the regional director of nursing, ASM #5 the regional director of operations and ASM #6, the regional director of maintenance was made aware of the above concerns. No further information was provided prior to exit.

Based on observation, staff interview, and facility document review it was determined facility staff failed to store and serve food in a sanitary manner in one of one facility kitchens. The findings include: On 02/26/2024 at approximately 10:50 a.m. an inspection of the kitchen was conducted with OSM (other staff member) #1, dietary manager. 1. On 02/26/2024 at approximately 10:55 a.m., an observation of inside of the walk-in refrigerator during the initial tour of the facility kitchen revealed an open package of sliced cheese, resting on the second shelf from the top. 2. On 02/26/2024 at approximately 11:05 a.m., an observation of the facility's dry storage room revealed a scoop next to an empty plastic bag, laying on top of a flour bin. 3. On 02/26/2024 at approximately 11:45 a.m., an observation during the meal preparation in the facility's kitchen revealed OSM #14's beard was not covered. Further observation revealed OSM #13's hair was hanging out from underneath his ball cap while he was setting an and plating food from the steam table in the facility's kitchen. 4. On 02/26/2024 at approximately 11:50 a.m., an observation of the tray line in the facility's kitchen revealed OSM #15 and OSM #16 wearing gloves and removing plated food from the top of the steam table, placing their thumb on the surface of the plate near the food and placing it on the meal trays. Further observations of OSM #15 revealed she was opening and closing a reach-in refrigerator behind her retrieving additional food items for the resident's meal trays while wearing the same gloves she used to remove the plated food from the steam table. Further observations of OSM #16 revealed he would roll the food carts off to the side when they were filled with meal trays, retrieve an empty food cart, position it behind him and continue to remove the plated food from the steam table wearing the same gloves. At approximately 12:30 p.m., OSM #1 observed the above activity with the surveyor. On 02/26/2024 at approximately 3:05 p.m., an interview was conducted with OSM #1, regarding the observation stated above. She stated the cheese, and the flour scoop should have been covered to prevent cross contamination. When asked about OSM #13's hair and OSM #14's beard, she stated they should have been covered. When asked about the observation of OSM #15 and OSM #16, placing their gloved finger on the surface of the plated food after touch other un-sanitized items, OSM #1 stated they should be picking up the plates from the bottom and not placing their fingers on the surface of the plates. The facility's policy Receiving and Storage of Food documented in part, 8. All foods stored in the refrigerator or freezer will be covered, labeled, and dated (use by date). The facility's policy Food Preparation and Service documented in part, Food Service/Distribution. 6. Bare hand contact with food is prohibited. Gloves are worn when handling food directly and changed between tasks. Disposable gloves are single-use items and are discarded after each use. 7. Food and nutrition services staff wear hair restraints (hair net, hat, beard restraint, etc.) so that hair does not contact food. On 02/27/2024 at approximately 4:40 p.m., ASM (administrative staff member) #1, administrator, ASM #2, director of nursing, were made aware of the above findings. No further information was provided prior to exit.

Based on observation, resident interview, staff interview, facility document review, and clinical record review, it was determined the facility staff failed to accommodate needs for one of 49 residents, Resident #145. The findings include: For Resident #145, the facility staff failed to maintain the call light in a position where she could access it. The most recent MDS (minimum data set) assessment, a quarterly assessment, with an ARD (assessment reference date) of 2/2/24, coded the resident as scoring a 15 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was not cognitively impaired. A review of the MDS Section GG-functional abilities and goals coded the resident as requiring supervision for eating, extensive assistance for toileting, bathing and bed mobility. A review of the comprehensive care plan dated 10/27/23 revealed, FOCUS: The resident is at risk for falls related to a history of Falls, orthostatic hypotension, fall history, ESRD with hemodialysis, DM and anemia. INTERVENTIONS: Be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. The resident needs prompt response to all requests for assistance. Nonskid socks or shoes when out of bed as tolerated. On 2/26/24 at 2:15 PM, an observation was made of Resident #145 in her room. Resident #145 was sitting in her wheelchair in front of her bedside cabinet. Her call bell was observed to be attached to container on the top of her bedside cabinet. When asked where her call bell was, Resident #145 stated, It is not where I can reach it. Do you see it? On 2/26/24 at 2:30 PM, an interview was conducted with CNA (certified nursing assistant) #3. When asked to locate Resident #145's call bell, CNA #3 stated it was clipped on top of her bedside cabinet. CNA #3 was observed clipping the call bell within reach of Resident #145 An interview was conducted on 2/28/24 at 9:50 AM with CNA #6. When asked the process for call bells within resident's reach, CNA #6 stated every resident should be able to reach their call bell. On 2/28/24 at 2:20 PM, ASM (administrative staff member) #1, the administrator, ASM #2, director of nursing, ASM #3, the regional director of nursing, ASM #5 the regional director of operations and ASM #6, the regional director of maintenance was made aware of the above concerns. A review of the facility's Answering the Call Light policy revealed, The facility will maintain a functional call light system and will make all reasonable efforts to ensure timely responses to the resident's requests and needs. When the resident is in bed or confined to a chair be sure the call light is within easy reach of the resident. No further information was provided prior to exit.

Based on staff interview, clinical record review, and facility document review, it was determined that the facility staff failed to maintain a complete and accurate MDS (minimum data set) assessment for two of 49 residents in the survey sample, Residents #120 and #42. The findings include: 1. For Resident #120 (R120), the facility staff failed to code the quarterly MDS assessment with an ARD (assessment reference date) of 2/15/2024 for dialysis. On the most recent MDS assessment, a quarterly assessment, with an ARD (assessment reference date) of 2/15/2024, the resident scored nine out of 15 on the BIMS (brief interview for mental status) assessment, indicating the resident was moderately impaired for making daily decisions. Section O failed to evidence documentation of dialysis services within the 14 day assessment period. The physician orders for R120 documented in part, Hemodialysis at (Name, phone number and address of dialysis center) on Monday Wednesday Friday. Pick up time 11am. Order Date: 11/25/2023 . The comprehensive care plan for R120 documented in part, The resident has ESRD (end stage renal disease) and receives Hemodialysis. Hemodialysis at (Name, phone number and address of dialysis center) on Monday, Wednesday Friday. Pick up time 11am. Date Initiated: 06/22/2023. Revision on: 12/01/2023. The progress notes for R120 documented in part, - 2/6/2024 15:33 (3:33 p.m.) Resident alert and oriented to self. Resting quietly in bed with eyes closed most of shift. Dialysis site warm, dry and intact. No s/s (signs/symptoms) of infection noted. Access site to left arm positive for bruit and thrill . - 2/7/2024 10:26 (10:26 a.m.) Resident returned to unit via WC (wheelchair) at 17:45 pm. No acute distress noted. VS (vital signs) stable. Post dialysis completed . - 2/8/2024 16:15 (4:15 p.m.) Physician/NP (nurse practitioner) note . Plan: Chronic, stable, MWF hemodialysis schedule . Currently on HD (hemodialysis) MWF. Tolerating HD well . On 2/28/2024 at 9:14 a.m., an interview was conducted with LPN (licensed practical nurse) #5, MDS coordinator. LPN #5 stated that they followed the RAI (resident assessment instrument) manual when completing the MDS assessments. She stated that when completing Section O regarding dialysis she reviewed any hospital documentation, physician orders, and any dialysis flow sheets. LPN #5 was asked to review the quarterly MDS with the ARD of 2/15/2024 for R120 regarding dialysis to determine if coded. On 2/28/2024 at 9:20 a.m., LPN #5 stated that they had reviewed the quarterly MDS for R120 with the ARD of 2/15/2024, and dialysis services were missed during the assessment. She stated that the MDS should have been coded for dialysis services because there was an order and documentation that R120 received dialysis and they had revised the MDS to reflect that. According to the RAI Manual, Version 1.16, dated October 2018, section O0100J documented in the coding instructions for Column 2, 1. Review the resident's medical record to determine whether or not the resident received or performed any of the treatments, procedures, or programs within the last 14 days. It further documented, . Code peritoneal or renal dialysis which occurs at the nursing home or at another