Every finding on record at Loudoun Rehabilitation and Nursing Center

2.a. For Resident #15 (R15), the facility staff failed to assess the resident to determine if the resident could safely spend time unsupervised on the courtyard patio and failed to provide supervision and a safe environment on the courtyard patio. R15 was unsupervised and fell on the courtyard patio. The resident sustained a head injury that required hospitalization, two staples for a laceration, and a C2 (second cervical) vertebral fracture. R15's diagnoses included but were not limited to congestive heart failure, muscle wasting and atrophy, paranoid personality disorder, auditory hallucinations, and dementia. R15's comprehensive care plan dated 7/19/23 failed to document information regarding the resident spending time outside on the courtyard patio. A review of R15's clinical record revealed the resident sustained falls on 1/9/25, 2/25/25, 3/23/25, and 3/27/25. R15's Morse fall scale assessments dated 1/9/25, 2/25/25, 3/23/25, and 3/27/25 documented the resident was at a high risk for falling. On the most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 2/21/25, the resident scored 11 out of 15 on the BIMS (brief interview for mental status), indicating the resident was moderately cognitively impaired for making daily decisions. An activities note dated 1/31/25 documented, Resident at 11:30 today, the housekeeping director noticed that resident was trying to access the outside looking for a 'cat'. The director went outside for him to check and confirmed there was no cat. He then explains that every nursing home has a cat. Residents' cognitive health seems to be altered. Continues to try to leave to the patio in inappropriate clothing for the weather. A physical therapy progress note dated 4/27/25 documented, Remaining Impairments: strength impairments, decreased dynamic balance, balance deficits and decreased functional capacity. A nurse's note dated 4/30/25 documented, Resident Observed laying on ground outside in Paddio [sic]/Back yard. Upon skin assessment noted blood on head 0.5cm (centimeter) x 0.01cm to scalp. assisted resident off the ground with 3 persons to assist. and back to the room. Assessed resident no other injury noted. Physician notified with new order to send resident to ED (Emergency Department) for evaluation secondary to resident currently on Eliquis (a blood thinning medication). Scanty blood noted to scalp. Family POA (Power of Attorney) notified (name). Hospital documentation dated 4/30/25 revealed R15 sustained a fractured second cervical vertebra and a head laceration to the scalp that required two staples. R15 was re-admitted to the facility on [DATE]. Further review of R15's clinical record (including physical therapy documentation, nursing assessments, physician/nurse practitioner notes, and nurses' notes for 1/31/25 through 5/11/25) failed to reveal the facility staff assessed R15 to determine if the resident could safely spend time unsupervised on the courtyard patio and failed to reveal the facility staff implemented interventions to ensure the resident was supervised while going outside. On 5/13/25 at 4:17 p.m., an interview was conducted with LPN (licensed practical nurse) #2. LPN #2 stated the physical therapy staff complete assessments to determine if residents can safely go out to the patio unsupervised and there was no nursing assessment. LPN #2 stated R15 resides on the second floor and has a wander guard device so if the resident attempted to get on the elevator and go to the first floor, an alarm would sound when he attempted to get on the elevator. On 5/13/25 at 5:15 p.m., an observation of R15 was conducted. No wander guard was observed on the resident's body or wheelchair. Also, a review of R15's clinical record failed to reveal documentation regarding a wander guard. On 5/13/25 at 5:02 p.m., an interview was conducted with OSM (other staff member) #4 (a physical therapist who treated R15). OSM #4 stated R15's cognition and safety awareness was poor. OSM #4 stated she educated R15 that he needed to wait for someone to help him with transfers and obtaining items from the ground and he would not wait. OSM #4 stated R15 does not listen to staff education and is going to do what he wants to do. OSM #4 stated R15 has got to lift his bottom up when transferring or will fall, the resident has a history of falling, and the resident scoots out of the wheelchair. OSM #4 stated residents are not routinely assessed by therapy staff to determine if they can safely spend time on the courtyard patio unsupervised unless a resident says he or she wants to go outside or going outside aligns with their rehab goals. OSM #4 stated she did not think R15 was assessed to determine if he was safe while outside and unsupervised. On 5/14/25 at 7:53 a.m., an observation of R15 was conducted. No wander guard was observed on the resident's body or wheelchair. On 5/14/25 at 8:15 a.m., an observation of the courtyard patio was conducted. The patio was located on the first floor approximately 12 feet from the elevator. The patio door was unalarmed and accessible by opening the door. The following was observed on the patio: -pebbled pavers -multiple tables, chairs, benches, and wooden garden beds -a covered swing -a rectangular metal propane grill with two 20-pound propane tanks -a triangular corner waterfall rock pond (approximately 16 feet [base] by seven feet [corner] by seven feet [corner]); a rail was observed spanning across the base edge of the pond but there was open space (approximately three feet) between the rail and the ground. On 5/14/25 at 8:20 a.m., ASM (administrative staff member) #1 (the administrator) provided a list that documented R15 (and another resident) independently used the courtyard. ASM #1 stated this list was generated based on talking with staff. On 5/14/25 at 8:31 a.m., an interview was conducted with OSM (other staff member) #12 (an anonymous staff member). OSM #12 stated R15 used to go outside to the courtyard patio almost daily and stated the resident said he was leaving food for cats and dogs. OSM #12 stated that at times, the resident was supervised during activities but at other times, the resident was unsupervised. On 5/14/25 at 8:47 a.m., another interview was conducted with OSM #4. OSM #4 stated R15 was non-compliant with rehab recommendations and education. OSM #4 stated she was not aware R15 had been going outside on the courtyard patio and had not been evaluated. On 5/14/25 at 9:07 a.m., an interview was conducted with LPN #4. LPN #4 stated R15 is, always all over the place and always sneaks around. LPN #4 stated sometimes R15 went outside on the patio and sometimes R15 went outside the front entrance but the last time she was aware of the resident going outside was when the resident fell on the patio. LPN #4 stated R15 was currently physically capable of wheeling himself outside to the patio. On 5/14/25 at 11:25 a.m., another interview was conducted with LPN #2. LPN #2 stated she mistakenly spoke when she said R15 had a wander guard, and the resident did not have a wander guard. LPN #2 stated she was the nurse caring for R15 on 4/30/25. LPN #2 stated that on that date, another nurse brought R15 upstairs and said the resident had fallen on the courtyard patio and hit his head on the grill. LPN #2 stated she assessed R15, and the resident was alert and moving all extremities but there was blood coming from his head. LPN #2 stated the nurse practitioner ordered for R15 to be transferred to the hospital because the resident was prescribed a blood thinning medication. On 5/14/25 at 12:37 p.m., ASM (administrative staff member) #1 (the administrator) and ASM #2 (the director of nursing) were notified of IJ (Immediate Jeopardy). The facility presented the following IJ removal plan which was accepted on 5/14/25 at 9:31 p.m. 1. Director of Nursing will instruct resident that he is unable to access the courtyard alone as of 5/14/25. Resident #15 is currently on therapy caseload for improving strength, functional mobility, transfers, gait, endurance, utilizing a reacher & self care. He is currently independent in his wheelchair. Morse Fall Scale and BIMs was completed 5/14/25. Nursing staff that work that unit have been educated to not allow resident to use courtyard without supervision on 5/14/25. A staff member will be posted at the door of the patio 24 hours a day until a locking system can be installed on the courtyard door. 2. Other residents using the courtyard independently could be affected by this practice. List of residents using courtyard independently has been generated as of 5/14/25. 3. The Director of Nursing or designee will educate all staff that resident is unable to access the courtyard alone as of 5/14/25. All staff are being re-educated on ensuring residents requesting to use courtyard without supervision have been assessed by therapy for independence outdoors and will not be allowed to work until re-educated. If therapy is unable to assess a resident who desires to go into the courtyard, the resident will not be able to enter the courtyard alone until the assessment is complete. This assessment will be completed within 3 business days. Should the therapy assessment deem a resident unsafe in the courtyard, the resident will not be allowed to be in the courtyard unsupervised and this will be reflected on their plan of care and in a progress note. Facility staff or family/visitor for that resident will provide supervision. 4. Therapy will screen all new admissions for their ability to go outside independently for the next 6 weeks. Current residents will be screened quarterly for their ability to go outside independently. A list of residents who require supervision to be in the courtyard will be placed on each unit and the receptionist desk. Any resident attempting to enter the courtyard without supervision will be redirected. 5. AOC: 5/14/25 Time: 11:59pm On 5/14/25 at 7:45 p.m., an interview was conducted with OSM #3 (a physical therapist who treated R15). OSM #3 stated residents who present with a fall risk and decreased safety awareness are not safe when unsupervised outside because there is more of a chance for falls and risk of hospitalization. OSM #3 stated R15 had not been assessed for being outside in the courtyard patio unsupervised because staff knows the resident is not safe out there. OSM #3 stated there is a downhill slope at the entrance to the patio and now construction is being completed. OSM #3 stated R15 is safe as long as he doesn't transfer himself without assistance, but the resident does. On 5/15/25 at 9:52 a.m., an interview was conducted with OSM #2 (an occupational therapist). OSM #2 stated there are many components to determine if a resident can safely go out into the courtyard such as managing the door, inclines, declines, coordinating around the area, and cognition. On 5/15/25 the survey team, through observations, interviews, and documentation review, verified the removal plan had been fully implemented by the facility. On 5/15/25 at 12:39 p.m., ASM #1 was informed that the abatement plan was verified. On 5/16/25 at 8:55 a.m., ASM #1 was informed the IJ had been abated. On 5/20/25 at 9:43 a.m., an interview was conducted with LPN (licensed practical nurse) #3 (the nurse who observed R15 on the ground in the courtyard patio on 4/30/25). LPN #3 stated that on 4/30/25, he was inside the building on the first floor and a family member came to him and asked him to go to the courtyard patio. LPN #3 stated he went out to the patio and found R15 laying in front of his wheelchair with his right elbow and legs on the ground, and his head facing the grill. LPN #3 stated that by looking at R15's position and the injury on the resident's head, it looked like R15 hit his head on the grill. LPN #3 stated R15 had two bananas and a shovel, and the resident stated he wanted to plant the bananas in the ground. On 5/20/25 at 11:25 a.m., an interview was conducted with ASM #1. ASM #1 stated a comprehensive assessment including residents' functional and cognitive abilities should be completed to determine if a resident can safely go out on the courtyard patio unsupervised. On 5/20/25 at 1:58 p.m., ASM #1 presented a form titled, Outdoor Safety Screening Tool that was developed after Immediate Jeopardy. The form documented, Trigger Questions: BIMs score (BIMs to be completed same day as screen). If BIMs score is 12 or below, resident is supervised outdoors and remainder of tool does not need to be completed. The facility policy titled, Accidents and Supervision documented, The resident environment will remain as free of accident hazards as is possible. Each resident will receive adequate supervision and assistive devices to prevent accidents. This includes: 1. Identifying hazard(s) and risk(s). 2. Evaluating and analyzing hazard(s) and risk(s). 3. Implementing interventions to reduce hazard(s) and risk(s). 4. Monitoring for effectiveness and modifying interventions when necessary .1. Identification of Hazards and Risks- the process through which the facility becomes aware of potential hazards in the resident environment and the risk of a resident having an avoidable accident. a. All staff (e.g., professional, administrative, maintenance, etc.) are to be involved in observing and identifying potential hazards in the environment, while taking into consideration the unique characteristics and abilities of each resident. b. The facility should make a reasonable effort to identify the hazards and risk factors for each resident. c. Various sources may include, but are not limited to: i. Quality assessment and assurance (QAA) activities. ii. Environmental rounds. iii. MDS/CAA (minimum data set/care area assessment) data. iv. Medical history. v. Physical exam. iv. Facility assessment. vii. Individual observation. e. This information is to be documented and communicated across all disciplines. 2. Evaluation and Analysis- the process of examining data to identify specific hazards and risks and to develop targeted interventions to reduce the potential for accidents. Interdisciplinary involvement is a critical component of this process. a. Analysis may include, for example, considering the severity of hazards, the immediacy of risk, and trends such as time of day, location, etc. b. Both the facility-centered and resident-directed approaches include evaluating hazard and accident risk data, which includes prior accidents/incidents, analyzing potential causes for each hazard and accident risk, and identifying or developing interventions based on the severity of the hazards and immediacy of risk. c. Evaluations also look at trends such as time of day, location, etc. 3. Implementation of Interventions- using specific interventions to try to reduce a resident's risks from hazards in the environment. The process includes: a. Communicating the interventions to all relevant staff. b. Assigning responsibility. c. Providing training as needed. d. Documenting interventions (e.g., plans of action developed through the QAA Committee or care plans for the individual resident). e. Ensuring that the interventions are put into action. f. Interventions are based on the results of the evaluation and analysis of information about hazards and risks and are consistent with relevant standards, including evidence-based practice. g. Development of interim safety measures may be necessary if interventions cannot immediately be implemented fully. h. Facility-based interventions may include, but are not limited to: i. Educating staff. ii. Repairing the device/equipment. iii. Developing or revising policies and procedures. i. Resident-directed approaches may include: i. Implementing specific interventions as part of the plan of care. ii. Supervising staff and residents, etc. iii. Facility records document the implementation of these interventions. 4. Monitoring and Modification- Monitoring is the process of evaluating the effectiveness of care plan interventions. Modification is the process of adjusting interventions as needed to make them more effective in addressing hazards and risks. Monitoring and modification processes include: a. Ensuring that interventions are implemented correctly and consistently. b. Evaluating the effectiveness of interventions. c. Modifying or replacing interventions as needed. d. Evaluating the effectiveness of new interventions. 5. Supervision- Supervision is an intervention and a means of mitigating accident risk. The facility will provide adequate supervision to prevent accidents. Adequacy of supervision: a. Defined by type and frequency. b. Based on the individual resident's assessed needs and identified hazards in the resident environment. 2.b. For Resident #15 (R15), the facility staff failed to maintain a safe environment in the resident's bedroom. A can of Krylon [NAME] aerosol varnish spray was observed in the resident's room. On 5/14/25 at 10:00 a.m., a can of Krylon [NAME] aerosol varnish spray was observed on a table in R15's room. The material safety data sheet for Krylon [NAME] dated 3/13/15 documented, OSHA/HCS status: This material is considered hazardous by the OSHA Hazard Communication Standard. Signal word Hazard statements: Danger Extremely flammable aerosol. Contains gas under pressure; may explode if heated. Causes skin and eye irritation. Suspected of causing cancer. May be fatal if swallowed and enters airways. May cause respiratory irritation. May cause drowsiness and dizziness. On 5/19/25 at 3:49 p.m., the Krylon [NAME] material safety data sheet was reviewed with LPN (licensed practical nurse) #8. LPN #8 stated the substance was flammable, hazardous and carcinogenic and with those properties, the substance should not be in a resident room because the resident may use it. LPN #8 stated she notifies a supervisor or manager if she finds an unsafe substance in a resident's room. On 5/20/25 at 4:45 p.m., ASM (administrative staff member) #1 (the administrator) and ASM #2 (the director of nursing) were made aware of the above concern. The facility policy titled, Accidents and Supervision documented, The facility shall establish and utilize a systematic approach to address resident risk and environmental hazards to minimize the likelihood of accidents. No further information was presented prior to exit. Based on observation, resident interview, staff interview, facility document review, and clinical record review, it was determined that the facility staff failed to provide a safe environment for a census of 97 residents on 12/21/24 and failed to provide supervision to prevent accidents for 2 of 31 residents in the survey sample, Resident #23 and #15. This resulted in a determination of Immediate Jeopardy (IJ). After Immediate Jeopardy was removed, the scope and severity were lowered to a level 3, isolated. The findings include: 1. The facility staff failed to A) provide a safe environment for a census of 97 residents on 12/21/24 and B) notify the fire department of a fire that occurred in the enclosed patio area at the facility on 12/21/24. On 12/21/24, Resident #23 (R23), a resident with known history of unsupervised smoking, threw a lit cigarette into the trash can in the enclosed patio area resulting in a fire which cracked the glass on the patio entrance door. A) On the most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 2/17/25, the resident scored 14 out of 15 on the BIMS (brief interview for mental status) assessment, indicating the resident was cognitively intact for making daily decisions. On the quarterly MDS assessment with an ARD of 11/17/24, the resident scored 13 out of 15 on the BIMS assessment, indicating the resident was cognitively intact for making daily decisions. On 5/14/25 at 9:52 a.m., an interview was conducted with R23 in their room. When asked about smoking, R23 stated that they were a current smoker and smoked 1-2 times a day outside of the facility and had last smoked on 5/13/25. R23 stated that the facility did not allow smoking on the property, but he was allowed to go off the property and smoke and described taking the elevator downstairs to the basement, going out the loading dock doors and outside to a cigarette disposal receptacle located off the property. R23 stated that they kept their cigarettes and lighter in the closet where their clothes were, but an unknown nurse had taken them away on 5/13/25 and did not tell him why. When asked about the fire on 12/21/24, R23 stated that he remembered the incident. R23 stated that someone did not put out a cigarette and had put it in the trash can which caught fire on the patio. When asked about the wander guard monitor, R23 stated that staff had placed a monitor on him a while ago but he had taken it off and thrown it away. No wander guard monitor was observed on R23's person or on R23's wheelchair. The progress notes for R23 documented in part, - Effective Date: 10/08/2024 19:54 (7:54 p.m.) Type: Medical Visit . History: 40 pack history of tobacco use; currently smokes 1/4 ppd (pack per day). H/o (history of) of ETOH (alcohol) abuse in the past . Current Tobacco Use. -40 pack year history, - Cont (continue) Nicoderm, -Counsel on cessation . - 11/24/2024 03:22 (3:22 a.m.) Note Text: Nicoderm CQ Transdermal Patch 24 Hour (Nicotine) Apply 1 patch transdermally one time a day for tobacco abuse and remove per schedule. Pharmacy. Active: 10/8/2024 08:00. Resident who wears a transdermal nicotine patch has been going downstairs to the first floor and outdoors smoking. The supervisor told the resident several times that smoking isn't allowed on the premises and that he shouldn't be smoking. Writer re-enforced the information regarding smoking to the resident. - 12/21/2024 21:54 Note Text: Resident went to the patio to smoke even though he knows that the facility is a smoke free area. Resident put the lighter [sic] cigarette in the trash can and the trash can caught on fire. Fire extenguisher [sic] used to put the fire out. The glass door at the enterance [sic] of the patio is craked [sic] due to the heat from the fire. The resident admitted to putting the lighted cigarette in the trash can. Resident talked to about the dangers of smoking. 1 pack of cigarette [sic] and 2 lighters were taken from the resident for safe keeping. Will monitor closely. A sigh [sic] was placed on the door to prevent people from using the door. The nursing admission assessment for R23 dated 10/7/24 documented the resident being a current smoker, smoking 1-2 cigarettes per day. The assessment documented R23 requiring supervision when smoking and documented, Resident is smoker last time was before his admission to the hospital on [DATE] . The assessment further documented R23 was not an elopement risk. A smoking assessment for R23 dated 12/21/24 documented the resident being a current smoker, smoking 5-10 cigarettes per day. The assessment documented, .The resident is not safe to smoke. This is a smoke-free facility; [Name of R23] has disregarded our non-smoking policy. He put his cigarette in the patio trash can while it was still lit. The trash can caught fire. Luckily, staff was able to extinguish the fire swiftly. Resident is not able to smoke unsupervised. Our facility remains smoke free . The physician orders documented in part, Order Date: 4/3/2025. Special equipment: wander guard on at all times. Check placement and function every shift for monitoring right ankle. An elopement risk assessment dated [DATE] documented R23 being at risk to wander with a previous history of wandering and history of elopement. The comprehensive care plan for R23 documented in part, MD order for wander guard. Date Initiated: 04/03/2025 . The care plan failed to evidence documentation regarding R23's smoking status or smoking non-compliance. The clinical record failed to evidence documentation regarding rationale for the wander guard placement on 4/3/25, or checks of the wander guard from 4/3/25 to the present. The clinical record failed to evidence interventions put into place to prevent hazards from unsupervised smoking for the resident after they were first aware of the resident smoking at the facility. On 5/14/25 at 10:11 a.m., an observation was made of the facility loading dock area and parking lot area. Double doors opened to the loading dock area with a ramp area that opened to the parking lot. Approximately 100 yards across the paved parking lot a standing smoking receptacle was observed at the edge of the adjoining hospital property parking lot. On 5/14/25 at 9:58 a.m., an interview was conducted with CNA (certified nursing assistant) #8 who stated that staff had taken R23's smoking materials last year and they were kept at the nurse's station. On 5/14/25 at 10:05 a.m., an interview was conducted with LPN (licensed practical nurse) #2. When asked where R23's smoking materials were kept, LPN #2 stated that they were kept in a cabinet behind the desk at the nurse's station. When asked to see the location that they were stored, LPN #2 went to a cabinet located inside of the nurse's station and stated that they were not there. She stated that someone must have removed them because that was where they were. When asked about the smoking process at the facility, LPN #2 stated that they did not allow smoking and R23 was not allowed to smoke. She stated that last year was the last time she knew he was smoking as far as she knew. On 5/14/25 at 11:13 a.m., a follow up interview was conducted with LPN #2 who stated that last year R23's family had brought him cigarettes and a lighter and he had been caught smoking on the patio. She stated that time, the manager had called the family and told them that smoking was not allowed and not to give him any smoking materials. LPN #2 stated that R23 had been receiving a nicotine patch daily since coming to the facility to help him not smoke and he was not supposed to leave their floor but there were times when he tried to leave, and they redirected him. LPN #2 stated that R23 could leave the unit if they did not watch him, and they did not allow him to leave the unit because the last time he went outside he almost burned the place, and they did not know who brought the things to him. She stated that R23 was reliable, and she thought he knew if something happened but may have some short-term memory loss. When asked what staff did to keep R23 from going off the unit to smoke, LPN #2 stated that they provided snacks and drinks and explained to R23 about why he should not leave the unit. She stated that she explained to him about the Nicoderm patch and encouraged him and then he was fine. LPN #2 stated that she did not remove any smoking materials from R23 yesterday and it may have been another nurse. She stated that R23's wander guard was placed when they caught him smoking outside and the monitor would beep when he got near the elevator. She stated that R23 had tried to take the wander guard off the wheelchair in the past or left the wheelchair and tried to walk down without any assistance. She stated that when she worked with him she saw patterns and knew what he was trying to do so she would intervene. LPN #2 stated that R23 would say he was going to use the bathroom by the elevator because his was locked and they would have to stop him because he wanted to smoke. She stated that she did not have eyes on him for the entire shift, but the other staff watched him also and they relied on the wander guard to alert them if R23 was attempting to leave the unit. On 5/14/25 at 1:15 p.m., an interview was conducted with OSM #14, anonymous staff member, who stated that staff observed R23 outside smoking in the patio area about a week before the fire on 12/21/24 and it was reported to the former director of nursing in the stand-up meeting. OSM #14 stated that staff were watching R23 more closely now, but it was possible for him to go out because there were not always staff in the basement area to monitor who was coming down there, the doors were normally not locked, and the cameras down there had not worked for a long time. On 5/14/25 at 1:21 p.m., an interview was conducted with RN (registered nurse) #1. RN #1 stated that she was in front of the elevator on the first floor when she saw a bright light and turned and saw the fire in a trash can in the interior patio area. She stated that she ran out and moved R23 inside and got another staff member to get the fire extinguisher. She stated that the staff member put the fire out and she assessed R23, took the cigarettes and lighter and locked them in the medication cart. RN #1 stated that R23 told her that he did not know that the cigarette was still lit when he threw it in the trash can in the courtyard. She stated that she told R23 that it was a non-smoking facility, and the fire was out but could have been something else. RN #1 stated that she had seen R23 about 10 minutes prior to the incident when he told her that he was going to the bathroom downstairs. She stated that she had reported the fire to the former director of nursing who stated that she did not need to call the fire department because they had extinguished the fire. On 5/14/25 at 1:40 p.m., an interview was conducted with OSM #11, social worker. OSM #11 stated that when R23 was caught smoking and had caused the fire she was asked to speak with him about smoking. She stated that she talked to him and his family who felt that he should be able to smoke. OSM #11 stated that she had started looking for another facility that allowed smoking, but they had not been able to find any placement as of now but were still actively looking. She stated that R23's family had mentioned their dad had seen employees smoking and she had explained that they could not control hospital employees off their property and their dad should not be out far enough to see them. She stated that staff were aware that at one point he was going outside to the hospital property to smoke prior to the incident and it was probably in November 2024. She stated that since 12/24 she was not aware of him going out and she thought that he may have had stuff hidden in his room but was not aware of anyone removing anything yesterday. OSM #11 stated that she believed the daughters were bringing him the smoking materials but was not sure, as one daughter had admitted it in the past but not currently. She stated that R23 did not leave the unit that she knew of because her office was by the elevator. OSM #11 stated that when she was in her office she saw him go to the bathroom in the sunroom and he had a wander guard on and the elevator alarm would have sounded if he had gone on the elevator. She stated that she has never smelled smoke in the bathroom. OSM #11 stated that she recalled nursing reporting R23 had been caught out in the back of the facility smoking in morning stand up meeting, but nothing had happened. She stated that they always knew R23 was smoking, and the report was probably mid November 2024. OSM #11 stated that this was based on her emails with the family that discuss his care plan. She stated that she remembered that one of the night nurses had caught him outside smoking, and she thought that it was the former unit manager who had reported it in the meeting. On 5/14/25 at 5:49 p.m., an interview was conducted with OSM #16, former director of nursing. OSM #16 stated that R23 started sneaking out of the building soon after admission to smoke and they had spoken with him and his family about it being a non-smoking facility. She stated that they had attempted to find R23 a smoking facility and he had agreed not to smoke until he moved but they had reports that his family still took him out to smoke. On 5/16/25 at 9:30 a.m., an interview was conducted with OSM #11, anonymous staff member. OSM #11 stated that they had never witn[TRUNCATED]

