Every finding on record at Le Reve Rehabilitation & Memory Care

Based on interview and review record, the facility failed to ensure residents who were unable to carry out activities of daily living received the necessary services to maintain good nutrition, grooming, and personal and oral hygiene for 1 of 6 residents (Resident #9) reviewed for personal hygiene. The facility failed to provide Resident #9 with scheduled showers between 12/22/2025 and 03/04/2026. This failure could place residents, who require assistance from staff for personal hygiene, at risk of not receiving care and services contributing to overall poor hygiene, risk of experiencing a diminished quality of life, and possible skin infections.The findings included: Record review of Resident #9's Discharge MDS assessment, dated 03/04/2026, reflected a [AGE] year-old male admitted [DATE]. His BIMS was not completed, unable to determine his cognition. His diagnoses included Sequelae of Cerebral Infraction, (long-term neurological and physical deficits that persist after an ischemic stroke) Hemiplegia (complete paralysis) and Hemiparesis (partial weakness) affecting left non-dominate side, muscle weakness, lack of coordination, cognitive communication deficit. He was dependent on staff for showering/bathing, upper body dressing, lower body dressing. Record review of Resident #9's Comprehensive Person-Centered Care Plan, 12/24/2025, reflected, Resident #9 had an ADL performance deficit shower days are Tuesday, Thursday and Saturday with the intervention that Resident #9 was totally dependent on staff to provide bed bath/shower as necessary. Record review of the facility's shower sheet book from December 2025 through March 2026 reflect no staff had provided Residents #9 with a shower/bed bath. Record review of facility's grievance log dated February 2026 revealed Resident #9's family member stated no shower had been provided since admission. Record review of facility grievance log dated March 2026 revealed Resident #9's family member stated resident #9 had not received a shower since admission. During an interview on 05/11/2026 at 11:46 a.m., Resident #9's family member stated that Resident #9 passed away while in the hospital, and she revealed she had concerns with the facility. She stated that she had to provide Resident #9 with bed baths since he was admitted to the facility, because the staff would not provide him with a bed bath or shower. She stated that she filed a grievance with the facility in February and March to inform leadership of how the staff was treating Resident #9. She stated that the SW asked her whether it was her personal preference to provide Resident #9 with bed baths and Resident #9 family member stated no that it was not her preference to have to provide Resident #9 with a bath, but it needed to be done. During an interview on 05/12/2026 at 1:25 p.m., CNA D stated that they were assigned to Resident #9's hallway, and Resident #9's shower days were Tuesday, Thursday, and Saturday. CNA D stated bed bound residents received bed baths. She stated that she could not recall if she had provided Resident #9 with a bed bath. She stated that if a resident received a shower or bed bath they documented it on a shower sheet and turned the shower sheet into the nurse. She stated that even if a resident refused a shower or bed bath, they documented the resident refused. CNA D stated that if a sheet was not provided either the aide had forgotten to document on the sheet, may have forgotten to turn the shower sheet in or did not provide shower to the resident. She stated if a resident was not provided with a shower, they would become dirty and they had the right to be clean. During an interview on 05/12/2026 at 2:41 p.m., the SW revealed that Resident #9's family member did place a grievance that stated that the facility had not provided a shower or bed bath to Resident #9. The SW stated that she informed the previous administrator and (previous) DON A, and they conducted an impromptu meeting where the family member stated that she provided Resident #9 with showers. The SW stated, during that meeting, she asked was the family member's preference to provide showers and was told by Resident #9's family member that it needed to be done. During an interview on 05/13/2026 at 12:09 p.m., DON B stated her expectation was for residents to be on a shower schedule upon admission. Showers would be provided either Monday, Wednesday, and Friday or Tuesday, Thursday, and Saturday. DON B stated that it was not the responsibly of family members to provide shower or bed bath. DON B stated her expectation was for showers to have occurred on the scheduled days, and the risk to residents who did not receive a shower would be skin breakdown and dignity issues. An unsuccessful attempt to call the previous administrator was made on 05/12/2026 at 3:00 pm; left voicemail. No returned call received prior to exit.An unsuccessful attempt to call DON A on 05/12/2026 at 3:05 p.m. left voicemail. No returned call received prior to exit.Record review of the facility's policy, dated February 2018, titled, Bath, Shower/Tub, reflected, the purposes of this procedure are to promote cleanliness, provide comfort to the resident and observe the condition of the resident's skin.

Based on observations, interviews, and record reviews, the facility failed to review and revise the person-centered, comprehensive care plan for 2 (Resident #7 and Resident #8) of 6 residents reviewed for comprehensive care plan revisions. 1. The facility failed to update Resident #7's care plan for skin laceration to her right toe. 2. The facility failed to update Resident #8 and Resident 8's care plan non-pressure wound to his thigh. This failure could put residents at risk of not receiving the appropriate care, services, or treatments they need.Findings included: 1. Record review of Resident #7's Comprehensive MDS assessment, dated 03/11/2026, reflected a [AGE] year-old female admitted [DATE]. Her BIMS score was a 09, which implied moderate cognition. Her diagnosis included Chronic Obstructive Pulmonary Disease (a progressive, irreversible lung disease that restricts airflow and makes breathing difficult), Parkinsonism (a set of neurological movement disorders characterized by slowness of movement, muscle stiffness, tremors, and balance issues), laceration of right toe. Resident #7's skin and ulcer treatments were noted as pressure reducing device for chair, pressure reducing device for bed, turning/repositioning, and applications of ointments/medications. Record review of Resident 7's Care Plan 08/17/2025 revealed Resident #7 had a non-pressure ulcer to her sacrum. The care plan was not revised to reflect a laceration to her right toe. She received treatment per wound care physician orders. 2. Record review of Resident #8's Comprehensive MDS assessment, dated 03/12/2026, reflected a [AGE] year-old male admitted [DATE]. His BIMS score was a 14, which implied his cognition was intact. His diagnoses included non-pressure ulcer of the right thigh. Resident #8's skin and ulcer treatments were noted as pressure reducing device for chair, pressure reducing device for bed, turning/repositioning and applications of ointments/medications. Record review of Resident #8's Care Plan undated reflected no care plan or interventions addressing his non-pressure ulcer to the right thigh. He received treatment per wound care physician orders. During an observation and interview on 05/12/2026 11:00 a.m., Resident #7 was sitting in a wheelchair in her room. Resident #7 was wearing nonslip slippers. Resident #7 had an air mattress and cushion in her wheelchair. Resident #7 stated that she saw the wound care nurse once a week for her toe and it was healing. During an observation and interview, on 05/12/2026 1:50 p.m., Resident #8 was sitting up in a wheelchair in his room at his computer with a dressing noted near his knee. Resident #8 stated that he was admitted with the wound and that the wound care physician changed his dressing once per week. During an interview on 05/13/2026 at 10:02 a.m., the MDS Nurse stated that during the morning meeting, the nurse staff provided her updates to residents, which would trigger updates to the residents' Care Plan and MDS. The information that would provide a change was new diagnoses, new orders, any change to resident care needs. The MDS nurse stated the DON and the two nurses were always present during morning meetings. The MDS nurse stated that a new skin tear or wound should be placed on resident MDS and Care Plan. She stated that the risk to the resident if their MDS or care plan was not updated would be that they would not be provided the necessary care they require or worse with wound could lead to infection.During an observation on 05/13/2026 at 11:18 a.m., of wound care of resident #8 toe. No concerns with wound care. During an interview on 05/13/2026 at 11:39 a.m., LVN C stated that if there was a change in resident care, new diagnosis, new orders, or anything that happened with a resident it was discussed in the morning meeting. She stated the reason they informed the MDS nurse was so she could update the resident's care plan. She stated the risk to the residents not having their MDS or Care Plan updated was proper care wouldn't be followed for the residents. During an interview on 05/13/26 at 1049 AM, DON B stated she expected any changes in a resident to be shared with the team during the morning meeting, and for the MDS and Care Plans to be accurate and person centered. She stated that the MDS Coordinator was present for the morning meetings. She stated the ADM was working on getting every department head access so that other disciplines, such as dietary and social services, could contribute to making the care plans. The DON stated if care plans were not accurate, residents may not receive the appropriate care. During an interview on 05/13/2026 at 1:54 p.m., the ADM stated she expected MDS and Care Plans were completed accurately and updated timely with care that was up to date with the resident's conditions. Record review of the facility's Care Planning - Interdisciplinary Team policy dated 09/2013 reflected Our facility's Care Planning/ Interdisiplinary Team is responsible for the development of an individualized comprehensive care plan for each resident. 1. A comprehensive care plan for each resident is developed within seven days of completion of the resident assessment (MDS).

Based on observation, interview, and record review, the facility failed to maintain medical records on each resident that were accurately documented for 1 (Resident #2) of 6 residents reviewed for administration. The facility failed to document, at least once per shift, that the task turn/reposition for Resident #2 was completed. This failure could place residents at risk of developing skin breakdowns.Findings included: Record review of Resident #2's Quarterly MDS assessment, dated 04/27/2026, reflected a [AGE] year-old male admitted [DATE] and readmitted [DATE]. His BIMS score was a 03 which indicated severe cognitive impairment. His diagnoses included Osteomyelitis of Vertebra (serious spinal infection where bacteria or fungi invade the bones of the spine (vertebrae) and often adjacent discs), Sacral and Sacrococcygeal (the sacral region refers to the triangular bone at the base of the spine, formed by five fused vertebrae. The sacrococcygeal region involves the joint connecting the bottom of the sacrum to the tailbone) region, Hemiplegia (complete paralysis) and Hemiparesis (partial weakness) following cerebral infarction (stroke) affecting the right dominant side, non-pressure chronic ulcer of the buttocks with necrosis irreversible death of cells and living tissue) of muscle, pressure ulcer of left buttock, pressure ulcer of right buttock. The resident had two stage four pressure ulcers listed on admission. Resident #2 was dependent on staff for all functional abilities. Record review of Resident #2's care plan, undated reflected, Resident #2 had an ADL self-care performance deficit. Interventions with bed mobility revealed Resident #2 was totally dependent on staff for repositioning in bed as necessary. Record Review of Resident #2's task Turn/Reposition located in Resident #2's EHR for 04/16/26 through 05/13/2026 reflected missing documentation of the task being completed on the following days/ shifts: 04/16/26 - Second and Third shift04/17/26 - Second and Third shift04/20/26 -Third shift04/21/26 - Third shift04/22/26 - Third shift04/23/26 - Third shift04/24/26 - Third shift04/25/26 - Third shift04/26/26 - Third shift04/27/26 - Third shift04/28/26 - Third shift04/29/26 - Third shift04/30/26 - Third shift05/01/26 - Third shift05/02/26 - Third shift05/05/26 - Third shift05/07/26 - Second and Third shift05/08/26 - Second and Third shift05/11/26 - Second and Third shift05/13/26 - Second and Third shift During an interview on 05/12/2026 at 1:25 p.m., CNA D revealed that residents were required to be checked and changed every two hours and, during that time they were turned and repositioned. CNA D stated that they were to chart once per shift in electronic health record CNA D stated that if staff did not chart at least once per shift that they had did turn/reposition that would mean the staff member forgot to document the task or that they had not completed the task. She stated the risk to the resident if task was not documented would potentially lead to skin breakdowns. During an observation and interview on 05/13/2026 at 9:04 a.m., Resident #2 was in bed laying on his left side sleep. Resident #2's family member was at his bedside and stated that the facility did not turn him every two hours as required. She stated they may staff turned him twice per shift, but not every two hours like they were supposed to. During an interview on 05/13/2026 at 13:39 a.m., LVN C revealed the facility policy was to check/change and turn/reposition residents every two hours. She stated that the aides were required to chart in the EHR system at least once per shift. LVN B stated that if it was not charted it did not happen. LVN B stated the risk of staff not documenting residents being checked/changed and turned/repositioned at least once per shift meant that the task wasn't completed and that could cause skin to break down. During an interview on 05/13/2026 at 12:09 p.m., DON B stated that it was her expectation for staff to check/change and turn/reposition every two hours. She stated that staff were required to chart once per shift. She stated if EHR did not show they charted it meant the task was not performed. The DON stated that if the care provided was not documented, the risk to the resident was skin breakdowns or prevention of wounds healing. During an interview on 05/13/2026 at 1:54 p.m., the ADM stated that her expectations were to document for check and change/repositioning and turning was once per shift. She stated if it was not documented, it did not happen. The ADM stated that if it was not documented, the risk to the resident would be skin breakdowns and prevent healing of resident who had wounds. Record review of the facility's policy titled Charting and Documentation dated 07/2017 reflected All services provided to the resident, progress toward the care plan goal, or changes in the resident's medical, physical, functional, or psychosocial condition, shall be documented in the resident's medical record.

Based on interviews and record reviews the facility failed to ensure that all alleged violations involving misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures for one (Resident #1) of five residents reviewed for reporting.The facility failed to ensure a report for an allegation of misappropriation of resident property was submitted within 24 hours to the State Agency after Family Member A alleged Resident #1 was missing property on 01/27/2026.This failure could place residents at risk of abuse, physical harm, mental anguish, and emotional distress.In a record review of Resident #1's face sheet printed 04/22/2026 revealed diagnoses of Malignant neoplasm of unspecified part of unspecified bronchus or lung (a cancerous tumor); Asthma (a chronic, long-term disease); Hodgkin's lymphoma (cancer); Hypothyroidism (underactive thyroid); Neoplastic (Malignant) Related Fatigue (Cancer-Related Fatigue); and Anorexia (a serious, often chronic eating disorder).There was no completed MDS or care plan of Resident #1, due to Resident #1 being in the facility for less than 72 hours prior to passing away.In a record review of Resident #1's progress notes revealed she was admitted to the facility on [DATE] and passed away 01/26/2026. During an interview on 04/22/2026, at 12:47 p.m., LVN A, stated that in January she received a call about a missing diamond ring and she immediately told the prior Director of Nursing and she told her not to worry about it, Administrator A was taking care of it and she never heard about it again.During an interview on 04/22/2026, at 1:04 p.m., Family Member A stated that Administrator A called him on 01/27/2026 and informed him that the ring could not be found. Family Member A reported that during his visit with Resident #1 on 01/25/2026, she had been wearing her wedding ring on her left hand and her anniversary ring on her right hand. He further stated that Resident #1 had lost weight due to her cancer, making the ring easier to remove; however, he indicated it would not have fallen off on its own. He added that he had personally searched through her bedding and clothing but was unable to locate the ring. In a record review of the facility's grievances from 01/2026 through 03/2026 revealed only one grievance related to missing items, submitted by Family Member A on 01/27/2026, regarding a missing anniversary ring. Further review revealed Administrator A indicated that neither he nor staff were able to locate the ring. As a result, the grievance could not be resolved, as the ring remained missing and no individual was identified as responsible.In a record review on 04/22/2026; of TULIP there were no intakes from this facility for this allegation.During an interview on 04/22/2026, at 2:56 p.m., Administrator B stated that Administrator A was no longer employed at the facility. She stated she started working at the facility April 2, 2026. Administrator B stated she had been unaware of the issue but, now that she was, she would initiate an investigation. She said the policy states that an allegation of abuse or neglect needs to be reported within 2-hours or 24-hours if the allegation does not involve abuse and no one was seriously injured.In a record review of the facility's Abuse Investigation and Reporting Policy dated July 2017 revealed, .ReportingAll alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of an unknown source and misappropriation of property will be reported by the facility administrator or his/her designee, to the following persons or agency:The state licensing/certification agency responsible for surveying/licensing the facility;.Law enforcement officials.An alleged violation of abuse, neglect, exploitation, or mistreatment (including injuries of unknown source and misappropriation of resident property) will be reported immediately, but not later than;Two (2) hours if the alleged violation involves abuse OR has resulted in serious bodily injury; or Twenty-four (24) hours if the alleged violation does not involve abuse AND has not resulted in serious bodily injury.

Based on interview and record review, the facility failed to use the services of a registered nurse for at least 8consecutive hours a day, 7 days a week for 7 of 31 days in March 2026 reviewed for RN coverage. The facility failed to ensure they had an RN on duty on 03/05/2026 (Friday), 03/06/2026 (Saturday), 03/11/2026 (Wednesday), 03/17/2026 (Tuesday), 03/18/2026 (Wednesday), 03/23/2026 (Monday) and 03/24/2026 (Tuesday). This failure placed residents at risk of missing nursing assessments, interventions, care and treatment. Findings included: Record review of March 2026 Time Card Report dated 03/01/2026 to 03/31/2026 reflected zero hours worked by an RN on 03/05/2026 (Friday), 03/06/2026 (Saturday), 03/11/2026 (Wednesday), 03/17/2026 (Tuesday), 03/18/2026 (Wednesday), 03/23/2026 (Monday) and 03/24/2026 (Tuesday). In an interview on 04/01/2026 at 12:46 p.m. the Human Resource/Staffing Coordinator stated the previous DON had been terminated on 02/28/2026 and that it was her responsibility to schedule an RN at least 8 hours every day. The Human Resource/Staffing Coordinator stated she did her best to schedule an RN there but there were times when she could not find anyone to cover the shift and would have to have an LVN to cover the shift instead. In an interview on 04/01/2026 at 1:14 p.m. the Administrator stated she had started the day before and that she had hired a DON that would start in 2 weeks. She stated her expectation was that the facility would have an RN at least 8 hours per day every day. She stated the risk to the residents was that the nurse may not be able to provide the needed care. Record review of the facility's policy titled Director of Nursing Services, dated August 2006 reflected the following: The Nursing Services department is under the direct supervision of a Registered Nurse. The Director is a Registered Nurse licensed by this state and has experience in nursing service administration, rehabilitative and geriatric nursing. The Director is responsible for assessing the nursing requirements for each resident admitted and assisting the attending physician in planning for the resident's care. The Administrator was not able to provide a policy regarding 8 hours of RN coverage prior to exit.