facility, record treatments of hemofiltration, Slow Continuous Ultrafiltration (SCUF), Continuous Arteriovenous Hemofiltration (CAVH), and Continuous Ambulatory Peritoneal Dialysis (CAPD) in this item . On 2/28/2024 at 2:18 p.m., ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing, ASM #3, the regional director of nursing, ASM #5, the director of operations, and ASM #6, the regional director of plant services were made aware of the concern. No further information was provided prior to exit. 29125 2. For Resident #42 the facility staff failed to complete a discharge MDS (Minimum Data Set) assessment. A review of the clinical record revealed the Discharge Summary which documented that Resident #42 was discharged from the facility to the community on 10/26/23. Further review failed to reveal a discharge MDS assessment was completed. On 2/28/24 at 9:45 AM, an interview was conducted with LPN #5 (Licensed Practical Nurse) the MDS nurse. She stated that there wasn't one. She stated that it should have been done on 10/26/23. She stated that it looked like it was never opened and she was going to open it right now. She stated that the system tracks the assessments and identifies when assessments need to be done and puts them on a scheduler. She stated that it will show you when you are missing assessments. She stated that it looked like the tracking for the assessments were cleared out, so it did not indicate that one needed to be done or was late. When asked what process is followed to determine when assessments needed to be completed, she stated the RAI manual (Resident Assessment Instrument). A review of the RAI Manual Version 1.18.11 dated October 2023, page 2-39 documented, Discharge Assessment - Return not anticipated .Must be completed when the resident is discharged from the facility and the resident is not expected to return to the facility within 30 days. Must be completed (item Z0500B) within 14 days after the discharge date (A2000 + 14 calendar days). Must be submitted within 14 days after the MDS completion date (Z0500B + 14 calendar days) On 2/28/24 at 2:39 PM, ASM #1 (Administrative Staff Member) the Administrator and ASM #2 the Director of Nursing were made aware of the findings. No further information was provided by the end of the survey.

Based on staff interview and clinical record review, it was determined that the facility staff failed to revise the comprehensive care plan for two of 49 residents in the survey sample, Residents #23 and #107. 1. For Resident #23 (R23), facility staff failed to revise the comprehensive care plan to identify the specific behaviors being monitored for the use of Zyprexa (1). R23 was admitted to the facility with diagnoses that included but were not limited to psychotic disturbances. On the most recent comprehensive MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 02/01/2024, R23 scored 7 (seven) out of 15 on the BIMS (brief interview for mental status), indicating R23 was severely impaired of cognition for making daily decisions. Section N Medications coded R23 as receiving antipsychotic medication. The physician's order for R23 documented in part, Zyprexa Oral Tablet 2.5 MG (milligrams) (Olanzapine) Give 0.5 tablet by mouth two times a day for bipolar disease related to vascular dementia, unspecified severity .Order Date: 2/12/24. The eMAR (electronic medication administration record) for R23 dated February 2024 documented the physician's order as stated above and Behaviors - Monitor for the following: itching, picking at skin, restlessness, (agitation), hitting, increase complaints, biting, kicking, spitting, cussing, racial slurs, elopement, stealing, delusions, hallucinations, psychosis, aggression, refusing care. Document Y if monitored and none of the above was observed. N if monitored and any of the above was observed, select chart code 'Other / See Nurse's Note' and progress note findings every shift for Behavior Monitoring. The eMAR revealed R23 received Zyprexa T 9:00 a.m. and at 5:00 p.m. from 02/01/2024 through 02/27/2024. Review of the eMAR revealed R23 demonstrated behavior(s) 60 of 81 opportunities. Further review of the eMAR failed to evidence the specific behavior(s) being monitored. The facility's progress notes for R23 dated 02/01/2024 through 02/26/2024 failed to evidence documentation of R23's behaviors being monitored. The comprehensive care plan for R23 dated 04/20/2024 documented in part, Focus. The resident uses psychotropic medications r/t (related to) Depression and Bipolar disorder. Date Initiated: 04/20/2024. Under Interventions the care plan failed to document the behavior(s) being monitored. On 02/28/2024 at approximately 12:23 p.m., an interview was conducted with LPN (licensed practical nurse) #5, MDS coordinator. When asked to describe the purpose of the comprehensive care plan LPN #5 stated to make resident's needs and wants known, provides a nursing intervention plan and to meet the resident's needs. After reviewing R23's comprehensive care plan dated 04/20/2024, LPN #5 was asked if the care plan included documentation of R23's behaviors being monitored. She stated no and that they should have been on the care plan When asked why the behaviors should have been on the care plan LPN #5 stated it makes the care plan patient specific. When asked what guidance she follows for revising the care plan LPN #5 stated the RAI (resident assessment instrument) manual. On 02/28/2024 at approximately 2:20 p.m., ASM (administrative staff member) #1, administrator, ASM #2, director of nursing, ASM #3, regional director of nursing, ASM #5, director of operations and ASM #6, regional director of maintenance, were made aware of the above findings. No further information was provided prior to exit. References: (1) Used to treat the symptoms of schizophrenia. This information was obtained from the website: Olanzapine: MedlinePlus Drug Information. 2. For Resident #107 (R107), facility staff failed to revise the comprehensive care plan to identify the specific behaviors being monitored for the use of Risperdal (1). R107 was admitted to the facility with diagnoses that included but were not limited to schizoaffective disorder (2). On the most recent comprehensive MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 11/24/2023, R107 scored 3 (three) out of 15 on the BIMS (brief interview for mental status), indicating R107 was severely impaired of cognition for making daily decisions. Section N Medications coded R107 as receiving antipsychotic medication. The physician's order for R107 documented in part, Risperdal Tablet 0.5 MG (milligrams). Give 1 tablet by mouth two times a day related to schizoaffective disorder. Start Date 10/13/2023. The eMAR (electronic medication administration record) for R107 dated February 2024 documented the physician's order as stated above and Behaviors - Monitor for the following: itching, picking at skin, restlessness, (agitation), hitting, increase complaints, biting, kicking, spitting, cussing, racial slurs, elopement, stealing, delusions, hallucinations, psychosis, aggression, refusing care. Document Y if monitored and none of the above was observed. N if monitored and any of the above was observed, select chart code 'Other / See Nurse's Note' and progress note findings every shift for Behavior Monitoring. The eMAR revealed R107 received Risperdal at 8:00 a.m. and at 8:00 p.m. from 02/01/2024 through 02/27/2024. Review of the eMAR revealed R107 demonstrated behavior(s) 61 of 81 opportunities. Further review of the eMAR failed to evidence the specific behavior(s) being monitored. The facility's progress notes for R107 dated 02/01/2024 through 02/27/2024 failed to evidence documentation of R107's behaviors being monitored. The comprehensive care plan for R107 dated 10/20/2023 documented in part, Focus. The resident uses psychotropic medications r/t (related to) schizoaffective disorder. Date Initiated: 10/20/2023. Under Interventions the care plan failed to document the behavior(s) being monitored. On 02/28/2024 at approximately 12:23 p.m., an interview was conducted with LPN (licensed practical nurse) #5, MDS coordinator. When asked to describe the purpose of the comprehensive care plan LPN #5 stated to make resident's needs and wants known, provides a nursing intervention plan and to meet the resident's needs. After reviewing R107's comprehensive care plan dated 04/20/2024 LPN #5 was asked if the care plan included documentation of R107's behaviors being monitored. She stated no and that they should have been on the care plan When asked why the behaviors should have been on the care plan LPN #5 stated it makes the care plan patient specific. When asked what guidance she follows for revising the care plan LPN #5 stated the RAI (resident assessment instrument) manual. On 02/28/2024 at approximately 2:20 p.m., ASM (administrative staff member) #1, administrator, ASM #2, director of nursing, ASM #3, regional director of nursing, ASM #5, director of operations and ASM #6, regional director of maintenance, were made aware of the above findings. No further information was provided prior to exit. References: (1) Used to treat the symptoms of schizophrenia. This information was obtained from the website: Olanzapine: MedlinePlus Drug Information. (2) Severe mental disorders that cause abnormal thinking and perceptions. Two of the main symptoms are delusions and hallucinations. This information was obtained from the website: https://medlineplus.gov/psychoticdisorders.html.