Based on staff interview, and facility document review, the facility staff failed to ensure effective communication training was completed for five of five direct care staff employee reviews. The findings include: For CNA (certified nursing assistant) #10, CNA #11, RN (registered nurse) #2, LPN (licensed practical nurse) #11, and OSM (other staff member) #7 (the director of rehab), the facility staff failed to ensure effective communication training was completed. CNA #10 was hired on 11/1/23. CNA #11 was hired on 10/10/23. RN #2 was hired on 4/1/23. LPN #11 was hired on 4/1/23. OSM #7 was hired on 4/1/23. The facility staff failed to provide evidence that these five employees had completed effective communication training. On 5/20/25 at 10:52 a.m., an interview was conducted with RN #3 (the education coordinator). RN #3 stated she assigns trainings for staff in a computerized training system and completes face-to-face in-services. RN #3 stated approximately three weeks ago, she and the director of nursing identified the need for effective communication training and plans to hold a session regarding this with staff next week. On 5/20/25 at 11:26 a.m., another interview was conducted with RN #3. RN #3 stated effective communication training is important because she wants to make sure staff communicate with residents and the interdisciplinary team accordingly and timely. On 5/20/25 at 4:45 p.m., ASM (administrative staff member) #1 (the administrator) and ASM #2 (the director of nursing) were made aware of the above concern. The facility policy titled, Training Requirements documented, Training content includes, at a minimum, with compliance to twelve (12) hours annual training: a. Effective communication for direct care staff. No further information was presented prior to exit.

Based on observation, staff interview and facility document review, it was determined the facility staff failed to transport resident personal laundry in a sanitary manner on one of two floors, second floor. The findings include: On 7/21/25 at 2:07 p.m. an observation revealed a rolling rack of clean resident clothes being pushed down the Teal Wing on the second floor. Observation of the clothing rack failed to evidence that the clothes were covered while being transported. A second observation was made on 7/21/25 at 2:48 p.m. on the [NAME] Wing on the second floor of a clothing rack with resident personal clothing, not covered while being transported. An interview was conducted with OSM (other staff member) #1, laundry aide, on 7/22/25 at 11:00 a.m. When asked about the process for putting the residents' clean laundry in their rooms, OSM #1 stated he puts the clean laundry on the cart that is labeled with the resident room numbers. He stated he brings the cart to the floor and goes room by room putting things away. The above observations were shared with OSM #1. OSM #1 stated the cart should be covered when he is transporting the clean laundry to the resident rooms and it was not covered yesterday, he didn't cover it yesterday. The facility policy, Handling Clean Linen, documented in part, 5. Guidelines for the storage of clean linen include, but are not limited to the following: a. Clean linen shall be delivered to resident care units on covered linen carts with covers down. ASM (administrative staff member) #1, the administrator and ASM #2, the director of nursing, were made aware of the above concern on 7/22/25 at 3:41 p.m. No further information was provided prior to exit.

Based on staff interview, and facility document review, the facility staff failed to ensure behavioral health training was completed for four of five employee reviews. The findings include: For CNA (certified nursing assistant) #10, RN (registered nurse) #2, OSM (other staff member) #7 (the director of rehab), and OSM #26, (a dietary aide) the facility staff failed to ensure behavioral health training was completed. CNA #10 was hired on 11/1/23. RN #2 was hired on 4/1/23. OSM #7 was hired on 4/1/24 and OSM #26 was hired on 4/3/23. The facility staff failed to provide evidence that these four employees had completed behavioral health training. On 5/20/25 at 10:52 a.m., an interview was conducted with RN #3 (the education coordinator). RN #3 stated she assigns trainings for staff in a computerized training system and completes face-to-face in-services. RN #3 stated approximately three weeks ago, she and the director of nursing identified the need for behavioral health training and plans to hold a session regarding this with staff next week. On 5/20/25 at 11:26 a.m., another interview was conducted with RN #3. RN #3 stated behavioral health training is important because the facility staff have been seeing a lot more patients with behavioral issues and it's important for staff to identify and monitor their behaviors and follow up with psychiatry. On 5/20/25 at 4:45 p.m., ASM (administrative staff member) #1 (the administrator) and ASM #2 (the director of nursing) were made aware of the above concern. The facility policy titled, Training Requirements documented, Training content includes, at a minimum, with compliance to twelve (12) hours annual training: f. Behavioral health. No further information was presented prior to exit.

Based on staff interview, clinical record review and facility document review, it was determined that facility staff failed to notify the physician and responsible party as required for three of 31 current residents in the survey sample, Residents #1 (R1), R24 and R29. The findings include: 1. For R1, facility staff failed to notify the physician and responsible party (RP) when the Lidocaine (1) patch was not available. R1 was admitted to the facility with diagnoses that included but were not limited to hemiplegia (2). On the most recent comprehensive MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 03/25/2024, R1 scored 11 out of 15 on the BIMS (brief interview for mental status), indicating R1 was moderately impaired of cognition for making daily decisions. Section J0100 Pain Management coded R1 as having occasional pain. The physician's order for R1 documented, Lidocare Arm/Neck/Leg Patch 4 % (four percent) (Lidocaine). Apply to right upper back/neck topically (on the outside of the body) one time a day for myalgia (3) removed the patch at 1800 (6:00 p.m.) and remove per schedule. Order Dare: 8/9/2023. Start Date: 8/10/2023. The eMARs (electronic medication administration records) for R1 dated January 2025, February 2025, March 2025 and April 2025 documented in part, Lidocare Arm/Neck/Leg Patch 4 % (Lidocaine). Apply to right upper back/neck topically one time a day for myalgia removed the patch at 1800 (6:00 p.m.) and remove per schedule. Start Date: 8/10/2023 0800 (8:00 a.m.). The eMAR for R1 dated January 2025 for the administration of Lidocaine at 8:00 a.m. documented, 13 on 01/03/2025, 01/04/2025, 01/05/2025, 01/10/2025 and 9 (nine) on 01/20/2025 and on 01/27/2025. The eMAR Chart Codes documented, 13=Medication Not Available and 0=Other / See Progress Notes. The eMAR for R1 dated February 2025 for the administration of Lidocaine at 8:00 a.m. documented, 9 on 02/05/2025 and on 02/13/2025. The eMAR for R1 dated March 2025 for the administration of Lidocaine at 8:00 a.m. documented, 13 on 03/10/2025 and 9 on 03/04/2025, 03/05/2025, 03/15/2025 and on 03/17/2025. The eMAR for R1 dated April 2025 for the administration of Lidocaine at 8:00 a.m. documented, 13 on 04/05/2025 and 9 on 04/01/2025 and on 04/14/2025. Review of the facility's progress notes for R1 dated 01/01/2025 through 04/28/2025 failed to evidence documentation regarding the eMAR codes of 13 and 9 on the dates listed above. The facility's packing lists from (Name of Medical Supply Company) were reviewed. The packing lists with the following dates documented: 01/07/2025 documented 10 boxes of Lidocaine patches shipped on 01/07/2025, 01/14/2025 documented 7 (seven) boxes of Lidocaine patches shipped on 01/14/2025, 01/21/2025 documented 12 boxes of Lidocaine patches shipped on 01/21/2025, 01/28/2025 documented 12 boxes of Lidocaine patches shipped on 01/28/2025, 02/04/2025 documented 12 boxes of Lidocaine patches shipped on 02/04/2025, 02/11/2025 documented 12 boxes of Lidocaine patches shipped on 02/11/2025, 02/17/2025 documented 12 boxes of Lidocaine patches shipped on 02/17/2025, 02/25/2025 documented 8 (eight) boxes of Lidocaine patches shipped on 02/25/2025, 03/04/2025 documented 12 boxes of Lidocaine patches shipped on 03/04/2025, 03/11/2025 documented 16 boxes of Lidocaine patches shipped on 03/11/2025, 03/25/2025 documented 14 boxes of Lidocaine patches shipped on 03/25/2025, 04/01/2025 documented 14 boxes of Lidocaine patches shipped on 04/01/2025, 04/16/2025 documented 14 boxes of Lidocaine patches shipped on 04/16/2025 and 04/29/2025 documented 14 boxes of Lidocaine patches shipped on 04/29/2025. The facility's list of House Supply of Over-the-Counter Medicine documented in part Lidocaine, 4% Patches. On 05/15/2025 at approximately 11:20 a.m. an interview and observation of facility supplies was conducted with OSM (other staff member) #17, central supply coordinator. He was asked to describe the procedure for ordering and maintaining supplies in the facility for the residents and staff. OSM #17 stated he orders PPE (personal protective equipment), medical supplies, incontinence supplies, dry and wet wipes, supplements, resident hygiene and grooming supplies (e.g., toothbrush, toothpaste, combs, body soap, peri cleaner, etc), peri cleaner and over the counter medications (e.g., vitamins, acetaminophen, etc ). He stated that there is a supply room on each floor in the facility and he checks them twice a day to determine what supplies need to be restocked and when he restocks the supply rooms the items are rotated to help eliminate expired items being used. OSM #17 stated that on Fridays he checks the supply rooms and restocks double the common supplies (e.g., incontinent supplies, wipes, gloves, PPE) to cover the weekend. He also stated that a nurse on each of the units has a key to access the central supply room to get any supplies they may run out of in the supply rooms. When asked about ordering supplies OSM #17 stated he submits the order through an electronic ordering system to the vendor. He stated that the purchasing manager for the facility reviews the order and makes the final decision as to what is ordered based on cost effectiveness and quantity needed. On 05/19/2025 at approximately 2:00 p.m., an interview was conducted with LPN (licensed practical nurse) #2. When asked about coding on a resident's eMAR she stated when a resident is administered the medication there is a check mark, and if the resident refuses the medication, it is coded the number 9 (nine) and it is documented in the progress note. After reviewing the nursing progress notes dated January 6, 2025, the eMAR notes dated January 6, 2025, at 10:58 am., January 2025 eMAR for R1, LPN #2 was asked about the code 9 above her initials on 01/06/2025 for Lidocaine at 8:00 a.m. She stated the medication was not available. LPN #2 further stated that sometimes they had the Lidocaine and sometimes they did not. When asked about the procedure when a resident refused their medication or it was not available, she stated that the physician or NP (nurse practitioner) should be notified each time and documented in the progress notes. On 05/19/2025 at approximately 4:00 p.m. an interview was conducted with LPN #8, regarding the coding on a resident's eMAR. She stated that code 9 indicates that they do not have the medication or it's on the way from the pharmacy, code 13 indicated that the medication was not available and not in the facility, and a check mark (?) indicated the medication was administered. After reviewing the eMAR dated March 10 coding R1's Lidocaine was 13, not available at 8:00 a.m., and the eMAR notes for the same day, LPN #8 was asked about the absence of documentation to the pharmacy about the medication not being available. She did not have an explanation. When asked to describe the procedure when a resident's medication is not available, she stated that the pharmacy is notified, and it is documented in the resident's progress notes. When asked if the physician is notified that a resident did not receive a medication and/ or it was not available for administration she stated no. On 05/19/2025 at approximately 4:10 p.m. an interview was conducted with LPN #10 regarding the coding on a resident's eMAR. She stated that code 9 (number nine) indicated that they do not have the medication, code 13 indicated that the medication was not available and not in the facility, and a check mark (?) indicated the medication was administered. When asked to describe the procedure when a resident's medication is not available, LPN #10 stated the nurse practitioner or physician is notified and it is documented in the progress notes. On 05/20/2025 at 9:20 a.m., an interview was conducted ASM (administrative staff member) #2, director of nursing, regarding the coding on a resident's eMAR. She stated a check mark (?) indicated the medication was given, code 9 refers to a progress note that explains why a medication was not given and code 13 indicated that the medication was not in the facility. She further stated that if the medication is not on the medication cart, the nurse should be checking the supply rooms and the Pixis (an automated medication dispensing system) for over-the-counter medications. When asked to describe the procedure when a resident's medication is not available ASM #2 stated that the physician and the responsible party or the resident, if they are their own responsible party, should be notified and it should be documented in the progress notes. On 05/21/2025 at approximately 8:30 a.m. an interview was conducted with OSM #17 regarding over-the-counter medications. He stated the procedure for ordering over-the-counter medications is the same procedure he followed when ordering other supplies as described during the interview on 05/15/2025. He stated that he checks the supply room on the first floor, the inventory in the central supply room and checks the director of nursing and the nursing staff to see if they need any specific medications other than what is normally ordered. He stated the order for over-the-counter medications is sent in once a week on Mondays and usually arrives by Wednesday or Thursday of the same week. When asked about the quantity the Lidocaine patches are shipped in, he stated that each case contains 12 boxes, and each box contains five patches. On 05/20/2025 at 1:14 p.m., an interview was conducted ASM #2, director of nursing after reviewing R1's eMARS for the dates listed above, the progress notes dated 01/01/2025 through 04/28/2025. ASM #2 stated that R1's lidocaine patch was not available on the dates listed above that were coded thirteen and nine on the eMARs listed above. She further stated that there was no documentation that the physician or RP was notified when the medication was unavailable. The facility's policy Unavailable Medications documented in part, 4. Medications may be unavailable for a number of reasons. Staff shall take immediate action when it is known that the medication is unavailable: b. Notify physician of inability to obtain medication upon notification or awareness that medication is not available. Obtain alternative treatment orders and/or specific orders for monitoring resident while medication is on hold. 5. If a resident misses a scheduled dose of the medication, staff shall follow procedures for medication errors, including physician/family notification, completion of a medication error report, and monitoring the resident for adverse reactions to omission of the medication. On 05/20/2025 at approximately 4:30 p.m., ASM (administrative staff member) #1, administrator, ASM #2, director of nursing, and ASM #4, regional administrator, were made aware of the above findings. No further information was provided prior to exit. Complaint deficiency References: (1) Used to stop pain. This information was obtained from the website:https://www.drugs.com/cdi/lidocaine-patch.html. (2) Loss of muscle function in part of your body. This information was obtained from the website: https://medlineplus.gov/paralysis.html. (3) The medical term for muscle pain. This information was obtained from the website: https://myclevelandclinic.org/health/symptoms/myalgia-muscle-pains. 2. For Resident #24 (R24), the facility staff failed to notify the RR (resident representative) of a new medication order. On the annual MDS (minimum data set) with an ARD (assessment reference date) of 2/7/24, R24 was coded as being moderately cognitively impaired. A review of R24's clinical record revealed the following order dated 8/16/24: Valacyclovir (1) HCl Oral Tablet 1 GM (gram) (Valacyclovir HCl) Give 2 tablets by mouth every 12 hours for herpes labialis for 1 Day. A review of R24's August 2024 MAR (medication administration record) revealed he received the medication as ordered. Further review of R24's clinical record failed to reveal evidence that his RR (resident representative) was notified of this new medication order. On 5/19/25 at 2:31 p.m., LPN (licensed practical nurse) #2 was interviewed. She stated if a resident has a new diagnosis requiring a new medication, the RR should always be notified. She stated the nurse who processes the order is responsible for this notification. She added: [The RR] needs to be aware of what is going on with the resident. On 5/20/25 at 4:27 p.m., ASM (administrative staff member) #1, the administrator, and ASM #2, the director of nursing, were informed of these concerns. No additional information was provided prior to exit. Reference (1) Valacyclovir is used to treat herpes zoster (shingles) and genital herpes. It does not cure herpes infections but decreases pain and itching, helps sores to heal, and prevents new ones from forming. This information is taken from the website https://medlineplus.gov/druginfo/meds/a695010.html. 3. For Resident #29 (R29), the facility staff failed to notify the responsible party and physician of multiple medication refusals between 4/1/24-6/30/24. On the most recent MDS (minimum data set) assessment, a quarterly assessment with an ARD (assessment reference date) of 5/19/24, the resident scored one out of 15 on the BIMS (brief interview for mental status) assessment, indicating the resident was severely impaired for making daily decisions. The assessment documented no behaviors or rejection of care. The admission record for R29 documented the daughter as the financial and care power of attorney and emergency contact. Review of the eMAR (electronic medication administration record) for R29 dated 4/1/24-4/30/24 documented the following scheduled medications: - Amlodipine Besylate 5 mg tab. Give 1 tablet orally one time a day for HTN (hypertension). Scheduled daily at 9:00 a.m. - Benztropine Mes 1mg tablet. Give 1 tablet orally two times a day for EPS (extrapyramidal symptoms). Scheduled daily at 9:00 a.m. and 5:00 p.m. - Clonidine 0.1 mg/day patch. Apply 1 patch transdermally one time a day every Thu for HTN and remove per schedule. Scheduled to remove at 7:59 a.m. and apply at 8:00 a.m. weekly on Thursdays. - Famotidine 40 mg tablet. Give 1 tablet orally one time a day for GERD (gastroesophageal reflux disease). Scheduled daily at 8:00 a.m. - Furosemide 40 MG tablet. Give 1 tablet orally one time a day for Edema. Scheduled daily at 8:00 a.m. - Incruse Ellipta 62.5 MCG Inh 1 capsule inhale orally at bedtime for COPD (chronic obstructive pulmonary disease). Scheduled daily at 9:00 p.m. - Losartan Potassium 50 mg tab. Give 1 tablet orally one time a day for HTN. Scheduled daily at 8:00 a.m. - Potassium Cl ER 20 MEQ Tablet. Give 1 tablet orally one time a day for Supplement. Scheduled daily at 8:00 a.m. - Risperdal Consta 25 mg VIAL Inject 1 vial intramuscularly one time a day every 14 day(s) for Schizophrenia. Scheduled on 4/3/24 and 4/26/24. - Carbidopa-Levodopa 25-100 Tab. Give 1 tablet orally three times a day for Parkinsons. Scheduled daily at 9:00 a.m., 1:00 p.m., and 9:00 p.m. - Depakote Sprinkles Oral Capsule Delayed Release Sprinkle 125 MG (Divalproex Sodium). Give 2 capsule by mouth three times a day for Mood DO (disorder). It can be sprinkled into food or drinks. Scheduled daily at 6:00 a.m., 2:00 p.m., and 10:00 p.m. - Hydralazine 50 mg Tablet. Give 1 tablet orally three times a day for HTN. Scheduled daily at 9:00 a.m., 1:00 p.m. and 9:00 p.m. All medications scheduled between 4/1/24-4/30/24 were documented as not administered with a 9 or 2 documented. The administration key documented in part, 2=Drug refused and 9=Other/See Progress Notes. Review of the eMAR for R29 dated 5/1/24-5/31/24 documented the medications as listed above from the April 2024 eMAR except for the Risperdal Consta 25 mg VIAL Inject 1 vial intramuscularly scheduled on 5/10/24 and 5/24/24 and the Depakote Sprinkles 125 MG decreased to twice a day scheduled at 9:00 a.m. and 5:00 p.m. starting on 5/17/24. All medications scheduled between 5/1/24-5/31/24 were documented as not administered with a 9 or 2 documented except for the Benztropine mes 1mg on 5/14/24 at 5:00 p.m., Carbidopa/Levodopa 25-100 tab on 5/6/24 and 5/18/24 at 9:00 p.m., Incruse Ellipta 62.5mcg on 5/18/24 at 9:00 p.m., and Hydralazine 50mg on 5/6/24 at 9:00 p.m. and 5/18/24 at 9:00 p.m. The administration key documented in part, 2=Drug refused and 9=Other/See Progress Notes. Review of the eMAR for R29 dated 6/1/24-6/30/24 documented the medications as listed above from the April 2024 eMAR except for the Risperdal Consta 25 mg VIAL Inject 1 vial intramuscularly scheduled on 6/7/24 and 6/21/24 and the Depakote Sprinkles 125 MG scheduled at 9:00 a.m. and 5:00 p.m. All medications scheduled between 5/1/24-5/31/24 were documented as not administered with a 9 or 2 documented except for the Famotidine 40mg, Furosemide 40mg, Losartan Potassium 50mg and Potassium CL ER 20meq on 6/18/24 at 8:00 a.m., and the Carbidopa/Levodopa 25-100 tab on 6/18/24 at 9:00 a.m. The administration key documented in part, 2=Drug refused and 9=Other/See Progress Notes. Review of the progress notes/eMAR administration notes documented R29 refusing medications. The notes failed to evidence notification of the physician/nurse practitioner or responsible party of the refusals of medication. Physician notes on 4/1/24 and 6/10/24 documented a history of refusal of medications. On 5/19/25 at 2:34 p.m., an interview was conducted with LPN (licensed practical nurse) #2 who stated that R29 occasionally would agree to take her medications but refused them most of the time. She stated that R29 had behaviors of yelling, throwing things and being aggressive to staff. She stated that when R29 refused the medication they attempted again after leaving for a little while and if she still refused they documented it. She stated that the responsible party and the nurse practitioner should be notified every time a resident refuses medication. She stated that she did not recall calling the responsible party and that she may have notified the nurse practitioner, but she should have documented it in the notes. On 5/19/25 at 2:40 p.m., an interview was conducted with ASM (administrative staff member) #3, nurse practitioner. ASM #3 stated that she remembered that R29 was non-compliant with medications and care, and it was difficult to give her the medication. She stated that R29 was aggressive, and she had continued the medication orders because she needed them and there were times when she would take them so the strategy was to keep as much in her system that she would let them, and to try to stay on top of the behaviors. On 5/20/25 at 9:11 a.m., an interview was conducted with ASM #2, the director of nursing who stated that when a resident refused their medications they first attempted to find out why they were refusing them and try to educate the resident. She stated that if the resident was not alert and oriented they notified the power of attorney and the physician what was going on and they may be able to do an alternative treatment or medication. She stated that they should care plan the refusals and have more frequent rounds with the psychiatry provider. The facility policy Notification of Changes dated 9/24, documented in part, .The facility must inform the resident, consult with the resident's physician and /or notify the resident's family member or legal representative when there is a change requiring such notification . On 5/20/25 at 4:18 p.m., ASM #1, the administrator and ASM #2, the director of nursing were made aware of the above concern. No further information was obtained prior to exit.