Based on interview and record review, in response to allegations of abuse, neglect, exploitation, or mistreatment, the facility failed to prevent further potential abuse, neglect, exploitation, or mistreatment while the investigation was in process. For one resident (Resident #1) out of 5 residents reviewed for neglect and abuse.The facility failed to prevent further potential abuse, neglect, exploitation, or mistreatment by LVN A by allowing him to work and have direct contact with the resident while the allegations were still under investigation.An IJ was identified on 09/20/2025. The IJ template was provided to the facility on [DATE] at 8:07 pm. While the IJ was removed on 09/22/2025, the facility remained out of compliance at a scope of isolated and a severity level of potential for more than minimal harm that is not immediate jeopardy, because the facility allowed the alleged perpetrator to remain in the facility and to have direct contact with other residents on 08/16/2025 and 08/17/2025.These failures could result in residents experiencing serious harm, impairment, or death due to the facility failure of protecting residents.Findings include:Record review on 09/18/2025 at 4:00 pm of LVN A's Employee Disciplinary Action, dated 08/19/2025 revealed he was discharged due to a violation on 08/16/2025. LVN A's comments: Will be more competent in my approach and be more mindful of my actions. LVN A signed the disciplinary action.Record review of facility PIR dated 08/22/2025, with an allegation of neglect, reflected that Resident #1 sustained a fall in her room on 08/16/2025 at approximately 5:00 am. When the family notified the facility staff of Resident #1's fall, staff completed an x-ray. The x-ray revealed that the resident sustained a femur fracture. Resident #1 was expected to return to the facility upon completion of hospital stay. In service was completed for falls and Social Worker completed safe survey's which showed no trend. Action taken post-investigation revealed continued fall education and monitor resident for further healing during the process. LVN A's witness statement included in the PIR, not dated, or signed, revealed LVN A went into Resident #1's room and saw that she was on the floor between her bed and her roommate's bed. The resident was placed back in bed. LVN A was going to come back to assess her but became busy and forgot to assess her. The facility found the allegation to be confirmed. Safe surveys in the PIR dated 08/19/2025 indicated the residents felt safe, they knew who to report concerns to and would inform staff if they didn't feel safe. In service on ANE and falls was conducted on 08/18/2025 and 08/19/2025 and quizzes were given to staff which revealed that the staff understood the training. A witness statement included in the PIR, dated 08/18/2025 signed by the Administrator, reflected the Administrator attempted to speak to Resident #1 with her family member as a translator and she didn't remember falling or what she was doing before she fell. While reviewing the PIR there the facility did not include what they were doing to prevent this from occurring again other than in-servicing staff.In an interview with the Administrator on 09/18/2025 at 5:10 pm she stated that she had discovered that LVN A worked the night of 08/16/2025 from looking at the timecards. In an interview with the DON on 09/18/2025 at 5:19 pm she stated that she immediately suspended LVN A but had no written documentation of his suspension.In a record review on 09/19/2025 at 1:14 pm of the nursing schedule for 08/16/2025 from 10:00 pm to 6:00 am on 08/17/2025 LVN A worked station 1.In a record review on 09/20/2025 at 1:10 pm of LVA A's timecard on 08/16/2025 revealed he clocked in at 9:56 pm and clocked out 08/17/2025 at 6:29 am.In an interview with the Administrator on 09/20/2025 at 3:13 pm she said that LVN A was to be suspended because it was alleged that he didn't assess, document or inform the oncoming nurse of Resident #1's fall and should have been suspended while he was under investigation for failure to report.In an interview with the DON on 09/20/2025 at 4:48 pm when asked what the process for suspension was, she said the employee would come in and write a statement and be suspended until the investigation was completed. The DON said once she is notified, she informs the Administrator. She added that staff gets suspended to protect residents.In an interview with LVN A (on the telephone) on 09/20/2025 at 4:58 pm when asked when his last day of work was, he stated he worked 08/16/2025 from 10:00 pm until 6:30 am on 08/17/2025.This was determined to be an IJ on 09/20/2025 at 8:07 pm. The Administrator, the DON and RDO were notified, and the Administrator was provided with the IJ template on 09/22/2025 at 3:35 pm.In an interview with the RDO on 09/21/2025 at 10:55 am he said that staff members are suspended for any alleged allegation of abuse or neglect, to protect the residents from any further abuse, neglect or harm. He said the guidelines for suspension are to be made in person, if not possible, by phone, but a disciplinary form should be filled out to document the disciplinary action and conclusion. He said he felt it was lack of oversight from the Administrator and DON, to ensure the suspension was enacted and followed up with the staff (member) to make sure.The following Plan of Removal was submitted by the facility and accepted on 09/21/2025 at 4:37 pm:Plan of RemovalThe facility failed when Nurse A worked an additional shift and the Administrator and DON did not ensure that any further potential abuse and neglect, exploitation or mistreatment was prevented. The facility failed to monitor the suspended Nurse A was not completed. The facility failed to ensure that all residents have the right to be free from abuse and neglect. The facility failed to ensure that the procedure for the Facility Abuse Investigation and Reporting Policy by The Administrator and Director of Nursing ensures ongoing investigation and corrective measures completed.The Administrator and DON were educated on Immediate Reporting & Follow-Up Procedure - Abuse Prevention remove the risk and ensure no further abuse occurs through prompt protective measures, leadership oversight, and staff accountability. The RDO provided re-education to the administrator and DON on 09/21/25.The RDO completed education and competencies material understanding suspensions to ensure the Administrator and Director of Nursing understand to ensure abuse neglect, reporting completed on 09/21/2025.Summary of IJ and corrective action to be reviewed by QAPI committee ongoing moving forward to ensure ongoing compliance. The Administrator, Director of Nursing and/or HR oversee notify the RDO of all suspensions. The administrator and DON will have the suspension check sheet signed and dates and sent to the RDO. HR in conjunction with all managers, as soon as she gets suspension, remove them from the system, fill out the suspension form and post suspension alert, alert all staff with our group messaging that the individual is suspended and is not allowed in the building pending the investigation. All managers and managers on duty will be alerted by HR who should be and who shouldn't be working when a suspension occurs and will revoke their access. The Administrator and DON are responsible for informing the employee clearly of the suspension and reason, providing written suspension notice to the employee document time, date, and persons present during communication, notify HR for personal records update. In conjunction with HR and the RDO, they will make sure their access is removed from the system with documentation emailed completion to the RDO. The Administrator and DON will start the investigation. The RDO will do daily calls with Human Resources on all personal items and suspensions incidents, along with weekly audits to review suspensions by monitoring time sheets, all investigations, incidents accidents and self-reports. Suspensions require suspension forms filled out signed and dated, alert all managers and staff through group messaging that the individual is suspended and not allowed in the building pending the investigation and the suspension alert forms for staff posted. The Medical Director was notified of the new IJ and plan of removal on 09/21/2025. Monitoring of the POR included the following:In an interview with the Administrator on 09/21/2025 at 4:45 pm she stated that she received training from the RDO about reporting and follow up for Abuse Prevention and she did a written quiz on ANE, and she said the facility now has a check list to make sure that suspensions, staff education, internal facility actions are carried out in a professional fashion. She stated that her training was a good refresher.In an interview with the DON on 09/21/2025 at 4:55 am she stated that she received ANE training this morning on how to conduct the investigations, protocol and who to contact upon suspension of a staff member (The Administrator, RDO and the staff members to be suspended). She said that she had taken a written test in conjunction with training, that the training and protocols being put into place now will stop another incident like this from occurring in the future. She stated that she did not learn anything new, but it was a good refresher.In an interview with the Administrator on 09/22/2025 at 1:01 pm she stated that she is aware of the new forms, and after that the staff member is immediately suspended, the RDO and HR are notified to make sure that the identified suspended staff member is not on the premises during the course of investigation.In an interview with the DON on 09/22/2025 at 1:05 pm she said that she had also received the new training and described the new process in the same manner as the Administrator.In an interview with the RDO on 09/22/2025 at 1:15 pm he said that the suspension protocol is that the Administrator and DON notify him and HR and then they document the contacted staff member who is suspended and make sure the document is signed and dated. We, with HR, will make sure everyone is informed.Record review of Immediate Reporting and Follow-Up Procedure, revealed in-services were conducted with the Administrator and DON by the RDO and interviews with the Administrator and DON revealed they understood the training they received. An IJ was identified on 09/20/2025. The IJ template was provided to the Administrator on 09/20/2025 at 8:07 pm. While the IJ was removed on 09/22/2025, the facility remained out of compliance at a scope of isolated and a severity level of potential for more than minimal harm that is not immediate jeopardy, because the facility allowed the alleged perpetrator to remain in the facility and to have direct contact with other residents on 08/16/2025 and 08/17/2025.

Based on interviews and record reviews the facility failed to ensure each resident had the right to be free from neglect. For one resident (Resident #1) out of 5 residents reviewed for deprivation of goods and services. LVN A failed to follow protocol after Resident #1 had a fall. LVN A picked Resident #1 off the floor and returned her to her bed without conducting an assessment and reporting the incident to RP, DON, and Physician. This resulted in Resident #1 not being diagnosed with a fracture on her left hip and a right dislocated shoulder for 11 hours.An IJ was identified on 09/19/2025, the IJ template was provided to the facility on [DATE] at 3:35 p.m. While the IJ was removed on 9/22/2025. The facility remained out of compliance at a scope of isolated with the severity level at a potential for more than minimal harm that is not immediate jeopardy, because all staff had not been trained.This failure has the potential to result in serious injury or death as a result of abuse and neglect.Findings include:Record review of Resident #1's quarterly MDS, dated [DATE], reflected Resident #1 was an [AGE] year-old female with an initial admission date of 04/12/2023 with a diagnosis of muscle weakness, Alzheimer's disease, hypothyroidism (when your thyroid gland doesn't make enough thyroid hormones to meet your body's needs), unspecified lack of coordination, other abnormalities of gait and mobility, and chronic kidney disease. She had a BIMS score of 2 which indicates severe cognitive impairment. Resident #1 required supervision or touching assistance with toileting hygiene, oral hygiene, and eating and partial/moderate assistance where an employee does less than half the work showering or bathing, upper and lower body dressing, and personal hygiene. Resident #1 walked with a walker. Record review of Resident #1's quarterly MDS, dated [DATE], reflected Resident #1 had a BIMS score of 2 which indicates severe cognitive impairment. Resident #1 required substantial/maximal assistance (help of 1-2 staff members) with showers, toileting hygiene, oral hygiene and sitting to standing position. Resident #1 was listed as needing a wheelchair. New diagnosis of displaced intertrochanteric fracture of unspecified femur (a severe fracture of the upper part of the thigh bone), and pain in left hip. Record review of Resident #1's care plan dated initiated 04/14/2023 and revised on 08/13/2024 revealed a focus for Resident #1 is a high fall risk. She had a fall at home prior admitting to hospital and coming here to facility Her fall before admission facility resulted to a (right) humerus fracture. The intervention for this goal was anticipate and meet her needs, follow facility fall protocol, (and) PT evaluate and treat as ordered or PRN.Record review of facility PIR dated 08/22/2025, with an allegation of neglect, reflected that Resident #1 sustained a fall in her room on 08/16/2025 at approximately 5:00 am. When the family notified the facility staff of Resident #1's fall, staff completed an x-ray. The x-ray revealed that the resident sustained a femur fracture. Resident #1 was expected to return to the facility upon completion of hospital stay. In service was completed for falls and Social Worker completed safe survey's which showed no trend. Action taken post-investigation revealed continued fall education and monitor resident for further healing during the process. LVN A's witness statement included in the PIR, not dated, or signed, revealed LVN A went into Resident #1's room and saw that she was on the floor between her bed and her roommate's bed. The resident was placed back in bed. LVN A was going to come back to assess her but became busy and forgot to assess her. The facility found the allegation to be confirmed. Safe surveys in the PIR dated 08/19/2025 indicated the residents felt safe, they knew who to report concerns to and would inform staff if they didn't feel safe. In service on ANE and falls was conducted on 08/18/2025 and 08/19/2025 and quizzes were given to staff which revealed that the staff understood the training. A witness statement included in the PIR, dated 08/18/2025 signed by the Administrator, reflected the Administrator attempted to speak to Resident #1 with her family member as a translator and she didn't remember falling or what she was doing before she fell. While reviewing the PIR there the facility did not include what they were doing to prevent this from occurring again other than in-servicing staff.Record review of Resident #1's progress notes revealed no evidence that LVN A reported a fall or completed any assessments for Resident #1. Record review of Resident #1's progress note dated 08/16/2025 at 8:18 pm written by RN B revealed at approximately 4:00 PM Resident #1's family member told RN B that Resident #1 was observed on the floor at around 5:15 am. Vital signs taken, hypotensive at 94/55, no visible signs of injury. She had limited ROM to LLE due to pain. Family at bedside and aware. The Physician was notified, and RN B was told to transfer Resident #1's to the hospital. Resident #1 transferred to the hospital at 8:04 pm. On 08/17/2025 at 10:05 am RN B documented that he called the hospital for an update on Resident #1 and was told she was admitted . (Approximately 11 hours after family said she fell.)Record review of the facility fall report dated 08/16/2025 found RN B documented an unwitnessed fall for Resident #1. Record review of hospital notes with a date of service 08/16/2025 at 10:42 pm revealed anterior shoulder dislocation.acute intertrochanteric fracture of the left femur (a break in the bone just below the hip joint).In an interview with the DON on 09/18/2025 at 12:10 pm the DON said she received a call from RN B on 08/16/2025 around 5:00 pm and he said that Resident #1's family member told him that Resident #1 had fallen around 5:00 am. RN B reported that LVN A had found Resident #1 on the floor and didn't report or assess the fall. When RN B called the DON, an in-house x-ray had been ordered and once it was determined that her femur was broken, RN B sent her to the ER. When asked what the protocol was when a resident has an unwitnessed fall, she said an assessment is completed, ask another staff member to assist with moving the resident, do a head to toe, complete an incident report, call the family, the DON, and the Physician. She said an in-service was completed for fall protocol, abuse, and neglect, but wasn't sure of the date it was completed. She said LVN A was terminated after the facility investigation.Record review of LVN A's Employee Disciplinary Action, dated 08/19/2025 reflected Nurse fail(s) to assess the resident when resident was observed by nurse on the floor got her up and place(d) her in bed. Date of violation 8/16/2025. LVN A was terminated. LVN A's comments: Will be more competent in my approach and be more mindful of my actions. LVN A signed the disciplinary action.In an interview with the Administrator on 09/18/2025 at 5:10 pm she stated that she and the DON investigated the fall for Resident A. She stated that she had discovered that LVN A worked the night of 08/16/2025 from looking at the timecards. She stated that the DON called her about Resident #1's fall. She stated the DON conducted in-services for Resident #1's fall, she stated that they covered what to do for falls and not picking up residents until assessed. She stated that the in-services had started on the weekend, possibly the 18th or the 19th. She stated the normal protocol for in-services for falls or incidents is they start as quickly as possible if not immediately. She stated that after the in-services that they try to continue the education by doing quizzes. She stated that LVN A told her directly that he had picked her up after the fall.In an interview with the DON on 09/19/2025 at 9:50 am she stated that she started her in-service training on the 08/18/2025. She said she didn't come to the facility that weekend and had instructed RN B about what to do to address the incident.In an interview with RN B, on 09/19/2025 at 10:02 am RN B said Resident #1's family member told him around 4:00 pm that Resident #1 had fallen early in the morning, he asked them how they knew, the family member said from the video in the resident's room. RN B completed an incident and accident report and immediately assessed the resident, found she had pain, notified the DON and Physician, and the Physician ordered an x-ray. RN B said the x-ray results were provided not too long afterwards which showed a fracture of the left hip. RN B said he contacted the Physician with the results of the x-ray and the Physician said to transfer Resident #1 to the hospital. RN B said Resident #1 left the facility around 8:00 pm. RN B said LVN A didn't tell him about Resident #1's fall. RN B said on 08/25/2025 he said the hospital told him about the dislocated shoulder. RN B reported he didn't notice a change in condition of Resident #1 prior to being told about her fall.In an interview with CNA J on 09/19/2025 at 4:57 pm he reported that he didn't notice a change in condition of Resident #1 prior to being told about her fall and said Resident #1 eats her breakfast and lunch in her room. He said her son takes the food tray from him and does all the set up and assists her with setting up her tray for meals.In an interview on 09/20/2025 at 9:55 am with the Activity Director she said prior to Resident #1's fall she'd come to activities but didn't participate, she'd watch but she participated in social celebrations, like birthdays. She said since her fall she hasn't participated in activities, she said she's asked if she wanted to participate but she's declined. The Activity Director said she did one-on-one activities with Resident #1 such as talking with her and discussing current events. In an interview with CNA F on 09/20/2025 at 10:45 am she reported that she didn't notice a change in condition of Resident #1 prior to being told about her fall and said Resident #1 eats her breakfast and lunch in her room, she said her son takes the food tray from her and does the set up and assists her with setting up her tray for meals.In an interview on 09/20/2025 at 12:31 pm with LVN A over the phone, he stated on 08/16/2025 that Resident #1's roommate found him between 3:00 am and 4:00 am, he said he found Resident #1 on the floor and put her back into bed. He said he left because he had been working on a trach, and he had to go back to suctioning. He said, I take full credit for leaving her, I made a mistake. He added that he didn't pass the information on to RN B about the fall. He said he knew he should have reported it to the next nurse, documented it, and made sure that the DON and Physician also knew. In an interview with CNA C on 09/20/2025 at 3:59 pm she reported that she didn't notice a change in the way Resident #1 was moving or behaving prior to being told about her fall and said Resident #1 eats her breakfast and lunch in her room, that her son takes the food tray from her and does the set up and assists her with setting up her tray for meals.Record review of the facility Falls and Fall Risk Managing policy dated 2001 Definition according to the MDS a fall is defined as unintentionally, coming to rest on the ground, floor, or other lower level, but not as a result of an overwhelming external force. A fall without injury is still a fall. Unless there is evidence suggesting otherwise, when a resident is found on the floor, a fall is considered to have occurred. There is nothing in the Falls and Fall Risk Managing policy that explains what staff members should do when a resident is found to have fallen.This was determined to be an IJ on 09/19/2025 at 2:55 pm. The Administrator and the DON were notified, and the Administrator was provided with the IJ template on 09/19/2025 at 3:35 pm.The following Plan of Removal was submitted by the facility and accepted on 09/20/2025 at 4:50 pm:Resident #1 sustained a fall and was placed back into bed by a nurse who failed to assess her. The resident's family notified the facility later onto the next shift that the resident had fall on video camera. Resident #1 had x-rays completed, notification to appropriate parties, and sent out to the hospital at this time. Resident #1 sustained a femur fracture and shoulder dislocation on 08/16/2025. Facility monitoring was not completed immediately. The facility failed to ensure that all residents have the right to be free from abuse and neglect. Facility failed to ensure that resident #1 was assessed or reported nor documented by the nurse on shift.1. The medical director was notified of IJ on 09/19/2025 at 4:00 pm.2. The Administrator and DON contacted the RDO and vice president regarding the IJ on 09/19/2025 per the lack of monitoring practices of the fall. The RDO and VP provided re-education to the administrator and DON on 09/19/2025.3. In-service conducted by the Director of Nursing with RNs and LVNs on assessment of residents when a fall has occurred and where to document assessments initiated on 09/19/2025 and will end on 09/20/2025. The training will include not picking up residents off of the floor without assessment for injuries, vital signs, etc. Resident #1 was found on the floor in her room by the nurse without proper assessment before placing the resident back into bed. The training will also ensure nurses are aware of the proper area in the EMR system to document the fall assessments. Incident reports and the SBAR report will be shown for any changes in condition. A checklist will be created for competencies for the RNs and LVNs with the director of nursing signing off. The nurses will show demonstration of the training by showing the DON where the assessments are located in the EMR system. This training will diligently explain that the nurses are to assess all residents prior to picking them up off of the floor such as the case with Resident #1. The nurses will verify understanding by returned demonstration on a staff member during a mock training with a staff member being on the floor and showing the assessment, such as taking vital signs, etc. The nurses will also be trained on who to notify during these assessments and will be shown the area where to place notation of all parties notified, including the responsible parties, physician, Director of Nursing, administrator, etc.4. In-service initiated by the administrator with all staff regarding abuse and neglect. This will be initiated on 09/19/2025 and will end on 09/20/2025. All staff will be trained on who the abuse coordinator is, the time frame to report abuse, neglect, or exploitation, the definition of ANE, and the different types of abuse. Staff will complete a quiz to verify understanding.5. In-service all nurses (RN and LVN) on fall policies and procedures. The training will be conducted by the Director of Nursing and will start from 09/19/2025-09/20/2025. The DON will verify understanding by having the nurses complete a quiz over fall policies.6. DON and/or designee, including the registered nurse supervisor on the weekends, will round daily on all residents to ask if they have observed any falls or any evidence of falls or injuries. The DON will train the RN supervisor via checklist of how to complete rounds, what questions to ask residents, and signs or symptoms of pain to look for. This will be initiated on 09/19/2025 and end on 09/20/2025. This will include all shifts, including weekends. If there are negative findings, we will take the appropriate steps as listed on the fall policy and procedure. Residents that are unable to communicate will be given a communication board for communication. The residents that are unable to utilize a communication board will be assessed for any change in conditions, such as grimacing.7. All nursing staff to be in-serviced in the above-mentioned areas prior to working the next assigned shift by the Director of Nursing, who will verify training completion. The DON will ensure all nurses have completed the fall quizzes.8. LVN A was terminated by facility on 08/19/2025.9. Director of Nursing and/or designee will be observing fall policies and protocols daily for one week and then 3x/ week thereafter for the next 30 days. The staff will be interviewed for facility fall protocols and procedures. The administrator will monitor that the DON monitors the nursing staff by reviewing the checklist and signing off. The DON will use a monitoring tool for each resident spoken to about any physical signs, restricted movement, and/or pain that they may have.10. Summary of IJ and corrective action to be reviewed by QAPI committee weekly x4 weeks or until substantial compliance is established and continued monthly for 90 days to ensure ongoing compliance. Any deficient practice will be discussed with the medical director at the time of occurrence and will also mention during the QAPI meeting. The Monitoring checklist will be reviewed at the QAPI meeting.Monitoring of the POR included the following:In an interview on 09/20/2025 at 7:30 pm the DON stated in-services were completed on all nursing staff.Record review of all in-service rosters, checklists, policies and in-services revealed in-services and quizzes were conducted with nursing staff by the DON and completed for fall protocol and ANE. Interviews were conducted between the dates of 09/20/2025 at 7:45 pm and 09/22/25 at 3:00 pm with 26 nursing staff members out of 31 nursing staff members, were asked the following questions:All:u Title/Name/Length of time at the facility?u Did you receive training on fall protocol, abuse, and neglect?u Did you take a quiz or answer questions about your training?u What is a fall?u Did you learn anything new from your latest in-services?u If you see a fall or find a resident on the floor, what do you do?u What if you see a fall?u Who do you report incidents/accident to?u Who is the abuse coordinator?DON, RN B, CNA C, CNA D, CNA E, CNA F, CNA G, CNA H, CNA I, CNA J, LVN K, RN L, CNA M, LVN N, RN O, LVN P, CNA Q, CNA R, CNA S, LVN T, CNA U, LVN V, LVN W, LVN X, CNA Y, and CNA Z representing and interviewed during the 6:00 AM to 2:00 PM, 2:00 PM to 10:00 PM and the 10:00 PM to 6:00 AM shifts, were able to answer all questions in a satisfactory manner that suggested training had been conducted and understood, written competencies had been conducted and completed.An IJ was identified on 09/19/2025, the IJ template was provided to the Administrator on 09/19/2025 at 3:35 pm. While the IJ was removed on 9/22/2025, the facility remained out of compliance at a scope of isolated with the severity level at a potential for more than minimal harm that is not immediate jeopardy, because all staff had not been trained.