Based on resident interview, clinical record review, staff interview, and facility document review, it was determined that the facility staff failed to follow professional standards of practice for one of 49 residents in the survey sample, Resident #166. The findings include: For Resident #166 (R166), the facility staff failed to administer medications timely and notify the physician when medications were administered past the scheduled timeframe. On the most recent MDS (minimum data set) assessment, an annual assessment, with an ARD (assessment reference date) of 1/11/2024, the resident scored an 15 out of 15 on the BIMS (brief interview for mental status) assessment, indicating the resident was cognitively intact for making daily decisions. On 2/26/2024 at 1:52 p.m., an interview was conducted with R166 who stated that they took pain medication and often their medications were given later than they were scheduled. R166 stated that this frustrated them and they never knew when they were able to get their medications, especially on the weekends. The physician orders for R166 documented in part, - Gabapentin Oral Capsule 300 MG (milligram). Give 1 capsule by mouth three times a day for neuropathy. Order Date: 08/22/2023 . - Metoprolol Tartrate Oral Tablet 25 MG. Give 1 tablet by mouth two times a day for hypertension. Order Date: 08/22/2023 . The eMAR (electronic medication administration record) for R166 dated 2/1/2024-2/29/2024 documented the Gabapentin oral capsule 300 mg scheduled to be administered at 9:00 a.m., 1:00 p.m. and 8:00 p.m. The eMAR further documented the Metoprolol Tartrate oral capsule 25 mg scheduled to be administered at 8:00 a.m. and 8:00 p.m. Review of the Medication Admin (administration) Audit Report for R166 dated 2/1/24-2/27/24 documented the following: - On 2/2/24: The scheduled 8:00 a.m. Metoprolol given at 11:02 a.m., and the scheduled 9:00 a.m. Gabapentin given at 11:06 a.m. - On 2/4/24: The scheduled 8:00 a.m. Metoprolol given at 12:27 p.m., and the 9:00 a.m. scheduled Gabapentin given at 2:14 p.m. - On 2/9/24: The scheduled 8:00 a.m. Metoprolol given at 10:02 a.m. - On 2/10/24: The scheduled 8:00 a.m. Metoprolol given at 10:49 a.m. and scheduled 9:00 a.m. Gabapentin given at 10:49 a.m. - On 2/11/24: The scheduled 9:00 a.m. Gabapentin given at 10:54 a.m. and the 8:00 p.m. Gabapentin and Metoprolol given at 10:26 p.m. - On 2/16/24: The scheduled 8:00 p.m. Gabapentin and Metoprolol given at 9:46 p.m. - On 2/18/24: The scheduled 8:00 a.m. Metoprolol given at 9:51 a.m. - On 2/20/24: The scheduled 8:00 a.m. Metoprolol given at 10:07 a.m. and the scheduled 9:00 a.m. Gabapentin given at 10:07 a.m. The nurses notes for R166 failed to evidence documentation regarding the late administration of the medications listed above. The comprehensive care plan for R166 documented in part, The resident has hypertension (HTN) r/t (related to) lifestyle choices. Date Initiated: 04/12/2023. Under Interventions it documented in part, .Give anti-hypertensive medications as ordered. Monitor for side effects such as orthostatic hypotension and increased heart rate (Tachycardia) and effectiveness. Date Initiated: 04/12/2023 . On 2/28/2024 at 9:26 a.m., an interview was conducted with LPN (licensed practical nurse) #6. LPN #6 stated that medications were administered within an hour before or an hour after the scheduled time. She stated that this was done because it was the physician's order and they were supposed to follow them. She stated that if medications were given outside of the scheduled timeframe window, they notified the physician to ask them if it was alright to give the medication late or hold it. She stated that this should be documented in the nurses notes. On 2/28/2024 at 10:18 a.m., an interview was conducted with RN (registered nurse) #3. RN #3 stated that medications were administered within an hour before or after the scheduled time. She stated that this was because there were a lot of residents to give medication to and the timeframe allowed them time to manage the medication administration within that window. She stated that if medications were not administered within the one hour before or after window, they notified the physician that the medication was not given at the scheduled timeframe and let the responsible party know. She stated that the physician gave an order whether to give the medication or not and this should be documented in the nurses notes. The facility provided policy, Medication Orders failed to evidence guidance on medication administration. According to Fundamentals of Nursing 6th Edition, 2005: [NAME] A. [NAME] and [NAME] Perry; Mosby, Inc., page 843, All routinely ordered medications should be given within 60 minutes of the times ordered . On 2/28/2024 at 2:18 p.m., ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing, ASM #3, the regional director of nursing, ASM #5, the director of operations, and ASM #6, the regional director of plant services were made aware of the concern. No further information was provided prior to exit.