Based on staff interview and facility document review, it was determined that the facility staff failed to obtain criminal background checks to screen for abuse of six of six contract employees. The findings include: On 05/13/2025 criminal background checks were requested from ASM (administrative staff member) #1, the administrator for six contracted construction workers who were observed working in the facility. On 05/14/2025 review of the documents provided by the facility failed to evidence criminal record background checks. The employees identified were: OSM (other staff member) #20, construction worker with a hire date of 06/24/2024. OSM #21, construction worker with a hire date of 06/24/2024. OSM #22, construction worker with a hire date of 06/24/2024. OSM #23, construction worker with a hire date of 04/07/2025. OSM #24, electrician with a hire date of 02/2025. OSM #25, electrician with a hire date of 06/24/2024. On 05/20/2025 at approximately 10:28 a.m., an interview was conducted with ASM #4, regional administrator, regarding background checks for construction workers in the facility. ASM #4 stated that the general contractor of the construction company stated the construction workers did not have social security numbers but could provide national background checks for the construction workers. ASM #4 stated she was provided background checks from Ecuador and accepted them. When asked if the background checks from Ecuador met the regulations ASM #4 stated she did not know if the background checks met the regulations. The facility policy Abuse, Neglect and Exploitation documented in part, I. Screening: A1. Background, reference, and credentials' check shall be conducted on potential employees, contracted temporary staff, student affiliated with academic institutions, volunteers and consultants. A2. Screenings may be conducted by the facility staff itself, third-party agency or academic institutions. A3. The facility will maintain documentation of proof that the screening occurred. On 05/20/2025 at approximately 4:30 p.m., ASM #1, administrator, ASM #2, director of nursing, and ASM #4, regional administrator, were made aware of the above findings. No further information was provided prior to exit.

Based on staff interview, clinical record review and facility document review, it was determined that facility staff failed to follow the physician's order for two of 31 current residents in the survey sample, Residents #1 (R1) and R2. The findings include: 1. For R1, facility staff failed to administer a Lidocaine patch (1) according to the physician's orders. R1 was admitted to the facility with diagnoses that included but were not limited to hemiplegia (2). On the most recent comprehensive MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of [DATE], R1 scored 11 out of 15 on the BIMS (brief interview for mental status), indicating R1 was moderately impaired of cognition for making daily decisions. Section J0100 Pain Management coded R1 as having occasional pain. The physician's order for R1 documented, Lidocare Arm/Neck/Leg Patch 4 % (four percent) (Lidocaine). Apply to right upper back/neck topically (on the outside of the body) one time a day for myalgia (3) removed the patch at 1800 (6:00 p.m.) and remove per schedule. Order Dare: [DATE]. Start Date: [DATE]. The eMARs (electronic medication administration records) for R1 dated [DATE], February 2025, [DATE] and [DATE] documented in part, Lidocare Arm/Neck/Leg Patch 4 % (Lidocaine). Apply to right upper back/neck topically one time a day for myalgia removed the patch at 1800 (6:00 p.m.) and remove per schedule. Start Date: [DATE] 0800 (8:00 a.m.). The eMAR for R1 dated [DATE] for the administration of Lidocaine at 8:00 a.m. documented, 13 on [DATE], [DATE], [DATE], [DATE] and 9 (nine) on [DATE] and on [DATE]. The eMAR Chart Codes documented, 13=Medication Not Available and 0=Other / See Progress Notes. The eMAR for R1 dated February 2025 for the administration of Lidocaine at 8:00 a.m. documented, 9 on [DATE] and on [DATE]. The eMAR for R1 dated [DATE] for the administration of Lidocaine at 8:00 a.m. documented, 13 on [DATE] and 9 on [DATE], [DATE], [DATE] and on [DATE]. The eMAR for R1 dated [DATE] for the administration of Lidocaine at 8:00 a.m. documented, 13 on [DATE] and 9 on [DATE] and on [DATE]. Review of the facility's progress notes for R1 dated [DATE] through [DATE] failed to evidence documentation regarding the eMAR codes of 13 and 9 on the dates listed above. The facility's packing lists from (Name of Medical Supply Company) were reviewed. The packing lists with the following dates documented: [DATE] documented 10 boxes of Lidocaine patches shipped on [DATE], [DATE] documented 7 (seven) boxes of Lidocaine patches shipped on [DATE], [DATE] documented 12 boxes of Lidocaine patches shipped on [DATE], [DATE] documented 12 boxes of Lidocaine patches shipped on [DATE], [DATE] documented 12 boxes of Lidocaine patches shipped on [DATE], [DATE] documented 12 boxes of Lidocaine patches shipped on [DATE], [DATE] documented 12 boxes of Lidocaine patches shipped on [DATE], [DATE] documented 8 (eight) boxes of Lidocaine patches shipped on [DATE], [DATE] documented 12 boxes of Lidocaine patches shipped on [DATE], [DATE] documented 16 boxes of Lidocaine patches shipped on [DATE], [DATE] documented 14 boxes of Lidocaine patches shipped on [DATE], [DATE] documented 14 boxes of Lidocaine patches shipped on [DATE], [DATE] documented 14 boxes of Lidocaine patches shipped on [DATE] and [DATE] documented 14 boxes of Lidocaine patches shipped on [DATE]. The facility's list of House Supply of Over-the-Counter Medicine documented in part Lidocaine, 4% Patches. On [DATE] at approximately 11:20 a.m. an interview and observation of facility supplies was conducted with OSM (other staff member) #17, central supply coordinator. He was asked to describe the procedure for ordering and maintaining supplies in the facility for the residents and staff. OSM #17 stated he orders PPE (personal protective equipment), medical supplies, incontinence supplies, dry and wet wipes, supplements, resident hygiene and grooming supplies (e.g., toothbrush, toothpaste, combs, body soap, peri cleaner, etc), peri cleaner and over the counter medications (e.g., vitamins, acetaminophen, etc ). He stated that there is a supply room on each floor in the facility and he checks them twice a day to determine what supplies need to be restocked and when he restocks the supply rooms the items are rotated to help eliminate expired items being used. OSM #17 stated that on Fridays he checks the supply rooms and restocks double the common supplies (e.g., incontinent supplies, wipes, gloves, PPE) to cover the weekend. He also stated that a nurse on each of the units has a key to access the central supply room to get any supplies they may run out of in the supply rooms. When asked about ordering supplies OSM #17 stated he submits the order through an electronic ordering system to the vendor. He stated that the purchasing manager for the facility reviews the order and makes the final decision as to what is ordered based on cost effectiveness and quantity needed. On [DATE] at approximately 2:00 p.m., an interview was conducted with LPN (licensed practical nurse) #2. When asked about coding on a resident's eMAR she stated when a resident is administered the medication there is a check mark, and if the resident refuses the medication, it is coded the number 9 (nine) and it is documented in the progress note. After reviewing the nursing progress notes dated [DATE], the eMAR notes dated [DATE], at 10:58 am., [DATE] eMAR for R1, LPN #2 was asked about the code 9 above her initials on [DATE] for Lidocaine at 8:00 a.m. She stated the medication was not available. LPN #2 further stated that sometimes they had the Lidocaine and sometimes they did not. On [DATE] at approximately 4:00 p.m. an interview was conducted with LPN #8, regarding the coding on a resident's eMAR. She stated that code 9 indicates that they do not have the medication or it's on the way from the pharmacy, code 13 indicated that the medication was not available and not in the facility, and a check mark (?) indicated the medication was administered. After reviewing the eMAR dated [DATE] coding R1's Lidocaine was 13, not available at 8:00 a.m., and the eMAR notes for the same day, LPN #8 was asked about the absence of documentation to the pharmacy about the medication not being available. She did not have an explanation. When asked to describe the procedure when a resident's medication is not available, she stated that the pharmacy is notified, and it is documented in the resident's progress notes. On [DATE] at approximately 4:10 p.m. an interview was conducted with LPN #10 regarding the coding on a resident's eMAR. She stated that code 9 (number nine) indicated that they do not have the medication, code 13 indicated that the medication was not available and not in the facility, and a check mark (?) indicated the medication was administered. On [DATE] at 9:20 a.m., an interview was conducted ASM (administrative staff member) #2, director of nursing, regarding the coding on a resident's eMAR. She stated a check mark (?) indicated the medication was given, code 9 refers to a progress note that explains why a medication was not given and code 13 indicated that the medication was not in the facility. She further stated that if the medication is not on the medication cart, the nurse should be checking the supply rooms and the Pixis (an automated medication dispensing system) for over-the-counter medications. On [DATE] at approximately 8:30 a.m. an interview was conducted with OSM #17 regarding over-the-counter medications. He stated the procedure for ordering over-the-counter medications is the same procedure he followed when ordering other supplies as described during the interview on [DATE]. He stated that he checks the supply room on the first floor, the inventory in the central supply room and checks the director of nursing and the nursing staff to see if they need any specific medications other than what is normally ordered. He stated the order for over-the-counter medications is sent in once a week on Mondays and usually arrives by Wednesday or Thursday of the same week. When asked about the quantity the Lidocaine patches are shipped in, he stated that each case contains 12 boxes, and each box contains five patches. On [DATE] at 1:14 p.m., an interview was conducted ASM #2, director of nursing after reviewing R1's eMARS for the dates listed above, the progress notes dated [DATE] through [DATE]. ASM #2 stated that R1's lidocaine patch was not available on the dates listed above that were coded thirteen and nine on the eMARs listed above. The facility's policy Unavailable Medications documented in part, 3. The facility shall follow established procedures for ensuring residents have a sufficient supply of medications. 4. Medications may be unavailable for a number of reasons. Staff shall take immediate action when it is known that the medication is unavailable: a. Determine reason for unavailability, length of time medication is unavailable, and what efforts have been attempted by the facility or pharmacy provider to obtain the medication. On [DATE] at approximately 4:30 p.m., ASM (administrative staff member) #1, administrator, ASM #2, director of nursing, and ASM #4, regional administrator, were made aware of the above findings. No further information was provided prior to exit. Complaint deficiency References: (1) Used to stop pain. This information was obtained from the website:https://www.drugs.com/cdi/lidocaine-patch.html. (2) Loss of muscle function in part of your body. This information was obtained from the website: https://medlineplus.gov/paralysis.html. (3) The medical term for muscle pain. This information was obtained from the website: https://myclevelandclinic.org/health/symptoms/myalgia-muscle-pains. 2. For Resident #2 (R2), the facility staff failed to follow physician orders to monitor vital signs every two hours. The physician's order summary for R2 documented in part, - Check Vital signs every 2 hours. every shift for Abnormal Vital signs (Elevated Temperature). Order Date: [DATE]. Start Date: [DATE]. The progress notes for R2 documented in part, - [DATE] 18:37 (6:37 p.m.) .Primary Chief Complaint: Fever. History Present Illness: The patient is alert and oriented to self. Current temperature readings are 101.9°F and Per Nurse dropped to 99.2°F earlier this am after first suppository insertion. A chest x-ray has been ordered. stat lab order, signs of infection were noted reviewed. prophylactic antibiotic orders and started. A single dose of Rocephin was administered, pending the chest x-ray. The next dose of Rocephin is scheduled for 1700 today . Plan: . Check vital signs every 2 hours . The comprehensive care plan for R2 documented, The resident has S&S (signs and symptoms) of potential fluid deficit r/t (related to) Poor intake and hypernatremia. IV (intravenous) fluids per MD order. Date Initiated: [DATE]. Created on: [DATE]. Under Interventions it documented in part, .Monitor vital signs as ordered/per protocol and record. Notify MD of significant abnormalities. Date Initiated: [DATE] . Review of the vital signs documented a temperature summary with temperatures documented twice on [DATE] and [DATE], once on [DATE], once on [DATE], [DATE], [DATE], [DATE], and [DATE], once on [DATE], twice on [DATE] and once on [DATE]. The vital signs failed to evidence checks every two hours as ordered. A review of the clinical record failed to evidence documentation of vital signs checked every two hours. On [DATE] at 3:48 p.m., an interview was conducted with LPN (licensed practical nurse) #8 who stated that vital signs were monitored as ordered or more often if indicated. She stated that they were documented in the vital signs portion of the electronic medical record. On [DATE] at 9:55 a.m., an interview was conducted with CNA (certified nursing assistant) #15 who stated that currently they did vital signs on long term care residents daily. She stated that day shift did odd numbered rooms and evening shift did odd number rooms. She stated that she did not recall how often they checked R2's vital signs when they resided at the facility. On [DATE] at 4:18 p.m., ASM (administrative staff member) #1, the administrator, and ASM #2, the director of nursing, were made aware of the above concern. No further information was provided prior to exit.

Based on staff interview and facility document review, the facility staff failed to complete an annual performance review for three of five CNA (certified nursing assistant) reviews. The findings include: For CNA #10, CNA #11, and CNA #12, the facility staff failed to complete an annual performance review. CNA #10 was hired on 11/1/23. CNA #11 was hired on 10/10/23. CNA #12 was hired on 10/23/23. The facility staff could not provide an annual performance review for the three CNAs. On 5/20/25 at 11:06 a.m., an interview was conducted with OSM (other staff member) #18 (the human resources assistant). OSM #18 stated she pulls a monthly report to see who is due for an annual performance review, based on their hire date, then she prints out blank performance reviews and provides them to the unit managers who are supposed to complete them. On 5/20/25 at 1:24 p.m., another interview was conducted with OSM #18. OSM #18 stated that annual performance reviews are important to make sure staff are compliant with facility needs, staff know the rules and protocols of the facility, and staff understand quality of care for the residents. On 5/20/25 at 4:45 p.m., ASM (administrative staff member) #1 (the administrator) and ASM #2 (the director of nursing) were made aware of the above concern. The facility policy titled, Training Requirements failed to document information regarding performance reviews. No further information was presented prior to exit.

Based on staff interview and clinical record review, it was determined that the facility staff failed to revise the comprehensive care plan for one of 31 residents in the survey sample, Residents #1 (R1). For R1, facility staff failed to revise the comprehensive care plan for the discontinued use of a voice amplifier. R1 was admitted to the facility with diagnoses that included but were not limited to muscle weakness. On the most recent comprehensive MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 03/25/2024, R1 scored 11 out of 15 on the BIMS (brief interview for mental status), indicating R1 was moderately impaired of cognition for making daily decisions. The physician's order for R1 documented in part, SPECIAL EQUIPMENT: Voice amplifier and charger will be stored at bedside per resident request. Day Nurse will give to assigned CNA before breakfast, Eve Nurse will obtain from CNA HS. every day and evening shift Monitor every shift for appliance safety/ensure use. Evening shift to charge amplifier at night. Order Date 05/24/2024. Start Date: 05/24/2024. The comprehensive care plan for R1 with a revision date 01/25/2024 documented in part, Focus. Resident requires assistance with self care and mobility R/T (related to) right sided hemiplegia, parkinson's with ADL (activities of daily living) fluctuations according to disease process. Revision on: 01/25/2024. Under Interventions it documented in part, Special Equipment: Voice amplifier and charger will be stored at bedside per resident request. Day Nurse will give to assigned CNA (certified nursing assistant) before breakfast. Eve (evening) nurse will obtain from CNA HS (hours of sleep). Date Initiated: 08/07/2024. On 05/14/2025 at approximately 8;00 a.m., an interview was conducted with OSM (other staff member) #30, speech therapist. When asked about the voice amplifier for R1 she stated that it was something that the family wanted R1 to try. OSM # 30 stated R1 attempted it in therapy a few times but did not like using and did not want it. She further stated that R1 does not use the voice amplifier. On 05/20/2025 at approximately 2:15 p.m., an interview was conducted with RN (registered nurse) #4, MDS coordinator. When asked to describe the procedure for revising a resident's care plan she stated it is revised quarterly. She also stated that if there is a new medication, change in medication or treatments, the care plan is updated immediately. She also stated that when updating or revising the care plan she would check the physician's orders and check with the resident's nurse and CNAs. After reviewing R1 care plan for the use of a voice she stated the care plan for the voice amplifier should have been reviewed and revised. The facility's policy Care Plan Revisions Upon Status Change documented in part, Policy:The purpose of this procedure is to provide a consistent process for reviewing and revising the care plan for those residents experiencing a status change. Policy Explanation and Compliance Guidelines: 1. The comprehensive care plan will be reviewed, and revised as necessary, when a resident experiences a status change. 2. Procedure for reviewing and revising the care plan when a resident experiences a status change: a. Upon identification of a change in status, the nurse will notify the MDS Coordinator, the physician, and the resident representative, if applicable. e. Staff involved in the care of the resident will report resident response to new or modified interventions. f. Care plans will be modified as needed by the MDS Coordinator or other designated staff member. g. The Unit Manager or other designated staff member will communicate care plan interventions to all staff involved in the resident's care. On 05/20/2025 at approximately 4:30 p.m., ASM (administrative staff member) #1, administrator, ASM #2, director of nursing, and ASM #4, regional administrator, were made aware of the above findings. No further information was provided prior to exit.

Based on staff interview, facility document review, and clinical record review, the facility staff failed to report an allegation of resident exploitation to the State Agency (SA) for one of 31 residents in the survey sample, Resident #28. The findings include: For Resident #28 (R28), the facility staff failed to report an allegation of exploitation to the SA when staff members became aware on 10/11/23. A review of R28's progress notes revealed the following: 10/11/2023 .Social / Psychosocial Note .Social Work Note: The Director of Nursing let this writer know that [R28]'s daughter expressed concerns that her father is being exploited of his funds by a friend of his whom she does not know. This writer met with [R28] who denied all allegations. [R28] in fact, is alert and oriented X4 and denied these allegations. [R28] did share his wishes .to no longer have his daughter manage his bank account. This writer reached out to the Ombudsman who recommended SS (social services) to contact APS (adult protective services) and file a report. This writer contacted [name of county] Adult Protective Services .today to file a report that [R28] wishes his daughter to be investigated. APS will be reaching out to SS Department when they have filed a claim. 1/4/2024 .Social / Psychosocial Note .This writer spoke with resident's APS worker regarding case for exploitation of funds. [APS worker] . stated she will be closing the case and has spoken to resident regarding issuing funds inappropriately and providing banking information to unknown individuals. Resident seems to be in denial and not receptive. APD (sic) requested facility become payee. SS will continue to provide support as needed. On 5/19/25 and 5/20/25, requests were made of facility management to provide evidence of a report to the SA regarding R28's allegation of exploitation. On 5/20/25 at 8:32 a.m., ASM (administrative staff member) #1, the administrator, was interviewed. He stated any reports of possible resident exploitation should be reported from front line team members to the manager, then the manager should report the allegation to the administrator or the DON (director of nursing). He stated the report should be made immediately. Following the report, the administrator or DON should submit a report to the SA and to APS. After the allegation is reported, the facility should immediately begin an investigation, including interviews with the resident, staff, and any outside party who may have knowledge of the situation. The SA should receive a final report with the results of the investigation within five business days. ASM #1 stated he was still looking for evidence that the allegation of exploitation of R28 had been reported to the SA. On 5/20/25 at 4:27 p.m., ASM #1, the administrator, and ASM #2, the director of nursing, were informed of these concerns. ASM #1 stated no report to the SA had been located as of yet. A review of the facility policy, Abuse, Neglect, and Exploitation, revealed, in part: 'Exploitation' means the deliberate misplacement, exploitation, or wrongful, temporary or permanent, use of a resident's belongings or money without the resident's consent .Reporting/Response .The facility will have written procedures that include .reporting of alleged violations to the Administrator, state agency, adult protective services, and to all other required agencies .within specified timeframes. No additional information was provided prior to exit.