Based on interviews and record reviews LVN A failed to assess Resident #1 which prevented her from receiving timely treatment. LVN A failed to follow protocol after Resident #1 had a fall. LVN A picked Resident #1 off the floor and returned her to her bed without conducting an assessment and reporting the incident to RP, DON, and Physician. This resulted in Resident #1 not being diagnosed with a fracture on her left hip and a right dislocated shoulder for 11 hoursFindings include:Record review of facility PIR dated 08/22/2025, with an allegation of neglect, reflected that Resident #1 sustained a fall in her room on 08/16/2025 at approximately 5:00 am. When the family notified the facility staff of Resident #1's fall, staff completed an x-ray. The x-ray revealed that the resident sustained a femur fracture. Resident #1 was expected to return to the facility upon completion of hospital stay. In service was completed for falls and Social Worker completed safe survey's which showed no trend. Action taken post-investigation revealed continued fall education and monitor resident for further healing during the process. LVN A's witness statement included in the PIR, not dated, or signed, revealed LVN A went into Resident #1's room and saw that she was on the floor between her bed and her roommate's bed. The resident was placed back in bed. LVN A was going to come back to assess her but became busy and forgot to assess her. The facility found the allegation to be confirmed. Safe surveys in the PIR dated 08/19/2025 indicated the residents felt safe, they knew who to report concerns to and would inform staff if they didn't feel safe. In service on ANE and falls was conducted on 08/18/2025 and 08/19/2025 and quizzes were given to staff which revealed that the staff understood the training. A witness statement included in the PIR, dated 08/18/2025 signed by the Administrator, reflected the Administrator attempted to speak to Resident #1 with her family member as a translator and she didn't remember falling or what she was doing before she fell. While reviewing the PIR there the facility did not include what they were doing to prevent this from occurring again other than in-servicing staff.Record review of Resident #1's progress notes revealed no evidence that LVN A reported a fall or completed any assessments for Resident #1. Record review of LVN A's Employee Disciplinary Action, dated 08/19/2025 reflected Nurse fail(s) to assess the resident when resident was observed by nurse on the floor got her up and place(d) her in bed. Date of violation 8/16/2025. LVN A was terminated. LVN A's comments: Will be more competent in my approach and be more mindful of my actions. LVN A signed the disciplinary action.In an interview with RN B, on 09/19/2025 at 10:02 am RN B said Resident #1's family member told him around 4:00 pm that Resident #1 had fallen early in the morning, he asked them how they knew, the family member said from the video in the resident's room. RN B completed an incident and accident report and immediately assessed the resident, found she had pain, notified the DON and Physician, and the Physician ordered an x-ray. RN B said the x-ray results were provided not too long afterwards which showed a fracture of the left hip. RN B said he contacted the Physician with the results of the x-ray and the Physician said to transfer Resident #1 to the hospital. RN B said Resident #1 left the facility around 8:00 pm. RN B said LVN A didn't tell him about Resident #1's fall. RN B said on 08/25/2025 he said the hospital told him about the dislocated shoulder. RN B reported that despite her injuries he didn't notice a change in condition of Resident #1 prior to being told about her fall.In an interview with CNA J on 09/19/2025 at 4:57 pm he reported that he didn't notice a change in condition of Resident #1 prior to being told about her fall and said Resident #1 eats her breakfast and lunch in her room. He said her son takes the food tray from him and does all the set up and assists her with setting up her tray for meals.In an interview with CNA F on 09/20/2025 at 10:45 am she reported that she didn't notice a change in condition of Resident #1 prior to being told about her fall and said Resident #1 eats her breakfast and lunch in her room, she said her son takes the food tray from her and does the set up and assists her with setting up her tray for meals.In an interview with CNA C on 09/20/2025 at 3:59 pm she reported that she didn't notice a change in the way Resident #1 was moving or behaving prior to being told about her fall and said Resident #1 eats her breakfast and lunch in her room, that her son takes the food tray from her and does the set up and assists her with setting up her tray for meals.In an interview on 09/20/2025 at 12:31 pm with LVN A over the phone, he stated on 08/16/2025 that Resident #1's roommate found him between 3:00 am and 4:00 am, he said he found Resident #1 on the floor and put her back into bed. He said he left because he had been working on a trach, and he had to go back to suctioning. He said, I take full credit for leaving her, I made a mistake. He added that he didn't pass the information on to RN B about the fall. He said he knew he should have reported it to the next nurse, documented it, and made sure that the DON and Physician also knew. This was determined to be an IJ on 09/19/2025 at 2:55 pm. The Administrator and the DON were notified, and the Administrator was provided with the IJ template on 09/19/2025 at 3:35 pm.The following Plan of Removal was submitted by the facility and accepted on 09/20/2025 at 4:50 pm:Resident #1 sustained a fall and was placed back into bed by a nurse who failed to assess her. The resident's family notified the facility later onto the next shift that the resident had fall on video camera. Resident #1 had x-rays completed, notification to appropriate parties, and sent out to the hospital at this time. Resident #1 sustained a femur fracture and shoulder dislocation on 08/16/2025. Facility monitoring was not completed immediately. The facility failed to ensure that all residents have the right to be free from abuse and neglect. Facility failed to ensure that resident #1 was assessed or reported nor documented by the nurse on shift.1. The medical director was notified of IJ on 09/19/2025 at 4:00 pm.2. The Administrator and DON contacted the RDO and vice president regarding the IJ on 09/19/2025 per the lack of monitoring practices of the fall. The RDO and VP provided re-education to the administrator and DON on 09/19/2025.3. In-service conducted by the Director of Nursing with RNs and LVNs on assessment of residents when a fall has occurred and where to document assessments initiated on 09/19/2025 and will end on 09/20/2025. The training will include not picking up residents off of the floor without assessment for injuries, vital signs, etc. Resident #1 was found on the floor in her room by the nurse without proper assessment before placing the resident back into bed. The training will also ensure nurses are aware of the proper area in the EMR system to document the fall assessments. Incident reports and the SBAR report will be shown for any changes in condition. A checklist will be created for competencies for the RNs and LVNs with the director of nursing signing off. The nurses will show demonstration of the training by showing the DON where the assessments are located in the EMR system. This training will diligently explain that the nurses are to assess all residents prior to picking them up off of the floor such as the case with Resident #1. The nurses will verify understanding by returned demonstration on a staff member during a mock training with a staff member being on the floor and showing the assessment, such as taking vital signs, etc. The nurses will also be trained on who to notify during these assessments and will be shown the area where to place notation of all parties notified, including the responsible parties, physician, Director of Nursing, administrator, etc.4. In-service initiated by the administrator with all staff regarding abuse and neglect. This will be initiated on 09/19/2025 and will end on 09/20/2025. All staff will be trained on who the abuse coordinator is, the time frame to report abuse, neglect, or exploitation, the definition of ANE, and the different types of abuse. Staff will complete a quiz to verify understanding.5. In-service all nurses (RN and LVN) on fall policies and procedures. The training will be conducted by the Director of Nursing and will start from 09/19/2025-09/20/2025. The DON will verify understanding by having the nurses complete a quiz over fall policies.6. DON and/or designee, including the registered nurse supervisor on the weekends, will round daily on all residents to ask if they have observed any falls or any evidence of falls or injuries. The DON will train the RN supervisor via checklist of how to complete rounds, what questions to ask residents, and signs or symptoms of pain to look for. This will be initiated on 09/19/2025 and end on 09/20/2025. This will include all shifts, including weekends. If there are negative findings, we will take the appropriate steps as listed on the fall policy and procedure. Residents that are unable to communicate will be given a communication board for communication. The residents that are unable to utilize a communication board will be assessed for any change in conditions, such as grimacing.7. All nursing staff to be in-serviced in the above-mentioned areas prior to working the next assigned shift by the Director of Nursing, who will verify training completion. The DON will ensure all nurses have completed the fall quizzes.8. LVN A was terminated by facility on 08/19/2025.9. Director of Nursing and/or designee will be observing fall policies and protocols daily for one week and then 3x/ week thereafter for the next 30 days. The staff will be interviewed for facility fall protocols and procedures. The administrator will monitor that the DON monitors the nursing staff by reviewing the checklist and signing off. The DON will use a monitoring tool for each resident spoken to about any physical signs, restricted movement, and/or pain that they may have.10. Summary of IJ and corrective action to be reviewed by QAPI committee weekly x4 weeks or until substantial compliance is established and continued monthly for 90 days to ensure ongoing compliance. Any deficient practice will be discussed with the medical director at the time of occurrence and will also mention during the QAPI meeting. The Monitoring checklist will be reviewed at the QAPI meeting.Monitoring of the POR included the following:In an interview on 09/20/2025 at 7:30 pm the DON stated in-services were completed on all nursing staff.Record review of all in-service rosters, checklists, policies and in-services revealed in-services and quizzes were conducted with nursing staff by the DON and completed for fall protocol and ANE. Interviews were conducted between the dates of 09/20/2025 at 7:45 pm and 09/22/25 at 3:00 pm with 26 nursing staff members out of 31 nursing staff members, were asked the following questions:All:u Title/Name/Length of time at the facility?u Did you receive training on fall protocol, abuse, and neglect?u Did you take a quiz or answer questions about your training?u What is a fall?u Did you learn anything new from your latest in-services?u If you see a fall or find a resident on the floor, what do you do?u What if you see a fall?u Who do you report incidents/accident to?u Who is the abuse coordinator?DON, RN B, CNA C, CNA D, CNA E, CNA F, CNA G, CNA H, CNA I, CNA J, LVN K, RN L, CNA M, LVN N, RN O, LVN P, CNA Q, CNA R, CNA S, LVN T, CNA U, LVN V, LVN W, LVN X, CNA Y, and CNA Z representing and interviewed during the 6:00 AM to 2:00 PM, 2:00 PM to 10:00 PM and the 10:00 PM to 6:00 AM shifts, were able to answer all questions in a satisfactory manner that suggested training had been conducted and understood, written competencies had been conducted and completed.An IJ was identified on 09/19/2025, the IJ template was provided to the DON on 09/19/2025 at 3:35 pm. While the IJ was removed on 9/22/2025, the facility remained out of compliance at a scope of isolated with the severity level at a potential for more than minimal harm that is not immediate jeopardy, because all staff had not been trained.

Based on interview and record review, the facility failed to use the services of a registered nurse for at least 8 consecutive hours a day, 7 days a week for 10 days of 60 days reviewed for RN coverage.This failure placed residents at risk of missed nursing assessments, interventions, care, and treatment.Based on interview and record review, the facility failed to use the services of a registered nurse for at least 8 consecutive hours a day, 7 days a week for 10 days of 60 days reviewed for RN coverage.This failure placed residents at risk of missed nursing assessments, interventions, care, and treatment.Findings included:The facility failed to ensure they had an RN on duty on 01/18 (SAT); 01/19 (SUN); 01/25 (SAT); 01/26 (SUN); 02/01 (SAT); 02/02 (SUN); 05/10 (SAT); 05/11 (SUN); 05/17 (SAT) and 05/18 (SUN).Review of staffing hours for January and May of 2025 reflected zero hours worked by an RN on the dates of 01/18 (SAT); 01/19 (SUN); 01/25 (SAT); 01/26 (SUN); 02/01 (SAT); 02/02 (SUN); 05/10 (SAT); 05/11 (SUN); 05/17 (SAT) and 05/18 (SUN).In an interview on 09/18/2025 at 11:17 AM the BOM revealed that he was aware of the missed days for RN hours and that the weekend charge nurse had quit and it had taken the facility some time to find a replacement. He stated that it could have been an issue because of a possible lack of supervision, and that assessments may not have been sufficient, and that interventions, care, and treatment may have been lacking in some fashion because of the absence of a registered nurse on those days.During an interview on 09/18/2025 at 11:43 AM the ADM stated that it is important to have an RN in the facility because they are licensed to do more for the residents than the LVN's can do especially assessments. We did have an RN resign earlier in the year and we did not have an RN for full coverage for some time. I know that we are supposed to have an RN every day and that not having an RN could affect the health and welfare of the residents.Record review of facility policy dated August 2023 reflected the following, Policy Statement: The nursing services department shall be under the direct supervision of a registered or licensed practical/vocational nurse at all times. Policy Interpretation and Implementation: 1. A registered or licensed practical/vocational nurse (RN/LPN/LVN) is on duty 24 hours per day, seven days per week, to supervise the nursing services activities in accordance with physician orders and facility policy. 2. A registered nurse (RN) is employed as the Director of Nursing Services. The DNS is on duty during the day shift Monday through Friday. During the absence of the DNS, a nurse supervisor/charge nurse is responsible for the supervision of all nursing department activities, including the supervision of direct care staff. 3. The nurse supervisor/charge nurses are registered nurses (RN) or licensed practical vocational nurses (LPN/LVN), and are duly licensed by the state. 4. The Director of Nursing Services and/or the nurse supervisor/charge nurse, as a minimum, is responsible for: a. making daily resident visits to observe and evaluate the residence, physical and emotional status; b. reviewing medication, cards for completeness of information, accuracy in the transcription of physician orders, and adherence to stop order policies;c. reviewing individual, resident care, plans for appropriate goals, problems, approaches, and revisions, based on nursing needs; d. Assuring that the residence plan of care is being followed; e. arranging schedule to allow time for supervision and evaluation of performance of nursing personnel, and paid feeding assistants; f. informing attending physicians and resident families of changes in the residence, medical condition; g. charting and documenting medical records as necessary; h. keeping Nursing Service Personnel, informed of status of residence, and other related matters through written reports and verbal communication; i. Assigning work schedules and staffing to meet the needs of residence; providing direct resident care as necessary or appropriate; j. and other tasks and functions, that may become necessary.