Based on observation, resident interview, staff interview, and facility document review, it was determined facility staff failed to provide treatment and services to maintain or improve mobility for one of 49 residents, Resident #66. The findings include: For Resident #66, the facility staff failed to provide the treatment of the left-hand splint for contracture. The most recent MDS (minimum data set) assessment, a quarterly assessment, with an ARD (assessment reference date) of 12/14/23, coded the resident as scoring a 15 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was not cognitively impaired. A review of the MDS Section GG-functional abilities and goals coded the resident as being totally dependent for dressing, personal hygiene and bathing. A review of the comprehensive care plan dated 11/4/22 revealed, FOCUS: Alteration in musculoskeletal status r/t contracture of left hand. INTERVENTIONS: Assist the resident with the use of supportive devices (left hand splints) as recommended. A review of the physician orders dated 7/18/23 revealed, Left hand resting splint. Nursing to place left hand splint one time a day for Left hand contracture-night shift. An interview was conducted on 2/26/24 at approximately 1:50 PM with Resident #66. When asked if she had any assistive devices, Resident #66 stated, Yes, there is a splint for my left hand. I am to wear it at night but since I have moved to this unit, the staff do not put it on consistently at night. A review of Resident #66's medical record evidenced transfer to this unit 1/12/24. A review of the January and February 2024 ADL (activities of daily living) record reveals, Dressing: How resident puts on, fastens and takes off all items of clothing, including donning/removing a prosthesis or TED hose and missing documentation on 1/21/24, 2/8/24, 2/14/24, 2/18/24 and 2/25/24. An interview was conducted on 2/27/24 at 6:15 AM with night shift CNA (certified nursing assistant) #1. When asked to describe the process with a resident who wears a splint, CNA #1 stated, We know what shift we are to apply it, we check the skin of the resident for any breaks or issues to report to the nurse and then we document it in the medical record. When asked where it is documented, CNA #1 stated, it is on the ADL record under dressing. When asked if that is where you would find evidence that the splint was applied, CNA #1 stated yes. An interview was conducted on 2/27/24 at 6:30 AM with night shift CNA #2. When asks to describe the process with a resident who wears a splint, CNA #2 stated, We check the resident's skin, apply it and make sure the resident is comfortable with it. We document this on our records under dressing. When asked if that is where you would find evidence that the splint was applied, CNA #2 stated yes, this is where it would be. On 2/28/24 at 2:20 PM, ASM (administrative staff member) #1, the administrator, ASM #2, director of nursing, ASM #3, the regional director of nursing, ASM #5 the regional director of operations and ASM #6, the regional director of maintenance was made aware of the above concerns. A review of the facility's Resident Mobility and Range of Motion policy revealed, Residents will not experience an avoidable reduction in range of motion (ROM). Residents with limited range of motion will receive treatment and services to increase and/or prevent a further decrease in ROM. Residents with limited mobility will receive appropriate services, equipment, and assistance to maintain or improve mobility unless reduction in mobility is unavoidable. No further information was provided prior to exit.

Based on observation, staff interview, facility document review and clinical record review, the facility staff failed to provide respiratory care consistent with professional standards, for two of 49 residents in the survey, Residents #180 and #60. The findings include: 1. For Resident #180 (R180), the facility staff failed to administer oxygen at the physician prescribed rate of two liters per minute. A review of R180's clinical record revealed a physician's order dated 2/09/24 for oxygen at 2 liters continuously via nasal cannula every shift. On 2/27/24 at 12:55 p.m., R180 was observed lying in bed receiving oxygen via nasal cannula at three-and-a-half liters per minute, as evidenced by the middle of the ball in the oxygen at three-and-a-half liter line. LPN #8 entered the room to help R180 and adjusted his oxygen to 3 liters a minute. On 2/27/24 at 3:58 p.m., R180 was observed lying in bed receiving oxygen via nasal cannula at three liters per minute, as evidenced by the middle of the ball in the oxygen concentrator flowmeter positioned on the three liter line. On 2/28/24 at 9:33 a.m., LPN (licensed practical nurse) #6 was interviewed. She stated that nurses should know how much oxygen to administer to a resident based on the resident's physician's order. LPN #6 stated that the middle of the ball in the oxygen concentrator should be on the two liter line if the order is for two liters. On 2/28/24 at 2:19 p.m., ASM (administrative staff member) #1, the administrator, and ASM #2, the director of operations, ASM #3, the regional director of nursing, ASM#5, the director of operations, and ASM #6, the director of maintenance were made aware of these concerns. Review of the facility policy, Oxygen Administration, revealed in part, Verify that there is a physician's order for this procedure. Review the physician's order for oxygen administration .Adjust the oxygen delivery device so that it is comfortable for the resident and proper flow of oxygen is being administered. No further information was presented prior to exit. 29125 2. For Resident #60, the facility staff failed to administer oxygen per the physician's order. A review of the clinical record revealed a physician's order dated 1/28/24 for Oxygen at 2 liters via nasal cannula every shift for SOB (shortness of breath). On 2/26/24 at 1:18 PM, an observation was made of Resident #60. The oxygen rate was set at 1.5 liters per minute as evidenced by the 1.5 liter mark was set across the center of the ball in the flowmeter. A review of the facility's oxygen concentrator user manual, page 28, documented, To properly read the flowmeter, locate the prescribed flowrate line on the flowmeter. Next, turn the flow knob until the ball rises to the line. Now, center the ball on the L/min (liters per minute). line prescribed. The figure drawing that demonstrated this indicated the ball in the flowmeter was positioned so that the line for the flow rate passed across the center of the ball. On 2/27/24 at 2:54 PM an interview was conducted with LPN (Licensed Practical Nurse) #4. She stated that the oxygen rate is set by the line for the liter mark goes across the middle of the ball on the flowmeter. She stated that if it was set for 1.5 liters and the order was for two liters, then it was not being administered as ordered. A review of the comprehensive care plan revealed one dated 11/12/22 for The resident has altered cardiovascular status related to hypertension. This care plan included an intervention dated 11/29/22 for Give oxygen as ordered by the physician. In addition, the comprehensive care plan included one dated 11/12/22 for The resident has altered respiratory status/Difficulty Breathing r/t (related to) Respiratory Failure with hypoxia, HX (history of PE (pulmonary embolism). This care plan included an intervention dated 11/12/22 for Provide oxygen as ordered. The facility policy Oxygen Administration documented, Verify that there is a physician's order for this procedure Turn on the oxygen at the number of liters / minute as ordered by the physician/practitioner On 2/27/24 at 4:30 PM, ASM #1 (Administrative Staff Member) the Administrator and ASM #2 the Director of Nursing were made aware of the findings. No further information was provided by the end of the survey.