Based on staff interview and clinical record review, it was determined that the facility staff failed to provide incontinence care for two of 31 residents in the survey sample, Residents #13 (R13) and R19. The findings include: 1. For R13, the facility staff failed to perform incontinence care. R13 was admitted to the facility with diagnoses that included but were not limited to dementia (1). On the most recent MDS (minimum data set), an annual assessment with an ARD (assessment reference date) of 03/14/2025, R13 scored 2 (two) out of 15 on the BIMS (brief interview for mental status), indicating the resident is severely impaired of cognition for making daily decisions. Section H0300 Urinary Continence coded R13 as being always incontinent. On 05/13/2025 at 12:42 p.m. until 5:00 p.m. continuous observations were conducted of R13. During the four hour and 17 minutes of observation, R13 was not checked by a nurse or a CNA (certified nursing assistant) for incontinence care. On 05/13/2025 at approximately 5:05 p.m. an interview was conducted with CNA #3. When asked if he was assigned to R13 for the 3:00 p.m. to 11:00 p.m. shift he stated yes. He asked to describe the procedure for residents who are dependent on staff for incontinence care. CNA #3 stated residents are checked for incontinence care at the beginning of each shift, checked every two hours throughout the shift and at the end of each shift. He also stated at the beginning of the shift he receives report from the previous shift CNA that includes the resident's condition, and which residents had received incontinence care. When asked about consequences a resident may encounter if they are left wet and/or soiled for extended periods of time he stated the resident could have skin breakdown. When asked if he received information regarding R13's incontinence care from the CNA on the previous shift (7:00 a.m. - 3:00 p.m.), CNA #3 stated he was not informed. When informed of the observation stated above, CNA #3 stated he would check R13 immediately. On 5/13/25 at 5:15 p.m., CNA (certified nursing assistant) #3 and CNA #4 were observed attempting to provide incontinence care to R13 in his room. R13 displayed stiffness and tremors in his arms, and stiffness in his legs as he sat in his wheelchair. CNA #3 repeatedly placed his hands on R13's arms attempting to pull the resident up from a sitting position in the wheelchair in order to transfer the resident to the bed for incontinence care. The resident repeatedly resisted; CNA #3 persisted in his efforts. CNA #4 told CNA #3 that R13 would not respond to this type of action, and that R13 would be able to transfer with minimal assistance if CNA #3 would not touch the resident. CNA #3 continued to attempt to take the resident's arm and assist him to move toward the bed. CNA #4 took over the effort, and assisted the resident to self-propel his wheelchair over to the sink area. CNA #4 stated: Put your hands on the counter and stand up. You are soaking wet. R13 refused to stand at the sink. CNA #4 assisted the resident to self-propel in the wheelchair back to the bed, and CNA #4 and CNA #3 physically lifted R13 from the wheelchair and moved him to a supine position on the bed. CNA #3 removed the resident's pants and incontinence brief. The brief was saturated with urine to the point that the brief contained hardened ridges where urine had pooled over time. The brief contained a large amount of feces, some of it soft, and some of it dried on the resident's buttocks. On 05/20/2025 at approximately 4:30 p.m., ASM (administrative staff member) #1, administrator, ASM #2, director of nursing, and ASM #4, regional administrator, were made aware of the above findings. No further information was provided prior to exit. Complaint deficiency Reference: (1) A loss of brain function that occurs with certain diseases. It affects memory, thinking, language, judgment, and behavior. This information was obtained from the website: https://medlineplus.gov/ency/article/000739.htm. 2. For R19, the facility staff failed to perform incontinence care. R19 was admitted to the facility with diagnoses that included but were not limited to a stroke. On the most recent MDS (minimum data set), an annual assessment with an ARD (assessment reference date) of 01/29/2025, R19 scored 0 (zero) out of 15 on the BIMS (brief interview for mental status), indicating the resident is severely impaired of cognition for making daily decisions. Section H0300 Urinary Continence coded R13 as being always incontinent. On 05/13/2025 at 12:42 p.m. until 5:00 p.m. continuous observations were conducted of R19. During the four hour and 17 minutes of observation, R19 was not checked by a nurse or a CNA (certified nursing assistant) for incontinence care. On 05/13/2025 at 5:00 p.m. an interview was conducted with CNA #6. When asked if she was assigned to R19 from the 3:00 p.m. to 11:00 p.m. shift she stated yes. When asked to describe the procedure for incontinence care for residents who are dependent on staff for incontinence care. CNA #6 stated residents are checked for incontinence care at the beginning of each shift, checked every two hours throughout the shift and at the end of each shift. She also stated at the beginning of the shift she receives report from the previous shift CNA that includes which residents have received incontinence care. When asked about consequences a resident may encounter if they are left wet and/or soiled for extended periods of time she stated the resident could have skin breakdown. When asked if she received information regarding R19's incontinence care from the CNA on the previous shift (7:00 a.m. - 3:00 p.m.), CNA #6 stated she was not informed. When informed of the observation stated above, CNA #6 stated she would check R19 immediately. On 5/13/25 at 5:02 p.m., CNA #6 entered R19's room carrying wipes and a clean incontinence brief. R19 saw the incontinence care supplies and started to shake her head. CNA #6 stated: I would like to change you. R19 continued to refuse. CNA #6 told the resident she would return again and ask about incontinence care just before dinner trays were distributed. CNA #6 stated R19 frequently refused incontinence care. CNA #6 stated even if a resident is known to refuse care, the care should still be offered every 2 hours. On 05/20/2025 at approximately 4:30 p.m., ASM (administrative staff member) #1, administrator, ASM #2, director of nursing, and ASM #4, regional administrator, were made aware of the above findings. No further information was provided prior to exit.

2. For R1, the facility staff failed to store a nebulizer (1) mask in a sanitary manner. R1 was admitted to the facility with diagnoses that included but were not limited to pneumonia. On the most recent comprehensive MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 03/25/2024, R1 scored 11 out of 15 on the BIMS (brief interview for mental status), indicating R1 was moderately impaired of cognition for making daily decisions. On 05/14/2024 at approximately 2:00 p.m. an observation of R1's nebulizer mask revealed it was sitting on top of R1's bedside table uncovered. On 05/14/2024 at approximately 5:00 p.m. an observation of R1's nebulizer mask revealed it was sitting on top of R1's bedside table uncovered. On 05/15/2024 at approximately 9:40 a.m. an observation of R1's nebulizer mask revealed it was sitting on top of R1's bedside table uncovered. The physician's order for R1 documented, Ipratropium-Albuterol Solution (2) 0.5-2.5 MG (milligrams)/3ML (milliliters). 1 (one) vial (small container) inhale orally two times a day for Shortness of breath. Order Date: 8/21/2024. On 05/20/2025 at approximately 4:00 p.m., an interview was conducted with LPN (licensed practical nurse) #8. When asked how a resident's nebulizer mask should be stored when not in use She stated that it should be placed in a plastic bag with the date, time and resident name. On 05/20/2025 at approximately 4:30 p.m., ASM (administrative staff member) #1, administrator, ASM #2, director of nursing, and ASM #4, regional administrator, were made aware of the above findings. No further information was provided prior to exit. References: (1) A small machine that turns liquid medicine into a mist. This information was obtained from the website: https://medlineplus.gov/ency/patientinstructions/000006.htm. (2) The combination of albuterol and ipratropium is used to prevent wheezing, difficulty breathing, chest tightness, and coughing in people with chronic obstructive pulmonary disease (COPD). This information was obtained from the website: https://medlineplus.gov/druginfo/meds/a601063.html. Based on observation, clinical record review, staff interview and facility document review it was determined that the facility staff failed to provide respiratory care and services consistent with professional standards of practice for two of 31 residents, Resident #2 and Resident #1. The findings include: 1. For Resident #2 (R2), the facility staff failed to implement pulmonology consult recommendations made to titrate oxygen to maintain SpO2 (oxygen saturation) >92% and encourage IS/Flutter (incentive spirometry/flutter valve) for pulmonary toileting. On the most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 2/8/25, the resident scored 0 out of 15 on the BIMS (brief interview for mental status) assessment, indicating the resident was severely impaired for making daily decisions. Section O documented no oxygen use. The progress notes for R2 documented in part, - 03/17/2025 15:47 (3:47 p.m.) Medical Visit. Reason for visit : Pulmonary Consult. Abnormal Chest X-ray . Assessment/Plan : Abnormal Chest X-ray . Encourage IS/Flutter for pulmonary toileting . - 03/19/2025 15:01 (3:01 p.m.) Type: Medical Visit. Reason for visit: Reason for visit-ID (infectious disease) consult- [Name of physician]consult- IV (intravenous) antibx - Pneumonia . Assessment/plan: Abnormal chest x-ray concern for pneumonia . incentive spirometry. continue supportive oxygen and wean as tolerated. Continue pulmonary toileting . - 03/21/2025 14:08 (2:08 p.m.) Type: Medical Visit. Reason for visit : Pulmonary Consult. Abnormal Chest X-ray . Assessment/Plan: Abnormal Chest X-ray. -Maintain SpO2 >92%. -Titrate Oxygen per facility policy to maintain SpO2 goal. -Encourage IS/Flutter for pulmonary toileting . - 03/26/2025 17:32 (5:32 p.m.) Type: Medical Visit. Reason for visit: ID progress note- ID consult- [Name of physician] consult- Previous IV antibx - Pneumonia . Assessment/plan: . incentive spirometry. continue supportive oxygen and wean as tolerated. Continue pulmonary toileting . - 03/28/2025 13:45 (1:45 p.m.) Medical Visit. Reason for visit: Pulmonary Consult . Assessment/Plan: Abnormal Chest X-ray. -Maintain SpO2 >92%, -Titrate Oxygen per facility policy to maintain SpO2 goal, -Encourage IS/Flutter for pulmonary toileting . - 03/28/2025 23:04 (11:04 p.m.) Note Text: Resident is Alert. Vitals taken; BP 95/60, P 64, Temp 97.8, Oxygen 90% at room temperature . - 03/29/2025 15:43 (3:43 p.m.) Note Text: Resident is observed having shortness of breath and physically unable to swallow medications. Difficulty swallowing noted Vital signs were 89/66 (blood pressure), p (pulse) 116, 02 (oxygen) 94, R (respirations) 28, and T (temperature) 98.0. Shift supervisor and Incoming nursing made aware to monitor the resident. - 03/30/2025 03:23 (3:23 a.m.) (Virtual physician visit note) Date of Service: 03/30/2025 12:52 AM CT Details: [Name of nurse] Patient Name: [name of R2] Primary Chief Complaint: General: Hospice Patient Declining. History Present Illness: Pt is not hospice but on comfort medications, is DNR (do not resuscitate) DNH (do not hospitalize) and nurse now notifies that pt is having significant decline: increased shortness of breath with RR (respiratory rate) 52, shallow, spO2 78% and HR 127. Pt is unresponsive, frail and cachectic on video evaluation. Nurse reports consult is planned for Hospice on Monday. Unfortunately the pt is presenting as actively dying at this time . Plan: . supplemental oxygen 2-4liters per NC PRN to keep spO2 >90%. Disposition: Stay at Facility. The physician orders for R2 documented an order for supplemental O2 2-4L per nasal cannula as needed to keep spO2 >90% as needed dated 3/30/25. Physician orders failed to evidence an order for incentive spirometry or recommendations made on 3/28/25 for titrating oxygen to maintain the SpO2 >92%. The eTAR (electronic treatment administration record) for R2 dated 3/1/25-3/31/25 documented oxygen use from 3/15/25-3/24/25 with discontinuation of the order on 3/25/25. The eTAR failed to evidence oxygen use or monitoring of oxygen saturations after 3/24/25 or incentive spirometry use. The eMAR (electronic medication administration record) for R2 dated 3/1/25-3/31/25 failed to evidence oxygen use or monitoring of oxygen saturations after 3/24/25 or incentive spirometry use. The vital sign summary for R2 documented oxygen saturations as follows between 3/24/25-3/30/25. - 3/24/25 16:03 (4:03 p.m.) 96% (room air). - 3/26/25 17:36 (5:36 p.m.) 96% (room air). - 3/27/25 22:45 (11:45 p.m.) 97% (room air). - 3/28/25 15:53 (3:53 p.m.) 94% (room air). - 3/30/25 02:30 (2:30 a.m.) 89% (oxygen via nasal cannula). Low of 90.0 exceeded. The comprehensive care plan for R2 documented in part, The resident has altered respiratory status/difficulty breathing r/t lung sarcoidosis. Date Initiated: 11/29/2023. The clinical record failed to evidence implementation of the pulmonology consult recommendations made for IS/Flutter for pulmonary toileting. The record failed to evidence staff response to the oxygen saturation of 90% documented in the progress notes on 3/28/25 or titrating oxygen to maintain the SpO2 >92%. On 5/19/25 at 3:48 p.m., an interview was conducted with LPN (licensed practical nurse) #8. LPN #8 stated that when the residents had pulmonary consults, they came back with the recommendations. She stated that the nurses put in the orders and clarified anything needed with the house nurse practitioner. She stated that when a resident needed an incentive spirometer they would put in an order telling staff how often to assist the resident to use it and document it on the eMAR or eTAR. She stated that when there were recommendations regarding maintaining oxygen saturation they would monitor it every shift and follow the orders when not in the parameters. LPN #8 stated that she was not sure what pulmonary toileting was but if an incentive spirometer was ordered they had them available in the supply closet. LPN #8 stated that she had called the NP who saw R2 virtually on 3/30/25 during the night shift. She stated that R2 had a rapid decline, and she had placed oxygen on him prior to calling the NP and she had increased it during the call. On 5/20/25 at 9:11 a.m., an interview was conducted with ASM (administrative staff member) #2, the director of nursing. ASM #2 stated that pulmonology consult recommendations were communicated with the staff who put the orders in. She stated that the consulting pulmonologist wrote notes with their recommendations in them. When asked about the recommendations on the pulmonology consult for R2, ASM #2 stated that the expectation was for the staff to check the oxygen saturations every shift or more often if the resident was in distress. She stated that an order should be put in for the incentive spirometer. ASM #2 stated that for R2 they should have been doing oxygen saturations more often, but she was not sure if he was strong enough to use the incentive spirometer at that time. She stated that he was still walking around at that time but was very weak and someone had to be with him at that point. The facility policy, Oxygen Administration dated 9/24, documented in part, Oxygen is administered to residents who need it, consistent with professional standards of practice, the comprehensive person-centered care plans, and the resident's goals and preferences . The facility failed to offer guidance on incentive spirometer use. On 5/20/25 at 4:18 p.m., ASM #1, the administrator and ASM #2, the director of nursing were made aware of the concern. No further information was provided prior to exit.

Based on staff interview and facility document review, it was determined that the facility staff failed to implement the abuse policy for of six of six contract employees and failed to investigate and report allegations of abuse and exploitation for one of 31 residents in the survey sample, Resident #18 (R18). The findings include: 1. On 05/13/2025 criminal background checks were requested from ASM (administrative staff member) #1, the administrator for six contracted construction workers who were observed working in the facility. On 05/14/2025 review of the documents provided by the facility failed to evidence criminal record background checks. The employees identified were: 1. OSM (other staff member) #20, construction worker with a hire date of 06/24/2024. 2. OSM #21, construction worker with a hire date of 06/24/2024. 3. OSM #22, construction worker with a hire date of 06/24/2024. 4. OSM #23, construction worker with a hire date of 04/07/2025. 5. OSM #24, electrician with a hire date of 02/2025. 6. OSM #25, electrician with a hire date of 06/24/2024. On 05/20/2025 at approximately 10:28 a.m., an interview was conducted with ASM #4, regional administrator, regarding background checks for construction workers in the facility. ASM #4 stated that the general contractor of the construction company stated the construction workers did not have social security numbers but could provide national background checks for the construction workers. ASM #4 stated she was provided background checks from Ecuador and accepted them. When asked if the background checks from Ecuador met the regulations ASM #4 stated she did not know if the background checks met the regulations. The facility policy Abuse, Neglect and Exploitation documented in part, I. Screening: A1. Background, reference, and credentials' check shall be conducted on potential employees, contracted temporary staff, student affiliated with academic institutions, volunteers and consultants. A2. Screenings may be conducted by the facility staff itself, third-party agency or academic institutions. A3. The facility will maintain documentation of proof that the screening occurred. On 05/20/2025 at approximately 4:30 p.m., ASM #1, administrator, ASM #2, director of nursing, and ASM #4, regional administrator, were made aware of the above findings. No further information was provided prior to exit. Based on staff interview, facility document review, and clinical record review, the facility staff failed to follow a policy to prevent abuse, and to report and investigate an allegation of resident exploitation for one of 31 residents in the survey sample, Resident #28, and for six of six contract staff records reviewed. The findings include: 1. For Resident #28 (R28), the facility staff failed to follow its policy to report an allegation of resident exploitation to the state agency (SA) and to investigate this allegation. A review of the facility policy, Abuse, Neglect, and Exploitation, revealed, in part: 'Exploitation' means the deliberate misplacement, exploitation, or wrongful, temporary or permanent, use of a resident's belongings or money without the resident's consent Investigation .An immediate investigation is warranted when suspicion of abuse, neglect, or exploitation, or reports of abuse, neglect, and exploitation, occur .Written procedures for investigation include .Identifying and interviewing all involved persons, including the alleged victim, alleged perpetrator, witnesses, and others who might have knowledge of the allegation .Providing complete and thorough documentation of the investigation .Reporting/Response .The facility will have written procedures that include .reporting of alleged violations to the Administrator, state agency, adult protective services, and to all other required agencies .within specified timeframes. A review of R28's progress notes revealed the following: 10/11/2023 .Social / Psychosocial Note .Social Work Note: The Director of Nursing let this writer know that [R28]'s daughter expressed concerns that her father is being exploited of his funds by a friend of his whom she does not know. This writer met with [R28] who denied all allegations. [R28] in fact, is alert and oriented X4 and denied these allegations. [R28] did share his wishes .to no longer have his daughter manage his bank account. This writer reached out to the Ombudsman who recommended SS (social services) to contact APS (adult protective services) and file a report. This writer contacted [name of county] Adult Protective Services .today to file a report that [R28] wishes his daughter to be investigated. APS will be reaching out to SS Department when they have filed a claim. 1/4/2024 .Social / Psychosocial Note .This writer spoke with resident's APS worker regarding case for exploitation of funds. [APS worker] . stated she will be closing the case and has spoken to resident regarding issuing funds inappropriately and providing banking information to unknown individuals. Resident seems to be in denial and not receptive. APD (sic) requested facility become payee. SS will continue to provide support as needed. On 5/19/25 and 5/20/25, requests were made of facility management to provide evidence of a report to the SA regarding R28's allegation of exploitation and of an investigation of the allegation. On 5/20/25 at 8:32 a.m., ASM (administrative staff member) #1, the administrator, was interviewed. He stated any reports of possible resident exploitation should be reported from front line team members to the manager, then the manager should report the allegation to the administrator or the DON (director of nursing). He stated the report should be made immediately. Following the report, the administrator or DON should submit a report to the SA and to APS. After the allegation is reported, the facility should immediately begin an investigation, including interviews with the resident, staff, and any outside party who may have knowledge of the situation. The SA should receive a final report with the results of the investigation within five business days. ASM #1 stated he was still looking for evidence that the allegation of exploitation of R28 had been reported to the SA. On 5/20/25 at 4:27 p.m., ASM #1, the administrator, and ASM #2, the director of nursing, were informed of these concerns. ASM #1 stated no report to the SA or evidence of an investigation had been located as of yet. No additional information was provided prior to exit.