Based on observation, interview and record review the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for four of four ( Resident #46, #16, #17, and #54) and two of three (DA A and DA B) staff members reviewed for infection control procedures. Dietary Aide A failed to perform hand hygiene after direct contact with Residents #46 and #16 while serving meals in the main dining room.Dietary Aide B failed to perform hand hygiene after direct contact with Residents #17 and #54 while serving meals in the main dining room. This failure could place residents at risk for healthcare associated cross contamination and infections. Findings included:Record review of Resident #46's quarterly MDS assessment, dated 09/04/25, revealed a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #46 had diagnosis which included: dementia (brain confusion), hypertension (increased blood pressure), and diabetes (increased sugar levels). Resident #46 had severe cognitive impairment and required assistance of one staff for activities of daily living. Record review of Resident #16's quarterly MDS Assessment, dated 07/03/25, revealed a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #16 had diagnosis which included: dementia (brain disease that affects memory and behaviors), atrial fib (abnormal heart rhythm), hypertension (increased blood pressure), and depression (mood disorder). Resident #16,had moderate cognition impairment and required one staff for assistance with activities of daily living. Record review of Resident #17's annual MDS Assessment, dated 09/14/25, revealed a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #17 had diagnosis which included: Cardiovascular accident (stroke), heart failure, atrial flutter (irregular rhythm of the heart), and diabetes (increased sugar levels). Resident #17 was severely impaired for cognition and required one staff for assistance with activities of daily living. Record review of Resident #54's quarterly MDS Assessment, dated 07/25/25, revealed a [AGE] year-old male who admitted to the facility on [DATE]. Resident #54 had diagnosis which included: Hypertension (high blood pressure), depression (mental illness), and dementia (brain disease that affects memory and behavior). Resident #54 was cognitively able to make decisions and required assistance of one staff for activities of daily living. Observation on 09/17/25 beginning at 12:00 p.m. revealed DA A had adjusted her clothing, did not use hand sanitizer, and served a lunch tray to Resident #46. DA A touched the hand and shoulder of Resident #46 and prepared the meal tray for the resident to eat her lunch. DA A did not have on gloves. DA A was observed not to wash her hands or use hand sanitizer, available in the dining room. DA A walked over the serving cart that had lunch trays on the cart and took another tray off the cart serving the lunch meal to Resident #16. DA A touched Resident 16's edge of the dining table, unwrapped the eating utensils, and then took the lids off the dessert bowl. DA A left the resident's table without using hand sanitizer. Observation on 09/17/25 beginning at 12:20 p.m., DA B was observed coming out of the kitchen with a serving cart, with lunch meals on the cart. DA B was observed to serve Resident's #17's, setting up the resident's lunch tray, adjusting the chair at the table, and unwrapped the utensils removed tops off drinks, for the resident. She did not complete hand hygiene before going to the next resident. DA B served Resident #54's lunch meal, unwrapping his eating utensils and taking the lids off the drinks and the wrap off the top for the dessert. An interview on 09/17/25 at 1:45 p.m., DA A stated she did not complete hand hygiene after having direct contact with residents. DA A stated she was supposed to use the hand sanitizer in between serving each tray from the cart. She stated she washed her hands after having direct contact with the residents when she went back into the kitchen. DA A said she had been educated on completing hand hygiene, by the Dietary Manager. DA A stated the Dietary Manger had told her to always before she left the kitchen to serve the trays off the cart, she must wash her hands, she never said anything about using hand sanitizer between each tray served. DA A stated she did not sanitize her hands, because she was nervous and trying to get the lunch trays served. DA A stated if she did not wash or [NAME] her hands she could spread germs. An interview on 09/17/25 at 1:50 p.m., DA B stated she did not complete hand hygiene in the dining room after having direct contact with the residents. DA B stated she had washed her hands in the kitchen before coming out with the cart to serve the trays. After serving trays DA B stated she washes her hands when she goes back in the kitchen with the cart to get more lunch trays. DA B stated she thought before and after serving was enough, she did not realize you are supposed to use hand sanitizer or wash your hands in between each lunch tray. DA B stated the Dietary Manager had told her to always wash her hands before leaving the kitchen to serve the trays in the dining room, she never mentioned anything about cleaning your hands between each tray served. DA B stated if your hands are not clean you can spread germs to others. An interview with the DON on 09/17/25 at 2:13 p.m. revealed that all staff must complete hygiene after having contact with residents. She stated DAs were trained to use hand sanitizer between each tray that was served. The DON stated she was in the dining room with hand sanitizer available to use, but the kitchen staff did not ask to use it. The DON stated she had the hand sanitizer bottle with her; there was no other available for the dietary aides to use. The DON said the dietary aides should have known they could have gotten the hand sanitizer from me, I was standing there holding the bottle. The DON stated if the DAs do not use appropriate hygiene, they can spread germs to the residents and themselves. The DON clarified she did not have any in-services with the kitchen staff concerning handwashing, the Dietary Manager did. An interview with the Dietary Manger on 09/17/25 at 2:30 p.m., revealed the Dietary Manager had no in-services for hand sanitizing. The Dietary Manager stated, she had instructed all her staff serving meals in the dining room, to wash their hands before going out of the kitchen and when the staff returned to the kitchen. The Dietary manager stated she was unaware that you had to wash hands or use hand sanitizer between each meal tray that was served. The Dietary Manager stated if the hands were not clean the staff could spread germs to the residents and the staff. The Dietary Manager stated she knew the DON had conducted in-services on infection control, but the DON did not let her staff know when those in-services occurred. The Dietary Manger stated now that she knows she will be including this in her conversations she has with her staff, concerning infection control. Review of the facility's policy titled Infection Control dated revised October 2018 reflected, This facility's infection control policies and practices are intended to facilitate maintaining a safe, sanitary, and comfortable environment and to help prevent and manage transmission of diseases and infections. 1. This facility's infection control policies and practices apply to all personnel. 2 The objectives of our infection control policies and practices are to: a. prevent, detect, investigate, and control infections in the facility. b. Maintain a safe, sanitary, and comfortable environment for personnel, residents, visitor, and the general public. 4. All personnel will be trained on our infection control policies and practices upon hire and periodically thereafter.

Based on observation, interview, and record review, the facility failed to ensure medication was stored securely on 1 of 1 medication cart (hall100) reviewed. The facility did not ensure Hall 100 medication cart was locked when unattended. This failure could place residents who reside on hall 100 at risk of drug diversion. Findings Include: Observation on 03/21/2025 at 4:30 AM revealed a medication cart parked on hall 100 and the lock was in the open (unlocked) position. The surveyor was able to open the cart drawers. Observation and interview on 03/21/2025 at 4:32 AM revealed LVN A exited a resident room and approached the medication cart. LVN A stated he was assigned to the medication cart, and it was unlocked. Interview on 03/21/2025 at 5:42 am with LVN A revealed, the medication cart contained wound care supplies, resident medications and narcotics. He stated he forgot to lock the medication cart and that it should always be locked when he walked away from it. He stated the risk was someone could walk by and get into the cart. Interview on 03/21/2025 at 10:10 AM with the DON revealed, the expectation was the medication cart should be locked when staff was not directly working with the cart. It was a HIPPA concern and a medication concern. The risk was a visitor, resident, or inappropriate personnel would get into the cart. Interview on 03/21/2025 at 11:00 AM with Administrator revealed, the medication cart should be locked if it was out of site and not actively working in the cart. Review of policy Storage of Medication revised on April 2019 revealed, the facility stores all drugs and biologicals in a safe, secure, and orderly manner.9. Unlocked medication carts are not left unattended.

Based on observation, interview, and record review the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for one (Resident #1) of three resident reviewed for infection control. The facility failed to ensure on 12/09/24 LVN A avoided taking a bottle of wound cleanser and a tube of medicated cream into the resident's room, and then returning the containers to the treatment cart, which contained treatment supplies for other residents. This failure could place residents at risk of cross-contamination and development of infections. Findings included: Review of Resident #1's Face Sheet, dated 12/09/2024, reflected resident was an [AGE] year-old male admitted on [DATE]. Resident #1 had a diagnosis of left ankle pressure ulcer. Review of Resident #1's Quarterly MDS ( tool used to measure health status) Assessment, dated 11/27/2024, reflected moderate cognitive impairment with a BIMS score of 11. Section M reflected a pressure reducing device for the bed and chair. Review of Resident #1's [NAME] Wound Physician's Order, dated 12/05/2024, reflected NON - PRESSURE WOUND OF THE LEFT, LATERAL ANKLE FULL THICKNESS Primary Dressing(s) Santyl (medicated skin cream) apply once daily for 24 days; Xeroform (non-adherent dressing with antimicrobial) gauze apply once daily for 24 days Secondary Dressing(s) Gauze Island w/ bdr apply once daily for 24 days. Review of Resident #1's Comprehensive Care Plan, dated 12/06/2024, reflected will have intact skin, free of redness, blisters, or discoloration by/through review and one intervention listed was to Follow facility policies/protocols for the prevention/treatment of skin breakdown. Observation and interview on 12/09/24 at 03:05 PM revealed LVN A washed his hands and prepared the items needed for Resident #1's wound care. The medicated cream was stored in a small plastic bowl in the top drawer of the treatment cart. No other items were in the bowl. A spray bottle containing wound cleanser was taken from the top of the medication cart. Other wound care supplies were taken from another drawer of the treatment cart. LVN A did not sanitize the bottle of wound cleanser, the bowl containing the medicated cream, or the tube of medicated cream prior to taking these items into the resident's room. LVN A placed a barrier pad on one side of the resident's bedside table and placed the wound care items on the pad. LVN A did not sanitize the bedside table prior to placing the barrier pad on it. The small bowl containing the tube of medicated cream was placed on the other side of the bedside table where the resident had some personal items. LVN A washed his hands and put on clean gloves. He opened the dressing packages and applied the medicated cream to the xeroform gauze. LVN A adjusted the pillow under the resident's left leg to access the left ankle. LVN A peeled off the old dressing from the resident's left ankle and discarded it. He removed his gloves and washed his hands in the resident's room. He applied clean gloves, sprayed wound cleanser on the wound, and used gauze pads to clean the wound. LVN A washed his hands and put on clean gloves. He applied the xeroform gauze, then the secondary dressing to cover the wound. LVN A washed his hands. LVN A removed the bottle of wound cleanser and medicated cream from the resident's room. He placed the wound cleanser and small bowl containing the medicated cream on top of the treatment cart. He used hand sanitizer to clean his hands. LVN A unlocked the treatment cart and returned small bowl containing medicated cream to the top drawer of the treatment cart. LVN A did not sanitize the bottle of wound cleanser, the bowl containing the medicated cream, or the tube of medicated cream. LVN A stated he had been a nurse for many years and had experience providing wound care. LVN A stated at this facility the night shift nurse performed the wound care, so he did not do wound care. LVN A stated he should have sanitized the items before and after use in the resident's room, or put the medicated cream and wound cleanser in clean medication cups prior to going in the resident's room instead of taking the containers in. He stated this could cause cross contamination since they were taken into the resident's room and returned to the treatment cart. In an interview 12/09/24 at 03:20 PM, the DON stated to prevent cross contamination and for infection control purposes, the spray bottle of wound cleanser and tube of medicated cream should not have been taken into the resident's room and returned to the treatment cart. The DON stated there are small plastic medication cups available for the nurses to place creams or wound cleanser in to take into a resident's room. The DON stated she would in-service the nursing staff regarding this. Review of facility's policy Infection Control Policies and Practices, Revised October 2013, reflected maintain . sanitary environment . to help prevent and manage transmission of diseases and infections.

Based on observations, interviews, and record reviews, the facility failed to ensure the resident had the right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences for two (Residents #1 and #2) of ten residents reviewed for call lights. 1. Resident #1 was observed in bed (closest to the door) and her call light was observed hung on a dresser drawer beside the bed closest to the window separated by a wheelchair and privacy curtain. 2. Resident #2 was observed in bed and her call light was rolled up and hung on the wall between Resident #2's bed and the bed closest to the window. These failures could place residents at risk of not having their needs and preferences met and a decreased quality of life. Finding included: Record review of Resident #1's Face Sheet dated 10/18/2024, reflected a [AGE] year-old female who was admitted to the facility on [DATE]. Diagnoses included: unspecified intracapsular fracture of right femur, (hip fracture) fall on same level from slipping, tripping and stumbling without subsequent striking against object, nontraumatic chronic subdural hemorrhage (collection of blood on the brain's surface), and nondisplaced avulsion fracture (chip fracture) of right talus (bone in foot that connects the ancle to the leg). Record review of Resident #1's baseline care plan dated 10/11/2024 reflected, substantial / maximum assist for eating, hygiene, toileting, showers, dressing, bed mobility, and transfers. She was incontinent of bowel and bladder and cognition reflected impaired and confused. Resident #1 had a history of falls and call light was noted as a safety device used. Record review of Resident #1's progress note, dated 10/11/2024 at 9:38 PM reflected, At [8:00 PM Resident #1] was admitted to the facility from [hospital], DX FOR FALL WITH acute chronic intracranial subdural hematoma, this nurse welcome patient to the facility and instruct patient to always use the call button to call for help to prevent fall, call light at reach and bed on lowest position and will continue to monitor. Record review of Resident #1's fall risk assessment dated [DATE], reflected a sore of 50, which indicated a high risk for falling. Record review of Resident #2's Face Sheet dated 10/18/2024, reflected a [AGE] year-old female who was admitted to the facility on [DATE]. Diagnoses included: acute kidney failure (kidneys stop working suddenly), hemiplegia and hemiparesis following nontraumatic subarachnoid hemorrhage affecting non-dominant left side (one side paralysis), diabetes mellitus (a group of diseases that affect how the body uses sugar), hypomagnesemia (low level of magnesium), muscle weakness, unspecified dementia (a group of symptoms affecting memory, thinking and social abilities), and hypertension (high blood pressure). Record review of Resident #2's significant change MDS, dated [DATE], reflected a BIMS score of 3 which indicated severe cognate impairment. Functional abilities included dependent for toileting, hygiene, dressing and transfers. She was always incontinent of bowel and bladder. Resident #2 had a history of falls in the last month. Record review of Resident #2's care plan dated 09/19/2024 reflected, [Resident #2] demonstrates desire and behavior to lay prone on floor mat for comfort to sleep. Intervention: Anticipate and meet the resident's needs. [Resident #2] will allow staff to assist to desired position on floor mat for rest periods. Focus: [Resident #2] is High risk for falls. [Resident #2] has had an actual fall without injury. Interventions: Be sure [Resident #2's] call light is within reach and encourage the (sic) her to use it for assistance as needed. He (sic) needs prompt response to all requests for assistance. Fall mats to be placed bedside (sic). Record review of Resident #2's fall risk assessment dated [DATE], reflected a sore of 60, which indicated a high risk for falling. In an interview and observation on 10/18/2024 at 9:45am, Resident #3 said Resident #1 recently came to the facility after falling at home and required a lot of assistance. Resident #1 was observed in her bed (lowest position) and Resident #3 was in his wheelchair beside his bed closest to the window. This state surveyor asked Resident #1 if she used her call light to ask for assistance when she needed it, she said she did. Resident #3 said staff always told Resident #1 to ring the call light when she needed assistance. When asked where Resident #1's call button was, Resident #1 looked around and said she did not know. Resident #3 said he was looking for it too. This state surveyor pointed out to both Residents #1 and #3 that the call light was hung on a dresser drawer beside the bed closest to the window separated from Resident #1 by a wheelchair and privacy curtain. Resident #3 then pressed the call button. In an interview on 10/18/2024 at 9:50 AM, LVN A said Resident #1 was a fall risk and came to the facility after falling at home. She said Resident #1's call light should be in her reach so she could call for assistance when she required it. She said she rounded at least every two hours as did the CNAs. She said she was not sure why the call light was not placed in Resident #1's reach. An observation on 10/18/2024 at 9:55 AM revealed the Director of Therapy responded to the call light that was lit outside Resident #1's room. In an interview on 10/18/2024 at 10:13 AM, the Director of Therapy said she noticed Resident #1's call light while she was passing this state surveyor and LVN A in the hall. She said she went to respond to the call light. She said when she went into Resident #1's room, the call button was wrapped around the bedside table on Resident #3's side of the room and not accessible to Resident #1. The Director of Therapy said Resident #1 was new to the facility and was a fall risk and should have access to her call button to ensure her safety and that she could call for assistance if she needed to. In an interview on 10/18/2024 at 10:20 AM, the DON stated Resident #1 came to the facility from the hospital and was a fall risk. She said she should always have access to her call light to ensure she could get any assistance she might need. The DON said she expected call lights to be placed within reach of all residents. In an interview on 10/18/2024 at 12:25 PM, CNA B said she did not notice Resident #1's call light was not in her reach. She said residents needed to have access to their call light to call for assistance. An observation on 10/18/2024 at 1:10 PM revealed, Resident #2 in bed (lowest position). Resident #2's call light was rolled up and hung on the wall between Resident #2's bed and the bed closest to the window. In an interview on 10/18/2024 at 1:13 PM, LVN C said Resident #2's call light should be in her reach. She said the CNAs just put Resident #2 down to sleep and they must have forgotten to place the call light. She said she was not sure which CNAs. LVN C said all residents needed to have access to call lights, regardless if they used them or not, to ensure their needs were met and they had a means to call for assistance. In an interview on 10/18/2024 at 1:22 PM, the Social Worker stated residents should have access to call light to ensure their needs were met. She said all staff were responsible to ensure call lights were placed within reach of residents. In an interview on 10/18/2024 at 2:06 PM, CNA D said she did not put Resident #2 down to nap, so she did not know why the call light or fall mats were not placed. She said all residents should have access to call lights to prevent accidents because residents would try to get up on their own if they cannot call for assistance. She said she was trained on these but did not recall when the last in-service was. In an interview on 10/18/2024 at 3:15 PM, the DON repeated that she expected all staff to round at least every two hours and check that call lights were in reach of residents to ensure resident's safety. She said she rounded randomly as a follow up but all staff were responsible to ensure resindets were safe. In an interview on 10/18/2024 at 3:05 PM, the VP/acting ED said the facility did not have a policy that directly addressed call light placement. Record review of the facility's policy titled, Falls and fall risk, managing, revised March 2018, reflected, Based on previous evaluations and current data, the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling. Record review of the facility's policy titled, Accidents and hazards - investigating and reporting, revised July 2017, reflected, .3. This facility is in compliance with current rules and regulations governing accidents and/or incidents involving a medical device.