Based on resident interview, staff interview, facility document review and clinical record review, it was determined that the facility staff failed to provide trauma informed care for two of 49 residents in the sample Resident #169 and Resident #159. The findings include: 1. For Resident #169, the facility failed to evidence provision of trauma informed care. Resident #169 was admitted to the facility on [DATE] with diagnoses that included but were not limited to sickle cell disease. The most recent MDS (minimum data set) assessment, a quarterly assessment, with an ARD (assessment reference date) of 12/26/23, coded the resident as scoring a 15 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was not cognitively impaired. A review of the comprehensive care plan dated 6/5/23 revealed, FOCUS: At risk for psychosocial well-being problem related to pain and weakness. INTERVENTIONS: Monitor/document residents' feelings relative to unhappiness, anger. A trauma informed care plan was not initiated until 2/26/24 once survey began. A review of the facility's Trauma Informed Screen dated 6/5/23 revealed, Have you ever experienced a type of event that was unusually or especially frightening, horrible, or traumatic? Coded 'yes'. Physical, emotional or sexual abuse at any age? Coded 'yes'. A review of the physician order dated 9/18/23 revealed, Psychiatrist consult as needed. A review of the psychiatry note dated 8/18/23 revealed, Review of Systems: Depression: Denies sadness, tearfulness, poor sleep, poor appetite, low energy, poor concentration, guilt, lack of interest. Mania: Denies impulsivity, grandiosity, recklessness, excessive energy, decreased need for sleep, increased spending beyond means, talkativeness, racing thoughts, hypersexuality. Anxiety: Denies nervousness, palpitations, rapid breathing, nausea, headaches, hypervigilance, agoraphobia, nightmares, compulsions, syncopal attacks, restlessness, sweaty-clammy skin, diarrhea, dizziness, startles easily, panic attacks, avoidance behavior, flashbacks, tingling in hands or feet, obsessions. Diagnosis: Depression: Untreated. Exacerbated by recent adjustment to pain meds. Starting Cymbalta. Titrate dose as indicated for depression and pain. There was no evidence of routine or quarterly social services notes. An interview was conducted on 2/26/24 at approximately 1:30 PM with Resident #169. When asked if she has had trauma, Resident #169 stated, yes. When asked if she is talking with anyone, Resident #169 stated, yes, psychiatry. An interview was conducted on 2/28/24 at 12:35 PM with OSM (other staff member) #11, the assistant director of social services. When asked to describe the trauma informed care process, OSM #11 stated, when residents are admitted to the facility, they are required to do a trauma informed screen. They ask all the questions on the screen, if they indicate they have been traumatized, they put a progress note in about the trauma. OSM #11 stated, We ask the resident if they want to speak to psychiatry (psych), we inform the physician and nursing and we update the care plan. Social services do the trauma informed care plan. When asked to describe social services process for residents with a positive trauma informed care screening, OSM #11 stated, There is a joint process with nursing regarding any behaviors, nursing would be the ones to reach out to the physician if there are any behaviors. We both make sure that psych NP (nurse practitioner) sees the resident. The triggers would be on the care plan most likely. We make sure they are seen by psych on a regular basis. An interview was conducted on 2/28/24 at 12:40 PM with OSM #3, the director of social services. When asked about social services role in trauma informed care, OSM #3 stated, there are quarterly assessments done and if a behavior occurs. An interview was conducted on 2/28/24 at 1:00 PM with RN (registered nurse) #3. When asked what to describe the process for trauma informed care for residents, RN #3 stated, Well, I would have to ask my unit manager about what we would need to do for residents with trauma. I do not know. On 2/28/24 at 2:20 PM, ASM (administrative staff member) #1, the administrator, ASM #2, director of nursing, ASM #3, the regional director of nursing, ASM #5 the regional director of operations and ASM #6, the regional director of maintenance was made aware of the above concerns. A review of the facility's Trauma Informed Care policy, revealed, The facility will provide appropriate and compassionate care specific to individuals who have experienced trauma. This facility supports a culture of emotional well-being and physical safety for staff, residents, and visitors. Trauma-informed care is culturally sensitive and person-centered. Caregivers are taught strategies to help eliminate, mitigate, or sensitively address a resident's triggers. Staff are provided in-service training about trauma, its impact on health, and post-traumatic stress disorder in the context of the healthcare setting. Nursing staff and/or social workers are trained on screening tools, trauma assessment and how to identify triggers associated with re-traumatization. Staff are guided in evidence-based organizational. No further information was provided prior to exit. 2. For Resident #159, the facility failed to evidence provision of trauma informed care. Resident #159 was admitted to the facility on [DATE] with diagnoses that included but were not limited to Burns 20-29% of body. The most recent MDS (minimum data set) assessment, a quarterly assessment, with an ARD (assessment reference date) of 11/17/23, coded the resident as scoring a 13 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was not cognitively impaired. A review of the comprehensive care plan dated 2/9/23 revealed, FOCUS: The resident has a mood problem related to depression, schizoaffective disorder. INTERVENTIONS: Monitor/record/report to MD prn mood patterns signs/symptoms of depression, anxiety, sad mood as per facility behavior monitoring protocols. Monitor/record/report to MD prn risk for harming others: increased anger, labile mood or agitation, feels threatened by others or thoughts of harming someone, possession of weapons or objects that could be used as weapons. A trauma informed care plan was not initiated until 2/26/24 once survey began. A review of the facility's Trauma Informed Screen dated 6/5/23 revealed, Have you ever experienced a type of event that was unusually or especially frightening, horrible, or traumatic? Coded 'yes'. Unexpected life events (death or a child, personal illness, etc.)? Coded 'yes'. A review of the physician order dated 6/24/23 revealed, Psychiatrist consult as needed. A review of the psychiatry note dated 8/18/23 revealed, She was admitted after a long hospitalization . She had sustained burns over most of her body, including her face, after dropping a cigarette on herself while smoking on the porch of the adult home she was living in. Schizoaffective disorder: psychotic signs/symptoms stable but patient with poor insight into her ability to take care of herself and be successful outside of this facility. Requested social services to initiate talk therapy. Patient in agreement. There is no evidence of talk therapy being initiated by social services or routine/quarterly social services notes. An interview was conducted on 2/26/24 at approximately 2:00 PM with Resident #159. When asked if she has had trauma, Resident #159 stated, Yes, you can see my burn marks. When asked if she is talking with anyone, Resident #159 stated, yes, psychiatry. An interview was conducted on 2/28/24 at 12:35 PM with OSM (other staff member) #11, the assistant director of social services. When asked to describe the trauma informed care process, OSM #11 stated, when residents are admitted to the facility, they are required to do a trauma informed screen. They ask all the questions on the screen, if they indicate they have been traumatized, they put a progress note in about the trauma. OSM #11 stated, We ask the resident if they want to speak to psychiatry (psych), we inform the physician and nursing and we update the care plan. Social services do the trauma informed care plan. When asked to describe social services process for residents with a positive trauma informed care screening, OSM #11 stated, There is a joint process with nursing regarding any behaviors, nursing would be the ones to reach out to the physician if there are any behaviors. We both make sure that psych NP (nurse practitioner) sees the resident. The triggers would be on the care plan most likely. We make sure they are seen by psych on a regular basis. An interview was conducted on 2/28/24 at 12:40 PM with OSM #3, the director of social services. When asked about social services role in trauma informed care, OSM #3 stated, there are quarterly assessments done and if a behavior occurs. An interview was conducted on 2/28/24 at 1:00 PM with RN (registered nurse) #3. When asked what to describe the process for trauma informed care for residents, RN #3 stated, Well, I would have to ask my unit manager about what we would need to do for residents with trauma. I do not know. On 2/28/24 at 2:20 PM, ASM (administrative staff member) #1, the administrator, ASM #2, director of nursing, ASM #3, the regional director of nursing, ASM #5 the regional director of operations and ASM #6, the regional director of maintenance was made aware of the above concerns. No further information was provided prior to exit.