Based on staff interview, facility document review, and clinical record review, the facility staff failed to provide a safe discharge for one of 31 residents in the survey sample, Resident #28. The findings include: For Resident #28 (R28), the facility staff failed to discharge the resident to a safe environment with a comprehensive discharge plan. A review of R28's clinical record revealed he was admitted to the facility with diagnoses including Parkinson's disease and alcoholism. Further review of the clinical record revealed multiple progress notes documenting the resident's continued alcohol abuse, including the following progress notes: 2/3/2024 16:16 (4:16 p.m.) Health Status Note .At around 1330 (1:30 p.m.) patient came back from outing. When patient returned this writer went in to take his vitals. Pt (patient) was noted aggressive, screaming, appeared red, slurring words. Pt was redirected. Noted smells of alcohol. Supervisor/NP (nurse practitioner) aware. 2/3/2024 22:45 (10:45 p.m.) Health Status Note .Resident went out to buy beer, got drunk but was calm on this shift, although he complained a little bit about his dinner in his room. 2/21/2024 15:20 (3:20 p.m. Medical Visit .Diagnoses: ETOH abuse .CIWA Clinical Institute Withdrawal Assessment for Alcohol (1) inpatient .Parkinson's Disease .Psych: irritable mood, normal affect .HX (history) of ETOH (alcohol) abuse .patient noted to have gone on LOA (leave of absence) and returned intoxicated recently, counsel alcohol cessation, follow and support process for risk reduction rt (related to) ETOH use. 4/12/2024 16:48 (4:48 p.m.) Medical Visit .Pt. asked to be seen by staff for recert (recertification) .Asked by staff to eval (evaluate) pt (patient) for q (each) 30/60 day follow up .Reason for admission: Diagnoses: Debility, Alcohol dependence .Parkinson's disease .Assessment/Plan: Worsening weakness, unsteady gait, unintentional weight loss, multiple falls Suspected due to chronic alcoholism .Alcohol use/withdrawal .As per the patient last drink was 1 week ago however the daughter at bedside disagrees. We will place on CIWA protocol .Rehab potential: fair. Further review of the clinical record revealed the following notes regarding the resident's discharge from the facility: 2/29/2024 11:05 (a.m.) IDT (Interdisciplinary Team) Note .IDT Quarterly CARE PLAN MEETING .POC (plan of care) reviewed/discussed and continued. All questions presented by Mr. [NAME] were addressed by the IDT members .Recommendations for psych (psychiatric) referral made due to resident behaviors of irritation and aggression. The Social Services dept (department) will continue to monitor and address concerns as they arise. [R28] remains a long-term care placement and has been issued a 30 day notice due to nonpayment, Will continue plan of care with goals and approaches. SS (social services) will continue to provide support as needed. 4/29/2024 16:08 (4:08 p.m.) COMMUNICATION - with Resident .Writer met and spoke w/ (with) [R28] in regard to his move out plan, he informed that w/ his income he would not be able to afford a hotel, but he has a backup for a family member in which he would not disclose to pick him up Saturday. He stated If the Family Member does not come then he has no other options no money, I asked what county his ID listed and he Informed me [name of county], requested if tomorrow 4/30 we could look into shelters. 4/30/2024 14:22 (2:22 p.m.) COMMUNICATION - with Resident .Admin (administrator) and Writer met w/ resident to inform of discharge plan. Resident agreed and understood terms and options provided. Will discharge Saturday. 5/4 Resident states a Friend will be picking him up, but he seems unsure. informed facility will provide transportation and pay for hotel for a few nights. Writer Called several Shelters and found one that will accept in [name of adjacent state]. 5/4/2024 17:25 (5:25 p.m.) Health Status Note .RESIDENT discharged WITH ALL BELONGINGS AT 1625 (4:25 p.m.). NO DISTRESS NOTED. RESIDENT SIGNED DISCHARGE PAPER. A review of facility documents revealed a Notice of Transfer or discharge date d 2/8/24. This notice contained, in part, the following: To: [R28] The purpose of this letter is to inform you that after careful consideration, it is our plan to transfer or discharge you for the following reasons .[R28] failed, after reasonable and appropriate notice, to pay (or to have paid under Medicare or Medicaid) a stay at the nursing facility. Total amount due to the facility is $6251.60 and you and/or your representative were previously given notice of payment due on 1/22/2024. The notice contained information regarding immediate payment instructions, appeal resources, and ombudsman contact information. The notice did not indicate a proposed date of discharge or a discharge location. The notice was signed by the former facility administrator, ASM (administrative staff member) #6. R28's record review failed to reveal evidence of the date he received this notice. On 5/19/25 at 4:01 p.m., OSM (other staff member) #11, a social worker, was interviewed. She stated she began working at the facility in December 2023. She stated her role in a resident's planned discharge is to find out the discharge destination, and to determine the resident's medical needs at discharge. These could include durable medical equipment, wound care services, home health services, and outpatient therapy services. She stated she would set up psychiatric services if those are needed and would handle getting the resident's prescriptions to the resident's pharmacy of choice. She explained that in order to facilitate a safe discharge, the facility must know exactly where the resident will be living. After reviewing the discharge notification letter addressed to R28, OSM #11 confirmed there was no date of discharge, and no discharge destination contained in the letter. She stated ASM #6 instructed her to find placement for [R28] because he had to be discharged . According to her, ASM #6 told her the facility would pay for three nights in a hotel if that's what was needed, but [R28] had to leave regardless. OSM #11 told ASM #6 she was not comfortable discharging R28 to a hotel and attempted to find an alternative. She stated she located a homeless shelter in an adjacent state, contacted the shelter staff, and was assured there would be a bed for the resident. She stated at one time, she, ASM #6, and R28 agreed on a discharge date and time, but the plan changed several times after the agreement was made. OSM #11 stated ASM #6 was clear on me leaving out certain things about the discharge. He wanted me to leave out the final discharge location and the real reason we were discharging [R28]. OSM #11 stated she was not aware of R28's alcohol abuse and dependency as she had only been employed by the facility for a few months when R28 was discharged . She stated the resident's discharge plan should have included substance abuse counseling, and there was no plan to address the resident's substance abuse after discharge. She stated: This was not a safe discharge, adding the social services team was kept out of the loop until the very last days of discharge management for R28. On 5/19/25 at 4:21 p.m., OSM #19, the director of social services, was interviewed. After reviewing the facility's notification of discharge to R28, she stated there was no indication of the date the resident received the notification or the discharge destination. She stated she was not directly involved in R28's discharge but remembers advising OSM #11 because OSM #11 was new to the facility. She added: [ASM #6] was basically doing [this discharge] solo, without anyone's input. On 5/20/25 at 8:32 a.m., ASM #1, the administrator, was interviewed. He stated that a resident, the facility staff would need to make sure the resident would have everything medically needed after discharge. He stated it was difficult for him to speak to the specifics of R28's discharge because it was well before the beginning of his employment at the facility. On 5/20/25 at 10:08 a.m., OSM #19 stated she had searched R28's records and could not find any evidence that the resident had been discharged safely. She stated the progress notes were not clear about where the resident was going and about with whom the resident left the facility. She explained that if the social workers are aware that a resident with alcohol dependency is discharging, this should be addressed in the resident's discharge plan. She added: That is part of social services' responsibilities. On 5/20/25 at 4:27 p.m., ASM #1, the administrator, and ASM #2, the director of nursing, were informed of these concerns. A review of the facility policy, Transfer and Discharge, revealed, in part: If the information in the [discharge] notice changes prior to effecting the transfer or discharge, the Social Services Director or designee must update the recipients of the notice as soon as practicable once the updated information becomes available. For significant changes, such as a change in the transfer or discharge destination, a new notice will be given that clearly describes the change(s) and resets the transfer or discharge date in order to provide 30-day advance notification .Orientation for transfer or discharge will be provided and documented to ensure safe and orderly transfer or discharge from the facility, in a form and manner that the resident can understand. Depending on the circumstances, this orientation may be provided by various members of the interdisciplinary team .The nurse caring for the resident at the time of discharge is responsible for ensuring the Discharge Summary is complete and includes, but not limited to, the following .A post discharge plan of care that is developed with the participation of the resident and the resident's representative(s) which will assist the resident to adjust to his or her new living environment .Supporting documentation shall include evidence of the resident's or resident representative's verbal or written notice of intent to leave the facility, a discharge plan, and documented discussions with the resident and/or resident representative. No additional information was provided prior to exit. Reference (1) The CIWA-Ar assesses the severity of common symptoms of alcohol withdrawal syndrome, including but not limited to tremors, sensory disturbances, and agitation. Generally, mild alcohol withdrawal is defined as a CIWA-Ar score of 8 or less. CIWA-Ar scores between 8 and 15 indicate moderate withdrawal, and scores above 15 imply severe withdrawal. This information is taken from the website https://www.ncbi.nlm.nih.gov/books/NBK442882/.

Based on observation, resident interview, staff interview and clinical record review, it was determined that facility staff failed to promote resident's dignity for two of 31 current residents in the survey sample, Residents #1 (R1) and R7. The findings include: 1a. For R1, facility staff failed to wash R1's hands before eating and stood while providing feeding assistance. R1 was admitted to the facility with diagnoses that included but were not limited to hemiplegia (1). On the most recent comprehensive MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 03/25/2024, R1 scored 11 out of 15 on the BIMS (brief interview for mental status), indicating R1 was moderately impaired of cognition for making daily decisions. GG0130 Self-Care coded R1 as requiring Partial/moderate assistance - helper does ESS THAN HALF the effort. Helper lifts or holds trunk or limbs, but provides less than half the effort with eating and coded Dependent for Personal hygiene: The ability to maintain personal hygiene, including combing hair shaving, applying makeup, washing/drying face and hands. On 05/12/2025 at approximately 1:20 p.m. R1 was observed in her room sitting in her wheelchair with an over-the-bed table in front of her and placed R1's lunch on the over-the-bed table. Further observations failed to evidence CNA (certified nursing assistant) #8 washing R1's hands before R1 started eating. At approximately 1:25 p.m. another observation of R1 revealed CNA #8 standing next to R1 while providing feeding assistance to R1. On 05/14/2025 at approximately 5:00 p.m. an interview was conducted with R1. When asked she felt about the CNA standing next to her when he was providing her with feeding assistance, R1 stated that it made her uncomfortable and that the staff should sit when assisting her. When asked about not having her hands washed before eating R1 stated that the staff do not wash her hands before or after eating her meals. On 05 19/2025 at approximately 3:06 p.m. an interview was conducted with CNA #8. When informed of the above observations and interview with R1, CNA #8 stated he recalled the situation. CNA #8 stated the unit (long term care) was short staffed that day and it took time to get back to R1 because he had all the lunch trays to deliver to residents that could eat independently and had residents to feed. He stated he did not have enough help. When asked about standing while he provided feeding assistance to R1, he stated it was not dignified. He further stated that he should have been sitting next to or in front of R1 when assisting with the meal. When asked about washing R1's hands before and after eating, CNA #8 stated it should be done, and it is not dignified for residents not to clean their hands before and after eating. The facility's policy Resident's Rights documented in part, 4. Respect and dignity. The resident has a right to be treated with respect and dignity. The facility's policy Activities of Daily Living documented in part, Policy Explanation and Compliance Guidelines: 3. A resident who is unable to carry out activities of daily living will receive the necessary services to maintain good nutrition, grooming, and personal and oral hygiene. On 05/20/2025 at approximately 4:30 p.m., ASM (administrative staff member) #1, administrator, ASM #2, director of nursing, and ASM #4, regional administrator, were made aware of the above findings. No further information was provided prior to exit. Complaint deficiency References: (1) Loss of muscle function in part of your body. This information was obtained from the website: https://medlineplus.gov/paralysis.html. 1b. For R1, the facility staff failed to serve the meal at the same time the roommate received their meal in the same room. On 05/12/2025 at approximately 12:55 p.m. R1 was observed in her room sitting in her wheelchair with an over-the-bed table in front of her, dressed, neat and clean. Further observations revealed R1's lunch tray sitting on a counter next to the sink approximately six feet away from the resident. An observation of R1's roommate revealed she was sitting on the edge of her bed eating her lunch independently. At 1:20 p.m. CNA (certified nursing assistant) #8 entered R1's room and set up R1's lunch on the over-the-bed table in front of R1. On 05/14/2025 at approximately 5:00 p.m. an interview was conducted with R1. She was asked how she felt about waiting 25 minutes to receive her lunch on 05/12/2025 while her roommate ate their own meal while she waited. R1 stated that she should not have to wait that long, and the food could get cold. On 05 19/2025 at approximately 3:06 p.m. an interview was conducted with CNA #8. When informed of the above observations and interview with R1 regarding CNA #8 stated he recalled the situation. When asked about R1 having to wait 25 minutes to receive her lunch while her roommate was eating and finished their meal before R1 received her meal, CNA #8 stated the facility was short staffed that day and it took time to get back to R1 because he had two other residents to feed. He further stated it was not dignified to have R1 wait for her meal while her roommate was eating. On 05/20/2025 at approximately 4:30 p.m., ASM (administrative staff member) #1, administrator, ASM #2, director of nursing, and ASM #4, regional administrator, were made aware of the above findings. No further information was provided prior to exit. 2. For R7, facility staff stood while providing feeding assistance. R7 was admitted to the facility with diagnoses that included but were not limited to muscle weakness. On the most recent comprehensive MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 03/04/2024, R7 scored 5 (five) out of 15 on the BIMS (brief interview for mental status), indicating R1 was severely impaired of cognition for making daily decisions. GG0130 Self-Care coded R7 as requiring Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as resident completes activity. Assistance may be provided throughout the activity or intermittently. On 05/12/2025 at approximately 1:30 p.m., an observation revealed R7 receiving assistance with feeding by CNA (certified nursing assistant) #8. Further observations revealed CNA #8 was standing next to R7's bed while providing assistance. On 05 19/2025 at approximately 3:06 p.m. an interview was conducted with CNA #8. When informed of the above observations and interview with R1, CNA #8 stated he recalled the situation. When asked about standing while he provided feeding assistance to R7, he stated it was not dignified. He further stated that he should have been sitting next to the bed when assisting with the meal. On 05/20/2025 at approximately 4:30 p.m., ASM (administrative staff member) #1, administrator, ASM #2, director of nursing, and ASM #4, regional administrator, were made aware of the above findings. No further information was provided prior to exit. Complaint deficiency

Based on staff interview, clinical record review and facility document review, it was determined the facility staff failed to implement the comprehensive care plan for one of 31 residents in the survey sample, Resident #2. The findings include: For Resident #2 (R2), the facility staff failed to implement the comprehensive care plan to A) provide showers on dates in August, September and October of 2024, B) provide incontinence care on dates in January and February of 2025 and C) monitor vital signs as ordered. On the most recent MDS (minimum data set) a quarterly assessment with an ARD (assessment reference date) of 2/8/25, the resident scored 0 out of 15 on the BIMS (brief interview for mental status) assessment, indicating the resident was severely impaired for making daily decisions. The assessment documented R2 dependent on staff for showering/bathing and always incontinent of bowel and bladder. An annual assessment with an ARD of 6/12/24 documented R2 dependent on staff for showering/bathing and always incontinent of bowel and bladder. A) The comprehensive care plan for R2 documented in part, Resident requires assistance with self care and mobility R/T (related to) dementia, schizophrenia. Date Initiated: 11/28/2023. Under Interventions it documented in part, Shower/Bathing; Dependent. Date Initiated: 01/31/2025. It further documented, [Name of R2] has an ADL self-care performance deficit r/t Dementia, depression, Schizophrenia and alcohol dependence. re-admitted to the center on 7/13/23 with new order. See MAR. Date Initiated: 07/14/2023. Under Interventions it documented in part, .Provide sponge bath when a full bath or shower cannot be tolerated. Date Initiated: 07/14/2023. The resident requires staff assistance with bathing/showering and as necessary. Date Initiated: 07/14/2023 . Review of the ADL documentation for R2 dated 8/1/24-8/31/24 documented Shower Schedule: Mon/Thur Eve Shift. On 8/26/24 it documented 1,NA,NA. The documentation key documented in part, Task Completed? 0-Yes, 1-No . NA- Not Applicable . Review of the ADL documentation for R2 dated 9/1/24-9/30/24 documented Shower Schedule: Mon/Thur Eve Shift. On 9/19/24 it documented 1,NA,NA. The documentation key documented in part, Task Completed? 0-Yes, 1-No . NA- Not Applicable . On 9/23/24 it documented 1,NA,5. The documentation key documented in part, Task Completed? 0-Yes, 1-No . NA- Not Applicable .Skin Observation .5-None of the above observed . Review of the ADL documentation for R2 dated 10/1/24-10/31/24 documented Shower Schedule: Mon/Thur Eve Shift. On 10/28/24 it documented 1,NA,5. The documentation key documented in part, Task Completed? 0-Yes, 1-No . NA- Not Applicable .Skin Observation .5-None of the above observed . The clinical record for R2 failed to evidence refusals for baths/showers on the dates above. On 5/14/25 at 8:59 a.m., an interview was conducted with LPN (licensed practical nurse) #4 who stated that the purpose of the care plan was to show how to provide care for the residents, show what they needed and what the expectations were. She stated that the care plan was implemented and should be implemented to provide the care for the resident. On 5/20/25 at 9:11 a.m., an interview was conducted with ASM (administrative staff member) #2, director of nursing. ASM #2 stated that the shower documentation on the ADLs looked like it said not applicable and she was not sure why it would be not applicable. She stated that the shower/bathing, dependent documentation listed underneath the shower schedule showed the amount of assistance required to have a shower and it did not show that a shower was provided. On 5/20/25 at 9:55 a.m., an interview was conducted with CNA (certified nursing assistant) #15 who stated that R2 required total care with all ADLs. She stated that R2 was dependent for bathing and was always incontinent and wore briefs. CNA #15 stated that showers were provided twice a week and his were Mondays and Thursdays on the evening shift. She stated that the care they provided was evidenced by documenting it in the electronic medical record and any refusals were documented there and reported to the nurse. On 5/20/25 at 2:00 p.m., ASM #2 stated that she had spoken with a staff member who had documented the NA on the ADL documentation and normally it was documented when it was not the residents scheduled shower dates. She stated that those were his dates so it may have been an accident. She stated that NA does not apply to showers. The facility provided policy Care Plan Revisions Upon Status Change dated 9/24, failed to evidence guidance regarding implementing the care plan. On 5/20/25 at 4:18 p.m., ASM #1, the administrator and ASM #2, the director of nursing were made aware of the concern. No further information was provided prior to exit. B) The comprehensive care plan for R2 documented in part, The resident has bowel and bladder incontinence r/t impaired mobility. Date Initiated: 11/29/2023. Under Interventions it documented in part, Brief Use: The resident uses disposable briefs. Change as soiled and frequently with rounding. Date Initiated: 11/29/2023. Clean peri-area with each incontinence episode. Date Initiated: 11/29/2023 . It further documented, [Name of R2] has an ADL self-care performance deficit r/t Dementia, depression, Schizophrenia and alcohol dependence. re-admitted to the center on 7/13/23 with new order. See MAR. Date Initiated: 07/14/2023. Under Interventions it documented in part, . Skin Inspection: The resident requires SKIN inspection every shift and after each incontinence episode, Observe for redness, open areas, scratches, cuts, bruises and report changes to the Nurse. Date Initiated: 05/11/2023. Revision on: 07/07/2023 . Review of the ADL documentation for R2 dated 1/1/25-1/31/25 failed to evidence incontinence care/toileting assistance provided on evening shift 1/7/25 and 1/17/25 and night shift on 1/4/25 and 1/31/25. The dates documented NA or were blank. The documentation key documented NA-not applicable. Review of the ADL documentation for R2 dated 2/1/25-2/28/25 failed to evidence incontinence care/toileting assistance provided on evening shift 2/9/25 and 2/11/25 and night shift on 2/1/25, 2/2/25, 2/8/25, 2/14/25, 2/21/25, 2/22/25 and 2/28/25. The dates documented NA or were blank. The documentation key documented NA-not applicable. The clinical record for R2 failed to evidence refusals for incontinence care on the dates above. On 5/14/25 at 8:59 a.m., an interview was conducted with LPN (licensed practical nurse) #4 who stated that the purpose of the care plan was to show how to provide care for the residents, show what they needed and what the expectations were. She stated that the care plan was implemented and should be implemented to provide the care for the resident. On 5/20/25 at 9:55 a.m., an interview was conducted with CNA (certified nursing assistant) #15 who stated that R2 required total care with all ADLs. She stated that R2 was always incontinent and wore briefs. She stated that the care they provided was evidenced by documenting it in the electronic medical record and any refusals were documented there and reported to the nurse. On 5/20/25 at 4:18 p.m., ASM #1, the administrator and ASM #2, the director of nursing were made aware of the concern. No further information was provided prior to exit. C) The comprehensive care plan for R2 documented, The resident has S&S (signs and symptoms) of potential fluid deficit r/t (related to) Poor intake and hypernatremia. IV (intravenous) fluids per MD order. Date Initiated: 01/18/2025. Created on: 01/20/2025. Under Interventions it documented in part, .Monitor vital signs as ordered/per protocol and record. Notify MD of significant abnormalities. Date Initiated: 01/18/2025 . The physician's order summary for R2 documented in part, - Check Vital signs every 2 hours. every shift for Abnormal Vital signs (Elevated Temperature). Order Date: 03/15/2025. Start Date: 03/15/2025. The progress notes for R2 documented in part, - 03/15/2025 18:37 (6:37 p.m.) .Primary Chief Complaint: Fever. History Present Illness: The patient is alert and oriented to self. Current temperature readings are 101.9°F and Per Nurse dropped to 99.2°F earlier this am after first suppository insertion. A chest x-ray has been ordered. stat lab order, signs of infection were noted reviewed. prophylactic antibiotic orders and started. A single dose of Rocephin was administered, pending the chest x-ray. The next dose of Rocephin is scheduled for 1700 today . Plan: . Check vital signs every 2 hours . Review of the vital signs documented a temperature summary with temperatures documented twice on 3/15/25 and 3/16/25, once on 3/18/25, once on 3/20/25, 3/21/25, 3/22/25, 3/23/25, and 3/24/25, once on 3/27/25, twice on 3/28/25 and once on 3/30/25. The vital signs failed to evidence checks every two hours as ordered. A review of the clinical record failed to evidence documentation of vital signs checked every two hours. On 5/14/25 at 8:59 a.m., an interview was conducted with LPN (licensed practical nurse) #4 who stated that the purpose of the care plan was to show how to provide care for the residents, show what they needed and what the expectations were. She stated that the care plan was implemented and should be implemented to provide the care for the resident. On 5/19/25 at 3:48 p.m., an interview was conducted with LPN #8 who stated that vital signs were monitored as ordered or more often if indicated. She stated that they were documented in the vital signs portion of the electronic medical record. On 5/20/25 at 4:18 p.m., ASM (administrative staff member) #1, the administrator, and ASM #2, the director of nursing, were made aware of the above concern. No further information was provided prior to exit.