Based on observations, interviews and record reviews, the facility failed to implement a comprehensive person-centered care plan for each resident to meet a resident's medical, nursing, and mental and psychosocial needs in order attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for one resident (Resident #2) of ten residents reviewed for care plans. The facility failed ensure Resident #2's care plan was followed to ensure fall mats were placed on either side of Resident #2's bed while she was in it. This failure could place residents at risk of injury and a decreased quality of life. Findings included: Record review of Resident #2's Face Sheet dated 10/18/2024, reflected a [AGE] year-old female who was admitted to the facility on [DATE]. Diagnoses included: acute kidney failure (kidneys stop working suddenly), hemiplegia and hemiparesis following nontraumatic subarachnoid hemorrhage affecting non-dominant left side (one side paralysis), diabetes mellitus (a group of diseases that affect how the body uses sugar), hypomagnesemia (low level of magnesium), muscle weakness, unspecified dementia (a group of symptoms affecting memory, thinking and social abilities), and hypertension (high blood pressure). Record review of Resident #2's significant change MDS, dated [DATE], reflected a BIMS score of 3 which indicated severe cognate impairment. Functional abilities included dependent for toileting, hygiene, dressing and transfers. She was always incontinent of bowel and bladder. Resident #2 had a history of falls in the last month. Record review of Resident #2's care plan dated 09/19/2024 reflected, [Resident #2] demonstrates desire and behavior to lay prone on floor mat for comfort to sleep. Intervention: Anticipate and meet the resident's needs. [Resident #2] will allow staff to assist to desired position on floor mat for rest periods. Focus: [Resident #2] is High risk for falls. [Resident #2] has had an actual fall without injury. Interventions: Be sure [Resident #2's] call light is within reach and encourage the (sic) her to use it for assistance as needed. He (sic) needs prompt response to all requests for assistance. Fall mats to be placed bedside (sic). Record review of Resident #2's fall risk assessment dated [DATE], reflected a sore of 60, which indicated a high risk for falling. An observation on 10/18/2024 at 1:10 PM revealed, Resident #2 in bed (lowest position) no fall mats on either side of the bed. The fall mats were observed folded up and leaned against the window wall of the room. In an interview on 10/18/2024 at 1:13 PM, LVN C said there should be fall mats on either side of Resident #2's bed because Resident #2 had a history of crawling from her bed to the floor to sleep. She said the CNAs just put Resident #2 down to sleep and they must have forgot to place the call light and fall mats. She said she was not sure which CNAs. In an interview on 10/18/2024 at 1:22 PM, the Social Worker stated Resident #2 was a fall risk and needed to have fall mats on either side of her bed when she was in bed. She said nursing and therapy staff provide training on fall interventions but was not sure when the last training was provided. In an interview on 10/18/2024 at 2:06 PM, CNA D said she did not put Resident #2 down to nap, so she did not know why the fall mats were not placed. She said fall matts needed to be in place to ensure Resident #2's safety. She said she was trained on these but did not recall when the last in-service was. In an interview on 10/18/2024 at 3:15 PM, the DON repeated that she expected staff to round at least every two hours and check that fall interventions were in place. She said all staff were responsible to ensure residents were safe and their needs were met. The DON said she rounded as well to check on residents. She said Resident #2 required a fall mat on either side of her bed because she had a history of crawling from her bed to the floor to sleep. Record review of the facility's policy titled, Falls and fall risk, managing, revised March 2018, reflected, Based on previous evaluations and current data, the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling. Record review of the facility's policy titled, Accidents and hazards - investigating and reporting, revised July 2017, reflected, .3. This facility is in compliance with current rules and regulations governing accidents and/or incidents involving a medical device.

Based on observations, interviews, and record reviews, the facility failed to ensure residents received adequate supervision and assistance devices to prevent accidents for one (Resident #2) of ten residents reviewed for accidents. The facility failed to ensure fall mats were placed on either side of Resident #2's bed while she was in it. Resident #2 was observed in bed (in the lowest position), closest to the door and fall mats were observed folded and leaning against the window wall across the room. This failure could place residents at risk of injury and a decreased quality of life. Findings included: Record review of Resident #2's Face Sheet dated 10/18/2024, reflected a [AGE] year-old female who was admitted to the facility on [DATE]. Diagnoses included: acute kidney failure (kidneys stop working suddenly), hemiplegia and hemiparesis following nontraumatic subarachnoid hemorrhage affecting non-dominant left side (one side paralysis), diabetes mellitus (a group of diseases that affect how the body uses sugar), hypomagnesemia (low level of magnesium), muscle weakness, unspecified dementia (a group of symptoms affecting memory, thinking and social abilities), and hypertension (high blood pressure). Record review of Resident #2's significant change MDS, dated [DATE], reflected a BIMS score of 3 which indicated severe cognate impairment. Functional abilities included dependent for toileting, hygiene, dressing and transfers. She was always incontinent of bowel and bladder. Resident #2 had a history of falls in the last month. Record review of Resident #2's care plan dated 09/19/2024 reflected, [Resident #2] demonstrates desire and behavior to lay prone on floor mat for comfort to sleep. Intervention: Anticipate and meet the resident's needs. [Resident #2] will allow staff to assist to desired position on floor mat for rest periods. Focus: [Resident #2] is High risk for falls. [Resident #2] has had an actual fall without injury. Interventions: Be sure [Resident #2's] call light is within reach and encourage the (sic) her to use it for assistance as needed. He (sic) needs prompt response to all requests for assistance. Fall mats to be placed bedside (sic). Record review of Resident #2's fall risk assessment dated [DATE], reflected a sore of 60, which indicated a high risk for falling. An observation on 10/18/2024 at 1:10 PM revealed, Resident #2 in bed (lowest position) no fall mats on either side of the bed. The fall mats were observed folded up and leaned against the window wall of the room. In an interview on 10/18/2024 at 1:13 PM, LVN C said there should be fall mats on either side of Resident #2's bed because Resident #2 had a history of crawling from her bed to the floor to sleep. She said the CNAs just put Resident #2 down to sleep and they must have forgot to place the call light and fall mats. She said she was not sure which CNAs. She said all residents needed to have access to call lights to ensure their needs were met. In an interview on 10/18/2024 at 1:22 PM, the Social Worker stated Resident #2 was a fall risk and needed to have fall mats on either side of her bed when she was in bed. She said nursing and therapy staff provide training on fall interventions but was not sure when the last training was provided. In an interview on 10/18/2024 at 2:06 PM, CNA D said she did not put Resident #2 down to nap, so she did not know why the fall mats were not placed. She said fall matts needed to be in place to ensure Resident #2's safety. She said she was trained on these but did not recall when the last in-service was. In an interview on 10/18/2024 at 3:15 PM, the DON repeated that she expected staff to round at least every two hours and check that fall interventions were in place. She said all staff were responsible to ensure residents were safe and their needs were met. The DON said she rounded as well to check on residents. She said Resident #2 required a fall mat on either side of her bed because she had a history of crawling from her bed to the floor to sleep. Record review of the facility's policy titled, Falls and fall risk, managing, revised March 2018, reflected, Based on previous evaluations and current data, the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling. Record review of the facility's policy titled, Accidents and hazards - investigating and reporting, revised July 2017, reflected, .3. This facility is in compliance with current rules and regulations governing accidents and/or incidents involving a medical device.

Based on interview and record review, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice for 1 of 4 residents (Resident #1) reviewed for quality of care. 1) The facility nurses failed to assess, treat, or monitor ant bites and pain for Resident #21 or seek treatment instructions from the physician. An Immediate Jeopardy was (IJ) was identified on 08/14/24 at 5:53 PM while the IJ was removed on 08/16/24, the facility remained out of compliance at a severity of No actual harm with a potential for more than minimal harm that is not immediate and a scope of isolated due to the facility still monitoring the effectiveness of their Plan of Removal. This deficient practice could place residents at risks of not obtaining the care that was needed, which could lead to a worsening of their condition, hospitalization , or death. Findings Included: Record review of Resident #21's Face Sheet, dated 08/14/2024, revealed a [AGE] year-old female who initially admitted to the facility on [DATE]. Resident #21 had a diagnoses which included the following: Aphasia (cannot speak), Hemiplegia (paralyzed on one side) and Hemiparesis (weakness on one side of the body) following Cerebral Infarction (stroke) affecting Right Dominant side, Type 2 Diabetes Mellitus (to much sugar), and Cerebral Infarction due to Thrombosis (blood clots) of Unspecified Cerebral Artery. (Family member #1 was listed as the responsible party/POA.) Record review Resident #21's Quarterly MDS Assessment, dated 05/22/24, revealed the resident was rarely/never understood and was cognitively severely impaired. Resident #21 required total or extensive assistance for bed mobility, dressing, toilet use, and personal hygiene. Further review of Resident #21's MDS reflected that Resident #21 was always incontinent of urine and bowel. Record review of Resident #21's Care Plan initiated on 02/22/2022 reflected Resident #21 had an Activities of Daily Living self-care deficit, and the interventions included that Resident #21 required limited-extensive assist to turn and reposition in bed and as necessary. Resident #21 required supervision to eat. Resident #21 required 2 staff for personal hygiene and oral care. The Care Plan reflected that Resident #21 had impaired cognitive function/dementia or impaired thought processes with interventions that included communicating with family family/caregivers regarding her capabilities and needs and to monitor/document/report PRN any changes in cognitive function, specifically changes in: decision making ability, memory, level of consciousness, mental status. The Care Plan reflected that Resident #21 had a communication problem related to Cerebral Vascular Accident. Resident #21 was Aphasic (inability to communicate). Resident #21 smiles when approached and could head/nod to yes and no questions and the interventions included encouraging Resident #21 to continue stating thoughts even if resident is having difficulty and to monitor/document/report as needed any changes in ability to communicate, potential contributing factors for communication problems. The Care Plan reflected that Resident #21 had Diabetes Mellitus and was taking medications per Medical Doctors orders, with interventions that included checking all of body for breaks in skin and treat promptly as ordered by doctor. The Care Plan reflected that Resident #21 had hemiplegia/hemiparesis (paralyzation of one side of the body), with interventions that included discuss with Resident #21's family/caregivers any concerns, fears, issues regarding diagnosis or treatments. An interview on 08/12/24 at 1:23 PM with Family Member #1 revealed on 07/14/24 Resident #21 was not in her regular room. CNA R explained on 07/14/24 Resident #21 had been moved to another room because ants and ant bites that were discovered on Resident #21. The family member stated were not notified of the ants or the room move before the family member had asked about it. In an interview on 08/12/24 at 1:56 PM CNA R stated that they had discovered ants on Resident #21 on the morning of 07/13/24 while getting Resident #21 ready for a bed bath. CNA R stated that there had been between 20 to 30 small black ants in the crook of Resident #21's right arm in the anterior of the right elbow. CNA R stated she immediately reacted and used the gathered bed bath equipment to immediately wipe off Resident #21's arm. CNA R stated that the area on Resident #21's arm where the ants had been present had been [NAME] and red. CNA R stated she did not see an ant trail leading to the bed, she then informed RN II about the ants and then took Resident #21 to a shower where she (CNA R) made sure there were no more ants on Resident #21. CNA R stated that Resident #21 was then temporarily moved to another room from the 100 hall to the 300 hall. CNA R stated that the welts on Resident #21's arm were much less noticeable after the shower and move. CNA R stated that housekeeping had cleaned out Resident #21's room and that Resident#21 had been moved back to Resident #21's original room on 07/16/24 on the 100 hall from the temporary room on the 300 hall. In an interview on 08/13/24 at 1:54 PM RN II stated that there had been no DON working on 07/13/24 but that RN II had told the ADON about the ants on Resident #21 and she had been told to move Resident #21 to another room and she had done a skin assessment and found no ant bites on Resident #21. She stated that she was unsure if she notated the skin assessment anywhere. RN II stated she assumed that the ADON had informed the DON about the ants on Resident # 21. RN II stated they did not remember if she had written any progress notes about the ants on Resident #21 or if she had contacted the ADON face to face or had contacted the ADON via phone. In an interview on 08/13/24 at 2:07 PM the ADON stated that there were no messages about Resident #21 moving rooms or being bitten by ants. The ADON stated that the facility used a phone messaging app to make sure that all nursing staff were informed of developments with residents and that information was passed. The ADON stated that if there was no evidence of any message being passed and that she had not been informed that it would have been up to RN II to contact the MD and the family of Resident #21. The ADON stated that she could find no evidence of an initial assessment, after treatment for ant bites notification of any room movements, notifications or new orders from the MD or skin assessments. The ADON stated she was not on the schedule on 07/13/24 and that the facility did not have a DON from 07/07/24 to 07/22/24. Record review of the facility pest sighting log of the last 6 months revealed that ants were sighted in Resident #21's room on 07/15/24 and treated by the pest control on 07/25/24. Record review of the facility's Incident Accident log dated 06/01/24 to 08/12/24 revealed that there were no incidents listed regarding any resident being bitten by ants or having to move rooms. Record review of Resident #21's progress notes from 06/01/24 to 08/12/24 revealed that there were no notes regarding Resident #21 having been bit by ants or having been discovered with ants on Resident #21's body. No notes were discovered that indicated that Resident #21's MD or Resident #21's family members had been notified that Resident #21 had been bitten by ants or that Resident #21 had received any post treatment for ant bites or pain resulting from ant bites. In an interview on 08/14/24 at 9:57 AM the ADM stated she had never been told that Resident #21 had been bitten by ants until the investigator informed her on 08/13/24. The ADM stated that Resident #21's family member had spoken to her on 07/14/24 about Resident #21 being moved to another room but that Resident #21's family member had not mentioned ants or ant bites. In an interview on 08/14/24 at 10:03 AM the DON stated she had started employment at the facility on 07/22/24 and she had not known about Resident #21 being bitten by ants, but that it should have been reported to head nursing staff so that Resident #21 could have been properly assessed and treated for ant bites; the MD should have been notified and the family should have been notified and they had not been informed. The DON stated that there could have been medical complications or undue pain caused to Resident #21 by not being properly treated for ant bites. In an interview on 08/14/24 at 11:33 AM the MD stated he had been unaware that Resident #21 had suffered ant bites or had moved rooms. The MD stated that he could find no evidence that Resident #21 had been issued any new orders for topical ointments for ant bites or evidence of any assessment or post assessments of Resident #21 related to ant bites. The MD stated that it was important he be informed about the ant bites on Resident #21 because of the risk of complications depending on Resident #21's morbidities and that Resident #21 may have missed care that Resident #21 might have needed. In an interview on 08/14/2024 at 2:32 PM Resident #21 was observed supine. Resident #21 indicated through hand gestures that she was fine. Resident #21 indicated through nodding her head that she had been bitten by ants on her right arm and indicated through nodding her head that the ant bites had caused her pain. In an interview on 08/14/24 at 4:25 PM the Director of Environmental Services stated that Pest control came to the facility twice a month and could be called in for extra visits. Director of Environmental services stated she did external rounds of the building to direct pest control services to active ant mounds near the building and that all staff were directed to note any insects in the facility in the pest sighting log. The Director of Environmental services stated that there had been no reports made that any residents had been bitten by ants and that staff cleaned rooms every day to make sure that pests like ants were not attracted to resident rooms. A record review of the facility's policy titled Change of Condition and Physician/Family Notification, dated January 2023, reflected Purpose: To ensure that resident's family and/or legal representative and physician are notified of resident changes that fall under the following categories: . A significant change in resident's physical, mental, or psychosocial status. (See below for examples). A need to significantly alter treatment. Transfer of the resident from the facility. Procedures: When any of the above situations exist, the licensed nurse will contact the resident's family and their physician . Each attempt will be charged as to time the call was made, who was spoken to, and what information was given to the physician .Prior to notifying the physician or health care provider, the nurse will make detailed observations and gather relevant and pertinent information to the provider, including (for example information prompted by the Situation, Background, Assessment Recommendation Communication Form . A record review of the facility's policy titled Requesting, Refusing and/or Discontinuing Care or Treatment, dated May 2017, reflected .Treatment is defined as services provided for purposes of maintaining/restoring health, improving functional level, or relieving symptoms . This failure resulted in an identification of an Immediate Jeopardy on 08/14/2024 at 5:53 PM. The Administrator was informed and provided the IJ template on 08/14/2024 at 5:55 PM and a Plan of Removal (POR) was requested. The Plan of Removal reflected: Per the information provided in the IJ template given on 8/14/24, the facility failed to take proper action in notification of resident change of condition. Facility failed to further notify executive administration, and/or resident family member. Per template, on 07/13/24, the CNA discovered ants on a resident with noticeable welts on the resident right arm. The CNA notified the charge nurse, who advised to bathe and relocate the resident to different room. The charge nurse failed to take further action in obtaining orders for medical treatment, and notification of a resident change to the physician, administration, and family. The MD, was notified of IJ on 8/14/24 at 06:00p.m. The DON and ADON initiated an in-service with nursing staff (CNA, CMA, LVN, RN) 8/14/24 on identifying when to conduct assessment on residents and where to document assessments. This in-service will be completed by 8.15.24. The DON and ADON initiated an in-service with nursing staff (CNA, CMA, LVN, RN) on 8/14/24 regarding when to provide treatment and/or care to residents. This in-service will be completed by 8.15.24. The DON and ADON initiated in-service with nursing staff on 8/14/24 (CNA, CMA, LVN, RN) regarding when to communicate with nursing supervisor, administrative team, physician, and family. This in-service will be completed by 8.15.24. This in-service will be completed by 8.15.24. The ADON initiated in-service when nursing staff (CNA, CMA, LVN, RN) on 8/14/24 regarding when to report significant changes in resident's condition. This in-service will be completed by 8.15.24. In-service initiated with all staff (Facility Wide) on 8/14/24 regarding notification of observed pest(s) by the ADON or ADM. This in-service will be completed by 8.15.24. Each department to provide in-services to every employee, prior to working next assigned shift. To be completed by 8.15.24. If staff member(s) are present for in-person training, training will be conducted by appropriate department head (The Director of Culinary Services. The Director of Environmental Services. The ADON and DON. The Director of Rehab. The ADM for monitoring of Department Heads). To be completed by 8.15.24. If staff member(s) are unavailable for in-person training, phone call will be performed as witnessed phone call with the ADM and DON. Phone call dialogue will provide a pre-test to employee, followed by in- service education, finishing with a post-call test. To be completed by 8.15.24. If staff member(s) do not answer/return phone call, notification will be given to scheduling manager (The ADON. The Director of Culinary Services. The Director of Environmental Services. The Director of Rehab. The ADM department head monitoring), to place hold on staff member shift availability until complete. Monitoring of understanding by clinical staff to be performed by the DON. Monitoring to include daily review of the 24-hr log with follow-up of the employee to ensure notification appropriately made. Monitoring will also include educational pre/post-test to be administered by 8.15.24. Pre/Post Tests with correlating policy will also be added to new-hire packet. The ADM to monitor compliance of DON. Skin assessments performed by the ADON, and [NAME] President of Clinical Services, completed on every resident, to be completed by 8/15/24. Results to be submitted upon completion. Environmental sweep of hallways, resident rooms, and exterior perimeter performed by the Director of Environmental Services, on 8/14/24 with no findings of pest(s). The Director of Environmental Services will monitor pest control by daily review of pest binder. Pest Control scheduled twice per month with 3rd party source and PRN for sightings. The ADM to monitor compliance of Director of Environmental Services. Summary of the IJ and corrective action to be reviewed by QAPI committee weekly x4 weeks or until substantial compliance established and continue monthly for 90 days to ensure ongoing compliance. Monitoring of the Plan of Removal included: A record review of in-services dated 8/14/2024, titled Conducting and Reporting Assessments, Providing Treatment and/or Care to Residents, Communicating with Nursing Supervisor, Administrative Team, Physician and Family, Reporting significant Changes in resident Condition, and Notification of Observed Pest(s), conducted by the ADM, DON, Director of Rehab, Director of Environmental services and the Director of Culinary services, reflected that all staff were educated on policy and procedures including assessments and notification to MD and Nurse Practitioners regarding change of condition. All Nursing staff were in-serviced and educated on policy and procedures regarding providing treatment and/or care to residents. Interviews were conducted on 08/15/24 at 9:18 AM to 08/16/24 at 1:23 PM with 4 RNs , 10 LVNs, 4 MAs, 18 CNAs, 2 Dietary Cooks, 2 HSKs, the ADM, ADON, SW, Director of Environmental Services, Director of Rehab, and Director of Culinary Services, who worked multiple shifts, revealed that they had all been in-serviced on Conducting and Reporting Assessments, Providing Treatment and/or Care to Residents, Communicating with Nursing Supervisor, Administrative Team, Physician and Family, Reporting significant Changes in resident Condition, and Notification of Observed Pest(s). The staff were able to identify examples on who, when, and where to report Assessments, Changes in Condition and Pest(s) sightings. Interviewed staff were knowledgeable on protocols and who they needed to report too. The staff reported verifying their competencies via a pre and post quiz. In an interview on 08/16/24 at 11:40 AM the [NAME] President of Clinical Services stated that the ADM and DON were in-serviced on all in-service topics and they stated their competency was verified via quizzes. The [NAME] president of Clinical Services stated for the next 30 days they and the DON would be monitoring, and stated if they identified any changes, they would contact the MD and family/POA immediately. The ADM and DON were informed the Immediate Jeopardy was removed on 08/16/24 at 1:35 PM. The facility remained out of compliance at a severity of No actual harm with a potential for more than minimal harm that is not immediate and a scope of isolated due to the facility still monitoring the effectiveness of their corrective systems.