Based on resident interview, staff interview, facility document review and clinical record review, it was determined that the facility staff failed to provide medically related social services for two of 49 residents in the sample Resident #169 and Resident #159. The findings include: 1. The facility failed to evidence provision of medically related social services for Resident #169. Resident #169 was admitted to the facility on [DATE] with diagnoses that included but were not limited to sickle cell disease. A review of the comprehensive care plan dated 6/5/23 revealed, FOCUS: At risk for psychosocial well-being problem related to pain and weakness. INTERVENTIONS: Monitor/document residents' feelings relative to unhappiness, anger. There was no trauma informed care plan initiated until 2/26/24 once survey began. A review of the facility's Trauma Informed Screen dated 6/5/23 revealed, Have you ever experienced a type of event that was unusually or especially frightening, horrible, or traumatic? Coded 'yes'. Physical, emotional or sexual abuse at any age? Coded 'yes'. A review of the physician order dated 9/18/23 revealed, Psychiatrist consult as needed. A review of the psychiatry note dated 8/18/23 revealed, Review of Systems: Depression: Denies sadness, tearfulness, poor sleep, poor appetite, low energy, poor concentration, guilt, lack of interest. Mania: Denies impulsivity, grandiosity, recklessness, excessive energy, decreased need for sleep, increased spending beyond means, talkativeness, racing thoughts, hypersexuality. Anxiety: Denies nervousness, palpitations, rapid breathing, nausea, headaches, hypervigilance, agoraphobia, nightmares, compulsions, syncopal attacks, restlessness, sweaty-clammy skin, diarrhea, dizziness, startles easily, panic attacks, avoidance behavior, flashbacks, tingling in hands or feet, obsessions. Diagnosis: Depression: Untreated. Exacerbated by recent adjustment to pain meds. Starting Cymbalta. Titrate dose as indicated for depression and pain. There was no evidence of routine or quarterly social services notes. An interview was conducted on 2/26/24 at approximately 1:30 PM with Resident #169. When asked if she has had trauma, Resident #169 stated, yes. When asked if she is talking with anyone, Resident #169 stated, yes, psychiatry. An interview was conducted on 2/28/24 at 12:35 PM with OSM (other staff member) #11, the assistant director of social services. When asked to describe the trauma informed care process, OSM #11 stated, when residents are admitted to the facility, they are required to do a trauma informed screen. They ask all the questions on the screen, if they indicate they have been traumatized, they put a progress note in about the trauma. OSM #11 stated, We ask the resident if they want to speak to psychiatry (psych), we inform the physician and nursing and we update the care plan. Social services do the trauma informed care plan. When asked to describe social services process for residents with a positive trauma informed care screening, OSM #11 stated, There is a joint process with nursing regarding any behaviors, nursing would be the ones to reach out to the physician if there are any behaviors. We both make sure that psych NP (nurse practitioner) sees the resident. The triggers would be on the care plan most likely. We make sure they are seen by psych on a regular basis. An interview was conducted on 2/28/24 at 12:40 PM with OSM #3, the director of social services. When asked about social services role in trauma informed care, OSM #3 stated, there are quarterly assessments done and if a behavior occurs. On 2/28/24 at 2:20 PM, ASM (administrative staff member) #1, the administrator, ASM #2, director of nursing, ASM #3, the regional director of nursing, ASM #5 the regional director of operations and ASM #6, the regional director of maintenance was made aware of the above concerns. A review of the facility's A review of the facility's Social Worker's Job Description revealed, Responsible for provide medically related social work services so that each resident may attain or maintain the highest practicable level of physical, mental, and psychosocial well-being. Identifies cognitive impairments, signs of mood problems, and psychosocial needs and follows up as needed. Trains staff in attending to resident's psychosocial needs and behavioral symptoms. No further information was provided prior to exit. 2. For Resident #159, the facility failed to evidence provision of medically related social services. Resident #159 was admitted to the facility on [DATE] with diagnosis that included but were not limited to Burns 20-29% of body, epilepsy and hypothyroidism. The most recent MDS (minimum data set) assessment, a quarterly assessment, with an ARD (assessment reference date) of 11/17/23, coded the resident as scoring a 13 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was not cognitively impaired. A review of the MDS Section GG-functional abilities and goals coded the resident as requiring supervision for mobility/transfers and eating. A review of the comprehensive care plan dated 2/9/23 revealed, FOCUS: The resident has a mood problem related to depression, schizoaffective disorder. INTERVENTIONS: Monitor/record/report to MD prn mood patterns signs/symptoms of depression, anxiety, sad mood as per facility behavior monitoring protocols. Monitor/record/report to MD prn risk for harming others: increased anger, labile mood or agitation, feels threatened by others or thoughts of harming someone, possession of weapons or objects that could be used as weapons. Trauma Informed care plan initiated 2/26/24 once survey began. A review of the facility's Trauma Informed Screen dated 6/5/23 revealed, Have you ever experienced a type of event that was unusually or especially frightening, horrible, or traumatic? Coded 'yes'. Unexpected life events (death or a child, personal illness, etc.)? Coded 'yes'. A review of the physician order dated 6/24/23 revealed, Psychiatrist consult as needed. A review of the psychiatry note dated 8/18/23 revealed, She was admitted after a long hospitalization . She had sustained burns over most of her body, including her face, after dropping a cigarette on herself while smoking on the porch of the adult home she was living in. Schizoaffective disorder: psychotic signs/symptoms stable but patient with poor insight into her ability to take care of herself and be successful outside of this facility. Requested social services to initiate talk therapy. Patient in agreement. There was no evidence of talk therapy being initiated by social services or routine/quarterly social services notes. An interview was conducted on 2/26/24 at approximately 2:00 PM with Resident #159. When asked if she has had trauma, Resident #159 stated, Yes, you can see my burn marks. When asked if she is talking with anyone, Resident #159 stated, yes, psychiatry. An interview was conducted on 2/28/24 at 12:35 PM with OSM (other staff member) #11, the assistant director of social services. When asked to describe the trauma informed care process, OSM #11 stated, when residents are admitted to the facility, they are required to do a trauma informed screen. They ask all the questions on the screen, if they indicate they have been traumatized, they put a progress note in about the trauma. OSM #11 stated, We ask the resident if they want to speak to psychiatry (psych), we inform the physician and nursing and we update the care plan. Social services do the trauma informed care plan. When asked to describe social services process for residents with a positive trauma informed care screening, OSM #11 stated, There is a joint process with nursing regarding any behaviors, nursing would be the ones to reach out to the physician if there are any behaviors. We both make sure that psych NP (nurse practitioner) sees the resident. The triggers would be on the care plan most likely. We make sure they are seen by psych on a regular basis. An interview was conducted on 2/28/24 at 12:40 PM with OSM #3, the director of social services. When asked about social services role in trauma informed care, OSM #3 stated, there are quarterly assessments done and if a behavior occurs. On 2/28/24 at 2:20 PM, ASM (administrative staff member) #1, the administrator, ASM #2, director of nursing, ASM #3, the regional director of nursing, ASM #5 the regional director of operations and ASM #6, the regional director of maintenance was made aware of the above concerns. No further information was provided prior to exit.