Based on staff interview and clinical record review, it was determined that the facility staff failed to keep residents free from neglect for two of 31 residents in the survey sample, Residents #13 (R13) and R19. The findings include: 1. For R13, the facility staff failed to check and perform incontinence care in a timely manner. R13 was admitted to the facility with diagnoses that included but were not limited to dementia (1). On the most recent MDS (minimum data set), an annual assessment with an ARD (assessment reference date) of 03/14/2025, R13 scored 2 (two) out of 15 on the BIMS (brief interview for mental status), indicating the resident is severely impaired of cognition for making daily decisions. Section H0300 Urinary Continence coded R13 as being always incontinent. On 05/13/2025 at 12:42 p.m. until 5:00 p.m. continuous observations were conducted of R13. During the four hour and 17 minutes of observation, R13 was not checked by a nurse or a CNA (certified nursing assistant) for incontinence care. On 05/13/2025 at approximately 5:05 p.m. an interview was conducted with CNA #3. When asked if he was assigned to R13 for the 3:00 p.m. to 11:00 p.m. shift he stated yes. He asked to describe the procedure for residents who are dependent on staff for incontinence care. CNA #3 stated residents are checked for incontinence care at the beginning of each shift, checked every two hours throughout the shift and at the end of each shift. He also stated at the beginning of the shift he receives report from the previous shift CNA that includes the resident's condition, and which residents had received incontinence care. When asked about consequences a resident may encounter if they are left wet and/or soiled for extended periods of time he stated the resident could have skin breakdown. When asked if he received information regarding R13's incontinence care from the CNA on the previous shift (7:00 a.m. - 3:00 p.m.), CNA #3 stated he was not informed. When informed of the observation stated above, CNA #3 stated he would check R13 immediately. On 5/13/25 at 5:15 p.m., CNA (certified nursing assistant) #3 and CNA #4 were observed attempting to provide incontinence care to R13 in his room. R13 displayed stiffness and tremors in his arms, and stiffness in his legs as he sat in his wheelchair. CNA #3 repeatedly placed his hands on R13's arms attempting to pull the resident up from a sitting position in the wheelchair in order to transfer the resident to the bed for incontinence care. The resident repeatedly resisted; CNA #3 persisted in his efforts. CNA #4 told CNA #3 that R13 would not respond to this type of action, and that R13 would be able to transfer with minimal assistance if CNA #3 would not touch the resident. CNA #3 continued to attempt to take the resident's arm and assist him to move toward the bed. CNA #4 took over the effort, and assisted the resident to self-propel his wheelchair over to the sink area. CNA #4 stated: Put your hands on the counter and stand up. You are soaking wet. R13 refused to stand at the sink. CNA #4 assisted the resident to self-propel in the wheelchair back to the bed, and CNA #4 and CNA #3 physically lifted R13 from the wheelchair and moved him to a supine position on the bed. CNA #3 removed the resident's pants and incontinence brief. The brief was saturated with urine to the point that the brief contained hardened ridges where urine had pooled over time. The brief contained a large amount of feces, some of it soft, and some of it dried on the resident's buttocks. On 05/20/2025 at approximately 5:08 p.m. an interview was conducted with LPN (licensed practical nurse) #13. When asked what would constitute neglect of a resident she stated it would include not feeding a resident, not administering their medications and not providing ADL (activities of daily living) care. When asked to describe the process for ensuring a resident who is dependent on incontinence care is not left wet or soiled she stated that the resident should be checked every two hours. LPN #13 also stated that it would be neglect if a resident was not checked every two hours for incontinence care. On 05/20/2025 at approximately 5:12 p.m. an interview was conducted with CNA (certified nursing assistant) #17. When asked what would constitute neglect of a resident she stated it would include leaving a resident unattended or not giving care. When asked to describe the process for ensuring a resident who is dependent on incontinence care is not left wet or soiled she stated that the resident should be checked every two hours. LPN #13 also stated that it would be neglect if a resident was not checked every two hours for incontinence care. On 05/20/2025 at approximately 4:30 p.m., ASM (administrative staff member) #1, administrator, ASM #2, director of nursing, and ASM #4, regional administrator, were made aware of the above findings. No further information was provided prior to exit. Complaint deficiency Reference: (1) A loss of brain function that occurs with certain diseases. It affects memory, thinking, language, judgment, and behavior. This information was obtained from the website: https://medlineplus.gov/ency/article/000739.htm. 2. For R19, the facility staff failed to check and perform incontinence care in a timely manner. R19 was admitted to the facility with diagnoses that included but were not limited to a stroke. On the most recent MDS (minimum data set), an annual assessment with an ARD (assessment reference date) of 01/29/2025, R19 scored 0 (zero) out of 15 on the BIMS (brief interview for mental status), indicating the resident is severely impaired of cognition for making daily decisions. Section H0300 Urinary Continence coded R13 as being always incontinent. On 05/13/2025 at 12:42 p.m. until 5:00 p.m. continuous observations were conducted of R19. During the four hour and 17 minutes of observation, R19 was not checked by a nurse or a CNA (certified nursing assistant) for incontinence care. On 05/13/2025 at 5:00 p.m. an interview was conducted with CNA #6. When asked if she was assigned to R19 from the 3:00 p.m. to 11:00 p.m. shift she stated yes. When asked to describe the procedure for incontinence care for residents who are dependent on staff for incontinence care. CNA #6 stated residents are checked for incontinence care at the beginning of each shift, checked every two hours throughout the shift and at the end of each shift. She also stated at the beginning of the shift she receives report from the previous shift CNA that includes which residents have received incontinence care. When asked about consequences a resident may encounter if they are left wet and/or soiled for extended periods of time she stated the resident could have skin breakdown. When asked if she received information regarding R19's incontinence care from the CNA on the previous shift (7:00 a.m. - 3:00 p.m.), CNA #6 stated she was not informed. When informed of the observation stated above, CNA #6 stated she would check R19 immediately. On 5/13/25 at 5:02 p.m., CNA #6 entered R19's room carrying wipes and a clean incontinence brief. R19 saw the incontinence care supplies and started to shake her head. CNA #6 stated: I would like to change you. R19 continued to refuse. CNA #6 told the resident she would return again and ask about incontinence care just before dinner trays were distributed. CNA #6 stated R19 frequently refused incontinence care. CNA #6 stated even if a resident is known to refuse care, the care should still be offered every 2 hours. On 05/20/2025 at approximately 5:08 p.m. an interview was conducted with LPN (licensed practical nurse) #13. When asked what would constitute neglect of a resident she stated it would include not feeding a resident, not administering their medications and not providing ADL (activities of daily living) care. When asked to describe the process for ensuring a resident who is dependent for incontinence care is not left wet or soiled she stated that the resident should be checked every two hours. LPN #13 also stated that it would be neglect if a resident was not checked every two hours for incontinence care. On 05/20/2025 at approximately 5:12 p.m. an interview was conducted with CNA (certified nursing assistant) #17. When asked what would constitute neglect of a resident she stated it would include leaving a resident unattended or not giving care. When asked to describe the process for ensuring a resident who is dependent on incontinence care is not left wet or soiled she stated that the resident should be checked every two hours. LPN #13 also stated that it would be neglect if a resident was not checked every two hours for incontinence care. On 05/20/2025 at approximately 4:30 p.m., ASM (administrative staff member) #1, administrator, ASM #2, director of nursing, and ASM #4, regional administrator, were made aware of the above findings. No further information was provided prior to exit. Complaint deficiency

Based on staff interview, facility document review, and clinical record review, the facility staff failed to provide required documentation for discharge for one of 31 residents in the survey sample, Resident #28. The findings include: For Resident #28 (R28), the facility staff failed to include the date of the planned discharge or the location of discharge for R28's discharge from the facility. A review of R28's clinical record revealed he was discharged from the facility on 5/4/24. A review of facility documents for R28 revealed a Notice of Transfer or discharge date d 2/8/24. This notice contained, in part, the following: To: [R28] The purpose of this letter is to inform you that after careful consideration, it is our plan to transfer or discharge you for the following reasons .[R28] failed, after reasonable and appropriate notice, to pay (or to have paid under Medicare or Medicaid) a stay at the nursing facility. Total amount due to the facility is $6251.60 and you and/or your representative were previously given notice of payment due on 1/22/2024. The notice contained information regarding immediate payment instructions, appeal resources, and ombudsman contact information. The notice did not indicate a proposed date of discharge or a discharge location. The notice was signed by the former facility administrator, ASM (administrative staff member) #6. R28's record review failed to reveal evidence of the date he received this notice. On 5/19/25 at 4:01 p.m., OSM (other staff member) #11, a social worker, was interviewed. She stated she began working at the facility in December 2023. After reviewing the discharge notification letter addressed to R28, OSM #11 confirmed there was no date of discharge, and no discharge destination contained in the letter. She stated ASM (administrative staff member) #6, a former administrator, instructed her to find placement for [R28] because he had to be discharged . She stated at one time, she, ASM #6, and R28 agreed on a discharge date and time, but the plan changed several times after the agreement was made. OSM #11 stated ASM #6 was clear on me leaving out certain things about the discharge. He wanted me to leave out the final discharge location and the real reason we were discharging [R28]. On 5/19/25 at 4:21 p.m., OSM #19, the director of social services, was interviewed. After reviewing the facility's notification of discharge to R28, she stated there was no indication of the date the resident received the notification or the discharge destination. She stated she was not directly involved in R28's discharge but remembers advising OSM #11 because OSM #11 was new to the facility. She added: [ASM #6] was basically doing [this discharge] solo, without anyone's input. On 5/20/25 at 8:32 a.m., ASM #1, the administrator, was interviewed. He stated it was difficult for him to speak to the specifics of R28's discharge because it was well before the beginning of his employment at the facility. On 5/20/25 at 4:27 p.m., ASM #1, the administrator, and ASM #2, the director of nursing, were informed of these concerns. A review of the facility policy, Transfer and Discharge, revealed, in part: The facility's transfer/discharge notice will be provided to the resident and the resident's representative in a language and manner in which they can understand. The notice will include all of the following at the time it is provided .The effective date of transfer or discharge .The specific location (such as the name of the new provider or description and/or address if the location is a residence) to which the resident is to be transferred or discharged .For significant changes, such as a change in the transfer or discharge destination, a new notice will be given that clearly describes the change(s) and resets the transfer or discharge date in order to provide 30-day advance notification. No additional information was provided prior to exit.

Based on staff interview, facility document review, and clinical record review, the facility staff failed to investigate an allegation of resident exploitation for one of 31 residents in the survey sample, Resident #28. The findings include: For Resident #28 (R28), the facility staff failed to investigate an allegation of exploitation when staff members became aware on 10/11/23. A review of R28's progress notes revealed the following: 10/11/2023 .Social / Psychosocial Note .Social Work Note: The Director of Nursing let this writer know that [R28]'s daughter expressed concerns that her father is being exploited of his funds by a friend of his whom she does not know. This writer met with [R28] who denied all allegations. [R28] in fact, is alert and oriented X4 and denied these allegations. [R28] did share his wishes .to no longer have his daughter manage his bank account. This writer reached out to the Ombudsman who recommended SS (social services) to contact APS (adult protective services) and file a report. This writer contacted [name of county] Adult Protective Services .today to file a report that [R28] wishes his daughter to be investigated. APS will be reaching out to SS Department when they have filed a claim. 1/4/2024 .Social / Psychosocial Note .This writer spoke with resident's APS worker regarding case for exploitation of funds. [APS worker] . stated she will be closing the case and has spoken to resident regarding issuing funds inappropriately and providing banking information to unknown individuals. Resident seems to be in denial and not receptive. APD (sic) requested facility become payee. SS will continue to provide support as needed. On 5/19/25 and 5/20/25, requests were made of facility management to provide evidence of an investigation regarding R28's allegation of exploitation. On 5/20/25 at 8:32 a.m., ASM (administrative staff member) #1, the administrator, was interviewed. He stated any reports of possible resident exploitation should be reported from front line team members to the manager, then the manager should report the allegation to the administrator or the DON (director of nursing). He stated the report should be made immediately. Following the report, the administrator or DON should submit a report to the SA and to APS. After the allegation is reported, the facility should immediately begin an investigation, including interviews with the resident, staff, and any outside party who may have knowledge of the situation. The SA should receive a final report with the results of the investigation within five business days. ASM #1 stated he was still looking for evidence that the allegation of exploitation of R28 had been investigated. On 5/20/25 at 4:27 p.m., ASM #1, the administrator, and ASM #2, the director of nursing, were informed of these concerns. ASM #1 stated no investigation had been located as of yet. A review of the facility policy, Abuse, Neglect, and Exploitation, revealed, in part: 'Exploitation' means the deliberate misplacement, exploitation, or wrongful, temporary or permanent, use of a resident's belongings or money without the resident's consent .Investigation .An immediate investigation is warranted when suspicion of abuse, neglect, or exploitation, or reports of abuse, neglect, and exploitation, occur .Written procedures for investigation include .Identifying and interviewing all involved persons, including the alleged victim, alleged perpetrator, witnesses, and others who might have knowledge of the allegation .Providing complete and thorough documentation of the investigation. No additional information was provided prior to exit.

2. For R1, the facility staff failed to provide a scheduled bath. R1 was admitted with diagnoses that included but were not limited to hemiplegia (1). On the most recent comprehensive MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 03/25/2024, R1 scored 11 out of 15 on the BIMS (brief interview for mental status), indicating R1 was moderately impaired of cognition for making daily decisions. Section GG 0130 Self Care coded R1 as being dependent for showers or bathing self. The facility's POC (point of care) sheet for R1 dated May 2025 documented, in part, Shower Schedule: Wed/Sat Eve (Wednesday/Saturday Evening) shift. Review of the POC revealed a a blank on 05/07/2025 for showers. The comprehensive care plan for R1 with a revision date 01/25/2024 documented in part, Focus. Resident requires assistance with self care and mobility R/T (related to) right sided hemiplegia, parkinson's with ADL (activities of daily living) fluctuations according to disease process. Revision on: 01/25/2024. Under Interventions it documented in part, Shower/Bathing: dependent. Date Initiated: 10/31/2023. On 05/20/2025 at approximately 2:00 p.m. an interview was conducted with CNA (certified nursing assistant) #15. When asked how and where it is evidenced that residents receive their scheduled showers, she stated that it is documented in PCC. On 05/20/2025 at approximately 4:30 p.m., ASM (administrative staff member) #1, administrator, ASM #2, director of nursing, and ASM #4, regional administrator, were made aware of the above findings. No further information was provided prior to exit. Complaint deficiency References: (1) The loss of muscle function in part of your body. Paralysis can be complete or partial. It can occur on one or both sides of your body. It can also occur in just one area, or it can be widespread. This information was obtained from the website: https://medlineplus.gov/paralysis.html. Based on observation, staff interview, clinical record review and facility document review, it was determined the facility staff failed to provide ADL (activities of daily living) care to a dependent resident for two of 31 residents in the survey sample, Resident #2 and Resident #1. The findings include: 1. For Resident #2 (R2), the facility staff failed to A) evidence showers provided on dates in August, September and October of 2024 and B) evidence incontinence care provided on dates in January and February of 2025. On the most recent MDS (minimum data set) a quarterly assessment with an ARD (assessment reference date) of 2/8/25, the resident scored 0 out of 15 on the BIMS (brief interview for mental status) assessment, indicating the resident was severely impaired for making daily decisions. The assessment documented R2 dependent on staff for showering/bathing and always incontinent of bowel and bladder. An annual assessment with an ARD of 6/12/24 documented R2 dependent on staff for showering/bathing and always incontinent of bowel and bladder. A) Review of the ADL documentation for R2 dated 8/1/24-8/31/24 documented Shower Schedule: Mon/Thur Eve Shift. On 8/26/24 it documented 1,NA,NA. The documentation key documented in part, Task Completed? 0-Yes, 1-No . NA- Not Applicable . Review of the ADL documentation for R2 dated 9/1/24-9/30/24 documented Shower Schedule: Mon/Thur Eve Shift. On 9/19/24 it documented 1,NA,NA. The documentation key documented in part, Task Completed? 0-Yes, 1-No . NA- Not Applicable . On 9/23/24 it documented 1,NA,5. The documentation key documented in part, Task Completed? 0-Yes, 1-No . NA- Not Applicable .Skin Observation .5-None of the above observed . Review of the ADL documentation for R2 dated 10/1/24-10/31/24 documented Shower Schedule: Mon/Thur Eve Shift. On 10/28/24 it documented 1,NA,5. The documentation key documented in part, Task Completed? 0-Yes, 1-No . NA- Not Applicable .Skin Observation .5-None of the above observed . The clinical record for R2 failed to evidence refusals for baths/showers on the dates above. The comprehensive care plan for R2 documented in part, Resident requires assistance with self care and mobility R/T (related to) dementia, schizophrenia. Date Initiated: 11/28/2023. Under Interventions it documented in part, Shower/Bathing; Dependent. Date Initiated: 01/31/2025. It further documented, [name of R2] has an ADL self-care performance deficit r/t Dementia, depression, Schizophrenia and alcohol dependence. re-admitted to the center on 7/13/23 with new order. See MAR. Date Initiated: 07/14/2023. Under Interventions it documented in part, .Provide sponge bath when a full bath or shower cannot be tolerated. Date Initiated: 07/14/2023. The resident requires staff assistance with bathing/showering and as necessary. Date Initiated: 07/14/2023 . On 5/13/25 at 9:57 a.m., an interview was conducted with OSM (other staff member) #14, anonymous staff member. OSM #14 stated that R2 was not showered for weeks when they were at the facility. OSM #14 stated that APS (adult protective services) came in to investigate a concern and they had started showering him but after the investigation they stopped showering him again. On 5/13/25 at 10:08 a.m., an interview was conducted with OSM #12, anonymous staff member. OSM #12 stated that R2 was rarely showered when they were at the facility, and they worried about the lack of care they received. On 5/14/25 at 5:49 p.m., an interview was conducted with OSM #16, the former director of nursing. OSM #16 stated that APS had come in to investigate concerns about care of R2 when they were at the facility. She stated that they had investigated the concern as well and were not able to substantiate any of the care concerns. OSM #16 stated that R2 did look disarrayed at times, and he had some staff that worked with him better than others. She stated that some were able to shower him and get him to do things. On 5/20/25 at 9:11 a.m., an interview was conducted with ASM (administrative staff member) #2, director of nursing. ASM #2 stated that the shower documentation on the ADLs looked like it said not applicable and she was not sure why it would be not applicable. She stated that the shower/bathing, dependent documentation listed underneath the shower schedule showed the amount of assistance required to have a shower and it did not show that a shower was provided. On 5/20/25 at 9:55 a.m., an interview was conducted with CNA (certified nursing assistant) #15 who stated that R2 required total care with all ADLs. She stated that R2 was dependent for bathing and was always incontinent and wore briefs. CNA #15 stated that showers were provided twice a week and his were Mondays and Thursdays on the evening shift. She stated that the care they provided was evidenced by documenting it in the electronic medical record and any refusals were documented there and reported to the nurse. On 5/20/25 at 2:00 p.m., ASM #2 stated that she had spoken with a staff member who had documented the NA on the ADL documentation and normally it was documented when it was not the residents scheduled shower dates. She stated that those were his dates so it may have been an accident. She stated that NA does not apply to showers. The facility policy, Activities of Daily Living (ADLs) dated 9/24, documented in part, The facility will, based on the resident's comprehensive assessment and consistent with the resident's needs and choices, ensure a resident's abilities in ADLs do not deteriorate unless deterioration is unavoidable. Care and services will be provided for the following activities of daily living: 1. Bathing, dressing, grooming and oral care; 2. Transfer and ambulation; 3. Toileting; 4. Eating to include meals and snacks; and 5. Using speech, language or other functional communication systems . A resident who is unable to carry out activities of daily living will receive the necessary services to maintain good nutrition, grooming, and personal and oral hygiene . On 5/20/25 at 4:18 p.m., ASM #1, the administrator and ASM #2, the director of nursing were made aware of the concern. No further information was provided prior to exit. B) Review of the ADL documentation for R2 dated 1/1/25-1/31/25 failed to evidence incontinence care/toileting assistance provided on evening shift 1/7/25 and 1/17/25 and night shift on 1/4/25 and 1/31/25. The dates documented NA or were blank. The documentation key documented NA-not applicable. Review of the ADL documentation for R2 dated 2/1/25-2/28/25 failed to evidence incontinence care/toileting assistance provided on evening shift 2/9/25 and 2/11/25 and night shift on 2/1/25, 2/2/25, 2/8/25, 2/14/25, 2/21/25, 2/22/25 and 2/28/25. The dates documented NA or were blank. The documentation key documented NA-not applicable. The clinical record for R2 failed to evidence refusals for incontinence care on the dates above. The comprehensive care plan for R2 documented in part, The resident has bowel and bladder incontinence r/t impaired mobility. Date Initiated: 11/29/2023. Under Interventions it documented in part, Brief Use: The resident uses disposable briefs. Change as soiled and frequently with rounding. Date Initiated: 11/29/2023. Clean peri-area with each incontinence episode. Date Initiated: 11/29/2023 . It further documented, [Name of R2] has an ADL self-care performance deficit r/t Dementia, depression, Schizophrenia and alcohol dependence. re-admitted to the center on 7/13/23 with new order. See MAR. Date Initiated: 07/14/2023. Under Interventions it documented in part, . Skin Inspection: The resident requires SKIN inspection every shift and after each incontinence episode, Observe for redness, open areas, scratches, cuts, bruises and report changes to the Nurse. Date Initiated: 05/11/2023. Revision on: 07/07/2023 . On 5/13/25 at 9:57 a.m., an interview was conducted with OSM (other staff member) #14, anonymous staff member. OSM #14 stated that R2 often smelled like urine and wore clothing that was wet with urine. On 5/13/25 at 10:08 a.m., an interview was conducted with OSM #12, anonymous staff member. OSM #12 stated that R2 often smelled like urine and the room smelled like urine frequently. On 5/13/25 at 10:25 a.m., an interview was conducted with OSM #11, anonymous staff member. OSM #11 stated that R2 was incontinent, and the room smelled strongly of urine. OSM #11 stated that R2's clothing was rarely changed and when it was reported to the former administration they became defensive anytime anyone brought it up but nothing ever changed. OSM #11 stated that staff kept R2's door closed most of the time. On 5/14/25 at 5:49 p.m., an interview was conducted with OSM #16, the former director of nursing. OSM #16 stated that APS had come in to investigate concerns about care of R2 when they were at the facility. She stated that they had investigated the concern as well and were not able to substantiate any of the care concerns. OSM #16 stated that R2 did look disarrayed at times, and he had some staff that worked with him better than others. She stated that some were able to shower him and get him to do things. On 5/20/25 at 9:55 a.m., an interview was conducted with CNA (certified nursing assistant) #15 who stated that R2 required total care with all ADLs. She stated that R2 was always incontinent and wore briefs. She stated that the care they provided was evidenced by documenting it in the electronic medical record and any refusals were documented there and reported to the nurse. On 5/20/25 at 4:18 p.m., ASM #1, the administrator and ASM #2, the director of nursing were made aware of the concern. No further information was provided prior to exit.