Based on interview, and record review the facility failed to notify the physician when a resident experienced ant bites and pain for 1 (Resident #21) of 5 residents reviewed for a notification of a change of condition, in that: RN II did not notify the Physician of Resident #21's change of condition on 08/13/24 when CNA R reported that Resident #21 had indicated experiencing pain to the anterior area of her right elbow to RN II concerns that Resident #21 had suffered ant bites that had resulted in welts on Resident #21's right arm. An Immediate Jeopardy was (IJ) was identified on 08/14/24 at 5:53 PM while the IJ was removed on 08/16/24, the facility remained out of compliance at a severity of No actual harm with a potential for more than minimal harm that is not immediate and a scope of isolated due to the facility still monitoring the effectiveness of their Plan of Removal. This deficient practice could place residents at risks of not obtaining the care that was needed, which could lead to a worsening of their condition, hospitalization , or death. Findings Included: Record review of Resident #21's Face Sheet, dated 08/14/2024, revealed a [AGE] year-old female who initially admitted to the facility on [DATE]. Resident #21 had a diagnoses which included the following: Aphasia (cannot speak), Hemiplegia (paralyzed on one side) and Hemiparesis (weakness on one side of the body) following Cerebral Infarction (Stroke) affecting Right Dominant side, Type 2 Diabetes Mellitus (Too much sugar), and Cerebral Infarction due to Thrombosis (blood clots) of Unspecified Cerebral Artery. (Family member #1 was listed as the Responsible Party/POA.) Record review Resident #21's Quarterly MDS Assessment, dated 05/22/24, revealed the resident was rarely/never understood and was cognitively severely impaired. Resident #21 required total or extensive assistance for bed mobility, dressing, toilet use, and personal hygiene. Further review of Resident #21's MDS reflected that Resident #21 was always incontinent of urine and bowel. Record review of Resident #21's Care Plan initiated on 02/22/2022 reflected Resident #21 had an Activities of Daily Living self-care deficit, and the interventions included that Resident #21 required limited-extensive assist to turn and reposition in bed and as necessary. Resident #21 required supervision to eat. Resident #21 required 2 staff for personal hygiene and oral care. The Care Plan reflected that Resident #21 had impaired cognitive function/dementia or impaired thought processes with interventions that included communicating with family family/caregivers regarding her capabilities and needs and to monitor/document/report PRN any changes in cognitive function, specifically changes in: decision making ability, memory, level of consciousness, mental status. The Care Plan reflected that Resident #21 had a communication problem related to Cerebral Vascular Accident. Resident #21 was Aphasic (inability to communicate). Resident #21 smiles when approached and could head/nod to yes and no questions and the interventions included encouraging Resident #21 to continue stating thoughts even if resident is having difficulty and to monitor/document/report as needed any changes in ability to communicate, potential contributing factors for communication problems. The Care Plan reflected that Resident #21 had Diabetes Mellitus and was taking medications per Medical Doctors orders, with interventions that included checking all of body for breaks in skin and treat promptly as ordered by doctor. The Care Plan reflected that Resident #21 had hemiplegia/hemiparesis (paralyzation of one side of the body), with interventions that included discuss with Resident #21's family/caregivers any concerns, fears, issues regarding diagnosis or treatments. Record review of Resident #21's electronic health record revealed that there were no progress notes, skin assessments, treatment for ant bites, follow up treatments, assessments, or record of notifying Resident #21's family or physician in relation to Resident #21 having to temporarily move rooms due to an ant infestation and ant bites. No Situation, Background, Assessment Recommendation Communication Report could be found in relation to Resident #21 being bit by ants, assessment, post treatment or room movement. An interview on 08/12/24 at 1:23 PM with Family Member #1 revealed on 07/14/24 Resident #21 was not in her regular room. CNA R explained on 07/14/24 Resident #21 had been moved to another room because ants and ant bites that were discovered on Resident #21. The family member stated were not notified of the ants or the room move before the family member had asked about it. An interview on 08/12/24 at 1:56 PM CNA R stated that Resident #21 was non-verbal, and that CNA R had worked with Resident #21 for a long time and was familiar with how to communicate with Resident #21 with yes/no questions and pointing. CNA R stated that while delivering Resident #21's breakfast tray, Resident #21 indicated she had pain in her right arm. CNA R stated she reported to RN ii that Resident #21 had indicated pain in her arm around 7:40AM on 07/13/24 and then continued with her morning duties. CNA R stated that when she returned to Resident #21's room around 8:20 AM, she was unsure if RN II had assessed Resident #21 yet. CNA R stated she had discovered ants on Resident #21 on the morning of 7/13/24 around 8:20 AM, while getting Resident #21 ready for a bed bath. CNA R stated that there had been between 20 to 30 small black ants in the crook of Resident #21's arm that Resident #21 had indicated to before. CNA R stated that she immediately reacted and used the gathered bed bath equipment to immediately wipe off Resident #21's arm. CNA R stated that the area on Resident #21's arm where the ants had been present had been [NAME] and red. CNA R stated she then informed RN ii about the ants and then took Resident #21 to a shower where CNA R made sure there were no more ants on Resident #21. CNA R stated that Resident #21 was then temporarily moved to another room from the 100 hall to the 300 hall. CNA R stated that the welts on Resident #21's arm were much less noticeable after the shower and move. CNA R stated that housekeeping had cleaned out Resident #21's room and that Resident #21 had been moved back to Resident #21's original room on 07/16/24 on the 100 hall from the temporary room on the 300 hall. An interview on 08/13/24 at 1:54 PM RN II stated that she did not remember if she had written any progress notes about the ants on Resident #21 or if she had contacted the ADON face to face or had contacted the ADON via phone. RN II stated she had not contacted the MD or Resident #21's family member/Power of Attorney about the ants or the room move. An interview on 08/13/24 ADON stated that there were no messages about Resident #21 moving rooms or being bitten by ants. The ADON stated that the facility uses a phone messaging app to make sure that all nursing staff are informed of developments with residents and that information is passed. The ADON stated that if there was no evidence of any message being passed and that she had not been informed that it would have been up to RN II to contact the MD and the family of Resident #21. The ADON stated that she could find no evidence of an initial assessment, after treatment for ant bites notification of any room movements, notifications or new orders from the MD or skin assessments. The ADON stated that she was not on the schedule on 07/13/24 and that the facility did not have a DON from 07/07/24 to 07/22/24. In an interview on 08/14/24 at 10:03 AM the DON stated that she had started employment at the facility on 07/22/24 and that she had not known about Resident #21 had been bitten by ants, but that it should have been reported to head nursing staff so that Resident #21 could have been properly assessed and treated for ant bites, the MD should have been notified and the family should have been notified and they had not been informed. The DON stated that there could have been medical complications or undue pain caused to Resident #21 by not being properly treated for ant bites. In an interview on 08/14/24 at 11:33 AM The MD stated that he was not informed that Resident #21 had suffered ant bites or had moved rooms. The MD stated that he could find no evidence that Resident #21 had been issued any new orders for topical ointments for ant bites or evidence of any assessment or post assessments of Resident #21 related to ant bites. The MD stated that it was important that he should have been informed about the ant bites on Resident #21 because of the risk of complications depending on Resident #21's morbidities and that Resident #21 may have missed care that Resident #21 might have needed. A record review of the facility's policy titled Change of Condition and Physician/Family Notification, dated January 2023, reflected Purpose: To ensure that resident's family and/or legal representative and physician are notified of resident changes that fall under the following categories: . A significant change in resident's physical, mental, or psychosocial status. (See below for examples). A need to significantly alter treatment. Transfer of the resident from the facility. Procedures: When any of the above situations exist, the licensed nurse will contact the resident's family and their physician . Each attempt will be charged as to time the call was made, who was spoken to, and what information was given to the physician . This failure resulted in an identification of an Immediate Jeopardy on 08/14/2024 at 5:53 PM. The Administrator was informed and provided the IJ template on 08/14/2024 at 5:55 PM and a Plan of Removal (POR) was requested. The Plan of Removal reflected: Per the information provided in the IJ template given on 8/14/24, the facility failed to take proper action in notification of resident change of condition. Facility failed to further notify executive administration, and/or resident family member. Per template, on 07/13/24, CNA discovered ants on resident with noticeable welts on resident right arm. CNA notified charge nurse, who advised to bathe and relocate resident to different room. Charge nurse failed to take further action in obtaining order for medical treatment, and notification of resident change to physician, administration, and family. The MD, was notified of IJ on 8/14/24 at 06:00p.m. DON and ADON initiated In-service with nursing staff (CNA, CMA, LVN, RN) 8/14/24 on identifying when to conduct assessment on residents and where to document assessments. This in-service will be completed by 8.15.24. DON and ADON initiated in-service with nursing staff (CNA, CMA, LVN, RN) on 8/14/24 regarding when to provide treatment and/or care to residents. This in-service will be completed by 8.15.24. DON and ADON initiated in-service with nursing staff on 8/14/24 (CNA, CMA, LVN, RN) regarding when to communicate with nursing supervisor, administrative team, physician, and family. This in-service will be completed by 8.15.24. This in-service will be completed by 8.15.24. ADON initiated in-service when nursing staff (CNA, CMA, LVN, RN) on 8/14/24 regarding when to report significant changes in resident's condition. This in-service will be completed by 8.15.24. In-service initiated with all staff (Facility Wide) on 8/14/24 regarding notification of observed pest(s) by ADON or ADM. This in-service will be completed by 8.15.24. Each department to provide in-service to every employee, prior to working next assigned shift. To be completed by 8.15.24. If staff member(s) are present for in-person training, training will be conducted by appropriate department head (Director of Culinary Services. Director of Environmental Services. ADON and DON. Director of Rehab. ADM for monitoring of Department Heads). To be completed by 8.15.24. If staff member(s) unavailable for in-person training, phone call will be performed as witnessed phone call with ADM and DON. Phone call dialogue will provide pre-test to employee, followed by in- service education, finishing with post-call test. To be completed by 8.15.24. If staff member(s) do not answer/return phone call, notification will be given to scheduling manager (ADON. Director of Culinary Services. Director of Environmental Services. Director of Rehab. ADM department head monitoring), to place hold on staff member shift availability until complete. Monitoring of understanding by clinical staff to be performed by DON. Monitoring to include daily review of 24-hr log with follow-up of employee to ensure notification appropriately made. Monitoring will also include educational pre/post-test to be administered by 8.15.24. Pre/Post Test with correlating policy will also be added to new-hire packet. ADM to monitor compliance of DON. Skin assessments, performed by ADON, and [NAME] President of Clinical Services, completed on every resident, to be completed by 8/15/24. Results to be submitted upon completion. Environmental sweep of hallways, resident rooms, and exterior perimeter performed by Director of Environmental Services, on 8/14/24 with no findings of pest(s). Director of Environmental Services will monitor pest control by daily review of pest binder. Pest Control scheduled twice per month with 3rd party source and PRN for sightings. ADM to monitor compliance of Director of Environmental Services. Summary of IJ and corrective action to be reviewed by QAPI committee weekly x4 weeks or until substantial compliance established and continue monthly for 90 days to ensure ongoing compliance. Monitoring of the Plan of Removal included: Interviews were conducted on 08/15/24 at 9:18 AM to 08/16/24 at 1:23 PM with 4 RN's, 10 LVN's, 4 MA's, 18 CNA's, 2 Dietary Cooks, 2 HSK's, the ADM, ADON, SW, Director of Environmental Services, Director of Rehab, and Director of Culinary Services, who worked multiple shifts, revealed that they had all been in-serviced on Conducting and Reporting Assessments, Providing Treatment and/or Care to Residents, Communicating with Nursing Supervisor, Administrative Team, Physician and Family, Reporting significant Changes in resident Condition, and Notification of Observed Pest(s). The staff were able to identify examples on who, when, and where to report Assessments, Changes in Condition and Pest(s) sightings. Interviewed staff were knowledgeable on protocols and who they needed to report too. The staff reported verifying their competencies via a pre and post quiz. An interview on 08/16/24 at 11:40 AM [NAME] President of Clinical Services stated that the ADM and DON were in-serviced on all in-service topics and [NAME] president of Clinical Services stated their competency was verified via quizzes. The [NAME] president of Clinical Services stated for the next 30 days [NAME] president of Clinical Services and DON would be monitoring, and stated if they identified any changes, they would contact the MD and family/POA immediately. A record review of in-services titled Conducting and Reporting Assessments, Providing Treatment and/or Care to Residents, Communicating with Nursing Supervisor, Administrative Team, Physician and Family, Reporting significant Changes in resident Condition, and Notification of Observed Pest(s), conducted by the ADM, DON, Director of Rehab, Director of Environmental services and the Director of Culinary services, reflected that all staff were educated on policy and procedures including assessments and notification to MD and Nurse Practitioners regarding change of condition. All Nursing staff were in-serviced and educated on policy and procedures regarding providing treatment and/or care to residents. The ADM and DON were informed the Immediate Jeopardy was removed on 08/16/24 at 1:35 PM. The facility remained out of compliance at a severity of No actual harm with a potential for more than minimal harm that is not immediate and a scope of isolated due to the facility still monitoring the effectiveness of their corrective systems.