Based on staff interview, clinical record review, and facility document review, it was determined that the facility staff failed to ensure two of 49 residents in the survey sample were free from unnecessary antipsychotic medications, Residents #23 and Resident #107. 1. For Resident #23 (R23), facility staff failed to identify and monitor the specific behaviors for the use of Zyprexa (1). R23 was admitted to the facility with diagnoses that included but were not limited to psychotic disturbances. On the most recent comprehensive MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 02/01/2024, R23 scored 7 (seven) out of 15 on the BIMS (brief interview for mental status), indicating R23 was severely impaired of cognition for making daily decisions. Section N Medications coded R23 as receiving antipsychotic medication. The physician's order for R23 documented in part, Zyprexa Oral Tablet 2.5 MG (milligrams) (Olanzapine) Give 0.5 tablet by mouth two times a day for bipolar disease related to vascular dementia, unspecified severity .Order Date: 2/12/24. The eMAR (electronic medication administration record) for R23 dated February 2024 documented the physician's order as stated above and Behaviors - Monitor for the following: itching, picking at skin, restlessness, (agitation), hitting, increase complaints, biting, kicking, spitting, cussing, racial slurs, elopement, stealing, delusions, hallucinations, psychosis, aggression, refusing care. Document Y if monitored and none of the above was observed. N if monitored and any of the above was observed, select chart code 'Other / See Nurse's Note' and progress note findings every shift for Behavior Monitoring. The eMAR revealed R23 received Zyprexa T 9:00 a.m. and at 5:00 p.m. from 02/01/2024 through 02/27/2024. Review of the eMAR revealed R23 demonstrated behavior(s) 60 of 81 opportunities. Further review of the eMAR failed to evidence the specific behavior(s) being monitored. The facility's progress notes for R23 dated 02/01/2024 through 02/26/2024 failed to evidence documentation of R23's behaviors being monitored. The comprehensive care plan for R23 dated 04/20/2024 documented in part, Focus. The resident uses psychotropic medications r/t (related to) Depression and Bipolar disorder. Date Initiated: 04/20/2024. Under Interventions the care plan failed to document the behavior(s) being monitored. On 02/27/2024 at approximately 2:50 p.m., an interview was conducted with LPN (licensed practical nurse) #3 who administered medications to R23. When asked to describe the types of behaviors a resident might display to justify the use of an antipsychotic medication, she stated some of the behaviors would be hitting, yelling, screaming, and kicking. When asked about documenting the behaviors LPN #3 stated the behaviors would be documented on the behavior sheet on the eMAR or in the progress notes. When asked why R23 was prescribed Zyprexa she stated she did not know what R23's behaviors were. When asked what behaviors were being monitored for R23 she stated R23 had a diagnosis of psychosis. On 02/28/24 at approximately 10:28 a.m., an interview was conducted with LPN #11, unit manager. When asked what behaviors were being monitored for R23 she was unable to identify the behavior(s). When asked about documenting the behaviors LPN #11 stated the behaviors would be documented on the behavior sheet on the eMAR or in the progress notes. After reviewing R23's February 2024 eMAR and progress notes dated 02/01/2024 through 02/26/2024, LPN #11 stated there was a lack of documentation identifying the specific behavior(s) being monitored. The facility's policy Behavioral Assessment, Interventions and Monitoring documented in part, Policy: 1. The facility will provide, and residents will receive, behavioral health services needed to attain or maintain the highest practicable physical, mental, and psychosocial well-being in accordance with the comprehensive assessment and plan of care. 6. The facility will comply with regulatory requirements related to the use of medications to manage behavioral changes. Monitoring: 1. If the resident is being treated for altered behavior or mood, the IDT will seek and document any improvements or worsening in the individual's behavior, mood, and function. 2. The IDT will monitor the progress of individuals with impaired cognition and behavior until stable. New or emergent symptoms will be documented and reported. On 02/28/2024 at approximately 2:20 p.m., ASM (administrative staff member) #1, administrator, ASM #2, director of nursing, ASM #3, regional director of nursing, ASM #5, director of operations and ASM #6, regional director of maintenance, were made aware of the above findings. No further information was provided prior to exit. References: (1) Used to treat the symptoms of schizophrenia. This information was obtained from the website: Olanzapine: MedlinePlus Drug Information. (2) Severe mental disorders that cause abnormal thinking and perceptions. Two of the main symptoms are delusions and hallucinations. This information was obtained from the website: https://medlineplus.gov/psychoticdisorders.html. 2. For Resident #107 (R107), facility staff failed to identify and monitor the specific behaviors for the use of Risperdal (1). R107 was admitted to the facility with diagnoses that included but were not limited to schizoaffective disorder (2). On the most recent comprehensive MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 11/24/2023, R107 scored 3 (three) out of 15 on the BIMS (brief interview for mental status), indicating R107 was severely impaired of cognition for making daily decisions. Section N Medications coded R107 as receiving antipsychotic medication. The physician's order for R107 documented in part, Risperdal Tablet 0.5 MG (milligrams). Give 1 tablet by mouth two times a day related to schizoaffective disorder. Start Date 10/13/2023. The eMAR (electronic medication administration record) for R107 dated February 2024 documented the physician's order as stated above and Behaviors - Monitor for the following: itching, picking at skin, restlessness, (agitation), hitting, increase complaints, biting, kicking, spitting, cussing, racial slurs, elopement, stealing, delusions, hallucinations, psychosis, aggression, refusing care. Document Y if monitored and none of the above was observed. N if monitored and any of the above was observed, select chart code 'Other / See Nurse's Note' and progress note findings every shift for Behavior Monitoring. The eMAR revealed R107 received Risperdal at 8:00 a.m. and at 8:00 p.m. from 02/01/2024 through 02/27/2024. Review of the eMAR revealed R107 demonstrated behavior(s) 61 of 81 opportunities. Further review of the eMAR failed to evidence the specific behavior(s) being monitored. The facility's progress notes for R107 dated 02/01/2024 through 02/27/2024 failed to evidence documentation of R107's behaviors being monitored. The comprehensive care plan for R107 dated 10/20/2023 documented in part, Focus. The resident uses psychotropic medications r/t (related to) schizoaffective disorder. Date Initiated: 10/20/2023. Under Interventions the care plan failed to document the behavior(s) being monitored. On 02/27/2024 at approximately 2:50 p.m., an interview was conducted with LPN (licensed practical nurse) #3. When asked to describe the types of behaviors a resident might display to justify the use of an antipsychotic medication, she stated some of the behaviors would be hitting, yelling, screaming, and kicking. When asked about documenting the behaviors LPN #3 stated the behaviors would be documented on the behavior sheet on the eMAR or in the progress notes. When asked why R107 was prescribed Risperdal she stated hallucinations. When asked what behaviors were being monitored for R107 she could not identify the specific behavior(s). On 02/28/24 at approximately 10:28 a.m., an interview was conducted with LPN #11, unit manager. When asked what behaviors were being monitored for R107 she stated hallucinations and delusions and had not observed any behaviors. When asked about documenting the behaviors LPN #11 stated the behaviors would be documented on the behavior sheet on the eMAR or in the progress notes. After reviewing R107's February 2024 eMAR and progress notes dated 02/01/2024 through 02/27/2024, LPN #11 stated there was a lack of documentation identifying the specific behavior(s) being monitored. On 02/28/2024 at approximately 2:20 p.m., ASM (administrative staff member) #1, administrator, ASM #2, director of nursing, ASM #3, regional director of nursing, ASM #5, director of operations and ASM #6, regional director of maintenance, were made aware of the above findings. No further information was provided prior to exit. References: (1) Used to treat the symptoms of schizophrenia. This information was obtained from the website: Olanzapine: MedlinePlus Drug Information. (2) A mental condition that causes both a loss of contact with reality (psychosis) and mood problems [depression or mania]. This information was obtained from the website: https://www.nlm.nih.gov/medlineplus.