Based on staff interview, facility document review, and clinical record review, it was determined the facility staff failed to administer an antibiotic for the treatment of a urinary tract infection. The resident missed six prescribed doses of Macrobid. The resident was sent out to the hospital three days later and admitted with septic shock from E. coli bacteremia/E.coli urinary tract infection, thus causing harm to one of two residents in the survey sample, Resident #1. The findings include: For Resident #1, the facility staff failed to administer six doses of the antibiotic, Macrobid (used to treat urinary tract infections) (1) prescribed to treat a urinary tract infection. On 12/30/23 Resident #1 was admitted to the facility with diagnoses that included but were not limited to: DRPLA (Dentatorubral-pallidoluysian atrophy - a progressive brain disorder) (2), metabolic encephalopathy, history of pneumonia, benign prostatic hyperplasia, dysphagia and dementia. The MDS (minimum data set) assessment, prior to transfer to the hospital on 8/2/24, a quarterly assessment, with an assessment reference date of 7/17/24, the resident scored a three out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was severely impaired for making daily decisions. In Section GG - Functional Goals, the resident was coded as being dependent upon staff for all of his activities of daily living. The nurse practitioner note dated, 7/19/24, documented in part, CC (chief complaint): Staff asked to see patient for recent fall, frequent attempts to get out of WC (wheelchair) .He is noted per staff with recent fall, no apparent injuries. He has been increasingly trying to get out of his WC without assistance which is new Assessment/Plan: No injuries noted, check labs. The laboratory test results collected 7/22/24, documented in part, CBC (complete blood count): WBC (white blood cell count) = 11.21 (reference range - 3.10 - 9.50 X10 3u/L). The infectious disease (ID) nurse practitioner note dated, 7/24/24, documented in part, Reason for visit: Known to ID service. AMS (altered mental status). He is noted per staff with recent fall, no apparent injuries. He has been increasingly trying to get out of his WC without assistance which is new. Labs ordered by this provider available for review, noted with AKI (acute kidney injury), with cr (creatinine) of 1.4 from baseline cr 0.8 on 3/21., elevated Na+ (sodium) and slight leukocytosis. Pt was also evaluated for COVID infection by our ID team. Pt with increased agitation on 7/23. Our team was notified. by primary team Assessment and Plan: Change in AMS in baseline confused pt - rule out infectious process vs. (verses) worsening underlying neurodegenerative disease vs. due to dehydration/electrolyte imbalances .Recommendations: Obtain clean catch midstream UA (urinalysis) with reflex to cx (culture) ordered. Obtain CXR (chest x-ray) - fax sent from out ID office. Hold off on starting antibiotics t this time. Repeat CBC with differential ordered for 7/25 AM (morning). Hydration. Monitor electrolytes. The nurse practitioner note dated, 7/24/24, documented in part, CC: Staff asked to see patient for review of labs (na+ sodium, cr. 1.4 WBC 11.21 7/23) .Labs ordered by this provider available for review, noted with AKI (acute kidney injury), with cr (creatinine) of 1.4 from baseline cr 0.8 on 3/21., elevated Na+ (sodium) and slight leukocytosis. This provider consulted with ID re: elevated WBC .Assessment/Plan: DC (discontinue) Cozaar (3). Ordered D5W (dextrose 5% and water) @ 100cc/h (cubic centimeters per hour) x one liter, repeat labs on Monday, consulted ID for WBC. Leukocytosis: Infection w/u (work up). The CXR report dated,documented in part, Impression: 1. Unremarkable frontal view chest. 2. No evidence of active tuberculosis is noted. The nurse practitioner note dated, 7/26/24, documented in part, CC: Staff asked tro see patient sp (status post) fall again, and to discuss with wife updates of care .Noted recently with AKI (acute kidney injury), with cr (creatinine) of 1.4 from baseline cr 0.8 on 3/21., elevated Na+ (sodium) and slight leukocytosis. This provider consulted with ID re: elevated WBC, CXR and urine studies are pending. Patient was given 1L (liter) D5W dt (due to) elevated Na+ and Cr. Cozaar was dc'd (discontinued). Repeat labs pending for Monday .Assessment and Plan: Off Cozaar; BP (blood pressure) is 133/78. Repeat labs pending for Monday. SP D5W at 100 cc/h x one liter. Labs and plan of care DW (discussed with) wife via telephone. Leukocytosis: Infectious w/u per ID, CXR pending., urine studies pending. Observed to have a fall again today. The Urine Culture Report printed 7/28/24, documented in part, > (greater than) 100,000 CFU/mL Escherichia coli. The nurse practitioner note dated, 7/30/24, documented in part, CC: Staff asked to see patient for lab review, noted positive growth on urine culture, continues with agitation, change from baseline .Repeat labs available for review, Cr remains elevated at 1.4. Na+ improved. WBC is increased, and urine studies are positive for E.coli (Escherichia coli) uti (urinary tract infection), mixed resistance .7/29 - WBC - 12.24 , 7/23 - WBC - 11.21. Assessment/Plan: + E. coli UTI. DW ID team who will follow. Macrobid per ID. Noted with WBC 12.24 .Noted UTI, insert foley and trial void after ABX (antibiotics). The ID nurse practitioner note dated, 7/30/24, documented in part, Reason for visit: ID progress note .Labs/diagnostic results: Labs reviewed. WBC increased to 12.24 on 7/29/24. 7/31 - CXR - negative. Urine cx (culture) grew E. coli sens (sensitive ) to all except #E.coli U TI. #change in AMS in baseline confusion pt - possible secondary to E. coli UTI vs. ? worsening underlying neurodegenerative disease, vs. due to dehydration/electrolyte imbalances .Recommendations: Start Macrobid for a total of 5 days. The physician order dated 7/30/24 at 1:29 p.m. documented, Macrobid Oral Capsule 100 mg (milligrams); Give 100 mg by mouth one time only for UTI for 5 days 100 mg PO (by mouth) twice daily. Review of the July 2024 MAR (medication administration record) documented the above order. The MAR documented the administration of the Macrobid on 7/30/24 at 3:10 p.m. The MAR did not evidence documentation any other times for the medication to be administered. There was a blank on the MAR for 7/31/24. The August 2024 MAR documented the above order and there were blanks for 8/1/24 and 8/2/24. Again, there was no times for administration documented on the MAR. Under the Temperature Tab in the computer, the following temperatures were documented: 7/27/24 at 3:26 p.m. - 97.4 degrees 7/29/24 at 10:30 p.m. - 98.0 degrees 8/2/24 at 7:00 p.m. - 101.0 degrees The nurse's note dated, 8/2/24 at 10:32 p.m. documented, OFFERED A CUP OF ICE WATER AT 1548 (3:48 P.M.), REPORTED TO HAVE VOMITED AT 16:10 (4:10 P.M.) DURING INCONTINENCE CHANGE. OFFERED CUP OF GINGER ALE AND RESIDENT DRANK ALL. RESIDENT SENT TO ER (EMERGENCY ROOM) DUE TO FEBRILE, SOB (SHORTNESS OF BREATH) AND HYPOXIA. VITAL SIGNS @ 16:20 (4:20 P.M.) 99.5 (TEMPERATURE), 20 (RESPIRATIONS) 130/56 (BP), 99 (HEART RATE). WETCOLD TOWELS PUT ON RESIENT'S FOREHEAD AND ARMPITS AT 16:30 (4:40 P.M.). AT 1700 (5:00 P.M.) TEMP. WAS STILL 99.5 AND WAS GIVEN 2 TABLETS OF TYLENOL 325 MG. AT TEMP RECHECIED, WAS 101.1 AND HAS VOMITED TWICE. ONE TIME ZOFRAN (5) 4 MG. PT NOTED HAVING LABORED BREATHING. VITALS RECHECKED AT 18:20 (6:20 P.M.) 21 (RESPIRATIONS) 105.4 (TEMPERATURE), 136/54 (BP), 143 (HEART RATE) 66% 3L (OXYGEN SATURATION ON 3 LITERS OF OXYGEN). PUT ON REBREATHER MASK ON 5L, WAS FLATUATION (SIC) B/N (BETWEEN) 73% AND 83%. SENT OUT AT 19:30 (7:30 P.M.) ALL RESPECTIVE PARTIES NOTIFIED. PT WAS REPORTED TO BE admitted TO (NAME OF HOSPITAL). 8/2/24 at 7:42 p.m. The emergency room physician note dated, documented in part, Chief Complaint: Fever. Altered Mental Status. 69 yo (year old) M (male) h/o (history of) Dentatorubral-pallidoluysian atrophy (DRPLA) progressive neurodegenerative disease living in long term care here in ED (emergency department) via EMS (emergency medical services) on CPAP (5) due to AMS and difficulty breathing. EMS reports staff rounded on him to find him hypoxic to the 60's put on NC. They started CPAP sats in mid-80's pt. altered. Have been febrile today. Temp 101. Been recently treated for UTI Physical Exam: BP: 100/67, Heart Rate: 115, Temp: 103.3, Resp Rate: 26 .Constitutional: Comments: Patient is toxic appearing altered responding only to pain increased work of breath tachypneic .Pulmonary: Breath sounds: No wheezing or rhonchi. Comments: Tachypneic increased work of breathing on CPAP on arrival . Medical Decision Making: Labs: ordered. Radiology: ordered. ECG/medicine tests: ordered XXX[AGE] year-old male with progressive neurodegenerative disease living in a long-term care facility here in the emergency department due to acute change in mental status hypoxia respiratory failure .Highly suspect sepsis possible respiratory failure secondary to poor reserve due to progressive neuro degenerative disease. Possible urinary tract infection source versus bacterial versus viral pneumonia versus aspiration pneumonia. There is no facial asymmetry he is generally weak. Called for stat pressors and a chest x-ray he does not appear volume overloaded lungs sound relatively clear anteriorly but his is extremely tachypneic lower extremity is not swollen abdomen is not swollen. Differential does include flash pulmonary edema acute valvular CHF (congestive heart failure) ACS pulmonary embolism. Highly suspect sepsis. Heart review do not see a recent echocardiogram. Patient does have a history of hypoxic respiratory failure due to fluid pneumonia in the past on chart review XR chest AP Portable - 8/2/24 at 7:57 p.m. Impression: No acute disease CT Chest Abdomen Pelvis WO (without) Contrast. Impression: Multifocal pneumonia .Clinical Impression: Sepsis. Acute hypoxic respiratory failure. Troponin level elevated. Pneumonia of both lungs due to infectious organism, unspecified part of lung. The hospital Discharge summary dated [DATE] documented in part, 69 y.o. Male with a history of Dentatorubral-pallidoluysian atrophy (DRPLA), ataxia, dysphagia, incontinence, hypertension, who resides in long-term care facility, was brought into ER by EMS on 8/2/24 for altered mentation and dyspnea. Patient was noted to be febrile with temperature of 103.3, mild leukocytosis of 9.9, acidotic with serum bicarb(bicarbonate) of 17, creatinine elevated at 1.9, was noted to be hypoxic into the 70's, required nasal cannula oxygen, saturating still in the 80%, admitted to the ICU for septic shock, acute respiratory failure with hypoxia, found to have E. coli bacteremia from urinary tract infection. Treated with broad-spectrum antibiotics, subsequently weaned off the Levophed (6), oxygen and transferred to regular floor on 8/6/24. Diagnoses: #Septic shock from E. coli bacteremia/E.coli urinary tract infection: Resolved. Off the Levophed. # E. coli bacteremia from UTI: E. coli resistant to ampicillin and ciprofloxacin. # Aspiration pneumonia: respiratory pathogens: not detected (8/2/24). [NAME] blood cell count: 19.0 (8/10/24) up from 18.8 (8/9/24), high 37.6 (8/5/24) Completed 7 days of antibiotics with IV (intravenous) Zosyn (7) .# Acute respiratory failure with hypoxia: From bilateral aspiration pneumonia. Resolved. On 12/4/24 at 11:25am An interview was conducted with ASM (administrative staff member) #3, the nurse practitioner, ASM #3 stated the resident had DRPLA, he was having a gradual decline in his condition. It's called a burden of chronic disease. Any assault on his system, they can't come back as fast. Each assault on his system, make them weaker each time. When asked of his urinary retention, ASM #3 stated the resident had obstructive uropathy, anatomically, due to an enlarged prostate and was being treated with two medications for that. The above laboratory tests were reviewed with ASM #3. She stated that once the resident is referred to ID, they take over the treatment of any infections. The ID note of 7/30/24 was reviewed with ASM #3. The July and August MARs were reviewed with ASM #3. When asked if the resident didn't get the antibiotic as prescribed, what is the likelihood for him to get sicker and then go septic, ASM #3 stated, when you have an infection, you need antibiotics. She couldn't say that was the cause for him going to the hospital but in the presence of infection they need antibiotics. She further stated the resident should have received the five days of antibiotics that were prescribed. On 12/4/24 at 11:59 a.m. An interview was conducted with RN (registered nurse) #1 When asked how she evidenced that she has given a medication, RN #1 stated it's documented on the MAR. There will be a check mark and the initials of the staff member giving the medication documented on the MAR. When asked what a blank on the MAR indicated, RN #1 stated, it (medication) wasn't given, there should be a check mark and the initials. On 12/4/24 at 12:31 p.m. An interview was conducted with ASM #2, the director of nursing,The above MARs were reviewed with ASM #2. ASM #2 stated she had looked at them. The ID doctor didn't put the orders in PCC (computer program) correctly. ASM #3 stated the resident only got one dose of the Macrobid. ASM #3 stated yes from that order it was supposed to be for five days. She stated the bigger problem was he, the resident, had aspirated prior to leaving the facility, he vomited and aspirated. When asked how she evidenced that a medication has been administered, ASM #3 stated it's signed off on the MAR. On 12/5/24 at 1:13 p.m. ASM #1 and ASM #2 were made aware of the concern for harm for Resident #1 On 12/5/24 at 4:48 p.m. An interview was conducted with ASM #2 When asked if an antibiotic is ordered twice a day, when should it be given, ASM #2 stated it could be given at 9:00 a.m. and 9:00 p.m. or 9:00 a.m. and 5:00 p.m. On 12/5/24 at 6:15 p.m. An interview was conducted with ASM #4, the ID nurse practitioner,When asked if she was aware of the resident didn't receive the antibiotic she ordered, ASM #4 stated the director of nursing had just told her about it. She stated she put it in the computer to be a one-time mediation, not a routine medication. She stated she ordered it for twice a day for five days. When asked if a resident vomits and possibly aspirates, would they get a fever within two hours. ASM #4 stated probably not. ASM #4 was told the temperature of the resident was over 105 when he went to the hospital, she stated that was probably not from aspiration. The facility policy, Medication and Treatment Order, failed to evidence documentation related to administering medications per the physician orders. No further information was provided prior to exit. References: (1) Macrobid - Nitrofurantoin is used to treat urinary tract infections. Nitrofurantoin is in a class of medications called antibiotics. It works by killing bacteria that cause infection. This information was obtained from the following website: https://medlineplus.gov/druginfo/meds/a682291.html (2) Dentatorubral-pallidoluysian atrophy (DRPLA) is a progressive brain disorder that causes involuntary movements, mental and emotional problems, and a decline in thinking ability. The average age of onset for DRPLA is around 30 years, but this condition can appear any time between infancy and mid-adulthood. The signs and symptoms of DRPLA differ somewhat between affected children and adults. When DRPLA appears before age [AGE], it most often involves episodes of involuntary muscle jerking or twitching (myoclonus), seizures, behavioral changes, intellectual disabilities, and problems with balance and coordination (ataxia). When DRPLA begins after age [AGE], the most frequent signs and symptoms are ataxia, uncontrollable movements of the limbs (choreoathetosis), psychiatric symptoms such as delusions, and deterioration of intellectual function (dementia). This information was obtained from the following website: Dentatorubral-pallidoluysian atrophy: MedlinePlus Genetics. (3) Cozaar is used alone or in combination with other medications to treat high blood pressure. This information was obtained from the following website: https://medlineplus.gov/druginfo/meds/a695008.html. (4) E.Coli - E. coli is the name of a type of bacteria that lives in your intestines. This information is obtained from the following website: https://medlineplus.gov/ecoliinfections.html. (5) Positive airway pressure (PAP) treatment uses a machine to pump air under pressure into the airway of the lungs. This helps keep the windpipe open during sleep. The forced air delivered by CPAP (continuous positive airway pressure) prevents episodes of airway collapse that block the breathing in people with obstructive sleep apnea and other breathing problems. This information was obtained from the following website: https://medlineplus.gov/ency/article/001916.htm. (6) Levophed is similar to adrenaline. It is used to treat life-threatening low blood pressure (hypotension) that can occur with certain medical conditions or surgical procedures. This information was obtained from the following website: https://www.drugs.com/mtm/levophed.html. (7) Zosyn - Piperacillin and tazobactam injection is used to treat pneumonia and skin, gynecological, and abdominal (stomach area) infections caused by bacteria. This information was obtained from the following website: https://medlineplus.gov/druginfo/meds/a694003.html.

Based on observation, staff interview, facility document review, and clinical record review, the facility staff failed to prepare and serve food and liquids to residents with orders for modified consistency diets for two of 41 residents in the survey sample, Residents #80 and #8. For Resident #8, the facility staff failed to serve pureed foods as ordered by the physician. For Resident #80, the facility staff served the incorrect food and fluid consistency which resulted in Resident #80 coughing and a nosebleed. The facility's deficient practice placed the resident at risk of infection, lack of oxygen to the brain, or death. This resulted in a determination of Immediate Jeopardy (IJ). After Immediate Jeopardy was removed, the scope and severity was lowered to a level 2 isolated. The findings include: 1. For Resident #80 (R80), the facility staff failed to serve food and liquid to the resident per the physician prescribed orders. R80 who had physician orders for pureed food and honey thick liquids was served a regular meal with thin liquids. The resident presented with coughing and a nosebleed after eating bites of regular oatmeal and thin milk. R80 was admitted to the facility on [DATE] with a diagnosis of dysphagia (difficulty swallowing food or liquid). A review of R80's clinical record revealed a physician's order dated 9/14/23 for a regular diet with a dysphagia pureed texture, honey/moderately thickened liquids, and pleasure feeds as tolerated. R80's comprehensive care plan created on 9/18/23 documented, Regular diet, Dysphagia Puree texture, Honey/Moderately Thick consistency, for Nutrition PLEASURE FEEDS AS TOLERATED . A speech therapy evaluation dated 10/12/23 documented, Patient presents with severe aphasia (a comprehension and communication disorder) and dysphagia, following a stroke which necessitates skilled SLP (speech language pathology) services for dysphagia to reduce signs and symptoms of aspiration .What modified liquid is recommended for the patient to swallow safely? = Moderately thick. What modified diet is recommended for the patient to swallow solids safely? = Pureed . On 11/29/23 at 8:24 a.m., CNA (certified nursing assistant) #7 served R80 the resident's roommate's meal tray. The meal ticket on the tray contained the roommate's name and documented a regular diet. The meal tray contained a regular biscuit with sausage gravy, shredded hash browns, oatmeal, and a carton of thin consistency milk. CNA #7 opened the milk carton and poured some of the milk on the oatmeal, lifted the lid off the plate, and left the room. R80 fed herself one bite of the oatmeal mixture and began to cough. R80 fed herself a second bite of oatmeal mixture, coughed and tried to clear her throat. She took a sip of honey thick water, which was on her over bed table. Her nose began to bleed. CNA #8 and OSM (other staff member) #4 (the speech therapist) entered the room. CNA #8 and OSM #4 recognized R80 had been served her roommate's meal tray. OSM #4 removed the meal tray. On 11/29/23 at 10:00 a.m., ASM (administrative staff member) #1 (the administrator), ASM #2 (the director of nursing), and ASM #4 (the regional minimum data set coordinator) were notified of Immediate Jeopardy (IJ). On 11/29/23 at 1:15 p.m., an interview was conducted with CNA #7. CNA #7 stated she identifies residents by looking at their wristbands but if they don't have a wristband then she looks at the names on the door. CNA #7 stated that this was her first day working at the facility, so she was paired with CNA #8. CNA #7 stated she has served meal trays a million times so when the trays arrived on the unit, she asked CNA #8 if she wanted her to start serving trays. CNA #7 stated she thought someone was going to assist her, but CNA #8 told her to go ahead and begin. CNA #7 stated that while she was serving trays, CNA #8 came to her and told her she accidentally gave the wrong tray to R80. CNA #7 stated she was unaware that the top name on the room name plate was the resident by the window and the bottom number on the room name plate was the resident by the door. CNA #7 stated that after she served the wrong tray to R80, CNA #8 told her the room numbers are posted on the light fixtures above the residents' beds so she should always look at that. On 11/29/23 at 1:25 p.m., an interview was conducted with CNA #8. CNA #8 stated that when serving meal trays, CNAs should compare the room numbers on the meal tray tickets with the room numbers that are posted on the light fixtures above residents' beds. CNA #8 stated CNA #7 wanted to pass meal trays by herself, so she told her twice that she had to compare the meal tray tickets to the room numbers on the light fixtures. CNA #8 stated that earlier this morning, she and OSM #4 noticed R80 had a nosebleed, so they entered the room and OSM #4 realized R80 had been served the roommate's meal tray. CNA #8 stated OSM #4 removed the meal tray, and she (CNA #8) notified the nursing management team. On 11/30/23 at 9:21 a.m., an interview was conducted with OSM #4. OSM #4 stated R80 came to the facility from Florida with a feeding tube and has orders for pleasure feeds with pureed food and honey thick liquids. OSM #4 stated the potential risks of R80 eating regular food and thin liquids includes aspiration with food and drink going into the lungs instead of the stomach. OSM #4 stated that 11/29/23 was CNA #7's first day so staff told her to look at the room numbers on the light fixtures in the rooms to identify the appropriate patients. OSM #4 stated that on 11/29/23, she was in a room across the hall from R80 and she saw R80 eating so she went over to R80 and saw the resident had received the wrong tray. OSM #4 stated she removed the tray and educated CNA #7. The facility policy titled, Food and Fluid Tray Identification and Service documented, POLICY: Appropriate identification/coding shall be used to identify and appropriate serve various diets and fluids. SPECIFIC PROCEDURES/ REQUIREMENTS: 1. To assist in setting up and serving the correct food trays/diets to residents, the Food Services Department will use appropriate computer generated identification diet cards to specify the resident specific ordered diets/fluids, name and room number. 2. The Food Services staff will check trays and/ or prepared meals for correct diets before they are provided to the resident. 3. Nursing staff or person assisting to deliver the meal to the resident, will check foods/fluids, name, room number for the correct diet and resident before serving the resident. 4. If there is an error, dietary Department and nursing supervisor will be immediately notified so that the appropriate food/fluid items can be served to the appropriate resident. The facility document titled, Bed Identification System documented, Each semi-private room has two numbers outside the room door. The room number on top is the resident bed by the window. The room number on the bottom is the resident bed by the door. For example, room [ROOM NUMBER] is the bed by the window. room [ROOM NUMBER] is the bed by the door. The facility presented the following IJ removal plan which was accepted on 11/29/23 at 5:30 p.m. Date: 11/29/23 ISSUE/CONCERN: F805- The facility staff failed to prepare and serve food and liquids to a resident prescribed a pureed diet and honey thick liquids. The wrong texture of diet and consistency of liquids was served to Resident #80. This resulted in a choking incident for this resident. Goals/Objectives/Expected Outcome: It is the policy of the facility to ensure that residents are protected from the likelihood of choking or aspirating from receiving the incorrect consistency of food or liquid. Action(s) Planned. 1. Correction for identified resident/system (if applicable) 2. How you will identify other potential residents and correct for them if needed? 3. System changes; what are you going to do differently to minimize recurrence? 4. Monitoring- explain how you will monitor that the plan and system changes are successful; include QA Committee oversight. 5. Add/modify tasks and plan as needed. CORRECTION: The resident's tray was immediately removed. The Nurse Practitioner and Speech Therapist were onsite and addressed the resident. Care was provided to address the resident's nose bleed until it was resolved. The resident will continue to be monitored by licensed nurses and the provider and responsible party will be notified of any changes in the resident's condition. OTHER POTENTIAL: Other residents with practitioner's ordered altered textured diets and thickened liquids are at risk for the deficient practice. Residents who had orders for altered textured diets and liquids were observed during tray pass. There were no discrepancies noted. SYSTEM CHANGES: List each action separately. -Dietary staff currently on duty have been trained on the proper preparation of pureed diets. Staff members will validate receiving and understanding the training. Dietary staff not present for this training will be trained at their next scheduled day of work, they will not prepare or fill trays until training has been completed. Dietary staff will audit each tray for proper diet order prior to leaving kitchen. -Clinical staff on duty have been training on proper tray identification and resident identification to ensure residents are served the appropriate diet and fluids. Staff members will validate receiving and understanding the training. Clinical staff not present for this training will be training at their next scheduled shift/day of work, they will not deliver or provide food or fluids to residents until training has been completed. -Current staff on duty have been trained on resident bed/room identification. Staff members will validate receiving and understanding the training. Other staff not present for this training will be trained at their next scheduled shift/day of work, they will not deliver or provide food or fluids to residents until training has been completed. -The Food Service Department will continue to use computer generated tray cards to specify the resident's prescribed diet and fluid orders. -The Food Service Department will continue to validate that the proper diet/fluid are provided on the tray according to the meal ticket during the preparation of the tray in the kitchen. -Nursing staff or persons assisting to deliver the meals to the residents, will check foods/fluids, resident name, room number for the correct diet and fluids before serving the resident. -The resident room/bed number has been placed above each bed to indicate the correct resident with the corresponding number. MONITORING/QA OVERSIGHT: -The Dietary Manager/designee will monitor 10% of resident meal trays for each meal x 1 week and then 10% for one meal each day x 3 weeks for meal consistency and fluid accuracy. Any discrepancies noted will be corrected immediately and staff re-educated and/or disciplined as necessary. -The Speech Therapist, licensed nurse, or facility leadership will monitor 100% of pureed and/or thickened liquid meal trays for each meal x 1 week then 10% for one meal each day x 3 weeks for meal consistency and fluid accuracy. Any discrepancies noted will be corrected immediately and staff re-educated and/or disciplined as necessary. All the above audits will be provided weekly to the administrator for review and oversight. An analysis of the audits will be presented to the QAPI committee for additional oversite and input. Compliance Date: 11/30/23 11:50 a.m. On 11/30/23 at 3:30 p.m., the survey team, through observations, interviews, and documentation review, verified the removal plan had been fully implemented by the facility. On 11/30/23 at 3:33 p.m., ASM #1, ASM #2, ASM #3 (the regional director of operations) were informed the removal plan had been verified and the IJ had been abated. 42183 2. For Resident #8 , the facility staff failed to serve pureed foods as ordered by the physician. The supper tray was observed to include textured rotisserie chicken and lima beans, bread, cheesy mashed potatoes, and vanilla ice cream. Resident #8 was admitted to the facility on [DATE] with diagnosis that included but were not limited to: dysphagia, oropharyngeal phase, Parkinson's disease and diabetes. The most recent MDS (minimum data set) assessment, a quarterly Medicare assessment, with an ARD (assessment reference date) of 11/6/23, coded the resident as scoring a 08 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was moderately cognitively impaired. A review of the MDS Section G-functional status coded the resident as requiring supervision for eating. MDS Section K0520. Nutritional Approaches: C. Mechanically altered diet - require change in texture of food or liquids (e.g., pureed food, thickened liquids)-yes. D. Therapeutic diet (e.g., low salt, diabetic, low cholesterol)-yes. A review of the comprehensive care plan dated 7/12/23, which revealed, FOCUS: The resident has nutritional problem or potential nutritional problem related to altered diet texture; Parkinson's, diabetes, dysphagia, long term care resident. INTERVENTIONS: Provide, serve diet as ordered. Monitor intake and record every meal. Gluten Free diet, Dysphagia Puree texture, Regular/Thin consistency. A review of the physician's orders dated 7/10/23, revealed, Consistent Carbohydrate Diet, Dysphagia Puree texture, Regular/Thin consistency. On 11/28/23 at 12:52 p.m., the food on a test tray was sampled by two surveyors. OSM (other staff member) #1, the dining services district manager, was present for the sampling. The pureed meat did not have a smooth appearance; it contained identifiable pieces/chunks of hamburger OSM #1 stated the pureed meat looked a little like pudding, but with small chunks of meat present. He stated: When you bite into it, it has small chunks of meat. He added: I don't have the equipment in this building to puree food to the consistency it needs to be. I have requested a [commercial grade food processor]. On 11/28/23 at 1:05 p.m., OSM #4, a speech therapist, observed and tasted the pureed meat on the test tray. She stated: It's more of a mechanical soft consistency. Some of it is pureed, but it has chunks of meat. She stated this pureed meat was not safe to serve to residents with orders for a pureed diet. She stated if those at risk residents ate this meat, they were at risk for aspirating and choking. She stated this meat could also leave residue in their mouths and the residents could choke later. She stated: It is a safety hazard. It is not appropriate for someone on a pureed diet. On 11/28/23 at 4:45 p.m., OSM #1 stated: The [commercial grade food processor] has been ordered and will be here tomorrow. I haven't had the right equipment since I started this job. A review of a purchase order dated 11/27/23 at 6:00 p.m. revealed a commercial grade food processor was on order for the facility. An interview was conducted on 11/28/23 at 4:50 PM with Resident #8. When asked if he receives a pureed diet, Resident #8 stated, they do. When asked if the food was of a smooth consistency, Resident #8 stated it was not. When asked if he had choked or coughed while eating any of his pureed meals, Resident #8 stated they had not. An interview was conducted on 11/28/23 at 5:45 PM with CNA (certified nursing assistant) #5, after Resident #8 was served their supper tray which was observed not to be pureed. When shown Resident #8's tray and when asked if it was pureed, CNA #5 stated, No, this is not the smooth consistency and texture that pureed food should be. An interview was conducted on 11/30/23 at 9:30 AM with OSM (other staff member) #4, the speech language pathologist. When asked the purpose of a pureed diet, OSM #4 stated, the purpose is to help residents with dysphagia to not aspirate. When asked the signs of aspiration, OSM #4 stated, throat clearing, coughing, double swallows and a wet vocal quality. When asked the texture of a pureed diet, OSM #4 stated, pureed diet is smooth and with no chunks. On 11/30/23 at 1:30 PM, ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing, ASM #3, the Regional Director of Operations and ASM #4, the Regional Director of MDS were made aware of the finding. A review of the facility's policy Therapeutic Diet revealed, Mechanically Altered Diet: means one in which the texture of a diet is altered. When the texture is modified, the type of texture modification must be specific and part of the physicians' or delegated registered or licensed dietitian order. A review of the facility's policy Specialized Diets revealed, Dietary precautions, including use of therapeutic and mechanically altered diets will be communicated to the interdisciplinary team. Diet orders will be communicated to the dietary department. Dietary orders, including restrictions and precautions will be documented in the resident's medical record, examples may include: Medication Administration Record, Special Instructions, Tasks for CNAs, Kardex, Dietary restrictions, precautions will be included in the resident's comprehensive plan of care. Meals will be prepared and served according to the prescribed diet. A menu card or tool that includes the diet order, any restrictions, precautions, and resident preferences/dislikes will be used by staff preparing and delivering the food to the resident. No further information was provided prior to exit.