Based on observation, interview and record review, the facility failed to ensure all assistive devices were maintained and free of hazards for six (Residents #1, #6, #23, #42, #38, and #53) of 6 residents reviewed for essential equipment. The facility failed to properly maintain wheelchairs for Residents #1, #6, #23 #42, #38, and #53. These failures could place residents at risk for equipment that is in unsafe operating condition, that could cause injury. Findings include : Review of Resident #1's quarterly MDS assessment, dated 07/03/24, reflected he was an [AGE] year-old male admitted to the facility on [DATE] with diagnoses of atrial fibrillation (irregular heart rate), hypertension (increased blood pressure), and neuromuscular dysfunction (loss of control of body movement). Further review of the MDS reflected the resident was cognitively moderately impaired and able to make decisions for themselves. Review of the Resident #1's plan of care dated 07/01/24 with updates reflected goals and approaches to include wheelchair mobility for locomotion. Observation on 08/12/24 at 12:10 p.m., revealed Resident #1 was sitting in his wheelchair, in the dining room and had no skin problems. The wheelchair's right armrest was cracked with foam exposed. There was dried food substances on the back of the wheelchair. Review of Resident #6's quarterly MDS assessment, dated 06/25/24, reflected she was a [AGE] year-old female admitted to the facility on [DATE], with diagnoses of Alzheimer's disease (forgetfulness & confusion), and muscle weakness (muscle deterioration). Further review of the MDS reflected the resident was cognitively severely impaired and unable to make decisions for themselves. Review of the Resident #6's plan of care dated 06/07/24 with updates reflected goals and approaches to include wheelchair mobility. Observation on 08/12/24 at 12:15 p.m., revealed Resident #6 was sitting in her wheelchair in the dining room and the wheelchair's right armrest was cracked, and rough with exposed foam. There were no skin tears on Resident #6's arms. The wheels of the wheelchair had dried food substance on both wheels and on wheel rims. Review of Resident #23's annual MDS assessment, dated 07/10/24, reflected he was an [AGE] year-old male admitted to the facility on [DATE], with diagnoses of cerebral infarction (stroke) muscle weakness (no strength), abnormalities of gait and mobility (unable to mobilize safety), and depression (mental illness). Further review of the MDS reflected the resident was moderately impaired for cognition and unable to make decisions for themselves. Review of the Resident #23's updated plan of care dated 07/17/24 with updates reflected goals and approaches to include wheelchair mobility. Observation and interview on 08/12/24 at 12:22 p.m., revealed Resident #23 was in his wheelchair in the dining room, and the wheelchair's left armrest was missing. The wheelchair's left side had an open screw hole, where the armrest belonged, that was sharp. There were no skin tears on the resident's arms. Resident #23 stated the armrest missing did not bother him, but at times it was rough on his arm. He said he had never been wounded from the armrest missing. Review of Resident #42's significant change MDS assessment, dated 07/03/24, reflected she was a [AGE] year-old female admitted to the facility on [DATE], with diagnoses of dementia (forgetfulness and confusion) muscle weakness (no strength), abnormalities of gait and mobility (unable to mobilize safety). Further review of the MDS reflected the resident was severely impaired for cognition and unable to make decisions for themselves. Review of the Resident #42's updated plan of care dated 07/24/24 with updates reflected goals and approaches to include wheelchair mobility. Observation on 08/12/24 at 12:25 p.m., revealed Resident #42 was sitting in her wheelchair in the dining room and the wheelchair's right and left armrests were cracked, with exposed foam. There were no skin tears on the resident's arms. The wheels of the wheelchair had dried food substance on both wheels and on wheel rims. Review of Resident #53's quarterly MDS assessment, dated 06/03/24, reflected he was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses of end stage renal disease (kidneys do not work) muscle weakness (no strength), and acquired absence of left leg (left leg missing below the knee). Further review of the MDS reflected the resident was alert and oriented for cognition and able to make decisions for themselves. Review of the Resident #53's updated plan of care dated 06/23/24 with updates reflected goals and approaches to include wheelchair mobility. Observation on 08/12/24 at 12:26 p.m., revealed Resident #53 was sitting in his wheelchair in the dining room and the wheelchair's right armrest was cracked, with exposed foam. There were no skin tears on the resident's arms. In an interview on 08/12/24 at 12:30 p.m. with Resident #53 revealed he was happy with his wheelchair, the facility had given it to him, but his arm rest was uncomfortable at times. The resident stated he had not told anyone about the wheelchair, he was just enjoying the chair. Review of Resident #38's quarterly MDS assessment, dated 06/06/24, reflected he was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses of end stage renal disease (kidneys do not work) muscle weakness (no strength), lack of coordination (not able to stand alone or walk safely), and hemiplegia right side (right side weakness unable to use). Further review of the MDS reflected the resident was severely impaired for cognition and unable to make decisions for themselves. Review of the Resident #38's updated plan of care dated 06/26/24 with updates reflected goals and approaches to include wheelchair mobility. Observation on 08/12/24 at 12:37 p.m., revealed Resident #38 was sitting in his wheelchair in the dining room and the wheelchair's right armrest was cracked, with exposed foam and the left armrest was missing. There were no skin tears on the resident's arms. In an interview and observation on 08/12/24 at 4:05 p.m., LVN B stated when a resident's wheelchair needed repair the staff were to report it to the maintenance supervisor. LVN B stated there was a maintenance book at the nurse's station, but he would report it in person. There was no maintenance logbook at the nurses station that could be located. In an interview and observation on 08/14/24 at 4:40 p.m. with CNA D revealed if there was a wheelchair that needed repair, she would tell the nurse. The CNA stated there was not a book that she knew of concerning maintenance logs. In an interview on 08/14/24 at 9:00 a.m., ith the Director of Environmental Services revealed the staff had not told her about any wheelchairs that needed repair. The Director of Environmental Services stated there was no process for repairing wheelchairs at this time and no random checks were done, and she knew if the wheelchair needed repair, it could injure the resident. The Director of Environmental Services stated she was unaware of any maintenance logs, the staff just usually told her. In an in interview on 08/13/24 at 1:30 p.m., with the Administrator revealed she was not aware of any wheelchairs that required repair in the facility. The Administrator stated she was not aware of any maintenance books at the nurse's station . The Administrator stated the facility would do a sweep of wheelchairs and order parts and repair the wheelchairs. The Administrator stated system would be put in place to monitor the wheelchairs and allow the staff to have a reporting system. Review of the Facility's Policy titled Assistive Devices and Equipment revised January 2020 reflected . 6. c. Device condition- devices and equipment are maintained on schedule . 8. Equipment maintained for the general use of all residents

Based on interview and record review, the facility failed to use the services of a registered nurse for at least 8 consecutive hours a day, 7 days a week for 4 of 90 days reviewed for RN coverage. The facility failed to ensure they had an RN on duty on for 4 days: 10/21/23; 11/14/23; 11/20/23 and 11/26/23. This failure placed residents at risk of missed nursing assessments, interventions, care, and treatment. Findings included: Review of the RN staffing hours for October 2023 reflected zero hours worked by an RN on 10/21/23. Review of the RN Staffing hours for November 2023 reflected zero hours worked by an RN on 11/18/23; 11/20/23: and 11/26/23. During an interview on 08/13/24 at 11:05 AM, the DON stated that she had only been employed at the facility a few weeks. She felt the facility met the RN requirement as the shift for the night nurse starts at 10:00pm and ends at 6 am. The DON stated that she felt like it is only counting 2 hours for one day and 6 hours for the next day and it may not be considered 8 consecutive hours. She stated she was not working for the facility during October and November last year when the days were not covered by RN staff, on the following dates: 10/21/23,11/14/23/11/20/23 and 11/26/23. She stated that she had worked at the facility a few weeks and all scheduled shifts met the RN coverage requirement. She stated that a lack of RN coverage could result in a decline in the resident's care, missed assessments and lack of treatment that could ultimately result in death. During an interview on 08/13/24 at 11:10 AM, the ADM stated stated that he would pull the sign in sheet for the dates to confirm whether the facility met the hours. During an interview on 08/13/24 at 12:45 PM with the Owner, he stated the facility had an issue with nursing last year. He stated they were cited during the last inspection and had not missed any hours since last year. He was able to review the PBJ and point out some of the dates that did not meet the staffing requirements: 10/21/23, 11/14/23, 11/20/23, and 11/26/23. He stated there were a few days when they had staff call in at the last minute and were not able to have someone at the facility for the full 8 hour shifts. Record review of facility policy dated August 2006 reflected the following: . Policy Statement: The nursing services department shall be under the direct supervision of a registered or licensed practical/vocational nurse at all times. Policy Interpretation and Implementation: 1. A registered or licensed practical/vocational nurse (RN/LPN/LVN) is on duty 24 hours per day, seven days per week, to supervise the nursing services activities in accordance with physician orders and facility policy. 2. A registered nurse (RN) is employed as the Director of Nursing Services. The DNS is on duty during the day shift Monday through Friday. During the absence of the DNS, a nurse supervisor/charge nurse is responsible for the supervision of all nursing department activities, including the supervision of direct care staff. 3. The nurse supervisor/charge nurses are registered nurses (RN) or licensed practical vocational nurses (LPN/LVN) and are duly licensed by the state. 4. The Director of Nursing Services and/or the nurse supervisor/charge nurse, as a minimum, is responsible for: a. making daily resident visits to observe and evaluate the residence, physical and emotional status; b. reviewing medication, cards for completeness of information, accuracy in the transcription of physician orders, and adherence to stop order policies; c. reviewing individual, resident care, plans for appropriate goals, problems, approaches, and revisions, based on nursing needs; d. Assuring that the residence plan of care is being followed; e. arranging schedule to allow time for supervision and evaluation of performance of nursing personnel, and paid feeding assistants; f. informing attending physicians and resident families of changes in the residence, medical condition; g. charting and documenting medical records as necessary; h. keeping Nursing Service Personnel, informed of status of residence, and other related matters through written reports and verbal communication; i. Assigning work schedules and staffing to meet the needs of residence; providing direct resident care as necessary or appropriate; j. and other tasks and functions, that may become necessary

Based on observation, interview, and record review the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in the facility's only kitchen, reviewed for food safety. 1. The facility failed to ensure the ice machine vent was free from dirt and dust. 2. The facility failed to ensure food items in the refrigerators, freezer and dry storage room were labeled with the item description (handwritten or manufacturer's label), the opened date and or the consume by or expiration by dates (if opened, 72 hours per the facility's policy or the manufacturer's expiration date); and stored in accordance with the professional standards for food service. 3. The facility failed to discard opened items stored in refrigerator, freezers and dry storage that were not properly labeled with the opened or prepped by date and or past the best buy, consume by or manufacturer's expiration dates. 4. The facility failed to store dented cans in the designated area for dented cans. These failures could place residents at risk for food-borne illness and cross contamination. Findings included: Observation of the Kitchen on 08/12/24 at 08:30 AM revealed the following: - The ice machine's front vent filter had dust particles. - On the prep table next to the ice machine there was a 32 oz bag of potato flakes, 13oz bag of brown gravy, no consume by, or an expiration dates. - On the prep table next to the ice machine, a personal item, medium size backpack was underneath food prep table. - 3 large clear square storage bins of cereal. Bin #1 labeled Cheerios and dated 08/09/2024, Bin #2 labeled Raisin Bran dated 08/09/2024, Bin #3 labeled Corn Flakes dated 07/11/2024. The dates did not indicate if it was opened, or consume by, or an expiration date. Observations of the three Reach-in refrigerators upon entrance to kitchen on 08/12/24 at 08:33 AM revealed the following: Refrigerator # 1 -On the top left shelf there were 12 -16oz blocks of butter. One of the blocks of butter was opened, exposed to air. -Top left shelf-had a large: zip top bag with a block of cheese dated 08/12/2024. The date listed on block cheese did not indicate if it was the opened or consume by or expiration date. -Top left shelf had a large zip top bag with an unidentified lunchmeat dated 08/09/2024. The date listed on zip top bag did not indicate if it was the opened or consume by or expiration date. There was no label of the item descriptions on the zip top bag. An interview on 08/12/2024 at 8:45am with the Director of Culinary Services, revealed when asked about the dated labels, she stated the white sticker labels were the received by date. She stated the handwritten dates were the use by or consumed by date. -Top right shelf: Had seven 46 FL oz cartons of apple juice dated 08/06/2024. The date listed on the cartons did not indicate if it was the opened or consume by or expiration date. One of the cartons of apple juice was opened and there was no a consume by or expiration date on the item. -Top right shelf had a large 36oz bottle of ranch manufactured date of 07/30/2024. The bottle of ranch there was no a consume by or expiration date on the item. -Middle shelf: had a large zip top bag with lettuce dated 08/09/2024. The date listed did not indicate an opened, consume by or expiration date. -Bottom right shelf had cooked eggs in a disposable plate dated 08/12/204 that was placed on top of parchment paper that covered 4 trays of uncooked bacon that was dated 08/12/2024. Reach in refrigerator # 3 -Top left shelf: there was an opened 24oz bag of dinner rolls dated 08/07/2024. The date listed did not indicate an opened, or consumed by, or expiration date. -Middle shelf: there was a large zip top bag with smoked sausage links dated 07/31/2024. The date listed did not indicate an opened, consumed by, or expiration date. -Top right shelf: there was a 66oz hazel nut coffee creamer that was opened. The date listed did not indicate an opened, consumed by, or expiration date. -Top right shelf: there was a 28 oz white chocolate mocha creamer that was opened with manufactured date 11/27/2024. The date listed did not indicate an opened, consumed by, or expiration date. -Top right shelf - There was a 24 oz mild salsa was opened with manufactured date 10/12/2025. The date listed did not indicate an opened, consumed by, or expiration date. -Top right shelf: There were three 25.4oz white grape sparkling wine bottles with manufactured date 10/12/2025. There was not a consumed by, or expiration date. -Middle right shelf: There was a plastic container with 8 boiled eggs, dated 08/11/2024. The date listed did not indicate if the date was a consume by, or expiration date. -Middle right shelf: There were 3 plates with pancakes on them. One plate of pancakes was not covered, exposed to air. No dates or label was listed on the plates. -Bottom right shelf: There were 6 bowls of unidentified puree food. No dates were listed to indicate how long the puree food was on the shelf nor a labeled description/name of the food item. -Right side bottom shelf there were 4 plates of unidentified meat patties dated 08/12/2024. The date listed did not indicate a consume by date. There was no label that identified or described the food item. -Bottom right shelf: Observed 2 small clear plastic containers with lids with unidentified puree food, both dated 08/12/2024. The date listed did not indicate if it was the consume by date. There was no label that identified or described the food item. An interview on 08/12/2024 at 9:07am with the Director of Culinary Services revealed the white stickers on items was the receive by date and the written date on items was the use by or expiration date. She stated once food items were opened; per policy the food items must be discarded after 3 days. She stated once liquids were opened, they were discarded after 7 days. Observations of the reach in freezer on 08/12/24 at 9:11 AM, revealed the following: Freezer #2 -Top right shelf: had a 3lb box of frozen yellow squash was opened and exposed to air. The box was dated received 07/24/2024 and opened 08/07/2024. -Middle right shelf: there was 5 large zip top bags of pancakes exposed to air. Pancakes dated 8/11/2024. The date listed did not indicate an opened or consume by date. - Middle right shelf: there was a large zip top bag of frozen meatballs exposed to air. The meatballs were dated 08/07/2024. The date listed did not indicate an opened or consume by date. -Middle right shelf there was a large bag of breaded okra pieces dated 07/25/24. The date listed did not indicate a received date, a consume by or expiration date. -Right bottom shelf: there was large zip top bag with large flat ham exposed to air. The meat was darkened and had medium ice crystals in the bag. The bag was dated 08/05/2024. The date listed did not indicate an opened date or consume by date. -Right top shelf: there was a15lb box of catfish fillets that was opened and exposed to air. The catfish was darkened and had medium ice crystals in the bag. The box of catfish was dated 07/24/2024. The date listed did not indicate an opened or consume by date. -Right top shelf: there was a 4oz box of porkchops that was opened and exposed to air. The porkchops had white ice crystals on them. The box was dated 08/07/2024. The date listed did not indicate an opened or consume by date. -Right top shelf: there was an opened large zip top bag with approximately 10 plus hash browns were exposed to air. The zip top bag was dated 07/31/204. The date listed did not indicate an opened date or consume by date. Observations of the Dry Storage Room on 08/12/24 at 9:40 AM revealed the following: -Shelfing rack behind the door to the storage room: top shelf had a 6lb 10oz canned mandarin oranges that was dented at bottom right. The canned oranges were dated 07/03/2024 with no manufactured date. The date listed did not indicate an expiration date. -Shelfing rack behind door entrance to storage room: On the bottom shelf there were 2 6lb 4oz diced pears. One can was dented at the bottom backside of the can and the second can was dented on front left side of the can. -Shelf #1 Top shelf: had a large zip top bag labeled tea and dated 08/07/2024. Two packs of unidentified tea with no label description dated 08/07/2024. The date listed did not indicate an opened date or expiration date. -Shelf # 1 Top shelf: had one 2lb 6oz canned chili no beans dented on right front and left side of can. The canned chili no beans dated 07/17/2024 with a manufactured date 10/15/2025. The date listed (07/17/2024) did not indicate an expiration date. -Shelf # 1 middle shelf: Had 1 box 16.9 oz of oatmeal pies was opened and dated 07/24/2024. The date listed did not indicated an opened date or consume by date or expiration date. A manufactured dated was not listed. -Shelf # 2 top shelf: large zip top bag with 5lb bag of cornbread opened and dated 07/18/2024. The dated listed did not indicate an opened or consume by date or expiration date. -Shelf #2 bottom shelf: Had approximately 10 bags of white bread dated 8/7/2024. The date listed did not indicate a consume by date or expiration date. -Shelf #4 top shelf: There was a16oz bag granulated calorie free sweetener opened. The manufactured date 07/25/2025. There was no open date or expiration date. -Shelf #4 top left there was a 1.2oz box of food coloring opened. The manufactured date 11/18/2023. There was no open date or expiration date. An interview on 08/12/2024 at 11:44 a.m. with Directory of Culinary Services, regarding the dented canned goods, she stated canned goods received without a manufactured date or produce date, they are used within a week of received date. She stated dented canned goods are stored with a label on the bottom row of shelf number. Regarding personal belongings, she stated staff's personal belongings are stored in her office or in lockers in the breakroom. (The Directory of Culinary Services did not state what the potential risk to residents was due to the failures.) Review of the facility's Food Receiving and Storage Policy, Date Revised July 2014, reflected Policy Statement: Foods shall be received and stored in a manner that complies with safe food handling practices. Policy Interpretation and Implementation: 1. Food services, or other designated staff, will maintain clean food storage areas at all times. 3.The food and nutrition services manager shall verify the latest approved inspection and also monitor the food quality of the supplier. 7. Dry foods that are stored in bins will be removed from original packaging, labeled, and dated (use by date). Such foods will be rotated using a first in - first out system. 8.All foods stored in the refrigerator or freezer will be covered, labeled, and dated (use by date). 11. Wrappers of frozen foods must stay intact until thawing. Review of the U.S. FDA Food Code 2022 reflected: Chapter 3 . section 3-201.11 Compliance and Food Law: . C. Packaged Food shall be labeled as specified in LAW, including 21 CFR 101 Food Labeling [* .(b) A food which is subject to the requirements of section 403(k) of the act shall bear labeling, even though such food is not in package form. (c) A statement of artificial flavoring, artificial coloring, or chemical preservative shall be placed on the food or on its container or wrapper, or on any two or all three of these, as may be necessary to render such statement likely to be read by the ordinary person under customary conditions of purchase and use of such food. The specific artificial color used in a food shall be identified on the labeling when so required by regulation in part 74 of this chapter to assure safe conditions of use for the color additive.], 9 CFR 317 Labeling, [*(a) When, in an official establishment, any inspected and passed product is placed in any receptacle or covering constituting an immediate container, there shall be affixed to such container a label .Marking Devices, and Containers, and 9 CFR 381 Subpart N Labeling and Containers, and as specified under S 3-202.18. Section 3-302.12 Food Storage Containers, Identified with Common Name of Food: Except for containers holding FOOD that can be readily and unmistakably recognized such as dry pasta, working containers holding food or food ingredients that are removed from their original packages for use in the food establishment, such as cooking oils, flour, herbs, potato flakes, salt, spices, and sugar shall be identified with the common name of the food. Section 3-501.17 . Commercial processed food: Open and hold cold . B. 1. The day the original container is opened in the food establishment shall be counted as Day 1. 2. The day or date marked by the food establishment may not exceed a manufacturer's use-by date if the manufacturer determined the use-by date based on food safety. C. 2. Marking the date or day of preparation, with a procedure to discard the food on or before the last date or day by which the food must be consumed on the premises, sold, or discarded as specified under (A) of this section. 3. Marking the date or day the original container is opened in a food establishment, with a procedure to discard the food on or before the last date or day by which the food must be consumed on the premises, sold, or discarded as specified under (B) of this section .Section 6-305.11 . Designation: Street clothing and personal belongings can contaminate food, food equipment, and food-contact surfaces. Proper storage facilities are required for articles such as purses, coats, shoes, and personal medications.