Based on staff interview and facility document review, the facility staff failed to meet staff vaccination requirements, 15 residents tested positive for COVID-19, and the facility staff failed implement their policy for COVID-19 vaccination for 11 of 166 employee records reviewed. The facility records documented that 15 residents had tested positive for COVID-19 during the previous four weeks but did not require hospitalization ; and the facility staff failed to provide evidence of approval of the employee's vaccination exemption as a condition of employment according to the facility's policy. The findings include: On 05/17/2022 the facility provided a document listing residents who tested positive for COVID-19 from 04/19/2022 through 05/13/2022 as requested. Review of the facility's COVID-19 employee vaccination matrix revealed that 11 of 166 employees were coded as Not vaccinated and their exemption was Pending. The facility's vaccine exemption form for OSM (other staff member) # 14, housekeeper, documented the form was signed by OSM #14, on 11/27/21. Review of OSM #14's employee record with OSM #2, human resource director, on 05/19/2022 at approximately 10:20 a.m., revealed a hire date of 04/25/2021. Further review failed to evidence an approved or unapproved exemption. The facility's vaccine exemption form for OSM #15, dietary aide, documented the form was signed by OSM #15 on 04/19/2022. Review of OSM #15's employee record with OSM #2 on 05/19/2022 at approximately 10:20 a.m., revealed a hire date of 04/26/2022. Further review failed to evidence an approved or unapproved exemption. The facility's vaccine exemption form for OSM #16, payroll, documented the form was signed by OSM #16 on 04/21/2022. Review of OSM #16's employee record with OSM #2 on 05/19/2022 at approximately 10:20 a.m., revealed a hire date of 03/30/2022. Further review failed to evidence an approved or unapproved exemption. The facility's vaccine exemption form for OSM #17, dietary aide, documented the form was signed by OSM #17 on 04/2022. Review of OSM #17's employee record with OSM #2 on 05/19/2022 at approximately 10:20 a.m., revealed a hire date of 03/16/2022. Further review failed to evidence an approved or unapproved exemption. The facility's vaccine exemption form for OSM #18, dietary aide, documented the form was signed by OSM #18 on 04/25/2022. Review of OSM #18's employee record with OSM #2 on 05/19/2022 at approximately 10:20 a.m., revealed a hire date of 04/06/2022. Further review failed to evidence an approved or unapproved exemption. The facility's vaccine exemption form for CNA (certified nursing assistant) #12 , temporary nursing aide, documented the form was signed by CNA #12 on 04/21/2022. Review of CNA #12's employee record with OSM #2 on 05/19/2022 at approximately 10:20 a.m., revealed a hire date of 05/12/2022. Further review failed to evidence an approved or unapproved exemption. The facility's vaccine exemption form for CNA #13, temporary nursing aide, documented the form was signed by CNA #13 on 04/28/2022. Review of CNA #13's employee record with OSM #2 on 05/19/2022 at approximately 10:20 a.m., revealed a hire date of 03/24/2022. Further review failed to evidence an approved or unapproved exemption. The facility's vaccine exemption form for CNA #14 , temporary nursing aide, documented the form was signed by CNA #14 on 05/12/2022. Review of CNA #14's employee record with OSM # 2 on 05/19/2022 at approximately 10:20 a.m., revealed a hire date of 04/05/2022. Further review failed to evidence an approved or unapproved exemption. The facility's vaccine exemption form for CNA #15, temporary nursing aide, documented the form was signed by CNA #15 on 05/13/2022. Review of CNA #15's employee record with OSM # 2 on 05/19/2022 at approximately 10:20 a.m., revealed a hire date of 03/16/2022. Further review failed to evidence an approved or unapproved exemption. The facility's vaccine exemption form for CNA #16, documented the form was signed by CNA #16 on 05/12/2022. Review of CNA #16's employee record with OSM #2, on 05/19/2022 at approximately 10:20 a.m., revealed a hire date of 03/02/2022. Further review failed to evidence an approved or unapproved exemption. The facility's vaccine exemption form for CNA #11, temporary nursing aide, documented the form was signed by CNA #11 on 04/21/2022. Review of CNA #11's employee record with OSM #2 on 05/19/2022 at approximately 10:20 a.m., revealed a hire date of 03/24/2022. Further review failed to evidence an approved or unapproved exemption. On 05/17/2022 at approximately 12:00 p.m., during the entrance conference, ASM (administrative staff member) #2, director of nursing, stated that they were the facility's infection preventionist. On 05/18/2022 at approximately 10:30 a.m., an interview was conducted with ASM #2. After reviewing the facility document listing residents who tested positive for COVID-19 from 04/19/2022 through 05/13/2022, ASM # 2 was asked if any of the residents on the list were hospitalized due to testing positive for COVID-19. ASM # 2 stated that none of the residents on the list were hospitalized . Review of residents listed who tested positive for COVID-19 from 04/19/2022 through 05/13/2022 failed to evidence they were hospitalized due to COVID-19. On 05/19/2022 at approximately 10:20 a.m., an interview was conducted with OSM #2 regarding the facility's vaccination exemption approval procedure. When asked what the abbreviation PN represented on the facility's COVID-19 employee vaccination matrix OSM #2 stated that the employee's exemptions were waiting to be approved. OSM #2 stated that when an employee completes the facility's exemption, either medical or religious exemption, it is emailed to their corporate office for approval. OSM #2 further stated that the facility's corporate office will send an email back to the facility indicating if the employee's exemption is approved. When asked how the corporate office indicates approval of the exemption OSM #2 stated that the email documents Approved. When asked what the time frame was for an employee's exemption approval OSM #2 stated that there was no specific time frame for the approval. When asked about the exemption approvals for the employees listed above OSM #2 stated that they did not have the approvals. When asked when the exemptions for the employees listed above were emailed to their corporate office OSM #2 stated that they did not send them to the corporate office and did not know if anyone had sent them. On 05/19/22 at approximately 4:00 p.m., an interview was conducted with ASM #2, director of nursing. When asked what special precautions are in place for unvaccinated staff to do direct care for unvaccinated residents ASM #2 stated that unvaccinated staff are tested twice weekly and when giving care they use an N95 mask, face shield, gown and gloves. ASM #2 also stated that the N95 mask and face shield were worn by unvaccinated staff all the time. On 05/20/2022 at 10:00 a.m., ASM #1, administrator, and ASM #2, director of nursing were informed that there was a concern for harm. On 05/23/2022 at 11:30 a.m., an interview was conducted with ASM #2, director of nursing. When asked to describe the COVID-19 vaccination procedure for new employees ASM #2 stated that new hires need to be vaccinated but didn't know if it was before they start working and they would have to look it up in the facility's policy. When restated the procedure for an employee's exemption describe by OSM #2 as stated above ASM #2 stated that the procedure was that the employee completed the exemption form prior to employment and sent to the corporate office for approval. The facility's policy Mandatory COVID-19 Vaccination Policy with a Review/Revised Date: 3/4/2022 documented in part, VIII. NEW HIRES. Potential candidates for employment will be notified of the requirements of this policy prior to the start of employment. All new employees are required to comply with the vaccination requirements (as defined by CMS) (Centers of Medicare/Medicaid Services) outlined in this policy as a condition of employment .If not vaccinated upon hire, new employees receive their first dose of vaccination or complete the exemption process (see Section IV. EXEMPTIONS) prior to providing any care, treatment, or other services for a [Name of Corporation] facility and/or its patients. Under IV. EXEMPTIONS it documented, Employees may request an exemption from mandatory vaccination if the vaccine is medically contraindicated for them or medical necessity requires a delay in vaccination. Employees also may be legally entitled to a reasonable accommodation if they cannot be vaccinated and/or wear a face covering (as otherwise required by this policy) because of a disability, or if the provisions in this policy for vaccination, and/or testing for COVID-19, and/or wearing a face covering conflict with a sincerely held religious belief, practice, or observance. Requests for exemptions must be initiated by completing the Request for A Medical Exemption to the COVID-19 Vaccination Requirement form or the Request for A Religious Exemption to the COVID-19 Vaccination Requirement form. See Appendix A, Exemption Forms. All such requests will be handled in accordance with applicable laws and regulations. No further information was provided prior to exit.