Based on staff interview, facility document review, clinical record review and in the course of a complaint investigation, it was determined that the facility staff failed to ensure adequate supervision and consistent implementation of a physician ordered assistive device to prevent an avoidable accidents for one of nine residents in the survey sample, Resident #1. The facility staff failed to ensure Resident #1's physician ordered tab alarm (an assistive safety device used to reduce falls) was re-applied in a timely manner. Resident #1, who was assessed as at risk for falls, was found without the physician ordered tab alarm in place and the facility staff left Resident #1 unsupervised without a tab alarm. Resident #1 subsequently fell and sustained a fractured pelvis and left wrist. The findings include: Resident #1 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. The most recent minimum data set (MDS), a 14 day assessment, with an assessment reference date of 3/4/17 coded Resident #1 as having scored four out of 15 on the brief interview for mental status indicating the resident was severely impaired cognitively to make daily decisions. The resident was coded as requiring assistance from staff for all activities of daily living. Resident #1's admission MDS assessment dated [DATE], coded the resident in section J1700, Fall History on Admission/Entry or Reentry as follows: A. Did the resident have a fall any time in the last month prior to admission/entry or reentry? A 9 was documented indicating the staff was unable to determine if a fall had occurred. Review of the physician's orders [REDACTED].* BED TAB (CHECK PLACEMENT AND FUNCTION) Every Shift .TX (treatment) -- Every Shift SPECIAL INSTRUCTIONS: FOR PATIENT SAFETY AWARENESS AND TO ALERT STAFF OF ATTEMPTS TO AMBULATE UNASSISTED. Review of the physician's history and physical dated 2/1/17 documented, She is increasingly confused and a fall risk. She is currently at the nurse station monitored one-to-one by nurses .She has a history of Alzheimer's-type dementia with worsening of cognitive status after the stroke and UTI (urinary tract infection). Review of the care plan initiated on 2/13/17 and revised on 2/19/17 documented, PROBLEM. Resident has risk for falls and/or history of falls related to, Unsteady/Impaired Gait, Short Term Memory Loss, Requires Staff Assistance for Transfers, Agitation/Unsafe Behavior. APPROACH. Apply personal alarm -- bed/chair Tab (alarm). Review of the February 2017 treatment administration record (TAR) documented, ALARM* BED TAB (CHECK PLACEMENT AND FUNCTION) Every Shift . TX (treatment) -- Every Shift SPECIAL INSTRUCTIONS: FOR PATIENT SAFETY AWARENESS AND TO ALERT STAFF OF ATTEMPTS TO AMBULATE UNASSISTED. It was documented that the bed alarm had been checked each shift from 2/1/17 to 2/15/17. Review of the fall risk assessment dated [DATE] documented that Resident #1's fall risk was 27. There was a box at the bottom of the page that documented, TOTAL SCORE. To be completed on admission and quarterly. If score is over 12, interventions will be put into place and the Care Plan revised. Review of the admission assessment dated [DATE] at 6:40 p.m. documented, COGNITIVE ABILITY. Confused. Review of the nurse's note dated 2/1/17 at 6:40 p.m. documented in part, [AGE] year old female arrived via stretcher from (name of hospital). [DIAGNOSES REDACTED].Other [DIAGNOSES REDACTED].Tab alarm applied Found by CNA (certified nursing assistant) climbing out of bed. Alarm went off. Transferred to recliner. Brought to nurses station. Review of the nurse's notes dated 2/5/17 at 3:30 a.m. Attempted to get out of bed x1. Patient was toileted and put back to bed. Tab Alarm in place. Will continue to monitor. Review of the nurse's note dated 2/5/17 at 9:30 a.m. documented, Trying to get out of the bed x3 (three times) w/o (without) help. Safety measures in place. At 2:00 p.m. it was documented, Attempt OOB (out of bed) x1, assisted to BSC (bedside commode) .Safety maintained and continue to monitor. Review of the nurse's note dated 2/15/17 at 3:20 a.m. documented, Patient slept well Will continue to monitor. At 4:00 a.m. it was documented, This Nurse was called to Patient's room. Patient was on the floor beside the bed lying on (left) side of her body. Assessment was done and Patient c/o (complained of) pain to (left) arm, (left) hip and her back Sent to emergency room for evaluation .When this Nurse called Son to make him aware he stated, She has fallen a lot of times and only had a bruised head. Review of the emergency room records dated 2/15/17 at 7:28 a.m. documented, (Name of Resident #1) is an 88 y.o. (year old) female Presents after fall. PT (patient) states she fell , does not know why, complains of left wrist and hip pain. She is at the rehab (rehabilitation), hx (history) of dementia and stroke, is only supposed to be up with assistance and per facility was out of bed Per rehab, (name of resident) is a two-person assist for ambulation and does not walk on her own or with the assistance of a walker. Past Medical History: .History of falling. Review of the left hip x-ray results dated 2/15/17 at 5:53 a.m. documented, Impression. Acute fracture of the left pubic tubercle (1) with extension to the left superior pubic ramus (2), moderate comminution and mild displacement. Possible acute nondisplaced fracture of the left pubic ramus. Acute fracture of the left sacral wing (3) with mild displacement. Review of the left wrist x-ray result dated 2/15/17 at 7:25 a.m. documented, Acute fracture of the metaphysis (4) of the distal radius (arm bone) which now demonstrates moderated displacement and volar angulation (5). An interview was conducted on 3/29/17 at 9:50 a.m. with RN (registered nurse) #1, the unit manager where the resident resided at the time of the fall. When asked what she remembered about the fall, RN #1 stated, The night time supervisor advised me of the fall at 4:40 in the morning. The resident was sent to the ER (emergency room ) and I knew it (the x-ray) was positive for a left wrist fracture. When asked what safety precautions had been in place at the time of the fall, RN #1 stated, A tab alarm. When asked if the alarm had been functioning at the time, RN #1 stated, The staff told me it was working. I asked if they had taken her to the bathroom, (name of LPN (licensed practical nurse) # 1) said yes that she and an aide had taken the resident to the bathroom at 2:00 a.m. It took about thirty minutes and they put her back to bed. When asked what the resident's cognitive status was, RN #1 stated, She was alert and oriented to herself only. She had a history of [REDACTED]. When asked if the resident had attempted to get out of bed on her own before, RN #1 stated, I think she had a couple times. When she tried to get out of bed she was too weak and couldn't get up. The fall investigation for Resident #1's fall was requested on 3/29/17 at 10:00 a.m. from ASM #2, the director of nursing. A telephone interview was conducted on 3/29/17 at 10:05 a.m. with LPN #1, the nurse caring for Resident #1 at the time of the fall. When asked what she remembered about that night, LPN #1 stated, We had taken her to the bathroom around 2:00 a.m. and put her back to bed. We were looking for the tab alarm and couldn't find it. It was a really busy night so I told the aide to go answer the lights and I said 'I'll go get one.' When I left the room I was stopped by one of the residents by the time I got back (to the resident's room) she had fallen. LPN #1 was asked why it took from 2:00 a.m. to 4:00 a.m. to get the tab alarm for the resident. LPN #1 stated, No, it was only 40 minutes and she hadn't tried getting up in a while. Review of Resident #1's fall accident report documented, Describe the Incident. This nurse was called to Patient's room. Patient was on the floor beside the bed. Lying on (left) side of her body. Assessment was done and Patient c/o (complained of) pain to (left) arm, (left hip) and her back. CIRCLE THE SAFETY DEVICES IN PLACE: Bed tabs and chair tabs were circled. Falls Investigation Review. History of Falls? Yes was circled. Tabs/Alarm in Use? Yes was circled. (*note at the time of the fall there was no tab alarm in place). A meeting was conducted on 3/29/17 at 11:10 a.m. with ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing and ASM #3 the assistant administrator. ASM #1 presented a letter dated 3/27/17 and addressed to the appropriate reporting agency outlining the resident's fall on 2/15/17. ASM #1 stated, We were going to mail this yesterday and then you came in. Because we did not know why you were here we didn't give this to you. Review of the letter documented in part, Meetings with the staff occurred on 2/16/2017 to further investigate the fall. (Name of resident) demonstrated as very weak, requiring 2 assist to ambulate and was not doing well in therapy due to weakness. (Name of resident) did not ambulate or use walker alone. A tabs monitor was ordered for (name of resident). The tabs alarm was documented in the MAR (medication administration record)/TAR (treatment administration record) as being in place on the evening shift and for the 11 - 7 (11:00 p.m. to 7:00 a.m.) shift of the fall. The C.N.A.(certified nursing assistant) caring for (Resident #1) states she does her vital signs on rounding at the first of the shift and she knows it was attached. She required max (maximum) assist of two to be ambulated to the bathroom. After returning the resident/patient from the restroom to her bed, the tabs alarm could not be located and a search of the room did not locate the device. C.N.A. explained that resident call lights were going off on the unit, so the Charge Nurse asked her to go ahead and answer the lights and the charge nurse would just get a new device for (name of resident). (Name of resident) had demonstrated in the past, behavior capability of using the call light; consequently the nursing call bell was left with the patient to call for help. The Charge Nurse was delaying in returning with the tabs device as she was called by another resident for assistance. ASM #2 stated she had developed a plan of correction. ASM #2 was asked the process she followed to investigate a fall, ASM #2 stated, We do a safety investigation with our falls and we meet every week with the interdisciplinary team for all falls. The unit manager goes down and talks to the staff. When asked if there were staff statements regarding Resident #1's fall, ASM #2 stated, We only do those if we suspect abuse. I started an investigation after APS (adult protective services) came in (about the incident). APS had been in the facility on 3/16/17. When asked if that was when they discovered that the resident did not have a tab alarm on at the time of the fall, ASM #2 stated it was. ASM #2 stated she had given an in-service on safety devices to the night shift on the unit Resident #1 resided. A request was made for the plan correction at this time. An interview was conducted on 3/29/17 at 12:05 p.m. with RN #1, the unit manager. When asked why residents have tab alarms, RN #1 stated, To raise awareness of them trying to get out of bed. When asked what should occur when a physician orders [REDACTED].#1 stated, That they have a tab alarm on at all times. When informed of the telephone interview with LPN #1, RN #1 stated she had not been aware that the resident was without the tab alarm. RN #1 was then asked if 40 minutes to replace a tab alarm was a long time. RN #1 stated it was. An interview was conducted on 3/29/17 at 12:35 p.m. with CNA #1 and CNA #2. When asked what they do for a resident with a tab alarm, CNA #1 stated, I have people who climb out of bed. We check their alarms. If it alarms I take off running. When asked if they had ever had a resident with a tab alarm fall, CNA #1 and #2 replied, No. When asked what they would do if a tab alarm needed to be replaced, CNA #1 stated, I'd keep them (the resident) with me until I get the alarm. We don't want them to fall. An interview was conducted on 3/29/17 at 1:00 p.m. with RN #5. When asked why a resident had a tab alarm, RN #5 stated, For safety for residents with a high risk for falling. When asked the process for checking the alarm, RN #5 stated, First when we do our rounds we check them. An interview was conducted on 3/29/17 at 1:05 p.m. with CNA #6. When asked what process staff follows if a tab alarm needs to be replaced, CNA #6 stated, I would tell the supervisor. When asked what he would do with the resident while he waited for the alarm, CNA #6 stated, I'd probably take them with me to make sure they're safe. An interview was conducted on 3/29/17 at 1:50 p.m. with ASM #2, the director of nursing. When asked about the process staff should follow if a physician ordered tab alarm was missing, ASM #2 stated, When two people are involved, one person should go out and get the tab alarm and the other one stays with the resident. The tab alarm doesn't prevent falls. When asked if the facility had had a resident fall while using a tab alarm, ASM #2 stated, Yes, we have had falls. The staff runs (when they hear them). We use them as an alert system. An interview was conducted on 3/29/17 at 2:58 p.m. with CNA #4, the CNA who had cared for Resident #1 the night she fell . When asked the process staff follow when a resident had a tab alarm, CNA #4 stated, First of all I ensure that everyone is in their bed and then I check to make sure the tab alarms are there. When asked if Resident #1 had a tab alarm on that night, CNA #4 stated, When I did her vital signs it was on. I have to touch her and I could see it. When asked about that night, CNA #4 stated, That night for some reason she was trying to get out of bed. When asked how she knew that, CNA #4 stated, The roommate called. When asked if the alarm had gone off, CNA #4 stated, No, because her legs were over the side of the bed but her body was on the bed. She said she wanted to go to the bathroom. I knew she couldn't ambulate because of her stroke. We took her to the bathroom and took her back to bed and started looking for the tab alarm. The nurse told me we need to put on a new tab alarm and then there were more than one call light on. By the time I got back to her it wasn't more than 15 minutes. When asked why she didn't stay with the resident while the nurse got the alarm, CNA #4 stated, Because we had multiple lights going on and this is a person who never gets out of bed. An interview was conducted 3/29/17 at 3:10 p.m. with CNA #5, an aide who cared for the resident. When asked if the resident tried to get out of bed, CNA #5 stated, Sometimes we would see her with her legs over the side of the bed. A couple times the tab alarm was ringing and she was sitting on the side of the bed. When asked if she usually had enough time to get to the resident when they hear the alarm and before they fell , CNA #5 stated, Yes ma'am. When we're at the nurse's station as soon as an alarm goes off everybody goes running. On 3/29/17 at 3:25 p.m. ASM #1, the administrator, ASM #2, the director of nursing and ASM #3, the assistant administrator were made aware of the concern for harm. On 3/29/17 at 4:45 p.m. ASM #2 and ASM #3 provided a copy of the plan of correction. PLAN OF CORRECTION: 1. Corrective Actions/New Interventions in place: Upon re-admission to this facility on 2/19/17, the resident was placed in a (name of company) low bed with mats next to each side of the bed. A tabs alarm for both bed and chair and a mattress alarm were in place for this Resident. 2. Other Potential Residents: All resident who are a fall risk with safety devices are potentially affected however, no non-compliance was noted. 3. Systemic Changes: Inservice meetings with Nursing Staff on the first floor unit were conducted as follows: a. Direction of Nursing held inservice on 2/16/16 at 6:30 AM with 11 - 7 shift to review policy and procedures in regard to falls, the Star Alert Program and safety devices (see attached attendance sheet). b. The RN Unit Manger held Nursing Huddle/Unit Meetings on 2/16/17 for both 7-3 (7:00 a.m. to 3:00 p.m.) shift and 3-11 (3:00 p.m. to 11:00 p.m.) shift. Content reviewed included Tab Alarms, Falls and Safety Devices. The incident/accident for Resident (resident's initials) was reviewed with the Staff (see attendance sheet). 4. Monitoring: A bi-monthly Quality Audit of all Safety Devices on first floor was conducted by the RN Unit Manager on 3/8/17 and 3/27/17 (see attached audits). The RN Unit Manager audited for the presence of a Physician order [REDACTED]. This audit will continue bi-monthly with a summary report submitted to the Performance Improvement Committee quarterly. The Performance Improvement Committee will review a summary pf (sic) the audits and provide additional recommendations, including the frequency of continued audits. The allegation of compliance date was 3/27/17. Review of the facility's policy on falls and safety devices did not evidence documentation pertinent to this incident. No further information was provided prior to exit. (1) Pubic tubercle -- a nodule or small eminence, especially one on a bone, for attachment of a tendon; see also tuber and tuberosity. Called also tuberculum. adj., adj tuber´cular, tuber´culate. This information was obtained from: http://medical-dictionary.thefreedictionary.com/Pubic+tubercle (2) Pubic ramus -- Either of the two barlike processes of the pubic bone that extend laterally and posteriorly from the pubic symphysis. This information was obtained from: http://medical-dictionary.thefreedictionary.com/pubic+ramus (3) Sacral wing -- A triangular bone made up of five fused vertebrae and forming the posterior section of the pelvis. This information was obtained from: http://www.thefreedictionary.com/sacrum (1) Metaphysis -- The wider part at the end of the shaft of a long bone, adjacent to the epiphyseal disk. This information was obtained from: http://medical-dictionary.thefreedictionary.com/metaphysis (2) Volar -- pertaining to the sole or palm: indicating the flexor surface of the forearm, wrist or hand. This information was obtained from: http://medical-dictionary.thefreedictionary.com/volar+angulation COMPLAINT DEFICIENCY