Based on observations, interviews, and record review, the facility failed to ensure a resident with urinary incontinence, based on the resident's comprehensive assessment, who enters the facility with an indwelling catheter received appropriate treatment and services for 1 (Resident #1) of six residents reviewed for quality of care, in that: LVN A, DON, and ADON failed to follow-up with physician after leaking was reported to the suprapubic catheter on 06/16/24 until 06/29/24 when surveyor intervened. An Immediate Jeopardy (IJ) was identified on 06/30/24. The IJ template was provided to the facility on [DATE] at 4:30 PM. While the IJ was removed on 07/01/24, the facility remained out of compliance at a scope of isolated and severity level of no actual harm with potential for more than minimal harm that is not immediate jeopardy due to the facility continuing to monitor the implementation and effectiveness of the corrective systems. This deficient practice placed residents at high risk of, or the likelihood of, serious injury or harm by not receiving treatment, developing complications such as injury to the urinary tract, and the development of sepsis. Findings included: Record review of Resident #1's Admission Record revealed a [AGE] year-old male, who admitted to the facility on [DATE] with the following diagnoses: Hemiplegia (refers to complete paralysis), affecting right dominant side; CKD, stage 2 (mild); retention of urine (a condition in which you are unable to empty all the urine from your bladder); and Down Syndrome. Record review of Resident #1's Annual MDS assessment, dated 05/08/24, revealed a BIMS score of 12 which suggested Resident #1 had a moderate cognitive decline. Resident #1's functional status required one-person substantial/maximal assistance with ADLs. Resident #1 was always incontinent of bowel and had a suprapubic indwelling catheter (a flexible tube inserted into the bladder, through a cut in the abdomen, and remains in place for continuous drainage of urine into a drainage bag). Resident #1's clinical physician orders reflected on the June 2024 Nurse Treatment Administration Record (nTAR) that each order was being performed as ordered: - Order date - 05/05/23: Catheter care with soap and water every shift and as needed. Every shift. - Order date - 09/23/23: Suprapubic output every shift. - Order date - 03/04/24: Change Suprapubic catheter with 16F (size of tubing) catheter with 10 cc balloon every 4 weeks along side with bed side bag. Every night shift every 4 weeks on Sunday. - Order date - 06/10/24: Clean and change dressing at catheter insertion site in the morning [04:00 AM - 06:00 AM] - Order date - 06/16/24: Barrier cream to Suprapubic catheter PRN every 6 hours as needed for skin irritation of skin every 6 hours as needed for skin irritation. [Discontinued 06/16/24] The orders to flush urinary catheter with 30 cc normal saline as needed to maintain patency every 8 hours as needed to keep catheter patent [order date: 05/09/23 - discontinued] did not reflect on the June 2024 nTAR. Record review of the Order Summary Report reflected an order written, 05/09/24, to Flush urinary catheter with 30 cc normal saline as needed to maintain patency. Every 8 hours as needed to keep catheter patent. The order status was discontinued. Review of Resident #1's progress notes indicated: - Nurse's Note Effective Date: 06/16/24 at 6:32 PM, LVN A entered, SEE SBAR FOR SUPRAPUBIC CATH - Nurse's Note Effective Date: 06/29/24 at 4:25 PM, the DON entered, just spoke with [family member] . requesting resident go to [2 hospital choices] . EMT present. - Nurse's Note Effective Date: 06/29/24 at 11:33 PM, LVN D entered, [Resident #1] return back to facility . suprapubic [SPC] replaced, no leakage noted . new order for cefdinir 300 mg capsule (antibiotic) for infection. Record review of SBAR documentation reflected LVN A notified the PCP on 06/16/24 at 6:19 PM that Resident's #1 SPC was not draining, brief was soaked with urine, and [LVN A] recommendation was for Resident #1 to see Urologist. No new orders. A review of Resident #1's hospital medical records dated 06/29/24 reflected [Resident #1] arrived at theER on [DATE] at 5:10 PM. Review of the interpretation of the urinalysis collected 06/29/24 at 6:07 PM indicated Resident #1 had a urine infection. Resident #1's suprapubic catheter was changed in the ER and Resident #1 was discharged back to the facility with a prescription for an antibiotic to be administered for 7 days. During an observation and interview on 06/29/24 at 10:10 AM, accompanied by CNA B, Resident #1 was observed in bed. [Catheter] Tubing dangled loosely from the right side of bed, attached to drainage bag. A cloudy yellow haze with white specks settled in the loop of the tubing and a scant amount of yellow cloudy urine was in the drainage bag. CNA B assisted by pulling back the covers to show the Suprapubic catheter (SPC) insert site at the lower abdomen above the pubic area. There was a 4x4 gauze placed over the site with one piece of paper tape horizontally placed across the top of the gauze, initialed and dated. The gauze flapped up and down as the covers were pulled back. There was leakage around the SPC insert site. CNA B detached the tape that secured the brief and pulled back between Resident #1's legs. The brief flopped down on the bed from the weight of the urine that filled the brief. The inner lining of the brief appeared squishy with yellow fluffy material that absorbed urine and had a strong odor. Resident #1 's pubic area was distended that indicated fullness from urine retention. There was a stat lock placed on Resident #1's right upper thigh to keep the catheter tubing from being pulled that appeared dirty and was pulled away from the skin. Resident #1 denied pain at the site but could not hold a meaningful interview due to his impaired cognition. During an interview on 06/29/24 at 10:38 AM, CNA B said she was familiar with Resident #1's care needs. CNA B said that she reported to LVN A the past 2 weekends (June 15 and 16; June 22 and 23) that Resident #1's brief was filled with urine and none in the drainage bag. CNA B said that LVN A acknowledged and informed that she notified the PCP. CNA B said that she notified LVN A because a urine filled brief was not normally seen with residents who had [urine] catheters. CNA B said that it was her responsibility to prevent skin breakdown by making sure Resident #1 was maintained clean and dry. During an interview on 06/29/24 at 3:43 PM, the DON said that she was familiar with Resident #1 and indicated Resident #1 recently had his [SPC] catheter replaced on or about May 26, 2024, when Resident #1 was sent to the hospital due to leaking around the insert site. The DON was informed by the surveyor the observation findings (06/29/24 at 10:10 AM). The DON said she had not been informed by LVN A or reviewed in the 24-hour reports about any change of condition since then related to Resident #1's urinary catheter. The DON said that she expected nurses to notify the MD, ADON, DON and NFA of any resident change in condition, the cause of decline and how the cause was determined. The DON said that she would expect the nurse to report to the MD, signs and symptoms, interventions, effectiveness, and to document communication with the MD. The DON said that she would expect the nurse to follow up with the MD if she did not get a reply within thirty minutes and notify the oncoming nurse to follow up as needed. The DON said that the nurse should maintain awareness of the resident's condition to be able to recognize changes and be knowledgeable of nursing interventions. During an outbound call on 06/30/24 at 4:30 PM, the FMD indicated vaguely recalled being notified about Resident #1's SPC leaking. Notifications were sent via a group text phone app. The FMD recalled an order was given to replace the SPC with a larger tubing and the resident ended up being sent out to the hospital (this incident occurred the end of May 2024 and was not relevant to the incident that occurred on 06/16/24). During an interview and record review on 07/01/24 at 12:03 PM, the ADON said she was familiar with Resident #1. The ADON described Resident #1's care needs as one person assist with ADLs and had a SPC. The ADON said that the nurses performed catheter care per shift to assess for any issues, such as leaking or drainage around insert site, cracks in the tubing, urine output and characteristics. The ADON indicated that the CNA also checked the catheter during incontinent care for any concerns that should be reported to the nurse. The ADON said that it was the nurse's responsibility to ensure catheter care was provided during their shift and as needed. The ADON said that the assigned nurse must ensure proper catheter care and the catheter must remain patent. Patency was maintained by flushing the catheter with 30 cc normal saline. The ADON indicated that catheter flushing was part of urinary catheter care batch orders. The ADON described a change in condition as anything outside of what was normal for the resident, not eating or sleeping more than usual. The ADON said that the nurse should assess the resident to determine the cause of change in condition, immediately notify the MD, then document findings. The ADON said that the SNF used a secured messaging app to notify the MD about resident clinical status and send pictures if needed. The ADON said that she, the DON, and NFA were included on MD notifications via the messaging app. The ADON reviewed the messaging app and saw that there was a message on 06/16/24 about Resident #1's SPC leaking and urine-soaked brief, without a reply from the MD. The ADON said that her expectation was that every nurse be responsible for the assignment given and for nurses to inform leadership when they were busy and needed assistance. An outbound phone call to LVN A on 06/29/24 at 12:40 PM, 06/30/24 at 1:10 PM and 07/01/24 at 6:15 PM were unanswered. LVN A did not return the phone calls. An outbound phone call to speak with Resident #1's RP on 06/29/24 at 12:54 PM was not answered. Record review of the facility's Suprapubic Catheter Care policy, revised October 2010, reflected the purpose of the procedure was to prevent skin irritation around the stoma site and to prevent infection of the resident's urinary tract. General Guidelines reflected: Observe the resident's urine level for noticeable increases or decreases. Should the resident indicate that his or her bladder is full or needs to void, report immediately to your supervisor. Observe the resident for signs and symptoms of urinary tract infection and urinary retention. Report findings to your supervisor. Notify the physician of any abnormalities in the skin assessment or the character of urine. Report other information in accordance with facility policy and professional standards of practice. Record review of the facility's Change in a Resident's Condition or Status policy, revised May 2017, reflected the purpose to ensure resident's family and physician are notified of changes that fall under: - an accident resulting in injury that has the potential for needed physician interventions - a significant change (example given: Abnormal lab results) - a need to significantly alter treatment - transfer of the resident from the facility Record review of the facility's Acute Condition Changes - Clinical Protocol policy, reviewed December 2022, reflected assessment and recognition, cause identification, treatment/management, monitoring and follow-up: 1. During the initial assessment, the physician will help identify individuals with a significant risk for having acute changes of condition during their stay; for example, and individual with an indwelling urinary catheter who has had recurrent symptomatic UTIs, someone with unstable VS, or recurrent pneumonia. 2. In addition, the nurse shall assess and document/report the following baseline information: VS; neurological status; current level of pain, and any recent changes in pain level; LOC . 3. Direct care staff, including nursing assistants will be trained in recognizing subtle but significant changes in the resident (for example, a decrease in food intake, increased agitation, changes in skin color or condition) and how to communicate these changes to the nurse. 6. Before contacting a physician about someone with an acute change of condition, the nursing staff will make detailed observations and collect pertinent information to report to the Physician; for example, history of present illness and previous and recent test results for comparison. a. Phone calls to attending or on-call physicians should be made by an adequately prepared nurse who has collected and organized pertinent information, including the resident's current symptoms and status. b. Nurses are encouraged to use the SBAR Communication Form and Progress note as a tool to help gather and organize information before notifying the Physician. the purpose to ensure resident's family and physician are notified of changes that fall under: - an accident resulting in injury that has the potential for needed physician interventions - a significant change (example given: Abnormal lab results) - a need to significantly alter treatment - transfer of the resident from the facility The NFA was notified of an Immediate Jeopardy (IJ) on 06/30/24 at 4:30 PM, due to the above failures and the IJ template was provided. The facility's Plan of Removal (POR) was accepted on 07/01/24 at 1:54 PM and included: Per the information provided in the IJ template given on 6/30/24, the facility failed to ensure that all nursing staff had training on foley catheter care and prevention of UTI/CAUTI. Facility failed to ensure a resident with urinary incontinence based on the resident's comprehensive assessment who entered the facility with an indwelling catheter received appropriate treatment and services to prevent UTI. 1. The medical director was notified of IJ on 6/30/24 at 04:35p.m. 2. Review completed by DON of all residents with catheters in facility to assure appropriate monitoring and treatment orders are in place. 3. Chart audits initiated by the DON and ADON on 6/29/24 for all residents with catheters to ensure documentation was noted in the chart. 4. DON, ADON, and clinical leadership-initiated education with nurses and CNAs on monitoring catheters, catheter care, and UTI/CAUTI prevention. 5. Inservice training and education will include determining significant changes, reporting s/s of change in condition, and communicating with department heads and MD/NP changes in condition. 6. Clinical corporate leadership provided education to DON on 6/30/24. 7. All licensed nurses will start competency skills checkoffs on catheter care starting on 6/30/24. 8. All CNAs will complete competency on catheter care initiated on 6/30/24. 9. This training and competencies will be completed in-person with all staff prior to the start of their next shift. Staff will not be allowed to work until they have completed the training and competency skills checkoffs. This training will be included upon new hire orientation and for PRN staff. 10. A QAPI meeting will be held 7/1/24 regarding the items in the IJ template that will include the following attendees: Medical Director, DON, ADON, Executive Director, Clinical Resource, and additional IDT members. The QAPI meeting will include the plan of removal items and interventions. 11. All residents with catheters will be reviewed during the weekly clinical meetings and the medical director will be consulted for any recommendations or suggestions as necessary. Meeting attendees will include the DON, ADON, Rehab Director, MDS 12. Coordinator. The DON and Executive Director will be responsible for ensuring this meeting is held weekly and all residents with catheters are reviewed. 13. Summary of IJ and corrective action to be reviewed by QAPI committee weekly x4 weeks or until substantial compliance established and continue monthly for 90 days to ensure ongoing compliance. On 07/01/24 the surveyor began monitoring if the facility implemented their plan or removal sufficiently to remove the IJ by: Record review of QAPI meeting minutes dated 07/01/24 revealed the QAPI team met to discuss the facility's failure to ensure nursing staff had received training on catheter care and prevention of UTI/CAUTI and steps the facility were taking to address the concern. During an interview and record review on 07/01/24 at 2:49 PM, the DON indicated that she conducted surveillance rounds to visualize each resident's (six residents) urinary catheter site for s/s of infection and patency. The DON indicated that she performed a chart audit on each of the six residents with a urinary catheter to assure appropriate monitoring and treatment orders were in place. Record review of order summaries for the six residents revealed treatment orders were entered and nTAR reflected orders were performed. Interviews conducted with nurses and CNAs scheduled on the 6A - 2P shift [RN F, CNA L, CNA J, MA M, LVN G, CNA I, and CNA N], on the 2P - 10P shift [LVN C, CNA O, CNA P, and CNA Q], and 10P - 6A shift [RN R] indicated they participated in an in-service training about recognizing change in condition, s/sx of UTIs, physician notification, and ANE. The topic of discussion included physician notification, documentation, and follow up orders. Each nurse stated in their own words the procedure was to notify physicians immediately about resident change in condition, verbalized steps taken to notify physician, entering and implementing new orders. Record review of in-services conducted by the DON and ADON dated 06/30/24 - 07/01/24 titled Flushing Supra-pubic Catheter (and irrigation) and Catheter Care - Infection Control, including pre-/post-test were on-going to achieve 100% nursing dept participation. On 06/30/24, an Immediate Jeopardy was identified. The NFA was notified and provided an IJ template on 06/30/24 at 4:30 PM. While the IJ was lowered on 07/01/24, the facility remained out of compliance at a scope of isolated and severity level of no actual harm with potential for more than minimal harm that is not immediate jeopardy due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems.