Every finding on record at Mira Vista Court

Based on observation, interview, and record review the facility failed to provide services to residents with reasonable accommodation of resident needs and preferences except when to do so would endanger the health or safety of the resident or other residents by not providing a call light system within reach for 1 of 10 residents (Resident #1) observed for call lights. The facility failed to ensure Resident #1 had a call light within her reach on 8-6-2026, at 11:25 AM, so Resident #1 could communicate to staff she needed assistance. The call light was hanging off the bed bar, approximately 3 inches from touching the floor, on the right side of the bed. Resident #1's right side of her body had paralysis, contracture of the right hand, and a broken right arm. Resident #1's left arm and/or hand could not reach the call light. This failure affected residents by placing them at risk for not getting their needs met and diminishing their quality of life. Record review of Resident #1's admission record dated 8-6-2026, indicated a [AGE] year-old female admitted to the facility on [DATE] and readmitted on [DATE]. Resident #1 had a primary diagnosis of Cerebral infarction due to thrombosis of right middle cerebral artery (a stroke caused by a blood clot blocking a major blood vessel supplying the brain) and secondary diagnoses of Hemiplegia and hemiparesis (total or partial paralysis that affects just one side of the body) affecting the right side, following a cerebrovascular disease, Aphasia (a brain-related language disorder that affects how you speak), and Bipolar disorder (mental health condition that causes extreme shifts in mood, energy, and activity levels). Record review of Resident #1's quarterly MDS, dated [DATE], revealed Resident #1 had a BIMS score of 4, which was severe cognitive impairment. The GG-Functional Abilities section revealed Resident #1 was totally dependent or maximal assist in all ADL areas and could not roll or sit up on her own. Record review of Resident #1's care plan dated 11-8-2024 and updated on 8-5-2026 indicated Resident #1 had a communication deficit with unclear speech, dementia, and was a fall risk D/T limited mobility and instructed the CNAs and nursing staff to keep call light in reach at all times. In an observation and interview on 8-6-2026 at 11:25 AM, revealed Resident #1 lying in bed with limited ability to communicate. Resident #1's right arm was observed to be in a sling. When asked where her call light was, Resident #1 indicated she used her left arm and hand to press on her call light but was unable to reach it. Resident #1's call light was observed to be hanging off the right side of her bed, through the right bed guard, a few inches from touching the floor. In an interview on 8-6-2026 at 11:30 AM, LVN A stated she worked in the hall where Resident #1 resided and had worked at the facility for 6 months. After being shown the location of Resident #1's call light, LVN A said the call light must have fallen off Resident #1's bed. LVN A said the nursing staff ensured resident's call lights stayed within reach by making observation rounds every 30-40 minutes and the CNAs make rounds every 1-2 hours. LVN A said it was the responsibility of all staff to ensure resident's call lights remain within their reach. LVN A said the risk to a resident, not being able to reach her call light, who was in the condition that Resident #1 was in, would be that Resident #1 would not have been able to contact staff for help. In an interview on 8-6-2026 at 11:44 AM, CNA B said she worked in the hall Resident #1 resided in and had worked at the facility for 8 months. When CNA B was informed that Resident #1's call light was not within Resident #1's reach, hanging off the right side of the bed, CNA B said she probably forgot to put the call light back within reach after assisting Resident #1 earlier. CNA B said the CNAs were responsible for ensuring resident's call lights stayed within their grasp. CNA B said she made rounds, in the hall she worked, to ensure resident's call lights remained within their grasp. In an interview on 8-6-2026 at 3:30 PM, PT C said she had worked at the facility for 8months, PTA D said she had worked at the facility for 1 year, and OT E said she had worked at the facility for 5 months. PT C, PTA D, and OT E said Resident #1 could not get out of bed on her own and was totally dependent on staff. PT C, PTA D, and OT E said it was critical that her call light button remain within her reach, as Resident #1 could have needed help. In an interview on 8-6-2026 at 5:25 PM, the DON said she had worked at the facility for 6 months and she expected the call light for Resident #1 to always remain within her reach. The DON said the staff, who were working in the hall that Resident #1 lived on, were responsible for ensuring Resident #1's call light stayed where she could reach it. The DON said staff should have been rounding every 2 hours ensuring call lights stayed within the resident's reach. The DON said the risk to Resident #1, not having her call light within her reach, was not getting her needs met. In an interview on 8-6-2026 at 5:55 PM, the Administrator said he expected staff working with Resident #1 to keep her call light within her reach. The Administrator said, any staff dealing with [Resident #1's] care was responsible to ensure that [Resident #1's] call light stayed where she could use it. The Administrator said the risk to Resident#1, not being able to reach her call light, was delays in getting help. Record review of the facility's policy, dated May 5, 2023, titled Nursing Policy and Procedures Subject: Call Lights, Responding To stated: .6. When leaving the patient or resident room, ensure the call light is placed within the patient's/resident's reach.

Based on observations, interviews, and record reviews, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable disease and infections for 1 of 5 residents (Resident #1) reviewed for infection control. CNA H and CNA I failed to wear the appropriate PPE for a resident on Enhanced Barrier Precautions when providing care to Resident #1. This failure could place residents at risk of exposure to infections from other residents. Findings included: Record review of Resident #1's quarterly MDS assessment, dated 08/04/25, revealed the resident was an [AGE] year-old male admitted to the facility on [DATE] with diagnoses which included stroke affecting his right side, and his ability to swallow and to speak, requiring the placement of a feeding tube. His Functional Ability assessment revealed he was completely reliant on staff for his ADLs. Record review of Resident #1's care plan, dated 5/21/25, revealed he was on Enhanced Barrier Precautions (infection control interventions designed to reduce the transmission of MDROs in nursing homes) related to his gastric tube and wounds. Observation and interview on 10/07/25 at 9:25 AM revealed there were postings outside Resident #1's room indicating he was on Enhanced Barrier Precautions, and PPE was stationed outside his room. CNA A stated Resident #1 was on precautions because he had a gastric tube as well as a wound on his leg. She stated staff had to wear a gown and gloves when providing care to the resident to prevent staff from transferring anything infectious from another resident to the resident on precautions. Observation on 10/07/25 at 11:05 AM of video footage supplied by Resident #1's Family Member revealed on 09/25/25 at 5:15 AM CNA H provided Resident #1 with incontinence care without wearing a gown. On 09/25/25 at 10:42 AM CNA I provided Resident #1 with incontinence care without wearing a gown. In an interview on 10/07/25 at 12:00 PM, the ADON stated residents with any artificial openings to their bodies were placed on Enhanced Barrier Precautions. She stated that included residents with gastric tubes, urinary catheters, wounds, and IVs. Staff were required to wear a gown and gloves while proving care to the resident, this prevented staff from introducing an infectious agent from another source to the resident that was on isolation precautions. After reviewing Resident #1's Family Member's video footage, the ADON stated the CNAs should have been wearing the proper PPE while they provided care. She stated there had been multiple in-services on infection control, so there was no reason for the staff not knowing when to wear PPE when it was indicated. Phone interview attempt on 10/07/25 at 1:06 PM with CNA H was unsuccessful, a voicemail was left. In an interview on 10/07/25 at 1:19 PM, CNA I revealed she had cared for Resident #1 multiple times. She stated she did not know what Enhanced Barrier Precautions meant, but she knew she had to wear a gown and gloves when taking care of Resident #1 but did not know the reason. CNA I stated she did not always wear a gown because she would get busy and forget. She acknowledged there was signage outside the rooms of residents on isolation, but she did not always pay attention to it. CNA I stated if the video from 09/25/25 showed she did not wear a gown, then she must not have worn one. Record review of the facility's Infection Prevention and Control policy, dated 05/15/23 reflected: 1. Enhanced Barrier Precautions expand the use of PPE (gowns and gloves) during high contact resident care activities that provide opportunities for transfer of MDROs to staff hands and clothing.A. EBP will be implemented for All residents with the following:1) Infection or colonization with a MDRO when Contact Precautions do not otherwise apply2) Wounds and/or indwelling medical devices (central lines, urinary catheter, feeding tube, tracheostomy/ventilator) regardless of MDRO colonization statusB. EBP will be implemented during the following high-contact resident care activities:1) . Changing briefs or assisting with toilet.

Based on observations, interviews, and record reviews, the facility failed to ensure that residents fed by enteral means received the appropriate treatment to prevent complications of enteral feeding including aspiration pneumonia, diarrhea, vomiting, dehydration, metabolic abnormalities, and nasal-pharyngeal ulcers for 1 of 9 residents (Resident #1) reviewed for enteral feed care. The facility failed to ensure Resident #1's tube feeding was paused when the head of his bed was lowered for incontinence care. This failure could place residents at risk for aspiration of their feeding solution. Findings included:Record review of Resident #1's quarterly MDS assessment, dated 08/04/25, revealed he was an [AGE] year-old male admitted to the facility on [DATE] with diagnoses which included stroke affecting his right side, and ability to swallow and to speak, required the placement of a feeding tube. His Functional Ability assessment revealed he was completely reliant on staff for his ADLs. Record review of Resident #1's care plan, dated 5/21/25, revealed he had a feeding tube and received continuous feeding via pump. Observation on 10/07/25 at 10:15 Resident #1 was in his bed with the head of the bed elevated about 30 degrees. Feeding pump was infusing at 70 ml/hr. Resident in no obvious distress. Observation on 10/07/25 at 10:22 AM revealed CNA A and CNA B providing Resident #1 incontinence care. CNA A lowered Resident #1's head to turn him for incontinence care. CNA A did not call a nurse in to pause Resident #1's feeding pump, nor did she pause it herself. The pump was infusing at 70 ml/hr. Incontinent care was completed, and the resident's head was raised again while the pump continued to infuse. In an interview on 10/07/25 at 9:12 AM, Resident #1's Family Member stated she monitored the resident's bed via electronic monitoring, and she expressed concerns about the resident's care, including staff not pausing his feeding pump when they lower the head of the bed. She stated she had brought her concerns to the Administrator and Resident #1's care seemed to have improved some since then. She stated the resident had not aspirated (inhaling stomach contents into the lungs) that she knew of. In an interview on 10/07/25 at 12:00 PM, the ADON stated any resident on a feeding pump was to have the pump paused by a nurse prior to having the head of their bed lowered, and the nurse was to restart the pump once the head of the bed was raised again. She stated leaving the pump running with the head flat could cause the resident to aspirate their enteral feed. The ADON stated after Resident #1's Family Member had spoken to the previous Administrator on 9/24/25, the DON had initiated an in-service on Enteral Feeding care, so staff should know about pausing the feeding pump. The ADON stated she would initiate another in-service immediately since the DON was not working. In an interview on 10/07/25 at 1:30 PM, CNA C stated she was just in-serviced by the ADON about the care of residents with feeding tubes. She stated she knew to have the nurse pause the pump before lowering the head of the bed and re-start it after she was done with care. She knew the risk of lowering the head of the bed with the pump infusing was aspiration. In an interview on 10/07/25 at 1:34 PM, CNA D stated residents with a feeding pump infusing had to have a nurse pause it before lowering the head and re-start it after the head was raised up. She knew the risk of lowering the head of the bed with the pump infusing was aspiration. In an interview on 10/07/25 at 1:44 PM, CNA E stated she was in-serviced by the ADON and knew to have a nurse pause and restart feeding pumps when the head of the bed had to be lowered for care. She knew the risk of lowering the head of the bed with the pump infusing was aspiration. In an interview on 10/07/25 at 1:50 PM, CNA F stated she had been in-serviced by the ADON on feeding pump care and knew to have a nurse to pause and restart the feeding pump when the head of the bed was lowered. She knew the risk of lowering the head of the bed with the pump infusing was aspiration. In an interview on 10/07/25 at 1:54 PM, CNA G stated she had just been in-serviced by the ADON on feeding pumps. She stated a nurse had to pause the pump before the head was lowered and then re-start when the resident's head was lifted back up. She knew the risk of lowering the head of the bed with the pump infusing was aspiration. In an interview on 10/07/25 at 1:58 PM, CNA A stated she had been in-serviced by the ADON on feeding pumps and knew to have a nurse present to pause and re-start the feeding pump before and after care. CNA A stated she did not pause the feeding pump for Resident #1 earlier because she did not think about it. She stated she had also been in-serviced previously on feeding pumps, but she would get busy and having to wait for a nurse can really put her behind on her jobs. She knew the risk of lowering the head of the bed with the pump infusing was aspiration. In an interview on 10/07/25 at 2:01 PM, CNA B stated she was orienting with CNA-A and this was her first CNA job. She stated she did not know about pausing the feeding pump until she was in-serviced by the ADON. In an interview on 10/07/25 at 2:30 PM, the Administrator stated Resident #1's family would have spoken to the previous Administrator as he had just assumed the position. Record review of the facility's Gastrostomy Tubes policy, dated 05/05/23, reflected the policy did not address pausing the pump when the head of the bed was not elevated.

Based on observation, interview, and record review the facility failed to ensure a resident who is was unable to carry out activities of daily living received the necessary services to maintain grooming, and personal and oral hygiene for 2 of 5 residents (Resident #12 and Resident #21) reviewed for ADL care. 1. The facility failed to ensure Resident #12's fingernails were cut and clean. 2. The facility failed to provide Resident #21 with personal hygiene and grooming during showers, leaving her with facial hair on her chin consisting of at least 10 strains of hair approximately an inch long as of 07/27/25. These failures could place residents at risk of not receiving hygiene care which could cause skin breakdown, a loss of dignity and self-worth. Findings included: 1. Review of Resident #12's MDS reflected the resident was a [AGE] year-old male who was admitted to the facility on [DATE]. His diagnoses included diabetes, stroke, non-Alzheimer's dementia, hemiplegia (weakness or paralysis affecting one side of the body), muscle wasting, and cognitive communication deficit. The resident had short and long term memory impairment and his cognitive skills were severely impaired and his speech was unclear. The MDS further reflected the resident required substantial/maximal assisted for personal hygiene. Review of Resident #12's care plan edited on 06/02/25 reflected he required assistance with activities of daily living. Goals included the resident would maintain a sense of dignity by being clean, dry, odor free and well groomed. Observation on 07/27/25 at 10:10 AM of Resident #12 revealed he was in bed with his eyes fixated on the TV. The resident was not able to speak but was able to make eye contact when he was being spoken to. The resident's legs appeared to be contracted but was able to move his hands. Resident #12's fingernails were about 1/2 inch long and both thumbs had dark substance underneath the nail. Interview on 07/27/25 at 12:06 PM with CNA A revealed Resident #12 was a diabetic therefore the nurse was responsible for cutting his fingernails. CNA A said the resident has long fingernails as long as she could remember and thought it was the resident's preference to have them that long therefore, she had not said anything to the nurse about having the fingernails cut. Interview on 07/29/25 at 1:49 PM with LVN B revealed she was on her third week working at the facility she was not sure who was responsible for cutting Resident #12's fingernails. LVN B said she had noticed the resident's fingernails were long and dirty and she had thought about cutting and cleaning them but had not gotten around to it. LVN B further stated it was important to keep resident's fingernails cut and clean because it was part of their hygiene needs. Interview on 07/29/25 at 1:57 PM with ADON C revealed resident fingernails were cut by the CNA's and if the resident was a diabetic, they would but cut by the nurses. ADON C said Resident #12 was a diabetic so his fingernails should have been cut by the charge nurse. ADON C said resident fingernails should be check during shower days and during skin assessments and cut as needed because the resident could cut themselves and get an infection. Interview on 07/29/25 at 2:20 PM with the DON revealed nail care was done by the CNA's and if the resident was a diabetic, it would be done by the nurses. The DON said it was important to keep nails clean and cut to keep germs out of the fingernails and to prevent injuries if the resident were to scratch themselves. 2. Record review of Resident #21's undated admission Record reflected she was a [AGE] year-old female admitted to the facility on [DATE] and last return 04/11/25. Record review of Resident #21's comprehensive MDS, dated [DATE], reflected a BIMS score of 11 indicating moderate cognitive impairment. Her Functional Status evaluation indicated she required substantial/maximal assistance with her personal hygiene. Diagnosis included high blood pressure, Renal Insufficiency (reduced blood flow to the kidneys), high blood sugar, traumatic brain injury (external force that disrupts normal brain function), seizure disorder (abnormal electrical activity in the brain), anxiety disorder (significant and uncontrollable feelings of fear), depression. Record review of Resident #21's care plan, last edited 06/27/25, reflected she had an ADL self-care deficit: Resident #21 has impaired functional mobility; requires assistance with ADLs due to history of traumatic brain injury and history of fracture. Goal: Resident will be clean, dressed appropriately to weather, participate to preferred activities and stable weight. Interventions included assess the degree of functional impairment. [NAME] with ADLs base on the current level of mobility. Encourage independence. Praise any attempt of independence. Encourage resident to perform self-care to the maximum ability. Observation and interview on 7/27/25 at 11:32 AM Resident #21 were noted to have facial hair on her chin, consisting of 10 hairs approximately an inch long. Resident #21 stated she was aware of the hair on her chin and tried to pull them as fast as she could. Resident #21 stated she did not like the idea of having any facial hair, made her feel uncomfortable; like everyone noticed them on her chin. Resident #21 stated she entered the facility with bed baths, recently had her first shower. Resident #21 stated her shower days were Monday and Thursdays and that she would like to have showers 3 times a week. Resident #21 stated her facial hair had not been addressed by her aide or nurse. Observation and interview on 07/29/25 at 9:47 AM with CNA D revealed she worked as needed with the facility and today was her first day back. CNA D stated aides were responsible for completing showers for residents. CNA D stated during showers she cleansed residents' whole body, hair, feet, private areas, teeth, and shaving (facial and underarms). Observation and interview on 07/29/25 at 9:52 AM with CNA D and Resident #21 revealed Resident #21 remained with facial hair. Resident #21 responded that she wanted to have the facial hair removed, that she tried to remove the facial hair however could not do it alone. Resident #21 expressed her shower day was supposed to have been on 07/28/25, someone asked me about a shower yesterday however it never happened. CNA D stated she understood how Resident #21 felt and would not want the hair on her chin as well, she further stated she would remove Resident #21's facial hair today. CNA D reported resident shower days were Monday, Wednesday, and Fridays, she could not find any current shower sheets. CNA D stated not completing scheduled showers and addressing Resident #21's facial hair placed her at risk of embarrassment and low self-esteem. Interview on 07/29/2025 9:55 AM with LVN E entered Resident #21's room and stated she was going to instruct CNA D to shave Resident #21's facial hair. LVN E stated was she aware Resident #21 had facial hair. LVN E stated she expected staff to address all areas of resident body care during showers which included shaving. LVN E stated if there were any tasks that were not addressed aides were supposed to report to her so that she could address the refusal with residents. According to LVN E not addressing resident's facial hair placed them at risk for dignity issues, ladies typically do not want hair on their face. Interview on 07/29/2025 1:58 PM with ADON revealed CNAs were responsible for completing showers on Residents' scheduled days, she further stated nurses were responsible to ensure aides fully completed their tasks. ADON stated during showers aides were responsible for addressing all resident's facial hair and nails, not doing so placed residents at risk of itchy skin, infection, and feeling dirty. Interview on 07/29/2025 2:25 PM with The DON revealed she expected CNAs to complete showers on shower days and to address all grooming needs, hair, teeth, total body care, nails, and facial hair, not doing so placed residents at risk of dignity concerns. Review of the facility's policy titled Activities of Daily Living, Optimal Function revised May 2023 reflected the following: Definition Activities of daily living (ADLs), refer to tasks related to personal care including, grooming, dressing, oral hygiene, transfer, bed mobility, eating, bathing, and communication system.

Based on observation, interview and record review, the facility failed to ensure residents fed by enteral means received the appropriate treatment and services to prevent complications of enteral feedings for 1 of 3 residents (Resident #35) reviewed for enteral nutrition.The facility failed to follow Resident #35's physician orders for enteral feeding when LVN E flushed with 30 cc's of water instead of 60 cc's before and after feedings on 07/29/2025. These failures could affect residents receiving enteral nutrition/hydration and place them at risk of dehydration. Findings included:Record review of Resident #35's undated admission Record reflected she was a [AGE] year-old female admitted to the facility on [DATE].Record review of Resident #35's comprehensive MDS, dated [DATE], reflected a BIMS score of 07 indicating moderate cognitive impairment. Her diagnosis included heart failure, high blood pressure, stroke, depression, asthma, and a use of a feeding tube. Record review of Resident #35's care plan, last edited 04/29/25, reflected Resident #35 required tube feeding related to diagnosis of stroke. Goal: Resident #35 will not exhibit signs of complications from feeding tube or enteral feeding solution. Interventions included to Assess for dehydration, assess for complications, monitor for signs of malnutrition, monitor weight, record, and monitor intake and output every shift. Administer feeding by feeding tube as ordered. Check for tube placement before feeding, water flush and medication administration. Flush feeding tube as ordered.Record review of Resident #35's physician order dated 04/18/25 revealed Enteral Feeding: Flush tube with 60 cc warm water before and after bolus feeding administration.Record review of Resident #35's physician order dated 06/28/25 revealed Enteral Feeding: Formula - Osomlite 1.5 Give 270 mL by bolus per feeding tube 5 times per day. Observation and interview on 07/27/25 at 1:32 PM with resident in her room just finished a shower. Resident has limited communication, Resident #35 points to her stomach when asked about her feeding tube. Interview on 07/27/25 at 1:35 PM with LVN F who stated Resident #35 does have a feeding tube, Resident #35 also pleasure feeds in the theater room to be observed by staff. Interview on 07/28/25 at 2:32 PM with ADON who stated Resident #35 did bolus feeding around 1:00 PM by LVN E. ADON revealed record review that LVN E administered feedings at 8:00 AM, 11:00 AM, 2:00 PM on 07/28/25. ADON expressed that nurses were responsible for administering tube feedings, and they were to check for placement, residual, and follow physician orders for the feedings.Observation of Resident #35's bolus feeding on 07/29/25 at 10:49 AM with LVN E revealed Resident #35 laid in bed. According to LVN E she prepared 60 cc of water for flushing, 1 carton of Osmolite 1.2 formula, gloves and gown due to Resident #35 on enhanced barrier precautions. LVN E lifted head of bed to 45-degree angle, observation of the feeding tube area dated 07/29/25 without any redness or signs of infection. LVN E stated residual was 10 cc's. LVN E stated she flushed the tube with 30 cc's of water. LVN E administered the formula by gravity with no complications. LVN E stated she was now going to flush with 30 cc of water . LVN E then ensured feeding tube was locked and resident had no concerns and LVN E performed doffing her gown and gloves and completed hand hygiene. Interview on 07/29/25 at 11:05 AM with LVN E who stated she provided Resident #35 with 30 cc's of water before and after feeding; that was what she normally did as facility protocol and she was told to do so by the ADON . Upon review of Resident #35's physician orders she revealed the orders called for 60 cc before and after feeding. According to LVN E she was responsible for administering Resident #35 with feedings, and that she should have followed physician orders to flush with 60 cc of water before and after each feeding. LVN E stated not doing so placed Resident #35 at risk of dehydration. LVN E stated she would contact the physician and advise him of her error. Interview on 07/29/25 at 11:10 AM with ADON who stated the facility does have a protocol to flush tube feedings with 30 cc of water before and after feedings. ADON stated she and LVN E went over the process for feeding due to surveyor request to observe Resident #35's feeding and she advised LVN E to follow facility protocol. ADON stated although we have a protocol, LVN E should have followed physician orders to flush with 60 cc of water before and after feedings, ADON stated nurses should review physician orders before the task and always follow the order. ADON stated not following physician orders to flush with 60 cc of water before and after feeding placed Resident #35 at risk of dehydration. Record review facility policy revised 05/05/23 titled Gastrostomy Tubes reflected:The facility must ensure the following:POLICY: Gastrostomy tubes may be used for residents who require enteral feedings to maintain nutrition the patient/resident will maintain acceptable parameters of nutritional status to include usual body weight or desirable body weight range, and electrolyte balance, unless the patient/resident clinical condition prohibits this, or the patient/resident preferences indicate differently. The patient/resident will be offered sufficient fluids to maintain proper hydration and health. The facility must ensure the following:1. The patient/resident who is able to consume enough food alone or with staff assistance will not be fed by enteral methods unless the patient/resident clinical conditions demonstrate that the enteral feeding was clinically necessary, and consent was obtained by the patient/resident and/or responsible party.2. The patient/resident that is fed by enteral methods receives the appropriate treatment and services to restore oral eating skills and prevent complications of enteral feeding, like aspiration pneumonia, diarrhea, vomiting, dehydration, metabolic abnormalities, and nasal-pharyngeal ulcers.

Based on observation, interview, and record review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 5 residents (Resident #38) reviewed for infection control. CNA A failed to wear a gown when providing care to Resident #38, who was on enhanced barrier precautions. This failure could place residents at risk of being infected by staff in contact with other residents with infections. Findings included: Review of Resident #12's MDS reflected the resident was a [AGE] year-old male who was admitted to the facility on [DATE]. His diagnoses included the following: diabetes, stroke, non-Alzheimer's dementia, hemiplegia (weakness or paralysis affecting one side of the body), muscle wasting, and cognitive communication deficit. The resident had short and long term memory impairment and his cognitive skills were severely impaired, and his speech was unclear. The MDS further reflected Resident #12 had a feeding tube. Review of Resident #12's care plan edited on 06/02/25 reflected Resident #12 was at risk for aspiration due to presence of feeding tube related to the diagnosis dysphagia (difficulty swallowing food or liquids) related to a CVA (stroke). Approaches included to administer feeding via g-tube as ordered. Further review of the resident's care plan reflected Resident #12 had a stage 4 pressure wound on his left lateral foot. Approaches included to turn and reposition frequently and keep boots on foot to offload. Observation on 07/27/25 at 10:07 AM revealed there was PPE hanging from Resident #12's room that included gloves, gowns, and masks. There was a sign on the door that reflected the following: Enhanced Barrier Precautions.everyone must wear gloves and gown for the following high contact resident care activities such as dressing, bathing/showering, transferring, providing hygiene, changing briefs or assisting with toileting.wound care: any skin opening requiring a dressing. Observation on 07/27/25 at 10:10 AM of Resident #12 revealed he was in bed with his eyes fixated on the TV. The resident was not able to speak but was able to make eye contact when he was spoken to. The resident's legs appeared to be contracted, and he had on a potus boot (boots that can be used for individuals who are bedridden or have limited mobility). on each foot. Prior to entering Resident #12's room CNA A she put on some gloves and no gown and then proceeded to take the boots off the resident so to check the skin integrity of the resident's feet and finally repositioned the resident in bed. Interview on 07/29/25 at 12:06 PM with CNA A revealed who stated if a resident was on enhanced barrier precautions staff needed to put on a gown and gloves prior to entering their room. CNA A said when she before she entered Resident #12's room she should have put on a gown but she said she asked another aide, but did not say who, and CNA A was told a gown did not need to be worn if they were just checking on the resident. CNA A further stated PPE should be worn to protect the residents from infections because they are providing care from room to room. Interview on 07/29/25 at 1:57 PM with the ADON revealed who stated gown and gloves should be worn prior to caring for Resident #12, who is was on enhanced barrier precautions, to prevent the spread of infection from resident to resident. Interview on 07/29/25 at 2:20 PM with the DON revealed who stated all residents on enhanced barrier precautions including Resident #12, staff must wear gown and gloves prior to entering the resident's room to provide care. It was important for the correct PPE to be worn because the staff could come in contact with bodily fluids, and it would help spread infections as staff go from room to room to provide care. Review of the facility's policy titled Transmission Based/Standard Precautions, and Enhanced Barrier Precautions revised May 2023 reflected the following: Policy 1. The facility will use transmission-based precautions when the routes of transmission is not completely interrupted using standard precautions alone. Procedures: Enhanced Barrier Precautions (EBP)1. Enhanced Barrier Precautions expand the use of PPE (gowns and gloves) during high-contact resident care activities that provide opportunities for transfer of MDROs to staff hands and clothing.A. EBP will be implemented for All residents with the following:. 2) Wounds and/or indwelling medical devices (central lines, urinary catheter, feeding tube.) B. EBP will be implemented during the following high-contact resident care activities:1. Dressing2. Bathing/showering3. Transferring4. Providing hygiene 5. Changing lines6. Changing briefs or assisting with toilet C. EBP requires the following PPE: 1. Gloves 2. Gown 3. Face protection is performing activity with risk of splash or spray.

Based on interview and record review, the facility failed to ensure the right to be free from misappropriation of property for 1 of 3 residents (Resident #1) reviewed for misappropriation of property. The facility failed to prevent the misappropriation of Resident #1's Hydrocodone 10/325's on 03/21/25 when LVN A diverted them. The noncompliance was identified as past noncompliance. The noncompliance began on 03/21/25 and ended on 03/22/25 . The facility had corrected the noncompliance before the abbreviated survey began. This failure could place residents at risk of misappropriation of property, missed medications and diminished quality of life. Findings included: Record review of Resident #1's Face Sheet, dated 06/05/25, reflected the resident was a [AGE] year-old male who originally admitted on [DATE] and readmitted on [DATE]. Record review of Resident #1's Quarterly MDS Assessment, dated 05/26/25, reflected he had a BIMS score of 15 which indicated no cognitive impairment. His active diagnoses included anxiety disorder (a group of mental health conditions characterized by excessive fear, worry, or dread that interferes with daily life), depression (a mood disorder that causes a persistent feeling of sadness and loss of interest in activities), and diabetes mellitus (a disease in which the body's ability to produce or respond to the hormone insulin is impaired). Record review of Resident #1's Physician's Order History for March 2025 reflected the following order: Hydrocodone-acetaminophen-Schedule II tablet; 10-325 mg; amt: 1-2 tablets; oral Special Instructions: Not to exceed > 3g of acetaminophen within 24 hrs from all sources. Hold for sedation. Every 6 Hours- PRN PRN 1, PRN 2, PRN 3, PRN 4 with an order start date of 03/06/25 and discontinue date of 06/04/25. Record review of Resident #1's Progress Notes for March 2025 reflected the following: -Labs reviewed by MD .Orders given to send resident to ER [sic] . on 03/20/25 1:25 PM written by the ADON -resident returned back to facility via non-emergent transportation . on 03/22/25 12:05 PM written by LVN B Record review of a provider investigation report, dated 03/27/25, reflected the following: Description of the Allegation: When [Resident #1] returned from the hospital on [DATE] it was discovered that his Hydrocodone 10/325 was missing .Investigation Summary: [Resident #1] received a new card of 60 Hydrocodone 10/325 on 03-16-25. The Hydrocodone was properly added to the Controlled Substance Card Count. [Resident #1] returned from the hospital on [DATE]. When [LVN B] went to administer a Hydrocodone 10/325 she could not find the count sheet nor the card holding the medication. [LVN B] called the pharmacy to confirm that the medication was delivered. 60 pills of Hydrocodone 10/325 was delivered on 03/16/25. The med room and other carts were searched. [LVN B] notified the [ADON] of the missing medication. [The ADON] notified the DON and Administrator. On 03-21-25 [LVN A] was working on the 100 hall where [Resident #1] resides. [LVN A] wasted a pitcher of water in the narcotic box on the 100 hall nurse med cart. [The DON] and the [MDS Coordinator] counted the narcotic box on 03-22-25. It appears that [LVN A] removed [Resident #1's] card of hydrocodone 10/325 and the count sheet from the cart at some point before the end of the shift on 03/22/25. [LVN A] had not returned the Administrators [sic] call after several attempts .Investigation Findings: Confirmed .Provider Action Taken Post-Investigation: [Resident #1's] Medication [sic] was replaced by the facility. Nurses were re educated [sic] on properly documenting on the Controlled Substance Card Count Sheet and proper counting of narcotic medication with the sign out sheets for the medication. Record review of an undated witness statement written by the DON reflected the following: On Friday, March 21,2025, [sic] I did a narcotic count for 100 hall med cart with [the MDS Coordinator]. We did a card and pill count after the nurse working the shift spilled the water pitcher into the narcotic drawer .We completed the count and did account for all of the cards with the matching sheet . Record review of an undated witness statement written by the MDS Coordinator reflected the following: On Friday, March 21, 2025, I did a narcotic count for hall 100 cart with [the DON]. We did a card and pill count after the water pitcher was spilt in the narcotic drawer .All the cards were accounted for with the matching sheets . Record review of the Controlled Substance Card Count Sheet for the 100 hall Nurse's medication cart reflected there were 19 cards on the cart on 03/20/25, 19 cards on 03/21/25, and 19 cards on 03/22/25. Interview on 06/05/25 at 8:45 AM with the Administrator revealed LVN A and LVN B were both agency nurses and after the incident on 03/21/25, he alerted their employer of his suspicions and had not planned to allow them to work at the facility again. Observation and interview on 06/05/25 at 9:10 AM revealed Resident #1 was in his bed resting. Resident #1 said he got his medications like he was supposed to and was not told his medications had been missing at one point. Interview and record review on 06/05/25 at 9:40 AM with LVN C revealed she was passing medications to residents. LVN C said she always counted both the cards in the narcotic box and the pills on each card and made sure that all the amounts were correct before starting or ending her shift. LVN C said if the card count or pill count was not right she would immediately inform management and would not take the cart keys from the other person. LVN C showed her narcotic count drawer and the card count and pill count matched what was on the sheets in the narcotic count book. Record review of the Controlled Substance Card Count Sheet reflected it had been filled out for each shift. Interview and record review on 06/05/25 at 9:50 AM with MA D revealed she was passing medications to residents. MA D said she always counted both the cards in the narcotic box and the pills on each card and made sure that all the amounts were correct before starting or ending her shift. MA D said if the card count or pill count was not right she would immediately inform management and would not take the cart keys from the other person. MA D showed her narcotic count drawer and the card count and pill count matched what was on the sheets in the narcotic count book. Record review of the Controlled Substance Card Count Sheet reflected it had been filled out for each shift. Interview and record review on 06/05/25 at 10:00 AM with MA E revealed she was passing medications to residents. MA E said she always counted both the cards in the narcotic box and the pills on each card and made sure that all the amounts were correct before starting or ending her shift. MA E said if the card count or pill count was not right she would immediately inform management and would not take the cart keys from the other person. MA E showed her narcotic count drawer and the card count and pill count matched what was on the sheets in the narcotic count book. Record review of the Controlled Substance Card Count Sheet reflected it had been filled out for each shift. Attempted phone interview on 06/05/25 at 10:39 AM with LVN A was unsuccessful as she did not answer or call back. Attempted phone interview on 06/05/25 at 10:42 AM with LVN B was unsuccessful as she did not answer or call back. Phone interview on 06/05/25 at 12:24 PM with RN F revealed she always checked the card and pill count on the cart before taking the keys. RN F said she recalled the card and pill count being correct when she counted with LVN A. RN F said she was not aware at the time of counting with LVN A that Resident #1's hydrocodone was missing. Interview on 06/05/25 at 11:39 AM with the MDS Coordinator revealed the DON called her over to witness the counting of the narcotic count on 03/21/25 . The MDS Coordinator said she and the DON counted all the cards on the cart and the pills in each card to make sure it was all correct. The MDS Coordinator said all the cards were there and so was Resident #1's hydrocodone cards as well. The MDS Coordinator said she was told that the nurse had spilled a pitcher of water in the narcotic drawer which was strange because she was not sure why someone would be pouring a pitcher of water into a cup over the open narcotic drawer. The MDS Coordinator said the nurse was from a staffing agency company and not an employee of the facility. The MDS Coordinator said she did not note anything missing at the time of the count on 03/21/25 and had no reason to believe anything was wrong. Interview on 06/05/25 at 11:48 AM with the ADON revealed she got a call on 03/21/25 and was told that the agency nurse wasted water so the DON and someone else had counted the cart to make sure everything was still there. The ADON said from what she was told, the count was correct and everything was fine. The ADON said it was not until Saturday (03/22/25) when Resident #1 came back from the hospital and requested pain medications that it was noted the medication was missing. The ADON said Resident #1 was supposed to come back from the hospital on Friday (03/21/25) but they decided to keep him one more night. The ADON said Resident #1 always needed his pain medications since he had a lot of pain. The ADON said usually a resident's narcotics were removed from the cart when they were not in the building so they were left on the cart for that reason since he was coming back that day. The ADON said LVN B called the pharmacy because she thought maybe they were not delivered or something but they said the medication was delivered the week prior and there was no way he had already used them all in that time frame. The ADON said they went back and counted and both of Resident #1's hydrocodone cards were missing. The ADON said after that they did a full count of all narcotics in the facility and made sure nothing else was missing. The ADON said they also began to in-service the staff regarding making sure that all the cards and pills were counted each shift and each day. The ADON said on the card count sheet staff were to document any changes to the card count if something was discontinued, used up, or added so they could keep better track of them all. The ADON said she checks the carts on Thursdays of every week to ensure accuracy and nothing else came up missing. The ADON said she believed the cards went missing during LVN A's shift, possibly when the water was wasted in the drawer. Interview on 06/05/25 at 12:28 PM with the DON revealed LVN A was working on 03/21/25 and sometime in the afternoon she wasted water all over the cart. The DON said she went to the cart to check it and saw there was not that much water but assumed some of it was already cleaned up. The DON said she wondered why LVN A was pouring water into a cup over the open narcotic drawer but did not question LVN A about it. The DON said she and the MDS Coordinator went through the cart to check and make sure all cards and pills were accounted for and they were. The DON said the next day, Resident #1's hydrocodone cards were missing from the cart. The DON said she knew the cards were in the cart the day before because she saw them in there while doing her cart check count. The DON said she immediately started an investigation and looked everywhere else in the facility for them. The DON said she had her suspicion though that LVN A had taken them at that point. The DON said she tried calling both LVN A and LVN B and never got responses from them since they were both agency staff. The DON said the facility already had a procedure in place where not only did staff count the narcotic pills on each card against the narcotic count sheet but they also counted the amount of cards that were supposed to be on the cart. The DON said all staff were re-in-serviced on the procedure to ensure that they were following it so no more medications would come up missing. The DON said since the incident happened, the ADONs had been monitoring the medication carts three times per week to make sure they were all correct and that no medications were missing. Interview on 06/05/25 at 1:17 PM with the Administrator revealed earlier in the day on 03/21/25 the DON was told that LVN A had spilled water in the narcotic drawer. The Administrator said the MDS Coordinator and the DON had counted all the cards and pills in the narcotic drawer after this happened to make sure nothing was missing. The Administrator said during that count nothing was missing and everything was accounted for. The Administrator said since the card count and the narcotic count sheets were all correct there was no reason to believe anything was missing. The Administrator said the next afternoon LVN B went to administer Resident #1 his norco medication and realized he did not have any. The Administrator said the DON had her suspicion about LVN A from the day before and the timing made sense that she was the one who took Resident #1's medications from the cart. The Administrator said he had called both LVN A and LVN B but since they were both from an agency they did not answer. The Administrator said he also submitted a police report regarding the taken medications . The Administrator said going forward the staff were re-educated on the facility's policy to count both the cards on the cart and the pills on each card against the sheets on the cart. The Administrator said the ADONs also go through the carts to ensure the counts were correct about once per week. The Administrator said no other medications had come up missing since this one incident. The Administrator said the purpose of staff following the policies and procedures to count the sheets was to make sure the counts were correct and no narcotic medications were missing. The Administrator said if staff were not doing this then residents could miss doses because their medications could come up missing. The Administrator said before the incident happened, the medication carts were checked only once per month for reconciliation. The Administrator said each nurse was responsible for checking the medication cart counts for each of their shifts. The Administrator said he expected staff to check their medication cart on each shift and if there was a discrepancy they should immediately report that to the DON. The Administrator said staff had been trained to check the medication cart count for accuracy on each shift before this incident happened. Record review of an in-service sheet, dated 03/22/25, reflected nurses and MAs were in-serviced regarding counting the narcotic cards and pills on their carts for each shift and if there was a discrepancy they were to immediately report that to the DON. Record review of a Police Report, dated 03/22/25, reflected one was submitted regarding the diverted medications. Record review of the facility's policy, revised 04/17/24, and titled Controlled Substances reflected: 5. If any discrepancy is found, nursing should check the patient's/resident's order sheets and medical record to see if a controlled substance has been administered and not recorded. Check previous recordings on the Controlled Substance Inventory Sheets for mistakes in arithmetic error in transferring numbers from one sheet to the next. A. If the cause of the discrepancy cannot be located and/or the count does not balance, the nurse must report the matter to the Director of Nursing/designee and generate the appropriate incident report. B. The DON/designee will then investigate to determine if a diversion has occurred.

Based on observation, interview, and record review the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 4 residents (Resident #1) observed for infection control. LVN A failed to properly dispose of soiled dressings and guaze when she provided with Resident #1 with wound care. This failure could lead to cross contamination and infection. Findings included: Record review of Resident #1's Quarterly MDS assessment dated [DATE] reflected the resident was an [AGE] year-old male, who admitted to the facility on [DATE] and readmitted on [DATE]. The resident had severe cognitive impairment with a BIMS score of 0. The MDS reflected Resident #1 had skin conditions, and he had diagnoses of an open lesion and pressure ulcer/injury. Record review of Resident #1's care plan dated 02/26/25 reflected the following: Problem: [Resident #1] has a lymphademic wound [a condition where excess lymph fluid accumulates in the tissues] to left posterior lateral calf. Goal: [Resident #1] lymphademic wound to left posterior lateral calf will heal without complications. Implement: Apply dressings per MD order. Problem: [Resident #1] has a lymphademic wound to right posterior lateral calf. Goal: [Resident #1] will not acquire any new open areas. Approach: Avoid shearing resident's skin during positioning, transferring, and turning. Problem: [Resident #1] has a Stage 4 pressure [involves full-thickness skin and tissue loss, exposing underlying structures like muscle, tendon, or bone] area to sacrum [the triangular bone that connects the lumbar spine and the pelvis] Goal: [Resident #1] ulcer will heal without complications. Approach: Treatment per MD order. Observation on 03/12/25 at 10:07 AM revealed LVN A preparing to provide Resident #1 wound care. LVN A washed her her hands, put on gloves, disinfected the table, and left it to dry. She then explained the procedure to Resident #1. She removed her gloves and washed her hands. She then put all the supplies together. LVN A next washed her hands, put on PPE, and put the feeding pump on hold. LVN A then removed the old dressing on the resident's left lower leg (calf) that was soiled with drainage, and she discarded it in the trash can. She removed her gloves, washed her hands, and put on new gloves. She then cleansed the wound on the resident's left calf and discarded the used gauze with blood in the trash can. Next, she removed her gloves and washed her hands. She pat dried the wound, applied calcium alginate with silver, covered it with Kerlix, and dated the dressing 03/12/25. She then removed her gloves, washed her hands, and put on gloves. Nex, she removed the old dressing on the resident's right leg, and she discarded the soiled dressing in the trash can. She removed her gloves, washed her hands, and put on new gloves. She then cleansed the wound on the resident's right calf and discarded the used gauze in the trash can. She removed her gloves and washed her hands. She pat dried the wound, applied calcium alginate with silver, covered it with Kerlix, and dated the dressing 03/12/25. She then removed her gloves and washed her hands. LVN A positioned Resident #1 on his left side. She removed the old dressing on the resident's sacrum, and she discarded the soiled dressing with darinage in the trash can. She removed her gloves, washed her hands, and put on new gloves. She cleansed the wound on the resident's sacral area and discarded the used gauze in the trash can. She removed her gloves and washed her hands. She pat dried the wound, applied collagen mixed with anasept, covered it with an island border dressing, and dated the dressing 03/12/25. She then removed her gloves and washed her hands. Finally, she positioned resident with the bed in low position with the resident's call light within reach, and she left the room. The soiled dressings and guaze remained in the trash can in the resident's room and were not in a biohazard bag. Observation on 03/12/25 at 12:00 PM with LVN A revealed the soiled wound dressings remained in the trash can in Resident #1's room. Interview on 03/12/25 at 3:17 PM with LVN A revealed she was aware she was supposed to discard soiled wound care dressing in a biohazard bag while performing wound care for Resident #1. LVN A stated she got distracted by other staff knocking on the door, and she did not realize she was throwing the soiled dressing in the trash can. She stated failure to discard soiled dressing in a biohazard bag was that it could risk exposure to staff thus leading to cross contamination and infection. She stated she could not recall training on how to discard soiled wound dressings. Interview on 03/12/25 at 3:37 PM with the ADON revealed she expected staff to dispose of soiled wound dressings in a biohazard bag. The ADON stated discarding soiled wound dressing in the trash can expose a risk of contamination to other staff and could lead to infection. She stated the facility had done trainings on infection control. Record review of the facility training records reflected training dated 03/12/25 facilitated by LVN A reflected the training was over disposing infectous waste properly is crucial for infection control involving segregation, secure storage and special disposal methods. Record review of the facility's Infection Prevention and Control Policies and Procedures, dated May 2023, reflected: .Dressing change nonsterile, sterile and sterile wet dispose of dressing according to standard of practice and applicable regulations

Based on observation, interview, and record review, the facility failed to ensure residents had the right to be free from abuse, neglect, misappropriation of resident property, and exploitation for 1 of 4 residents (Resident #1) reviewed for abuse. The facility failed to ensure Resident #1 was free from inappropriate touching by Resident #2 in which Resident #2 was observed to have his hand under the gown of Resident #1. The noncompliance was identified as past noncompliance that began on 12/17/24 and ended on 12/17/24. The facility had corrected the noncompliance before the investigation had begun. This failure could place residents at risk of unwanted touching by other residents and psychosocial harm. Findings included: Record review of Resident #1's undated face sheet reflected the resident was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses which included Alzheimer's disease, unsteadiness on feet, and muscle wasting. Record review of Resident #1's quarterly MDS assessment, dated 12/31/24, reflected her BIMS score was 5 indicating she had severe cognitive impairment. Her Functional Status assessment indicated she required maximum assistance with all of her ADLs. Record review of Resident #1's care plan, dated 12/17/24, reflected she was at risk of psychosocial well being related to allegations of abuse, with interventions of monitoring the resident for any changes in behaviors. Record review of Resident #2's undated face sheet reflected the resident was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses which included end stage kidney disease requiring dialysis, dementia, diabetes, and communication deficit. Record review of Resident #2's quarterly MDS assessment, dated 12/31/24, reflected his BIMS score was 6 indicating severe cognitive impairment. His Functional Assessment indicated he was independent in his ADLs. Record review of Resident #2's care plan, dated 12/17/24, reflected he was at risk for behavioral symptoms related to allegations of inappropriate behavior with residents and staff with intervention of 1:1 monitoring at all times and obtaining psychosocial therapy. Record review of the facility's investigation report reflected Resident #2 was observed to have his hand under the gown of Resident #1. Staff intervened immediately and separated the residents. Resident #2 was placed on 1:1 monitor by a CNA, and Resident #1 was assessed for any injury or psychosocial harm. Resident #1 had not exhibited inappropriate behaviors with other residents, only staff. Resident #1 appeared not to be aware of what had happened. Resident #2 was sent to the hospital for psych evaluation, and was returned with addition of Zoloft to his medication regime. The facility initiated search for alternative placement for Resident #2 when he returned from the hospital. Record review of the hospital records reflected Resident #2 was started on Zoloft again. Record review of psychologist note on 12/18/24 for Resident #2 reflected: His behavior is mostly likely due to dementia. The filter of what is appropriate and what is not, is not functional. So he just does things and doesn't know they are inappropriate (nor does he remember doing them). Unfortunately, no medication can fix this, so transfer to another facility may be best. Interview on 01/08/25 at 9:18 AM with Resident #2 revealed he did not know why he had a sitter (Restorative Aide currently) with him all the time. Resident #2 denied being inappropriate with staff or other residents. He later stated, they say I touched someone. Resident #2 blamed his medications for making him forgetful. Observation and interview on 01/08/25 at 9:50 AM revealed Resident #1 was pleasantly confused. The resident's family member was present and requested the resident not be interviewed about the event of her being touched inappropriately. The family member stated she had been notified immediately of what had happened by the facility and was at the facility within about 15 minutes of being notified. When the family member and the DON questioned Resident #1 about the incident, the resident denied anything had happened. The family member stated she was happy with how the facility had handled the situation and had no concerns about the resident's safety. Interview on 01/08/25 at 10:26 AM with the Housekeeper revealed she had entered the restorative dining area on 12/17/24 just after breakfast was over and witnessed Resident #2 with his hand under the gown, but above the underlying clothes of Resident #1. Resident #2's hand was at Resident #1's abdominal region. She told Resident #2 to remove his hand and reported it to the nurse. Resident #2 was immediately removed from the dining area. She stated Resident #1 did not appear to aware of what Resident #2 was doing and did not appear to be upset. The Housekeeper stated she had never had a negative interaction with Resident #2 in the past. Interview on 01/08/25 at 11:44 AM with the Restorative Aide revealed she was monitoring Resident #2 for any inappropriate comments and to prevent him from contacting any female residents. Any behaviors were reported to the nurse for them to document. The Restorative Aide stated Resident #2 was known to make inappropriate remarks to staff members and attempt to touch them inappropriately. She stated since 12/17/24 Resident #2 was monitored at all times by staff while he was in his room or whenever he left his room. Resident #2 would still make inappropriate comments to the staff, but he had no interactions with other residents. Interview on 01/08/25 at 11:54 AM with CNA A revealed staff were aware Resident #2 had started to make inappropriate remarks and try to touch them since around November 2024, but he had never tried to touch any other residents. She stated after his touching of Resident #1 in December he had been kept on 1:1 monitoring, and the resident rarely left his room. When he did leave the room, they stayed with him. She stated she had been in-serviced on abuse and neglect right after the incident and was able to identify several forms of abuse. Interview on 01/08/25 at 1:10 PM with the DON revealed Resident #2 was immediately placed on 1:1 monitoring after the event on 12/17/24. She stated she and Resident #1's family member interviewed the resident after she was back in her room and the resident denied anything happening. The DON stated the resident did not appear to be in any distress or upset. The resident wore a brief, shirt and pants, sometimes a blanket, and then a hospital gown on top. When she and the family member assessed the resident immediately following the incident, the resident's clothing and brief did not appear to be disturbed. The DON discussed having psych services meet with Resident #1, but the family member did not want the event to be continued to be discussed with the resident. The DON stated the facility immediately sent Resident #2 to the hospital for a psych evaluation, and they began to reach out to facilities with secured units for males. One facility was located and had accepted Resident #2, but his family objected to the transfer based on the facility's reviews. The DON stated Resident #2 would continue to stay on 1:1 monitoring until he was transferred. The DON stated Resident #2 had not demonstrated any behaviors towards other residents prior, only staff. The DON stated staff noted an increase in the resident's behaviors around November 2024 when the resident's BIMS score had decreased from 10 to 6, mild cognitive impairment to severe cognitive impairment. Interview on 01/08/25 at 2:10 PM with CNA B revealed staff were aware of Resident #2's behaviors and attempts to touch staff, but she had never seen or heard about him touching another resident until he did so in December. She knew he had been sent to the hospital afterwards and that he was on 1:1 monitoring ever since. She stated the restorative aides were used for monitoring, and a CNA was assigned for overnight monitoring. Staff were to report any behaviors to the nurse for her to document. CNA-B stated she had been in-serviced on abuse and neglect by the DON and ADON, and she was able to identify several types of abuse. Interview on 01/08/25 at 3:45 PM with the Administrator revealed he was the Abuse and Neglect Coordinator. He stated Resident #2 was sent to the hospital on 12/17/24 for a psychiatric evaluation, and he was returned the same day with a new medication added. The Social Worker began the process of locating another facility for the resident, sending out 10-12 inquiries. One facility did accept the resident, but his family objected to the transfer based on reviews of the facility. The decision was made to keep Resident #2 on 1:1 monitoring 24/7 until placement could be secured. An additional staff member was added to the schedule for the 1:1 monitoring to prevent a decrease in staffing. Record review of the facility's daily staffing schedules for January 2025 reflected one staff member identified for 1:1 monitoring on each shift. Record review of the facility's Abuse, Neglect, Exploitation, or Mistreatment policy, dated 10/01/20, reflected: .The facility's leadership prohibits neglect, mental and/or verbal abuse, use of a physical and/or chemical restraint . .5. Mistreatment means inappropriate treatment or exploitation of a resident. .7. Sexual abuse is non-consensual sexual contact of any type with a resident. Facility leadership will report immediately, but no later than 2 hours after the allegation is made, if the event causes serious bodily injury, and no later than 24 hours if the allegation does not result in serious bodily injury. .5. Ongoing assessment, care planning, and monitoring of those residents with special need that may lead to neglect is conducted, for example: A. History of aggressive behavior B. History of entering other resident rooms Record review of the facility's interventions reflected: 1. Resident #2 was placed on 1:1 monitoring, which continues. 2. Resident #1 was assessed for any injury or psychosocial harm. 3. Staff were in-serviced on abuse and neglect. 4. Resident #2 was assessed by psych services and his medications were adjusted. 5. The facility is seeking alternative placement for Resident #2.

Based on interview and record review, the facility failed to ensure the resident had the right to exercise their rights and to be treated with respect and dignity for 3 of 8 residents (Residents #1, #2, and #3,) reviewed for resident rights. CNA A failed to treat Residents #1, #2, and #3 with respect and dignity during her interactions with them. This failure could result in residents receiving medication or treatment without consent and decreased feelings of self-worth. Findings included: Record review of Resident #1's undated face sheet reflected the resident was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses which included breast cancer, spinal cancer with cord compression, left sided paralysis, and high blood pressure. Record review of Resident #1's quarterly MDS assessment, dated 08/30/24, reflected a BIMS score of 15, indicating she was cognitively intact. Her Functional Status assessment indicated she required substantial assistance with most of her ADLs. Record review of Resident #1's care plan, dated 9/17/24, reflected she was paraplegic (paralysis below the waist), and she had a self-care deficit related to her paralysis. Interview on 10/15/24 at 10:40 AM with Resident #1 revealed she had two interactions with CNA A in which she felt CNA A was rude and impatient with her. Resident #1 stated she called for incontinent care one night and CNA A responded. When CNA A entered she asked Resident #1 if she had her briefs and her wipes and had undone her brief and wiped her front. Resident #1 asked CNA A if she was supposed to have all that ready before she called for help., CNA A rolled her eyes and left to retrieve supplies. Resident #1 stated her second interaction was the next evening and went along the same lines as the previous interaction. Resident #1 stated she asked CNA A how she was supposed to do all of that when she was just recovering from back surgery, but CNA A did not answer and seemed to rush through the task. Resident #1 stated she was left to feel like she was a bother to CNA A and took up too much of her time. Resident #1 stated once she experienced care from other CNAs she realized how care was supposed to be done, that CNA A was being inappropriate, and notified the Administrator when he asked her about her care. Record review of Resident #2's undated face sheet reflected the resident was a [AGE] year-old male admitted to the facility on [DATE] and discharged to another facility on 08/21/24. Resident #2 had diagnoses which included right sided paralysis following a stroke, muscle weakness, diabetes, and high blood pressure. Record review of Resident #2's admission MDS assessment, dated 07/17/24, reflected a BIMS score of 12, indicating moderate cognitive impairment. His Functional Status assessment indicated he required assistance with his ADLs. Record review of Resident #2's care plan, dated 07/26/24, reflected he had mobility impairment related to his stroke, and short-term memory issues. Record review of the facility's Provider Investigation Report, 07/31/24 reflected Resident #2 stated CNA A told him to use his brief to have a bowel movement because it was easier to clean him up than get him to the bathroom. After CNA A cleaned him up he felt she did not do a good job, when he put his hand on his left thigh, he had stool on his hand. When he told CNA A about this she gave him a wipe to clean his hand with. Telephone interview on 10/16/24 at 12:35 PM with Resident #2's family member revealed Resident #2 had told her about the incident with a CNA that told him to soil his brief instead of taking him to the bathroom, and then did not clean him very well afterwards. Resident #2 told her the CNA seemed to be bothered to have to care for him and he felt upset with the CNA. Resident #2 reported the incident to the Administrator. Record review of Resident #3's undated face sheet reflected the resident was a [AGE] year-old male admitted to the facility on [DATE] and discharged on [DATE]. Record review of Resident #3's quarterly MDS assessment, dated 08/08/24, reflected a BIMS score of 3, indicating severe cognitive impairment. His Functional Status assessment indicated he was totally dependent on staff for his ADLs. Record review of Resident #3's care plan, dated 08/11/24, reflected he was considered a fall risk, resisted cares, and required assistance with his ADLs. Record review of the facility's Provider Investigation Report, dated 07/31/24, reflected Resident #3 had asked CNA A what time it was, and she responded, It's dark outside. Another incident he had to use his call light several times one night and CNA A seemed annoyed to have to answer the call lights. Interview on 10/16/24 at 2:45 PM with the Administrator revealed CNA A was suspended pending the investigation into the complaints against her. When he interviewed CNA A at the conclusion of his investigation she denied all the allegations and refused to accept any responsibility of her actions and attitude. The Administrator stated the decision was made to terminate CNA A for acting indifferently or rudely toward a resident. Interview attempts on 10/16/24 at 1:12 PM and 3:00 PM with CNA A via telephone were unsuccessful. Review of the facility's policy Resident Rights, revised on 11/01/2017, reflected: The facility staff will provide the resident with the right to an environment that preserves dignity and contributes to a positive self-image,

Based on interview, observation, and record review, the facility failed to ensure that residents with pressure ulcers received necessary treatment and services consistent with professional standards of practice to promote healing, prevent infection, and prevent new ulcers from developing for 1 of 4 residents (Resident #4) reviewed for quality of care. The facility failed to ensure Resident #4, who had a Stage 4 pressure ulcer on her left lateral ankle, was provided with wound care as ordered by the physician. This failure could place residents at risk of developing infections or worsening of their wounds. Findings included: Record review of Resident #4's undated face sheet reflected the resident was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses which included tumor in skull and face, dementia, multiple soft tissue injuries (pressure ulcers and wounds), and contractures. Record review of Resident #4's annual MDS assessment, dated 08/13/24, reflected a BIMS score was not calculated related to the resident's medical condition. Her Functional Status indicated she was totally dependent on staff for all of her ADLs. Record review of Resident #4's care plan, dated 10/08/24, reflected she had multiple pressure ulcers and skin tears, required assistance with her ADLs, and received nutrition via a feeding tube. Record review of Resident #4's physician's orders, 08/12/24, reflected an order for: Daily Wound Treatment: Stage 4 pressure wound to left lateral ankle cleanse area with ns, pat dry and apply collagen powder and anasept gel. Cover with island border gauze. Telephone interview on 10/14/24 at 10:00 AM with Resident #4's family member revealed they had concerns about the resident's care. The family member stated they did not think the resident's brief was not being changed regularly, staff were not providing appropriate peri-care, and her wound care was not being done every day. Observation of a photograph supplied by Resident #4's family member, date stamped 09/08/24 at 8:23 AM, revealed a dressing on Resident #4's left ankle with a date of 9/6 with initials. The dressing appeared to be loose on two sides, there was reddish drainage soaked through the dressing, and a trail of dried red fluid from the bottom of the dressing down to the bottom of the resident's foot. Observation on 10/15/24 at 9:40 AM of Resident #4's left ankle dressing was dated 10/14 with initials. The dressing was clean, dry and intact. Resident #4's brief did not appear saturated, and no odor of urine was noted. Observation on 10/15/24 at 10:15 AM revealed the Wound Care Nurse assisted by CNA B providing Resident #4 with wound care using clean technique throughout the procedure. Both staff wore appropriate PPE of gown and gloves, and the resident did not complain of discomfort. Interview on 10/15/24 at 10:35 AM with the Wound Care Nurse revealed she had been in her position for two weeks and had not interacted with the previous wound care nurse. The Wound Care Nurse reviewed the photograph submitted by Resident #4's family and stated the dressing should have been changed on 09/07/24, or whenever it was noted to be loose on the two sides or when the drainage soaked through the dressing. The Wound Care Nurse stated all nursing staff could provide wound care when she was not present by following the physician orders. Record review of Resident #4's September 2024 TAR reflected wound care to the resident's left ankle had been provided every day including on 9/7. The TAR did not reflect which nurse provided the care, only an x to indicate it was completed. Interview on 10/15/24 at 3:45 PM with LVN C revealed wound care was provided by the nursing staff whenever the Wound Care Nurse was not present at the facility. Wound care orders were present in the EHR to guide the staff. LVN C stated all dressings should be checked by the primary nurse every day and assessed for drainage, looseness, etcetera and notify the wound care nurse or change it themselves if needed. Interview on 10/16/24 at 2:21 PM with CNA D revealed she would report any issues with a dressing she noted while providing care to the resident's nurse. She stated if a dressing was coming off, or was dirty, she would notify the nurse immediately and help change the dressing if needed. Interview on 10/16/24 at 2:30 PM with CNA E revealed any time she discovered a resident's dressing needed to be changed she would notify the resident's nurse right away so it could be changed to prevent an infection. Interview on 10/16/24 at 3:00 PM with the DON revealed all nurses could provide wound care to residents and were expected to do so if the wound care nurse was unavailable, or if it needed to be changed emergently. Residents had wound care orders in the physician's orders that told the nurses how to provide the wound care needed. Review of the facility's Dressing Change Wound Evaluation policy, revised 06/01/15, reflected: An evaluation will be performed with each dressing change The evaluation is the ongoing process of noting wound characteristics each time a clinician sees that wound.

Based on interview and record review, the facility failed to ensure the resident had the right to exercise their rights and to be treated with respect and dignity for 1 of 3 residents (Resident #5) reviewed for resident rights. The facility failed to honor the request by Resident #5's resident appointed representative to refuse medical treatment from a Physician's Assistant. This failure could result in residents receiving medication or treatment without consent and decreased feelings of self-worth. Findings included: Record review of Resident #5's MDS dated [DATE] assessment reflected the resident was a [AGE] year-old female who admitted to the facility on [DATE]. Resident #5's diagnoses included a pubis (pubic bone) fracture, diabetes mellitus, anemia, unspecified dementia, unsteadiness on feet, muscle weakness, cognitive communication deficit (difficulty understand abstract information, and fall on same level. The MDS also reflected a BIMS score of 3, which indicated a severe cognitive impairment. Record review of Resident #5's undated face sheet refleced Resident #5 designated Family Member A as her resident representative. Record review of Resident #5's EHR reflected RN F documented on 09/15/24 at 2:40 PM Apt with Orthopedic Surgeon .on 09/16/24 at 9:40 AM . Interview on 10/16/24 at 10:15 am with Family Member A revealed he called the facility on 09/13/24 (Friday) and 09/14/24 (Saturday). Family Member A was unsure of the exact times and the names of the Receptionist who he spoke with. Family Member A stated that he spoke with the Receptionist on both occasions and told the Receptionist that he wanted Resident #5's orthopedic appointment on 09/16/24 canceled and Resident #5 was not to be taken to the appointment. Family Member A said that he called both days to ensure that Resident #5 was not taken to the appointment the following Monday (09/16/24). Family Member A stated he did not want Resident #5 to be seen by the Physician's Assistant that the appointment was scheduled with. Family Member A stated that he only wanted Resident #5 to be seen by a medical doctor, not a Physician's Assistant. Family Member A continued by stating that he also did not want Resident #5 to be driven in the facility van due to her fracture and the distance of the trip. Family Member A said that he called and spoke with the PA at the office that the referral was made. Family Member A stated that he told her that he did not want Resident #5 to be seen by her. Family Member A said that the PA confirmed her understanding that she was not to see Resident #5. The PA stated that she understood. Interview on 10/16/24 at 11:07 AM with the PA revealed Family Member A called and spoke with her. PA stated that Family Member A called and canceled the appointment before 09/16/24. PA confirmed that Family Member A did not want Resident #5 to be seen by a Physician's Assistant. He only wanted Resident #5 to be seen by an MD. The PA also stated that Resident #5 was dropped off by the facility the morning of 09/16/24 and was there with no escort. The PA stated that the resident was there for approximately 3 hours and was seen and examined by the PA. Interview on 10/16/24 at 11:12 AM with the Receptionist revealed she remembered receiving a call on 09/14/24 from Family Member A. The Receptionist stated Family Member A said that he needed to cancel Resident #5's appointment for Monday, 09/16/24. The Receptionist said that she walked the message back to the nurses' station and gave the message to the nurse on duty at the desk who said that they would take care of the message. Receptionist could not recall who was working that day. Interview on 10/16/24 at 1:19 PM with DON revealed the PRN nurse did not get the message of the appointment cancellation to the Monday through Friday nurse. DON stated that the driver took the resident to the appointment because the day shift nurse did not know about the appointment cancellation. Telephone interview was attempted on 10/16/24 at 12:29 PM with LVN-H, but the attempt was unsuccessful. Interview on 10/16/24 at 2:50 PM with the Administrator revealed the Weekend Receptionist took a message from Family Member A that said to cancel Resident #5's appointment on Monday (09/16/24). He stated the Receptionist then took the note to Resident #5's nurse, who then said they would take care of it. Administrator stated that he talked to the day and evening shift nurses, and they did not receive the note. Administrator revealed that after this incident, Resident #5 was sent out to the hospital to see the doctor per Family Member A's request. Record review of the facility's nurses report on 10/16/24 at 4:00 PM revealed there was no note given from 09/13/24 to 09/16/24 stating to cancel Resident #5's appointment. The nurses' report during that time period stated that Resident #5 had an appointment on 09/16/24. There was no indication that the appointment was canceled. Review of the facility's policy Resident Rights, revised on 11/01/2017, reflected: The facility staff will provide the resident with the right to an environment that preserves dignity and contributes to a positive self-image,

Based on observation, interview and record review, the facility failed to provide treatment and services to prevent complications of enteral feeding for one of five residents (Residents #1) reviewed for feeding tubes. The facility failed to provide treatment for Resident #1 dressing around g-tube site was labeled 08/20/23. The g-tube site was observed on 08/23/24. These failures could place residents at risk of infection. Findings included: Record review of Resident #1's face sheet dated 08/23/24 reflected the resident was a [AGE] year-old female with and admitted [DATE] and a readmitted [DATE]. Resident #1 diagnoses included: benign neoplasm of bones of skull and face (benign growths of bone that typically occur in the skull or jawbone), unspecified dementia, dehydration, and dysphagia-oral phase (difficult swallowing). Record review of Resident #1's Annual MDS Assessment, dated 08/13/24, reflected Resident and had BIMS score of 99 because resident was unable to complete interview. Section K swallowing/nutritional status reflected A) proportion of total calories the resident received through parenteral, or tube feeding is 51% or more. B) Average fluid intake per day tube feeding was 501 CC/day or more. Record review of Resident #1's care plan dated 08/14/24 reflected: Problems: [Resident #1] had a g-tube in place. Goals: [Resident #1] had a stable weight as evidenced by no significant weight loss of 5% or more in 30 days .Approach: Administer feeding via g-tube as ordered. Record review of Resident #1's Physician Orders report dated 08/23/24 reflected: Enteral Feeding: Tube site care. Once a day (10:00 PM-6:00 AM) every day and ordered on 07/17/24. Observation on 08/23/24 at 12:15 PM revealed Resident #1 g-tube site dressing had a date of 08/20/24. Interview on 08/23/24 at 1:47 PM with LVN A revealed overnight staff handled changing residents g-tube site dressing. LVN A revealed residents were at risk of developing an infection. Interview on 08/23/24 at 1:52 PM with LVN B revealed the overnight shift handled changing residents g-tube site dressing every day. LVN B stated residents were at risk for skin break down and infection. Interview on 08/23/24 at 2:10 PM with the DON revealed the treatment nurse handled changing g-tube site dressing Monday-Friday. She stated the overnight nurse handled changing the g-tube site dressing Saturday-Sunday. She revealed the electronic health monitoring system showed when task was needed to be completed in yellow, due in green and red when late. She revealed the tasked disappeared out of the system until the next schedule time. The DON stated she expected staff to check the g-tube site dressing when medication was administered. She stated residents were at risk of skin break down and infection such as yeast. Interview on 08/23/24 at 2:32 PM with the Treatment Nurse revealed she just started last week and Monday the 08/19/24 was her first day doing wound care by herself. The Treatment Nurse stated she believed a different shift took care of the g-tube site dressing. The Treatment Nurse stated not changing the g-tube site dressing could have caused skin break down. Interview via telephone on 08/27/24 at 11:30 AM with Nurse Practitioner C revealed the g-tube site dressing should be changed daily. The Nurse Practitioner stated residents have a likely hood for infection, drainage when g-tube site dressings were not changed. The DON was asked to provide a copy of the electronic monitoring record for Resident#1 related to g-tube site care from 08/20/24 to 08/23/24; however, this was not provided to the investigator prior to exit. Record review of the facility's Gastrostomy Tubes policy, dated May 2023, reflected: .2. The patient/resident that is fed enteral methods receives the appropriate treatment and services to restore oral eating skills and prevent complications of enteral feeding .

Based on observation, interview, and record review, the facility failed to ensure the resident's environment remained as free of accident hazards as was possible; and each resident received adequate supervision and assistance devices to prevent accidents for 1 (Resident #1) of seven residents reviewed for accidents. The facility failed to ensure staff checked on Resident #1 from 05:15 am until 07:50 am during which time she laid on the floor next to the bed. This failure could place residents at risk for serious injury and distress that could result in a decreased psychosocial well-being. Findings included: Record review of Resident #1's face sheet revealed an [AGE] year-old female admitted on [DATE] with a diagnosis of muscle wasting and atrophy, muscle weakness, lack of coordination, and dementia (memory loss). Record review of Resident #1's MDS assessment revealed a BIMS score of five indicating severe cognitive impairment. Further review revealed Resident #1 needed extensive assistance with two staff members for transferring and bed mobility. Record review of Resident #1's Care Plan dated 5/22/24, with a revision date of 6/05/24, revealed Resident #1 was at risk for falls due to medication use, cognition (mental status), and weakness. Record review of facility Incident/Accident form dated 6/08/24 revealed Resident #1 was found on the floor six times since admission on 5/10/24, 5/11/24, 5/14/24, 5/19/24, 6/02/24, and 6/05/24. Observation of Resident #1s room on 06/08/24 at 11:00 am, revealed Resident #1 bed in the lowest position, fall mat folded up and against the wall. Observation of video, dated 5/19/24 at 04:56 am, showed Resident #1 in the bed. Her bed was in lowest position. Then Resident #1 sat up and swung her legs over the side of the bed, both of her feet touched the ground. The Resident #1 laid back down. Fall mat was diagonal next to bed. Observation of video, dated 5/19/24 at 05:15 am, showed Resident #1 laying on the floor partially on fall mat with blankets. Observation of video, dated 5/19/24 at 06:59 am, showed Resident #1 laying on the floor on mat on her left side. The observation of the video, dated 5/19/24 at 07:50 am, showed that Resident #1 was still laying on the floor partially on the fall mat with blankets. A staff member entered the room, did not check on the resident, left, and returned a few seconds later with an additional staff member, then the video stopped. In an interview on 06/08/24 at 09:00 am, LVN A reported that staff worked eight hour shifts and shift changes were at 6am, 2pm, and 10pm. LVN A stated that she tried to check on residents at least four to five times per shift and maybe an hour to an hour and a half was the longest a resident was not checked on. If a resident was found on the floor, they were assessed for any bruising, any abrasions to the skin, and range of motion during a head-to-toe assessment. If a resident needed to go to the hospital, emergency medical services were called, the physician was notified, and the family was contacted. In an interview on 06/08/24 at 1:25 pm, with the DON revealed Resident #1 is on the facilities falling star program, due to frequent falls. The DON stated when residents are on the falling star program the staff are expected to check on those residents more frequent than every two hours, but stated there is not a set timeframe. The DON stated the facility implemented the for Resident #1 her bed is to be in lowest position, fall mat laid next to bed when Resident #1 is in bed, and during the day she is at the nurse's station so that staff can keep a closer eye on resident to minimize the risk of falls. In an interview on 06/08/24 at 1:45 pm, with ADON A revealed when she worked the floor as a nurse, all residents that ADON A would be caring for were checked prior to receiving report at shift change. In an interview on 06/08/24 at 1:50 pm, LVN B revealed all residents were checked on before receiving report at shift change. In an interview on 06/08/24 at 1:52 pm, LVN A stated she always checked every resident at shift change. In an interview on 06/08/24 at 1:58 pm, the DON stated there was an incident where Resident #1 was left on the floor for an extended amount of time. The DON reported that the resident comes out of the bed often. The DON reported the resident was found on the fall mat next to bed, sleep covered with blanket off of bed. In an interview on 06/08/24 at 2:11 pm, with the Administrator revealed the expectation for nurses is to round at least every two hours and if someone needed to be monitored more frequently than that would be discussed during morning meeting with staff. In an interview on 06/08/24 at 2:31pm, with the DON revealed it was unknown how long Resident #1 was on the floor, but it was a while. The DON reported that staff are expected to round on residents every two hours but should be checking on Resident #1 more often. The DON reports that when Resident #1 was on the floor for an extended amount of time that the staff were doing a changing round which takes longer to complete. The DON stated she instructed the staff to start their rounds with Resident #1 due to her frequent falls and she does not holler out or use call light.

Based on observation, interviews and record reviews the facility failed to maintain medical records that were complete and accurately documented for 1 (Resident #15) of 10 residents reviewed for resident records. The facility failed to accurately document Resident #15's use of arm sleeve on 05/28/24, 05/29/24 and 05/30/24 even though it was not performed. These failures could affect any resident, placing them at risk of inaccurate information and resulting inappropriate care. Findings included: Review of Resident #15's Face sheet dated 05/31/24 revealed the resident was an [AGE] year-old female admitted to the facility on [DATE] and readmitted on [DATE]. Review of Resident #15's quarterly MDS dated [DATE] revealed he had a BIMS score of 09, indicating moderate cognitive impairment. Further review revealed she had active diagnoses of unspecified symbolic dysfunctions, muscle wasting and atrophy, muscle weakness, local infection of the skin and subcutaneous tissue, unspecified. MDS assessment Section M - Skin condition indicated Resident #15 skin intact. Review of Resident #15's care plan revised on 05/20/24 revealed Problem: Resident is a new admission. admitted from THR Downtown Hospital. The resident's Baseline Care Plan will be developed within 48 hours of admission and provided to the resident and legal representative by completion of the comprehensive assessment. Goal: Resident's immediate health and safety needs will be identified. Approach: SKIN INTEGRITY: (X) Treatment- See Physician Orders. Review of Resident #15's physician orders, dated 04/12/24, reflected: Apply arm sleeve to right arm once a day, start time 7:00 AM Record review of Resident #15's May 2024 TAR revealed Resident #15's was provided with her arm sleeve. No indication of refusal was documented. Observation on 05/28/24 at 8:39 PM of Resident #15 in bed with eyes closed. Observed Resident #15 right forearm skin to be dry/flaky rash there was no device (arm sleeve) in place. No open wounds observed. Observation on 05/29/24 at 9:00 AM of Resident #15 in the activity room. Observed Resident #15 in her wheelchair, there was no arm sleeve in place observed to the right arm. Observation 05/29/24 at 12:58 PM of Resident #15 in the dining room. An attempt was made to interview Resident #15; however, she was not a good historian. Observed Resident #15 right forearm skin to be dry/flaky rash there was no arm sleeve in place. Observation 05/30/24 at 8:40 AM of Resident #15 on the hallway. An attempt was made to interview Resident #15; however, she was not a good historian. Observed Resident #15 right forearm skin to be dry/flaky rash there was no arm sleeve in place. Interview on 05/31/24 at 11:47 AM with LVN E revealed she was the nurse for Resident #15. She stated Resident #15 developed a skin rash to the right arm and Resident #15 would scratch herself which cause her to have small scratches. LVN E stated the doctor had ordered for Resident #15 to wear a geri sleeve (arm sleeve) to prevent Resident #15 from scratching her arm. LVN E stated Resident #15 would only allow them to put lotion on and refuses the arm sleeve. LVN E stated she had not attempted to put the arm sleeve today (05/31/24) due to Resident #15 attended activities. LVN E stated Resident #15 had not had the arm sleeve the last few days due to Resident #15 refusing. LVN E stated she had documented incorrectly and should had document refusal. LVN E stated not accurately documenting could affect the way Resident #15 received care. Interview on 05/31/24 at 11:13 AM with the DON revealed Resident #15 had an order for an arm sleeve due to Resident #15 developed a rash on her right arm. The DON stated Resident #15 would refuse the arm sleeve and would take it off. She stated her expectations are for the nurse to follow physician orders and attempt to put the arm sleeve and if refuse nurses should document the refusal. According to the DON by not accurately documenting was considered falsification. Interview on 05/31/24 at 12:28 PM with the ADON revealed Resident #15 had a physician order for a geri sleeve due to Resident #15 developed a skin rash. She stated the geri sleeve was used to protect Resident #15 from scratching. She stated her expectations were for the nurses to follow physician orders. She stated if resident refuses, she expected the nurses to document not administered and to notify the physician of the refusal and discontinue the order. The ADON stated by not documenting accurately led to false documentation. Review of facility policy entitled Nursing Policies and Procedures, dated revised 05/05/23, reflected: Documentation - Licensed Nursing - Medication and Treatments: The qualified nursing staff notes the time, date and dosage of all medications and treatments at the time they are administered and initials the note on the medication and/or treatment record. The nurse's full name and title must be written at least once on each page of the medication/Treatment Record or on an individual resident specific signature sheet. If a scheduled medication is withheld or not given as ordered, the nurse documents this and lists the reason for the patient/resident not receiving the medication. The attending physician or physician extender must be notified. Route of administration must be charted.

Based on interview and record review, the facility failed to ensure any drug regimen irregularities reported by the Pharmacist Consultant were acted upon, for 1 of 5 residents (Resident #38) reviewed for medication regimen review. The facility's Pharmacist Consultant recommended Residents #38's anxiety medication hydroxyzine required an additional consent form to be completed and uploaded to the resident's chart. This failure could place residents at risk for possible adverse side effects, adverse consequences, and decreased quality of life. Findings included: Review of Resident #38's Face sheet dated 05/31/24 revealed the resident was a [AGE] year-old male admitted to the facility on [DATE] and readmitted on [DATE]. Review of Resident #38's quarterly MDS dated [DATE] revealed he had a BIMS score of 12, indicating no cognitive impairment. Further review revealed she had active diagnoses of Parkinson's disease without dyskinesia, schizoaffective disorder, depressive type, anxiety disorder. Review of Resident #38's care plan undated, revealed the following: *Problem: Resident is receiving antipsychotic medications. Goal: Resident will not exhibit signs of drug related side effect or adverse drug reaction through next review date. Approach: Attempt a gradual dose reduction (if not contraindicated). Pharmacy consultant review. Monitor resident's behavior and response to medications. Review for continued need at least quarterly. *Problem: Resident has a diagnosis of anxiety. Goal: Resident will manage anxiety through effective coping mechanisms and pharmaceutical interventions through next review date. Approach: Administer medications as ordered. Monitor and report for signs and symptoms of adverse reaction to the physician. Review of Resident #38's physician's orders reflected an order for: * Hydroxyzine HCl tablet; 50 mg; Amount to Administer: 2 Tablets; oral; Twice a day; Take at noon and bedtime for anxiety disorder; Start date 08/01/23. *Hydroxyzine HCl tablet; 50 mg; Amount to Administer: 2 Tablets; oral; Twice a day; Take at noon and bedtime for anxiety disorder; Start date 11/08/23. Review of Resident #38's Medication Regimen Review, dated 10/19/23, reflected Please ensure there is an informed consent in resident's chart/profile for the following psychoactive medications: hydroxyzine Review of Resident #38's October 2023 MAR reflected Resident #38 received Hydroxyzine HCl tablet; 50 mg the entire month of October 2023. Review of Resident #38's November 2023 MAR reflected Resident #38 received Hydroxyzine HCl tablet; 50 mg; the entire month of November 2023. Review of Resident #38's Medication Regimen Review, dated 12/23/23, reflected Please ensure there is an informed consent in resident's chart/profile for the following psychoactive medications: hydroxyzine Review of Resident #38's December 2023 MAR Resident #38 received Hydroxyzine HCl tablet; 50 mg the entire month of December 2023. Review of Resident #38's Medication Regimen Review, dated 01/16/24, reflected Please ensure there is an informed consent in resident's chart/profile for the following psychoactive medications: hydroxyzine Review of Resident #38's January 2024 MAR reflected Resident #38 received Hydroxyzine HCl tablet; 50 mg; the entire month of January 2024. Review of Resident #38's February 2024 MAR reflected Resident #38 received Hydroxyzine HCl tablet; 50 mg; the entire month of February 2024. Review of Resident #38's March 2024 MAR reflected Hydroxyzine HCl tablet; 50 mg; Amount to Administer: 2 Tablets; oral; Twice a day; Take at noon and bedtime for anxiety disorder was discontinued on 03/01/2024. Interview on 05/31/2023 at 9:35 AM with Resident #38 revealed he could not recall if he signed consent forms for his medications. He denied having any issues with the medications he was currently taking. Interview on 05/31/24 at 11:05 AM with the DON revealed she had been employed since November 2023. The DON stated it was her responsibility to review the pharmacy consultant recommendations and to following up on them and the ADON's also assisted. The DON stated they had completed an audit on pharmacy review and they noticed that consents were missing or not completed. She stated they had to redo all of the resident consent forms. The DON stated Resident #38 consent form was obtained on 02/28/24. Review of Resident #38's informed consent form revealed it was signed on 02/28/24. Review of facility policy entitled Pharmacy Services Policies and Procedures, dated revised 04/17/24, reflected the following: Consultant Pharmacist: The medication regimen of each resident is reviewed by a licensed Pharmacist according to Federal, State, and Local regulations as well as current standards of practice. The pharmacist must report any irregularities to the Attending Physician, the facility's Medical Director and Director of Nursing, and these reports must be acted upon in a manner that meets the needs of the residents.

Based on observation, interview and record review, the facility failed to ensure residents fed by enteral means received the appropriate treatment and services to prevent complications of enteral feedings for 1 of 1 resident (Resident #252) reviewed for enteral nutrition. The facility failed to follow Resident #252's physician orders for enteral feeding. These failures could affect residents receiving enteral nutrition/hydration and place them at risk of health complications and decline in health. Findings included: Record review of Resident #252's face sheet dated 05/31/24 revealed the resident was [AGE] year-old male admitted on [DATE] with a diagnosis of gastrostomy status (artificial external opening into the stomach for nutritional support). Record review of Resident #252's admission MDS dated [DATE] revealed the resident had severe cognitive impairment with a BIMS score of 00. The assessment reflected Resident #252 MDS was still in process. Record review of Resident #252's undated care plan revealed the following: Resident #252 was at nutrition and /or dehydration risk; Goal reflected resident will maintain nutritional status as evidenced by no significant weight change; Interventions included monitor weights, skin report, and labs per policy, provide diet as ordered by physician, tube feeding and free water flushes as ordered. Record review of Resident #252's physician orders included the following: *General-dated -05/20/24 - Check blood sugar before meals and at bedtime; 8AM, 1PM, 5PM, 8PM *General-dated -05/20/24 -Enteral feeding; Glucerna 1.5 Flow rate (60/hour) x 20 hours via pump per g-tube. Special instructions: Date, and label tubing with each change. Every shift; First, Second, Third Record review of Resident #252's 05/20/24 - 05/30/24, MAR revealed Resident #252 had been administered Glucerna 1.5. Observation on 05/28/24 at 7:38 PM of Resident #252 revealed him in bed sleeping, Resident had a 3/4 empty bottle of Jevity 1.2 dated 05/27/24. Observation on 05/29/24 at 03:42 PM Resident #252's feeding machine revealed a 3/4 empty bottle of Jevity 1.2 dated 5/29/24. Observation and interview on 05/29/24 at 4:31 PM with LVN G revealed Resident #252 had a bottle of Jevity 1.2 hung on his machine. LVN G stated resident feeding machine went down at 4 PM; he will resume feeding with this bottle of formula at 8 PM; and his formula bottle would be changed once the bottle was empty. According to LVN G she needed to review physician orders to indicate which formula Resident #252 would be administered. LVN G reviewed the physician orders and revealed Glucerna 1.5 was the appropriate formula to administer to Resident #252. She stated Glucerna was for residents with diabetes which was what Resident #252 was supposed to be administered. LVN G stated resident blood sugar numbers had been ok with no concerns. LVN G stated someone may have grabbed the Jevity 1.5 by mistake. LVN G stated it was the responsibility of the nursing staff to ensure Resident #252 was administered formula according to physician orders. LVN G stated not doing so placed him at risk of his blood sugar readings being abnormal. LVN G stated she had worked on the 2-10 PM since 05/28/24 and did not recognize Resident #252 had been administered the wrong formula and it was her responsibility to review physician orders prior to administering any order. LVN G could not recall how long Resident #252 had been receiving Jevity 1.5 formula. Interview on 05/31/24 at 11:04 AM with ADON B revealed she was not aware Resident #252 was administered Jevity feeding formula. ADON B stated the reason that Resident #252 had the wrong formula was due to the nurse grabbing the wrong formula bottle. ADON B stated Glucerna was more suited for monitoring calorie intakes for people with Diabetes. ADON B stated not following physician orders placed Resident #252 at risk of elevated blood sugar readings. ADON B stated nurses on the floor were responsible for reviewing physician orders and following orders prescribed. ADON B stated if it was not possible to follow those orders the floor nurse should have reported to the physician so an alternate could have been administered and followed up with the Registered Dietician, ADON or DON and family. An attempted interview on 05/31/24 at 11:14 AM with Registered Dietician was unsuccessful. Interview on 05/31/24 at 1:30 PM with DON revealed her expectations were for nursing staff to follow physician orders, should an issue arise nursing staff would report any findings to herself or the ADON's and contact the physician immediately. The DON stated if it was a dietary concern ensure to contact the dietician as well and document. The DON stated if Resident #252's nutrition order was for Glucerna that was what should have been administered. The DON stated not following physician orders for Resident #252 placed him at risk for diarrhea/nausea. The DON stated all charge nurses, ADONs, and myself are all responsible for ensuring physician orders are being followed. Record review of the facility's Physician Orders policy dated 05/05/23, reflected: The qualified licensed nurse will obtain and transcribe orders according to Facility Practice Guidelines. 1. The qualified licensed nurse completes an admission medication regimen review from the transfer record from an acute care hospital, home, or other entity. Refer to the Admission Medication Regimen Review in Pharmacy Services policy and procedure manual. 2. A call is placed to the physician to confirm the orders and request any additional orders as needed Record review of the facility's Enteral and Parenteral Feedings policy, dated 05/05/23, reflected: .2. Obtain a Physician's order for all enteral and parenteral feedings. 3. Communicate orders with Nutrition Services. 4. Notify the facility RD of initial orders to receive enteral and parenteral fluids to secure an assessment of individual patient need. Notify Physician of completed assessment and obtain orders. Orders to include: A. The brand name of the formula B. Strength/concentration C. Rate/frequency/duration of feedings D. Amount and frequency of water to flush the tube. E. Route of administration F. Method of administration of the feeding 5. Monitor and report problems and complications to the Physician and Nutrition Services.

Based on observation, interview and record review, the facility failed to ensure an environment remained as free of accident hazards as is possible for 1 of 26 resident rooms reviewed for a safe environment. The facility failed to ensure Resident #53 did not have access to facility disposable razors. This failure could place residents at risk of accidents, injuries, or harming another resident. Findings included: Record review of Resident #53's Admission Record revealed the resident was an [AGE] year-old male admitted to the facility on [DATE] and reentered on 10/22/23. His diagnoses included lack of coordination, unsteadiness on feet, symptoms and signs involving cognitive functions and awareness, muscle weakness, hypertension (high blood pressure), unspecified atherosclerosis of native arteries of extremities, seizures, depression, restlessness, and agitation. Record review of Resident #53's Quarterly MDS assessment dated [DATE] revealed the resident had a BIMS score of 04 which indicated severe impairment. The MDS also revealed, Resident #53, required supervision or touching assistance with transfer and activities of daily living. Record review of Resident #53's Care Plan revealed a problem initiated on 01/17/24 for risk of harm or injury related to seizure disorder. Resident #53 will not injure self-secondary to seizure disorder. Intervention included to administer medications as ordered, assess characteristics before, during and after seizure. If seizure occurs, remove all restrictive clothing and objects of potential harm. Resident #53 requires assistance with all activity of daily living related to general weakness and poor safety awareness. Resident will have all activities of daily living needs met. Interventions included assistance with bathing, and personal hygiene. Observations on 05/28/24 8:00 PM Resident #53 was sitting in his room, in wheelchair, with a disposable navy-blue razor in his hand shaving the left side of his face. According to Resident #53, he liked to use a razor to shave his face. Resident #53 stated he did not require shaving cream, that dry shaving was ok to do. Resident #53 stated he did not require assistance from staff to do so. Resident #53 was observed to check his face a couple of times, stating that he was making sure he did not cut himself. Observation on 05/29/24 at 3:20 PM of Resident #53 in his room sitting and watching television. A package of disposable razors was observed on the resident's bedside table. Interview on 05/29/24 at 3:29 PM with CNA F revealed she just left Resident #53's room and gave him ice. CNA F stated, I did not see him with razor or a package of razor. If I noticed anything like that, I would have removed the razors and reported to the nurse what I have removed. CNA F stated Resident #53 having razors would place him at risk of cutting himself or other residents. Interview on 05/29/24 at 3:37 PM with LVN G revealed Resident #53 did ask for towels for a shower on 05/28/24. According to LVN G, staff were required to supervise Resident #53 during showers, but he did not like the supervision. According to LVN G, staff were supposed to shave residents and discard the razors after using them. LVN G stated when aides allowed residents to shave themselves it placed the residents at risk of injuring themselves. LVN G stated it was her expectation that staff alerted her if resident had razors in their possession. Observation and interview on 05/31/24 at 11:41 AM revealed ADON B entered Resident #53's room to remove the razors. She talked to him about allowing the staff to shave him or supervise him when he used the razor. ADON B stated Resident #53 told her he got the razors from a facility auction, but ADON B stated that was not true. ADON B stated upon review the razors were similar if not exact to what the facility used to complete shaving residents. According to ADON B, her expectation was that nursing staff observed residents and their rooms, to include removing anything that did not belong. ADON B stated not doing so placed residents at risk of cutting themself, infection, cause harm and prevent safety. Interview on 05/31/24 at 1:30 PM with the DON revealed Resident #53 should not have access to razors. The DON stated she expected staff to pay attention to resident environments, remove things that should not be in their possessions and report their findings. The DON stated nursing staff were to complete or supervise all residents with shaving. The DON stated aides were responsible for ensuring razors were not left with residents, and not doing so placed residents at risk of cutting themselves. Record review of the facility's Accident/Incident Reporting Patient/Resident policy, dated 11/01/17, reflected: The Facility's Leadership will follow the established guidelines for the reporting of accidents and incidents. An incident is any adverse outcome associated as a direct consequence of treatment or care. An accident is an unexpected, unintended event that can result in bodily injury.

Based on observation, interview and record review, the facility failed to ensure a resident with limited range of motion received appropriate treatment and services to increase range of motion and/or prevent further decrease in range of motion for one of three residents (Resident #47) reviewed for contracture management. The facility failed to apply rolled wash cloths to Resident #47's left contracted hand (a permanent tightening of the muscles) for contracture management. This failure could place residents at risk for a decline in range of motion, decreased mobility, worsening of contractures and a decline in physical capabilities. Findings included: Review of Resident #47's Face Sheet dated 05/31/24 revealed the resident was a [AGE] year-old male admitted to the facility on [DATE]. Review of Resident #47's quarterly MDS dated [DATE] revealed he had a BIMS score of 09, indicating moderate cognitive impairment. Further review revealed he had active diagnoses of sequelae of cerebral infarction, spastic hemiplegia affecting left dominant side, muscle weakness, other lack of coordination. The MDS further reflected the resident had functional limitation in range of motion upper extremity (shoulder, elbow, wrist, hand). Review of Resident #47's care plan revised on 04/25/24 reflected: Problem: ADLs Functional Status/Rehabilitation Potential Impaired physical mobility R/T contracture AEB limited range of motion. contracture of left hand, right knee, and left knee. Goal: Will be able to maintain current level of function through next review date. Approach: Monitor contracture for further contraction and report to MD. Place splints, carrot, washcloth to contracted area. Observation and interview on 05/28/24 at 8:36 PM revealed Resident #47 was in bed. He stated he was doing well. Observation of the resident's left hand revealed it was contracted, but there was no contracture management device in place. Resident #47 stated he was not sure if he needed a split; however, in the past staff would place a cloth in his hand. Resident #47 stated it had been a while since he last had one on. Resident #47 denied any pain or discomfort. Resident #47 revealed he had not refused to have anything placed in his left hand. Observation on 05/29/24 at 9:05 AM revealed Resident #47 in bed with his eyes closed. Observation of his left hand revealed it was contracted, but there was no contracture management device in place. Observation on 05/29/24 at 4:14 PM revealed Resident #47 in bed with his eyes closed. Observation of his left hand revealed it was contracted, but there was no contracture management device in place. Observation and interview on 05/31/24 at 10:06 AM of Resident #47 in bed. Observed Resident #47 left hand to be contracted there was no device in place. Resident #47 stated no one had place a washcloth in his left hand. Interview on 05/31/24 at 10:47 AM with LVN E revealed she was not sure if Resident #47 needed a washcloth or other devices for his left hand since she had never put one on. LVN E stated if Resident #47 was care planned to use a washcloth or other devices was because it was required and he needed it. LVN E stated it was the responsibility of the nurses or therapy to put them on. She stated Resident #47 was not on therapy. LVN E further stated it was important to keep the washcloths in the resident's hand to keep the contractures from worsening. Interview on 05/31/24 at 12:44 PM with the ADON B revealed they had recently ordered a splint for Resident #47; however, resident needed to be evaluated by therapy first before utilizing the splint. ADON B stated if Resident #47 was care planned to use a washcloth then it should be provided. She stated it was the nurse's responsibility to put in the washcloths, and it was her responsibility to ensure it was being provided to prevent contracture from worsening. Interview on 05/31/24 at 1:06 PM with the Director of Therapy revealed they had received Resident #47's elbow and knee splint yesterday 05/30/24. She stated they were just waiting on funding verification to be evaluated for services. She stated she was unaware of any splint or washcloth that Resident #47 needed for his left hand. She stated it would be nursing who was responsible. Interview on 05/31/24 at 1:15 PM with the DON revealed her expectation was for nursing staff to carry out the interventions in place that were listed for range of motion. She stated it was the responsibility of the nursing team to ensure interventions were in place for contractures. The DON stated she was aware of Resident #47's contractures, and therapy had ordered the appliances. She stated the risk of not following interventions would be further loss of joint mobility. Review of facility Restorative Nursing Policies and Procedures policy, dated 02/29/24, reflected the following: 1. Review care plan, determine the following: A. Active or Passive ROM exercises, B. Body Parts to be exercised, C. Number of repetitions, D. Special instructions.

Based on observation, interview and record review, the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for 1 of 10 Residents (Resident #15) reviewed for quality of care. The facility failed to follow physician orders to apply an arm sleeve, used to protect skin, on Resident #15's right arm. This failure placed residents at risk of not receiving appropriate care and worsening of their conditions. Findings included: Review of Resident #15's Face sheet dated 05/31/24 revealed the resident was an [AGE] year-old female admitted to the facility on [DATE] and readmitted on [DATE]. Review of Resident #15's quarterly MDS dated [DATE] revealed he had a BIMS score of 09, indicating moderate cognitive impairment. Further review revealed she had active diagnoses of unspecified symbolic dysfunctions, muscle wasting and atrophy, muscle weakness, local infection of the skin and subcutaneous tissue, unspecified. MDS assessment Section M - Skin condition indicated Resident #15 skin intact. Review of Resident #15's care plan revised on 05/20/24 reflected: Problem: Resident is a new admission. admitted from .Hospital. The resident's Baseline Care Plan will be developed within 48 hours of admission and provided to the resident and legal representative by completion of the comprehensive assessment. Goal: Resident's immediate health and safety needs will be identified. Approach: SKIN INTEGRITY: (X) Treatment- See Physician Orders. Review of Resident #15's physician orders, dated 04/12/24, reflected: Apply arm sleeve to right arm once a day, start time 7:00 AM Record review of Resident #15's May 2024 TAR revealed Resident #15's was provided with her arm sleeve. No indication of refusal was documented. Observation on 05/28/24 at 8:39 PM of Resident #15 in bed with eyes closed. Observed Resident #15 right forearm skin to be dry/flaky rash there was no device (arm sleeve) in place. No open wounds observed. Observation on 05/29/24 at 9:00 AM revealed Resident #15 in the activity room seated in her wheelchair, and she was not wearing an arm sleeve on her right arm. Observation 05/29/24 at 12:58 PM of Resident #15 in the dining room. An attempt was made to interview Resident #15, but she was not able to answer questions. The skin on Resident #15's right forearm skin was dry/flaky with a rash, and the resident was not wearing an arm sleeve. Observation 05/30/24 at 8:40 AM of Resident #15 in the hallway. An attempt was made to interview Resident #15, but she was not able to answer questions. The skin on Resident #15's right forearm skin was dry/flaky with a rash, and the resident was not wearing an arm sleeve. Interview on 05/31/24 at 11:47 AM with LVN E revealed she was the nurse for Resident #15. She stated Resident #15 developed a rash on her right arm, and Resident #15 would scratch herself which cause her to have small scratches. LVN E stated the doctor had ordered for Resident #15 to wear a geri sleeve (arm sleeve) to prevent Resident #15 from scratching her arm. LVN E stated Resident #15 would only allow them to put lotion on and refuses the arm sleeve. LVN E stated she had not attempted to put the arm sleeve today (05/31/24) due to Resident #15 attending activities. LVN E stated Resident #15 had not had the arm sleeve the last few days due to Resident #15 refusing. LVN E stated she had documented incorrectly and should had document refusal. LVN E stated she was unsure what the risk would be for not putting the arm sleeve on Resident #15. Interview on 05/31/24 at 11:13 AM with the DON revealed Resident #15 had an order for an arm sleeve due to Resident #15 having a rash on her right arm. The DON stated Resident #15 would refuse the arm sleeve and would take it off. She stated her expectation was for the nurse to follow physician orders and attempt to put the arm sleeve on the resident. If Resident #15 refused, the nurses should document the refusal. She stated the risk of not utilizing the arm sleeve was that it could cause the rash to worsen. Interview on 05/31/24 at 12:28 PM with the ADON revealed Resident #15 had a physician order for a geri sleeve due to Resident #15 having a rash. She stated the geri sleeve was used to protect Resident #15 from scratching. She stated her expectation was for the nurses to follow physician orders. She stated if the resident refused, she expected the nurses to document not administered and to notify the physician of the refusal and discontinue the order. The ADON stated it was the responsibility of the nurses to put the geri sleeve on the resident, and it was the ADONs responsibility to ensure it was being completed. She stated the risk of not utilizing the geri sleeve was that it could cause irritation to the area to worsen. Review of facility Nursing Policies and Procedures policy, revised dated 05/05/23, reflected the following: Subject: Physician Orders. The qualified licensed nurse will obtain and transcribe orders according to Facility Practice Guidelines .Upon admission, the Facility has physician orders for the resident's immediate care to include but not limited to: A. Dietary orders B. Medications, if necessary C. Routine care orders to maintain or improve the resident's functional abilities until staff can conduct a comprehensive assessment and develop an appropriate care plan.

Based on observation, interview, and record review the facility failed to ensure a resident received proper treatment and care to maintain good foot health for 1 (Resident #1) of 4 residents reviewed for foot care. (1) The facility failed to ensure Resident #1 who had a diagnosis of atherosclerosis of the extremities (A disease of the peripheral blood vessels characterized by narrowing and hardening of the arteries that affect blood supply to the legs and feet) (The peripheral vessels consist of the veins and arteries not in the chest or abdomen i.e., in the arms, hands, legs and feet) and peripheral vascular disease (a progressive circulation disorder that involves the narrowing, blockage, or spasms in the blood vessels as a result of arteriosclerosis) and was at risk for impaired blood flow to his feet, received assessments of his feet. (2) The facility failed to ensure consistent and timely skin assessments were provided. Resident #1's 09/05/23 scheduled weekly skin assessment was not provided. (3) Resident #1 was seen by the Podiatrist on 08/29/23 and placed a protective sleeve on the second toe of the left foot, gave orders to check the resident's feet daily and monitor for any new wounds/ulcerations. The facility failed to ensure podiatry orders were followed for Resident #1. On 09/10/23 Resident #1 was discovered with a discolored bandage on the second toe of the left foot, an open wound on the second toe of the left foot with bright red blood and yellow purulent (pus) drainage. An Immediate Jeopardy was identified 09/15/23 at 11:45 a.m. The IJ template was provided via email at 11:48 a.m. While the IJ was removed on 09/15/23, the facility remained out of compliance at a severity level of actual harm that is not immediate jeopardy, and at a scope of pattern due to all staff had not been trained on reporting changes in skin condition, new procedure for Podiatrist to exit with DON, the importance of carrying out orders timely, importance of completing weekly skin assessments, identifying skin impairments, notifying the physician for wound orders, documentation of assessments and approaches to aid in the prevention of skin breakdown. These failures placed all residents at risk of not receiving foot care consistent with professional standards of practice and complications from impaired circulation which could lead to possible infection, hospitalization , amputation, and death. Findings included: Review of Resident #1's physician's orders dated 09/2023 revealed the resident was a [AGE] year-old male who admitted to the facility on [DATE]. His diagnoses included atherosclerosis of the extremities and peripheral vascular disease. Review of Resident #1's significant change MDS assessment dated [DATE] revealed a BIMS of 5 indicating severely impaired cognition. The MDS assessment reflected the resident was always incontinent of bowel/bladder, totally dependent on two people for transfers, required extensive physical assistance of one person for bed mobility, dressing and personal hygiene. Review of Resident #1's care plan revised 08/30/23 revealed hospice services and diagnoses of hyperlipidemia (Elevated level of lipids such as cholesterol and triglycerides in the blood linked to atherosclerosis (hardening of the arteries) was addressed. Interventions included assessing skin integrity to help identify potential areas for skin breakdown, assessing for signs and symptoms of hyperlipidemia such as the color of the skin, skin turgor, peripheral circulation, and pedal pulses. Review of Resident #1's weekly skin assessments revealed a skin assessment dated [DATE] reflecting the resident's skin was clear. There was no subsequent weekly skin assessment for 09/05/23. Review of physician's orders, MARs/TARs dated 09/2023 reveled no Podiatry orders had been transcribed related to the visit on 08/29/23. Review of hospital records revealed Resident #1 admitted on [DATE] with diagnoses to include sepsis and cellulitis (Bacterial skin infection that causes redness, swelling, and pain in the infected area of the skin. If untreated, it can spread and cause serious health problems) of the second toe on the left foot. The records reflected the resident was assessed on admission with erythema (redness), blistering, purulent draining, and peeling skin to the second toe of left foot with bone exposed. The records reflected the left foot second toe amputation was scheduled for 09/14/23. Interview on 09/13/23 at 9:19 a.m. the DON stated Resident #1 was noted with redness to his left foot, second toe on 09/10/23. LVN B notified the resident's hospice and orders were received for antibiotic treatment. The facility staff were unaware the Podiatrist had visited the facility on 08/29/23 or that the Podiatrist had placed a protective sleeve on the resident's second toe of the left foot. The DON stated the Podiatrist left no orders with the nurse on 08/23/23. The DON stated LVN C was on duty on 08/29/23 when the Podiatrist visited and denied receiving any orders or instructions from the Podiatrist for Resident #1. LVN C told the DON she had performed a weekly skin assessment for Resident #1 on 08/29/23, noted a wrap on the second toe of the resident's left foot, but did not remove the wrap or assess the resident's toe underneath. The DON further stated Resident #1's weekly skin assessment scheduled for 09/05/23 was not completed by LVN A because the nurse told them she had been overwhelmed. The Administrator stated on 09/11/23 the facility became aware of the Podiatrist's progress notes, that included orders and instructions for the care of Resident #1, had been emailed to the facility on Friday 09/08/23. They stated Resident #1's toe was worse on 09/11/23 and continued to deteriorate. Orders were received to transfer the resident to the hospital on 09/12/23. The facility staff were unaware of the Podiatrist's orders/instructions until Monday (09/11/23), 13 days after the Podiatrist visit on 08/29/23. Interview on 09/13/23 at 10:05 a.m. the TN stated on 09/10/23 she was informed by LVN B that there was a problem with Resident #1's left foot. She assessed the resident and discovered his entire left foot was swollen, purple colored and the resident's second toe on the left foot was noted with a small open area. LVN B received orders for wound care and the antibiotic doxycycline 100 milligrams orally two times a day for 7 days. The TN stated she communicated with the Podiatrist on 09/12/23 and he told her his assistant typically left written orders with the charge nurse, but he did not specifically say orders were left for Resident #1. The TN stated she was not aware of the Podiatrist's visit on 08/29/23 or of any orders or instructions related to Resident #1 prior to 09/11/23. Interview on 09/13/23 at 1:08 p.m. the Podiatrist stated he visited Resident #1 on 08/29/23 and noted the resident had a reddened area on the second toe of the left foot. He stated the toe was pre-ulcerative, not open, but on its way to being an ulcer. He stated he placed a gel sleeve on the second toe for padding and protection. His assistant provided written orders to the charge nurse (unable to recall name). He stated he did not keep copies of his orders and had been providing services in the facility for two years in the same manner and never had any issues with nurses implementing his orders before. Interview on 09/14/23 at 2:25 p.m. the Podiatrist stated he expected nursing staff to remove the gel sleeve to assess/monitor Resident #1's toe daily per his orders for any skin breakdown until the redness dissipated. He specifically explained to the charge nurse the resident's toe was at risk for skin breakdown. Review of Resident #1's Podiatry progress notes dated 08/29/23 revealed the resident was assessed with an area of redness to the second toe of the left foot. Pedal pulses (rhythmical throbbing of the arteries that can be felt in the feet) were non-palpable (not found on clinical exam), and findings were consistent with decreased circulation. The notes reflected a gel sleeve was applied and staff had been educated on its use and to check the resident's feet daily and monitor for any new wounds/ulcerations. Interview on 09/13/23 at 3:48 p.m. LVN A stated she did not perform the scheduled weekly skin assessment for Resident #1 on 09/05/23 because she was busy and did not get around to it. She stated she was not aware of any issues with the resident's foot/toe or that the resident had been seen by the Podiatrist or she would have made the skin assessment a priority. She observed Resident #1's toe prior to sending him out to the hospital on 09/12/23 and it looked terrible. She stated the resident's toe was black colored, but the resident made no complaints of pain. Interview on 09/13/23 at 4:00 p.m. LVN B stated on 09/10/23 she noticed Resident #1 with dried blood-tinged drainage on his left sock. She removed the sock and noted an undated, soiled dressing on the resident's second toe. When she removed the dressing, she discovered the resident's toe was red colored with a dimed sized open area. She cleansed the area, applied a dry dressing, and notified the PA. LVN B stated the PA was in the facility and instructed her to call hospice and when she notified hospice orders were received to start an antibiotic. She stated she was not aware of any problems with Resident #1's toes or that the Podiatrist had seen the resident on 08/29/23. Observation on 09/14/23 at 11:28 a.m. revealed Resident #1 was in the hospital awaiting surgical amputation of his second toe on the left foot. The resident was resting flat in bed, with intravenous lines, bilateral compression boots in place and was mumbling incoherently. The resident's family was at the bedside and stated Resident #1 was cognitively impaired and did not understand what was going on. Observation with the hospital RN revealed the second toe on the left foot was black colored with an open area underneath the toe. The RN stated Resident #1 was receiving intravenous antibiotics and was scheduled for surgical amputation later in the day. Interview on 09/14/23 at 2:43 p.m. LVN C stated she was on duty 08/29/23 and provided care for Resident #1. She stated she did not know the Podiatrist was in the facility until she saw him in a resident's room. She stated the Podiatrist never introduced himself, and no one provided any orders or instructions related to Resident #1's care. She further stated she performed the resident's weekly skin assessment on 08/29/23 but was unable to recall if it was before or after the Podiatrist left. LVN C stated she never saw a bandage or sleeve on Resident #1's toe and there were no issues noted with the resident's skin during her assessment. Additionally, LVN C stated she saw the resident's toe on 09/10/23 after the open area had been identified and the toe was ugly, green/red colored and looked infected. She was not aware of any problems with the resident's toe until she saw it on Sunday 09/10/23. Interview on 09/14/23 at 3:45 p.m. CNA D stated she worked for hospice and provided care for Resident #1 Monday through Friday. She stated she showered the resident every Monday, Wednesday, and Friday. She stated the resident always wore socks and Croc style shoes and she changed his socks daily. CNA D stated she did not notice any issues with the resident's feet or toes and never saw any bandage, sleeve, or other type of dressing until Friday 09/08/23. On 09/08/23 she saw a band aid on one of the resident's toes on his left foot, covered the left foot with a trash bag and provided the shower as usual. When she completed the shower the band aid was still in place. CNA D further stated she was not exactly sure when she saw the band aid on the resident's toe, but whenever it was, she covered the left foot to ensure it did not get wet in the shower. Interview on 09/14/23 and 4:46 p.m. CNA E stated she provided care for Resident #1 prior to the resident's hospice admission (08/02/23) and provided showers. She stated she never saw any issues with the resident's foot or toes. The resident always wore socks and shoes and she never removed them since hospice was initiated. Interview on 09/15/23 at 11:00 a.m. the DON and Administrator were queried about procedures to ensure Podiatry orders were received and implemented by nursing staff. The DON stated the Podiatrist just gave the orders to the charge nurses and then emailed his progress notes. The DON was queried about how she ensured orders from Podiatry were transcribed and initiated for resident care. She and the Administrator stated there had been no plan/procedure in place. The Administrator stated the facility had never had any problems with Podiatry orders before. Review of the facility's policy/procedure entitled wound care policies and procedures revised 06/01/15 revealed licensed nurse skin checks was addressed. The policy was that all residents would have a thorough weekly skin evaluations performed by a licensed nurse. An Immediate Jeopardy was identified on 09/15/23 at 11:34 a.m. The Administrator was informed of IJ in the area of quality of care and the IJ template was provided via email at 11:48 a.m. and a POR was requested. The plan of removal was accepted on 09/15/23 at 6:32 p.m. and reflected: Interview on 09/15/23 at 4:26 p.m. the DON stated she had worked at the facility since 2018 and there had never been any training related to foot care and/or residents with impaired LE circulation. The DON stated it was important for weekly skin assessments to be performed to ensure residents with skin issues were treated to prevent further deterioration of the skin issues. She stated it was important to follow orders provided by the Podiatrist and perform assessments of residents with impaired circulation of the lower extremities to prevent infections. Interview on 09/15/23 at 6:05 p.m. CNA K stated she provided care for Resident #1 but did not remove his socks and was not aware of any problems with his foot/toe. Interview on 09/15/23 at 6:35 p.m. the Administrator stated he had communicated with corporate and there was no policy/procedure addressing foot care, podiatry services and/or assessments of residents with impaired circulation of the lower extremities. The plan or removal reflected: Resident #1 was discharged to the hospital on 9/12/23. An audit of notes from the podiatrist's current resident list was completed by The Director of Nursing on 9/13/23 to identify new physician orders. Any orders identified were completed at time of discovery. Assistant Director of Nursing/designee completed a skin audit on current residents to identify wounds and skin integrity issues on 9/12/23. None were identified. Director of Nursing/Designee will follow up via phone on 9/15/23 with the Podiatrist to the validate receipt of email education that was sent on 9/14/23. The education included ensuring a verbal exit with the Director of Nursing/Designee will occur prior to the physician leaving the building, ensuring new orders are identified and carried out timely. Licensed nurses were re-educated by the Director of Nursing/Designee on the exit process for the podiatrist on 9/14/23. Licensed Nurses were re-educated by the Director of Nursing/Designee on completing weekly skin assessments and identifying areas of skin impairment to include: o approaches to aid in prevention of further skin breakdown o documentation with description of any observed changes in skin integrity o notification of physician for new orders as indicated DON/designee will reeducate CNAs to report any change of condition related to skin integrity immediately to the charge nurse. The reeducation will be completed 9/16/2023. This reeducation will be completed by 9/15/23 by Director of Nursing/Designee. Licensed nurses and agency nurses who have not received the re-education by this date will receive it prior to their next scheduled shift and will be presented in New Hire and agency orientation by the Director of Nursing/Designee. The Director of Nursing/Designee will review weekly skin assessments Monday - Friday in clinical morning meeting to validate compliance. This began on 9/12/23. Director of Nursing/Designee will review wound consulting physician notes Monday - Friday in clinical morning meeting to validate orders are transcribed as written. This began on 9/15/23. Ad Hoc QAPI will be held on 9/15/23. The Medical Director was notified of the Immediate Jeopardy on 9/15/23. Review of in-service training material and training logs dated 09/12/23 and 09/15/23 revealed education was provided to licensed nurses and CNAs related to reporting any changes in skin condition, Podiatrist to exit with DON, the importance of carrying out orders timely, importance of completing weekly skin assessments, identifying skin impairments, notifying the physician for wound orders, documentation of assessments and approaches to aid in the prevention of skin breakdown. Interviews conducted with facility nurses and CNAS across multiple shifts on 09/15/23 from 5:35 p.m. to 6:20 p.m. revealed they verbalized comprehension of the in-service training. Staff interviewed were CNA F, LVN G, LVN H, CNA I, CNA J, CNA K, CNA L, LVN M, CNA N, RN O, RN P and CNA Q. The Administrator was notified on 09/15/23 at 7:16 p.m. that the Immediate Jeopardy was removed. However, the facility remained out of compliance at the severity level of actual harm that is not immediate jeopardy and at a scope of pattern due to the facility continuing to monitor the implementation and effectiveness of their plan of removal.

Based on observation, interview, and record review the facility failed to establish and maintain an infection prevention and control program with a system for preventing, identifying, and controlling infections and communicable diseases for all residents, staff, visitors, and other individuals providing services based upon the facility assessment and following accepted national standards for four of four halls reviewed for infection control. The facility failed to have an effective protocol in place to prevent the spread of COVID-19 that followed nationally accepted standards for contact tracing testing or broad-based testing. Resident #1 had a change in condition on [DATE], and he was sent to the hospital where he tested positive for COVID-19. Prior to being sent out to the hospital, Resident #1 visited his family member (Resident #2) daily, who also resided at the facility on another hall. Staff and residents were only tested if they were showing signs/symptoms of COVID-19 per their policy. The facility had not implemented contact trace testing or broad-based testing to identify others who may have been exposed. As of [DATE], 26 residents and 5 staff members had tested positive for COVID-19. An Immediate Jeopardy (IJ) was identified on [DATE]. The IJ template was provided to the facility on [DATE] at 4:37 PM. While the IJ was removed on [DATE], the facility remained out of compliance of no actual harm with potential for more than minimal harm that is not immediate jeopardy with a severity level of pattern because all staff had not been trained on testing during a COVID-19 outbreak. These failures placed residents at risk of exposure of COVID-19 virus which could result in serious illness, hospitalization , and/or death. Findings included: Interview on [DATE] at 9:00 AM with the Administrator revealed the facility had six residents that were COVID-19 positive. Review of Resident #1's MDS dated [DATE] reflected the resident was an [AGE] year-old male admitted to the facility on [DATE]. The resident's diagnoses included coronary artery disease, heart failure, hypertension, end stage renal disease, diabetes, and respiratory failure. Resident #1 had a BIMS of 15 (cognition intact) and was able to ambulate with supervision and setup only. Review of Resident #1's progress notes dated [DATE] entered by RN A revealed the following: resident had c/o chest pain .resident described chest pain as someone standing on his chest, and it hard for him to breath, stated pain was ,d+[DATE], and that the pain was not sharp Resident was sent to [Hospital] Review of Resident #1's clinical record revealed the resident had not been showing any signs or symptoms of COVID-19 prior to [DATE] Review of Resident #2's MDS dated [DATE] reflected the resident was an [AGE] year-old female admitted to the facility on [DATE]. The resident's diagnoses included atrial fibrillation, heart failure, hypertension, non-Alzheimer's dementia, and type 2 diabetes. Resident #2 had severe cognitive impairment with a BIMS score of 3 and required total care of staff for all ADLs. The MDS further reflected Resident #2 was on hospice care. Review of Resident #2's progress notes revealed the following: [DATE] - Resident was weak, Coughing and had a Fever 101.4, Hospice was notified and ordered a COVID test. Result came back positive for Covid Resident on contact isolation [DATE] - Resident continues on COVID-19 isolation precautions. Unable to make needs known, wheezing noted on Chest Auscultation, SOB noted Hospice notified and wants Comfort Medication to be given as needed with Breathing Treatment [DATE] - Resident expired, [Hospice] Nurse pronounced death Review of Resident #3's MDS dated [DATE] revealed the resident was an [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses included heat failure, hypertension, end-stage renal disease, diabetes, CVA (stroke), and malignant neoplasm of colon. Review of Resident #3's progress notes for the following dates revealed: [DATE]: Observed resident lying in bed, stated that her body was aching and had a sore throat, resident also appear to hoarse when taking. Assessed vital: B/P ,d+[DATE] Administer PRN clonidine, tramadol, placed cool towel on head, notified the [Doctor], N/O for covid testing Performed covid test and resident have a positive result [DATE]: Resident remains of airborne isolation as she tested positive for COVID 19 virus Lungs auscultated and lower lobes are very diminished, upper lobes sounded very congested [DATE]: Resident presents no s/s of COVID-19 Review of Resident #4's MDS dated [DATE] revealed the resident was a [AGE] year-old male admitted to the facility on [DATE]. His diagnoses included heart failure, hypertension, diabetes, and COPD. Review of Resident #4's progress notes on the following dates revealed: [DATE]: Resident asked this writer if He could be tested for COVID, I asked if He had any symptoms and he Stated He did not feel to well and was not sure if it was Covid or an Allergy. Notified [Doctor] and She said Resident should be tested for COVID, Resident was tested and Results was positive. Resident was moved to room [ROOM NUMBER] and put on COVID Isolations precaution [DATE]: Resident continues on COVID-19 isolation precautions. Alert and can make needs known. No complaints or pain or discomfort noted. Vitals within normal range. No congestion or chest pains noted Review of Resident #5's MDS dated [DATE] revealed the resident was an [AGE] year-old male admitted to the facility on [DATE]. His diagnoses included hypertension and non-Alzheimer's dementia. Review of Resident #5's progress notes for the following day revealed: [DATE]: Resident c/o headache/vertigo/low grad temp 99.6, MD notified and ordered covid test, results returned positive and patient transferred to room [ROOM NUMBER]B [DATE]: Resident continues on Isolation related to covid. Denies no complain Temp 97.8 Review of Resident #6's MDS dated [DATE] revealed the resident was a [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses included heart failure, end stage renal disease, Parkinson's disease, COPD, and respiratory failure. Review of Resident #6's progress for the following dated revealed the following: [DATE]: .Complaints of pain to lower back and congestion noted .MD was also notified of SOB and wheezing noted [DATE]: MD notified and gave orders for covid test. Test results were positive and orders were given to start isolation precautions [DATE]: Continues on COVID-19 isolation precautions. Alert and can make needs known. No complaints of pain or discomfort noted Interview on [DATE] at 9:34 AM with LVN B revealed Resident #1 was independent with most ADLs and was alert and oriented to person, place, time and situation. LVN B said Resident #1 would attend therapy daily and spend the rest of his day getting coffee and visiting his family member (Resident #2) who resided on the 100 hall. LVN B further stated they asked management about testing for staff and residents after Resident #1 tested positive for COVID-19, and they were told they were not testing per their facility policy. LVN B further stated she had not noticed any signs/symptoms of COVID-19 while caring for the resident. Interview on [DATE] at 9:50 AM with CNA C revealed she worked with Resident #1. CNA C stated the resident was independent with most ADLs. CNA C stated Resident #1 visited his family member, Resident #2, daily on the 100 hall. CNA C further stated she was not asked to test for COVID-19 after being around Resident #1 and she had not noticed Resident having any signs/symptoms of COVID-19 while she care for the resident. Interview on [DATE] at 10:38 AM with CNA D revealed she worked with Resident #2. CNA D stated Resident #1 visited Resident #2 daily and spent most of his day with her in her room. After Resident #1 tested positive, the staff were asked to wear surgical masks, but no one was asked to test. CNA D further stated she was not asked to test for COVID-19 after being around Resident #1 and she had not noticed Resident having any signs/symptoms of COVID-19 while she care for the resident. Interview on [DATE] at 10:38 AM with CNA J revealed she worked with Resident #2, and she appeared to be slowly declining prior to the resident passing away (did not specify the timeframe). The resident's family member, Resident #1, would visit her daily and stay in her room for long periods of time. CNA J stated some time after Resident #1 discharged to the hospital, Resident #2 began to sleep more and got a nasty cough. CNA J also said she or none of the other staff were asked to test for COVID-19 and they were only told to begin to wear masks again after Resident #1 tested positive for COVID-19 ([DATE]). Interview on [DATE] at 2:03 PM with the DON revealed Resident #1 was sent to the hospital ([DATE]) for a change in condition where he tested positive for COVID-19. After they were informed Resident #1 tested positive, they were only testing staff/residents that were showing signs and symptoms of COVID-19 per their facility policy. Interview on [DATE] at 3:11 PM with the Infection Control Preventionist revealed they had not conducted contact or widespread testing after Resident #1 was positive for COVID-19 because they were following their facility COVID-19 policy. The Infection Control Preventionist stated per their policy they were only doing symptom-based testing. Review of the facility's policy titled Infection Prevention and Control Policies and Procedures revised on [DATE] reflected the following: CORONAVIRUS DISEASE (COVID-19) Continue .Procedures: .3 Facility staff may test residents for COVID-19 when respiratory symptoms appear to identify positive cases Review of the facility's COVID Positive Residents/Staff List revealed the following: [DATE] - 1 resident [DATE] - 1 resident [DATE] - 1 staff [DATE] - 4 residents [DATE] - 2 residents [DATE] - 1 staff [DATE] - 1 resident [DATE] - 1 staff [DATE] - 2 residents and 1 staff [DATE] - widespread testing was conducted - 15 residents and 1 staff Interview on [DATE] at 11:33 AM with the Administrator revealed he contacted the local health department on [DATE]. The Administrator said he did not contact the local health department after Resident #1 tested positive for COVID-19, [DATE], because he had been told by the local health department to only send them a line listing of COVID-19 positive cases once a week. The Administrator further stated they facility was only doing symptoms based testing after Resident #1 tested positive for COVID-19 ([DATE]). Interview on [DATE] at 12:22 PM with the local health department revealed they wanted to know as soon as possible when a resident tested positive for COVID-19. The local health department also stated they continued to recommend testing of staff and residents per CDC recommendations. They further stated they also continued to recommend the facility conducted contact or widespread testing to help prevent the spread of COVID-19. Interview on [DATE] at 10:07 AM with the Medical Director revealed he was not aware the facility COVID-19 policies did not have prevention protocols in place or that the health department had not been contacted after their first COVID-19 positive resident. The Medical Director further stated moving forward they would relook at the infection control guidelines and adjust to CDC standards for prevention. Interview on [DATE] at 3:22 PM with the Health Department revealed they had just received an updated list from the facility of resident/staff positives for COVID-19, and the total was up to 55. Review of the facility's current Infection Prevention and Control Policies and Procedures, revised [DATE], reflected the following: Policy: In the event of a suspected or actual case of SARS-CoV-2/COVID-19, the Facility provides notification to the Clinical Services Director and Regional [NAME] President and initiates involvement of federal, state, and local health agencies for direction regarding current recommended strategies for prevention of spread of the disease and treatment methods .4. Facility staff shall notify its local/state health departments upon discovery of any positive cases of COVID-19 Review of the CDC's website, Infection Control: Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) | CDC accessed on [DATE], revealed: .Nursing Homes .Stay connected with the healthcare-associated infection program in your state health department, as well as your local health department, and their notification requirements. Report SARS-CoV-2 infection data to National Healthcare Safety Network (NHSN) Long-term Care Facility (LTCF) COVID-19 Module. See Centers for Medicare & Medicaid Services (CMS) COVID-19 reporting requirements. Managing admissions and residents who leave the facility: Admission testing is at the discretion of the facility. Pros and cons of screening testing are described in Section 1. Residents who leave the facility for 24 hours or longer should generally be managed as an admission. Empiric use of Transmission-Based Precautions is generally not necessary for admissions or for residents who leave the facility for less than 24 hours (e.g., for medical appointments, community outings) and do not meet criteria described in Section 2. Placement of residents with suspected or confirmed SARS-CoV-2 infection Ideally, residents should be placed in a single-person room as described in Section 2. If limited single rooms are available, or if numerous residents are simultaneously identified to have known SARS-CoV-2 exposures or symptoms concerning for COVID-19, residents should remain in their current location. Responding to a newly identified SARS-CoV-2-infected HCP or resident When performing an outbreak response to a known case, facilities should always defer to the recommendations of the jurisdiction's public health authority. A single new case of SARS-CoV-2 infection in any HCP or resident should be evaluated to determine if others in the facility could have been exposed. The approach to an outbreak investigation could involve either contact tracing or a broad-based approach; however, a broad-based (e.g., unit, floor, or other specific area(s) of the facility) approach is preferred if all potential contacts cannot be identified or managed with contact tracing or if contact tracing fails to halt transmission. Perform testing for all residents and HCP identified as close contacts or on the affected unit(s) if using a broad-based approach, regardless of vaccination status. Testing is recommended immediately (but not earlier than 24 hours after the exposure) and, if negative, again 48 hours after the first negative test and, if negative, again 48 hours after the second negative test. This will typically be at day 1 (where day of exposure is day 0), day 3, and day 5. Due to challenges in interpreting the result, testing is generally not recommended for asymptomatic people who have recovered from SARS-CoV-2 infection in the prior 30 days. Testing should be considered for those who have recovered in the prior ,d+[DATE] days; however, an antigen test instead of a nucleic acid amplification test (NAAT) is recommended. This is because some people may remain NAAT positive but not be infectious during this period. Empiric use of Transmission-Based Precautions for residents and work restriction for HCP are not generally necessary unless residents meet the criteria described in Section 2 or HCP meet criteria in the Interim Guidance for Managing Healthcare Personnel with SARS-CoV-2 Infection or Exposure to SARS-CoV-2, respectively. However, source control should be worn by all individuals being tested . In the event of ongoing transmission within a facility that is not controlled with initial interventions, strong consideration should be given to use of Empiric use of Transmission-Based Precautions for residents and work restriction of HCP with higher-risk exposures. In addition, there might be other circumstances for which the jurisdiction's public authority recommends these and additional precautions. If no additional cases are identified during contact tracing or the broad-based testing, no further testing is indicated. Empiric use of Transmission-Based Precautions for residents and work restriction for HCP who met criteria can be discontinued as described in Section 2 and the Interim Guidance for Managing Healthcare Personnel with SARS-CoV-2 Infection or Exposure to SARS-CoV-2, respectively. If additional cases are identified, strong consideration should be given to shifting to the broad-based approach if not already being performed and implementing quarantine for residents in affected areas of the facility. As part of the broad-based approach, testing should continue on affected unit(s) or facility-wide every ,d+[DATE] days until there are no new cases for 14 days. If antigen testing is used, more frequent testing (every 3 days), should be considered On [DATE] at 4:24 PM the Administrator, DON, and the Infection Control Preventionist were notified an Immediate Jeopardy was identified and a Plan of Removal was requested. The IJ template was provided. The Facility's Plan of Removal for Immediate Jeopardy was accepted on [DATE] at 9:52 AM and reflected the following: The 6 identified residents are in transmission-based precautions for COVID-19. Resident #1 no longer resides in the facility. Residents and/or employees who had close contact identified by root cause, contact tracing and have high risk exposure with the identified 6 COVID 19 positive residents and the 3 COVID 19 positive employees will be and tested for COVID 19 by [DATE] Resident who test positive for COVID 19 will be placed in transmission based precautions. Employees who test positive for COVID 19 will be sent home and return to work when the following criteria are met: At least 7 days have passed since symptoms first appeared if a negative viral test* is obtained within 48 hours prior to returning to work (or 10 days if testing is not performed or if a positive test at day ,d+[DATE]), and At least 24 hours have passed since last fever without the use of fever-reducing medications, and Symptoms (e.g., cough, shortness of breath) have improved. Resident and employees that do not test positive will don source control for 10 days and be tested every 3 days until there are no new cases for 14 days Director of nursing, Infection Preventionist and administrator were re-educated by the Regional [NAME] President of Operations and the Clinical Consultant on [DATE] on Implementing Infection Control Measures to prevent the spready and development of COVID 19 including: Any single new case of COVID 19 infection in any employee or resident should be evaluated to determine if others in the facility could have been exposed. Perform testing for all residents and employee identified as close contacts who have not tested positive for COVID 19 in the last 30 days. Testing is recommended immediately (but not earlier than 24 hours after the exposure) and, if negative, again 48 hours after the first negative test and, if negative, again 48 hours after the second negative test. This will typically be at day 1 (where day of exposure is day 0), day 3, and day 5. Daily monitoring of residents for signs and symptoms of COVID 19 a broad-based (e.g., unit, floor, or other specific area(s) of the facility) approach will be initiated if all potential contacts cannot be identified or managed with contact tracing or if contact tracing fails to halt transmission contact tracing and root cause analysis in infection control to prevent the spread of any infection The Director of Nursing / designee will re-educate licensed nurses on [DATE] on Implementing Infection Control Measures to prevent the spread and development of COVID 19 Any single new case of COVID 19 infection in any employee or resident should be evaluated to determine if others in the facility could have been exposed. Perform testing for all residents and HCP identified as close contacts who have not tested positive for COVID 19 in the last 30 days. Testing is recommended immediately (but not earlier than 24 hours after the exposure) and, if negative, again 48 hours after the first negative test and, if negative, again 48 hours after the second negative test. This will typically be at day 1 (where day of exposure is day 0), day 3, and day 5. Daily monitoring of residents for signs and symptoms of COVID 19 a broad-based (e.g., unit, floor, or other specific area(s) of the facility) approach will be initiated if all potential contacts cannot be identified or managed with contact tracing or if contact tracing fails to halt transmission Any licensed nurse not receiving this information by [DATE] will receive prior to their next scheduled shift, this will include any staff on FMLA, sick days or vacation. This information will also be presented to agency staff before reporting to assigned area. Staff will be screened prior to work for signs and symptoms of illness and not be allowed to work until symptoms are resolve. Residents will be screened daily for signs and symptoms of COVID 19 and placed in transmission-based precautions and or tested as necessary If a resident or employee tests positive for COVID 19, a root cause analysis will be completed to identify additional testing or screening that should be completed. The Medical Director was notified on [DATE] of the Immediate Jeopardy. Ad Hoc Quality Assurance Performance Improvement Meeting with the Administrator, Director of Nursing and Clinical Consultant and medical director was held on [DATE] to discuss contents of this plan and will be reported by the administrator to Quality Assurance Performance Improvement committee monthly for review and recommendations. The administrator will ensure implementation and monitoring of this plan of removal. Monitoring of the POR included: Review of the facility's COVID Positive Residents/Staff List provided by the Administrator on [DATE] revealed facility conducted widespread testing was conducted on [DATE] to [DATE] and there were an additional 15 resident and 1 staff that were positive for COVID-19. All residents were cohorted/isolated according to CDC recommendations. New staff identified were sent home to isolated. Observation on [DATE] through [DATE] revealed the facility had placed the proper PPE outside each isolation room for staff to don and doff. Interviews were conducted on [DATE] starting at 10:38 AM and completed on [DATE] at 10:20 AM with 14 staff members (Administrator, DON, Infection Control Preventionist, ADON, RN A, LVN B, LVN E, LVN I, LVN K, LVN L, RN M, LVN N, LVN O, LVN P) from various shifts regarding in-services which included testing after a COVID-19 outbreak. The staff members were able to explain the process when there is an COVID-19 outbreak. Testing will be conducted with residents and health care personnel identified as close contact. Testing will be done at day 1, 3 and 5. Staff were also in-serviced on the monitoring of residents for signs and symptoms of COVID-19. Record review of residents revealed newly identified residents with COVID-19 were being monitored every shift and COVID-19 negative residents were being monitored daily. An IJ was identified on [DATE]. While the IJ was removed on [DATE], the facility remained out of compliance at a level of no actual harm with potential for more than minimal harm that is not immediate jeopardy with a scope of pattern as the facility was continuing to monitor the implementation and effectiveness of their plan of removal.

Based on observation, interview, and record review, the facility failed to ensure a resident with a pressure ulcer received necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing for one (Resident #1) of four residents reviewed for pressure ulcers. The facility failed to implement physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . This failure could place residents at risk for deterioration of existing wounds/skin injuries. Findings included: Review of Resident #1's MDS dated [DATE] reflected he was [AGE] year-old male admitted to the facility on [DATE]. His diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS reflected the resident had moderately impaired cognition, was usually understood and usually understood others. The MDS reflected the resident did not have any unhealed pressure ulcers/injuries. Resident #1 required extensive assistance of two staff members for bed mobility and one person assist with other ADLs. Review of Resident #1's care plan dated 10/10/22 revealed he had an unstageable wound on his right buttocks. Care Plan approaches included applying dressings per MD order daily with Santyl, calcium, and dry dressing. Review of Resident #1's progress notes dated 09/30/22 revealed the following: New opening noted to left buttocks. Area cleansed with normal saline, pat dry, and dressing applied. Will let wound care know. Review of the Facility Wound Summary Report dated 09/30/22 revealed Resident #1 had a pressure ulcer to his left buttock, which was not present on admission, that measured 2 cm x 2 cm x 0.1 cm. Review of Resident #1's October 2022 monthly physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Observation on 10/12/22 at 11:52 AM with the Wound Care Nurse revealed Resident #1 had an open area on his left buttocks. The open area did not have a dressing and drainage was observed on the brief. There was slough noted to the wound, and the Wound Care Nurse measured the open area, and it was 7 cm x 4.5 cm x 1. Interview on 10/12/22 at 1:49 PM, CNA D revealed she had given Resident #1 a bed bath prior to therapy around 10:30 AM that morning and while she was changing the resident, the bandage on his buttocks came off. CNA D stated she had let the Wound Care Nurse know the bandage had come off. She also stated the resident had gone to therapy without a dressing on the wound on his buttocks because he was insistent about getting out of bed. Interview on 10/13/22 at 12:37 PM, PTA C revealed Resident #1 was in the hallway ready for therapy on 10/12/22. He stated he was not aware the resident had a wound on his buttocks. He stated he would have expected to have been informed about the wound to make sure he was not pushing on the area during therapy. Interview on 10/12/22 at 2:10 PM, the Wound Care Nurse revealed no one had let her know Resident #1's bandage had come off before he went to therapy. The Wound Care Nurse stated it was a common occurrence for her to find a wound without a dressing during wound care. She stated this was the third time she had noticed Resident #1 had no dressing on the wound when she went to provide care. She said the bandages would get soiled at times, and when the aides were providing care they would come off, but if that happened they should report to her or the charge nurse so that a new dressing could be put back on to prevent the wound from deteriorating or getting an infection. She stated when she was going to provide wound care to Resident #1 on 10/03/22 there was not a bandage on his wound, and she did not know who had taken it off and why. On Saturday, 10/08/22, she was not able to do her wound care rounds until about 5:00 PM that evening and treated Resident #1's wound around 8:00 PM that night. The resident did not have a dressing on his wound, and she did not know how long he had been without one. She statedthe wound on the resident's bottom had deteriorated and grown from the last time she saw it and treated it on Friday, 10/07/22. The Wound Care Nurse said at that time on Saturday, 10/08/22, she should have completed a communication form for the Wound Care Physician to see Resident #1 on his next visit, which was on Monday, 10/10/22, but she had forgotten. She stated she forgot to refer Resident #1 again during the Wound Care Physician's rounds at the facility on 10/10/22, therefore he still had not been seen or assessed by the Wound Care Physician. Review of Resident #1's Treatment Administration History revealed the following: .Scheduled Date: 10/08/22; Scheduled Time: 6:00 AM - 4:00 PM; Reason/Comments: Not Administered: Other, Comment: wound care nurse performed Interview on 10/13/22 at 10:42 AM with CNA B revealed she got Resident #1 up and dressed on Saturday, 10/08/22, around 10:30 AM or 11:00 AM. The CNA stated the resident did have a dressing on his buttocks, but she did not see what was under it. She went to LVN A and let her know his dressing was soiled and the nurse went to the resident's room to change it, but she (CNA) did not stay in the room during that time. Interview on 10/13/22 at 9:23 AM, LVN A revealed she had worked with Resident #1 on Saturday, 10/08/22. She stated the CNAs had gotten the resident up and dressed because he was going to be taken out on pass for a funeral service. She stated she did not remember if she had done wound care treatment on the resident . LVN A said she did put a bandage on his buttocks because Resident #1 had complained of pain. She did not remember seeing any wound to his buttocks . LVN A said she had put a bandage to the resident's buttocks, because I wanted to add extra cushion to his buttocks because he was complaining of pain. LVN A further stated the did recall seeing some redness to Resident #1's buttocks and she applied some barrier cream on it and again stated she had added the dressing for extra cushion only. Interview on 10/13/22 at 12:50 PM, Resident #1 revealed he was aware he had a wound on his buttocks, but he did not recall how long he had it or how he got it. He was asked if someone had changed his brief after he returned from the funeral service, and he said, I don't think so. Resident #1 was not able to recall if a bandage had put on his buttocks before he left to go out on pass. Interview on 10/13/22 at 12:55 PM, Resident #1's family revealed they took the resident out on pass on Saturday, 10/08/22, for a funeral service around 1:30 PM that day. Resident #1 was returned back to the facility around 3:00 PM or 3:30 PM, after the funeral service. The family further stated during that time Resident #1 was out, he was never taken to the bathroom, and they did not touch his brief, so they were not aware if the resident had a dressing on his wound. Interview on 10/14/22 at 11:05 AM, the DON revealed she was made aware Resident #1 had a wound to his buttocks on 09/30/22, and it was being treated by the Wound Care Nurse. She was made aware on Tuesday, 10/11/22, the resident's wound had deteriorated and that was also her first time looking at it. She said the wound was open and was reddened and there was drainage to the bandage. She was not made aware the wound care physician had not been contacted to evaluate Resident #1's wound and he should have told as soon as the wound had deteriorated. She was not aware there were days where Resident #1 had been found without a dressing to his wound until Wednesday, 10/12/22, when the observation had been made by the surveyor. The DON also said risks of not having a dressing on a wound could further damage the wound and she did not feel like 30 minutes was a big deal for Resident #1 to be without a dressing, while he was a therapy. Interview on 10/13/22 at 1:13 PM with the NP revealed she was made aware Resident #1 had a wound on his buttocks on 10/06/22, but she had not been able to see it because the resident was refusing her visits. She was notified on 10/11/22 that Resident #1's wound had gotten worse, but the facility had a Wound Care Physician that assessed and treated the resident wounds. The NP further stated the Wound Care Physician should have been notified as soon as the staff noticed the wound had deteriorated to evaluate and treat the wound. She also said risks of a resident not having a dressing to a wound included opening or irritation of the wound and infection. Review of the facility's current policy entitled, Wound Care Policies and Procedures Reference, revised June 2015 reflected the following: .Ongoing Evaluation Patient/residents at risk for pressure ulcer development and those with wounds should be monitored daily for changes in their skin condition any abnormal findings/changes (redness, rashes, bruises, open areas, etc) should be documented and reported to patient's/resident's primary care provider .Wound Evaluation The facility should have a system in place for daily observation of pressure ulcers/wounds which may include: .An evaluation of the status of the dressing Evaluation of potential complications (increase in size, redness, swelling, or drainage

Based on observation, interview and record review the Administrator and the DON failed to administer the facility in a manner that enabled it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being for two (Resident #21 and #22) of seven residents reviewed for gastrostomy (tube inserted through the abdomen into the stomach for the purpose of administering liquid nutrition and medications) care. 1) The Administrator failed to supervise the DON to ensure she monitored nursing staff for compliance with maintaining proper positioning for residents that received medications and/or feedings via gastrostomy tubes; and 2) The DON failed to supervise nursing staff regarding the positioning of residents receiving medications and/or feedings via gastrostomy tube. 3) The DON failed to train nursing staff regarding positioning of residents with gatrostomy tubes. An immediate jeopardy was identified on 02/05/16 at 4:55 PM. While the IJ was removed on 02/07/16, the facility remained out of compliance at a severity level of No actual harm with potential for more than minimal harm, and a scope of pattern because the staff were still being trained and the facility was monitoring the effectiveness of the Plan of Removal. These failures placed the facility's seven residents who received medication, fluids, and enteral feeding at risk for gagging/choking and/or aspiration possibly causing aspiration pneumonia, hospitalization and/or death. Findings included: 3) The Resident Admission Record dated 02/04/16 reflected Resident #21 was a [AGE] year-old male admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The MDS assessment, dated 01/31/16, reflected Resident #21 had a feeding tube and received 51% or more of calories through the feeding tube. His BIMS (Brief Interview for Mental Status) reflected a 14, indicating cognitively intact. Resident #21's January 2016 Consolidated Physician order [REDACTED]. Observation of medication pass on 02/04/16 at 8:27 AM, revealed LVN C administered medications to Resident #21 through his gastrostomy tube. Resident #21 was lying on his right side and had slid down in the bed upon entering the room. During the administration of the second crushed medication, Resident #21 began to gag as if he were about to vomit. LVN C paused the medication administration and asked if Resident #21 was alright, then once he cleared his throat, LVN C continued with the administration. Resident #21 stated, It's a good thing I have a strong gag reflex. Observation and interview on 02/04/16 at 8:55 AM, with LVN C revealed the facility policy for positioning of a resident with a gastrostomy tube was 30 to 45 degrees. LVN C then returned to Resident #21's room with the medication. LVN C was asked if she felt Resident #21 was positioned at 30 to 45 degrees. LVN C walked around each side of the bed looking at the sides, but did not respond. LVN C did not assess the position of Resident #21. She then administered the final medication to Resident #21 and flushed the gastrostomy tube with 60 cc water while Resident #21 was positioned less than 30 degrees. On 02/04/16 at 9:04 AM, the surveyor summoned the DON. The DON entered the room of Resident #21. Observation and interview with the DON revealed Resident #21 was not positioned appropriately. She said Resident #21 needed to be up in the bed a little bit with his head up a little more. The DON instructed LVN C to assist her and they repositioned Resident #21, pulling him up in the bed. The DON then took LVN C's stethoscope and assessed Resident #21's lung sounds and said they sounded clear. The DON said she would have LVN C in-serviced on [DEVICE] medications and positioning and she would have a nurse call the physician to report the choking episode to him. She also stated she would have a nurse call [MEDICAL TREATMENT] and let them know to monitor Resident #21 when he was in [MEDICAL TREATMENT] as he was scheduled to go there. An interview with LVN C on 02/05/16 at 2:45 PM revealed during the medication pass, she felt she could have raised Resident #21 up higher or turned him to the side, but it sounded like he was going to vomit. LVN C said she still had the gastrostomy tube in her hand, but she could have dropped it and grabbed the remote for the bed. LVN C said since Resident #21 had slid down in the bed, the head of the bed was elevated at 35 to 40 degrees but the resident was not. She further said if she went in to perform a medication administration in the future and Resident #21 was slid down in the bed, she would get another aide to go with her and help adjust him to the proper position before beginning the administration of the medications. During an interview with Resident #21 on 02/05/16 at 3:15 PM he said the nurses sometimes do not position him properly and that he had choked on the feeding before. During an interview with Resident #21 on 02/05/16 at 4:15 PM he said he felt afraid he might die during times when he gags/chokes. 4) Review of Resident #22's facility Face Sheet, dated 02/06/16, revealed she was a [AGE] year-old female admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #22's care plan, dated 11/01/15, reflected she required tube feeding related to dysphagia and nothing by mouth (NPO). The long-term goal was that she would not exhibit signs of complications from the feeding tube or enteral feeding solution. The care plan also reflected to Elevate HOB 30-45 degrees .Resident needs to be kept at 45 Degree Angle due to risk for Aspiration at all times. Resident #22's MDS assessment, dated 11/30/15, reflected she was severely impaired cognitively. She required extensive assistance from two plus people for bed mobility and was total assist from one person for eating. She had a feeding tube ([DEVICE]) and received 51% or more of her nutrition and 501 cc/day or more of her fluid intake per her tube feeding. Resident #22's current Physician orders, dated 02/06/16, reflected she was to have her enteral feeding solution at 45 cc/hr for 22 hours via her gastric tube ([DEVICE]). It further reflected to Elevate HOB 30-45 degrees during feeding and one hour after . On 02/05/16 at 2:20 PM, Resident 22 was observed in her room, in bed. She was awake and alert. Resident #22 had slid down in the bed. Resident 22's [DEVICE] was attached to the feeding pump and was running an enteral feeding solution at 46 cc/hr. 5) Review of the facility's Nursing Policy and Procedure titled, Medication Management Program, revised 07/24/14 reflected the following: .13. The authorized licensed or certified/permitted medication aide or by state regulatory guidelines staff member administers enteral medications as follows: A. Check position of patient/resident (forty (40) + degrees) 6) Review of the facility's Nursing Policy and Procedure titled, Gastrostomy Tubes, dated 02/24/12, revealed aspiration as a complication; however, there were no guidelines regarding the proper positioning of a resident during enteral feeding and/or medication administration. Keep patients sitting upright at 30 to 45 degrees during tube feeding and for one to two hours afterward to minimize incidence of nosocomial aspiration pneumonia and to allow gravity to help propel the food. This information was retrieved on 02/12/16 from: www.merckmanuals.com/professional/nutritional-disorders/nutritional-support <http://www.merckmanuals.com/professional/nutritional-disorders/nutritional-support> 7) During an interview with the DON on 02/07/16 at 2:10 PM when asked how the incident with Resident #21 occurred, the DON said the nurse was unable to perform under pressure. The DON said there were no prior in-services regarding [DEVICE]s that she could recall. When asked how she ensured her nurses were competent in their skills for caring for a resident with a [DEVICE], the DON said the nurses received competency check offs for medication passes regarding [DEVICE]s by the pharmacy. The DON also said the nurses were trained from the policy and procedure on [DEVICE]s and the CNAs received training on [DEVICE]s in CNA school. The DON said she could not recall any available computer trainings, but she was sure the facility did not have any training regarding [DEVICE]s during the orientation process. 8) An interview with the ADM on 02/07/16 at 2:40 PM when asked how the incident with Resident #21 and #22 occurred, the ADM said previous nurse turnover, bad hires, nurse with poor knowledge/skills, nurses/staff who don't have customer service attitude, and staff not seeming to care were all contributing factors. He stated he was still trying to assess who was trainable and who he should keep and who he should let go. When asked how he monitored his DON to ensure systems she monitored were being completed sufficiently he stated the Regional Clinical Manager reviews reports (incidents, etc.) and care needs. He also stated he monitors by being on the floor, reviewing QAPI reports, and from feedback from the family and residents. When asked what types of procedure were in place to make sure nursing needs of the residents were being met he said the daily clinical meetings, 24-hr reports, hall rounds, QAPI meetings, and clinical stats to determine problems and/or needs were all utilized. 9) An Immediate Jeopardy was identified on 02/05/16 at 4:55 PM. The ADM was notified of the IJ on 02/05/16 at 4:55 PM. The ADM, DON, and CSD were notified of the IJ on 02/05/16 at 5:00 PM. A Plan of Removal for the IJ was requested at that time. 10) The facility's POR was accepted on 02/07/16 at 3:20 PM. The plan reflected the following: --On 02/05/16 each resident with a Gastrostomy Tube was observed for proper positioning in bed with HOB 30-40 degrees with resident pulled up in bed and without slumping. There were none identified to be improperly positioned. Each resident with Gastrostomy Tube was evaluated for signs and symptoms of aspiration. --On 02/04/16 LVN C was given a 1 on 1 in-service by ADON A on proper medication administration via gastrostomy tube and resident positioning. LVN C was suspended pending investigation. --Licensed Nursing staff, Certified Nursing Assistants, and Medication Aides will be re-educated by CSD and members of Nursing Management beginning on 02/05/16 and ending on 02/06/16. After 02/06/16, no licensed nurse, certified nursing assistant, or medication aide will be allowed to work their scheduled shift until they have completed the required re-education. The re-education process will be validated using a post test. --The training will also be included in New Hire orientation and then annually thereafter. Re-education included: Facility policy and procedure for proper positioning of resident who requires a Gastrostomy Tube for medications and/or nutritional supplements. Identification of resident slumping in bed and not positioned 30-40+ degrees upright and expectation of repositioning properly. Documentation of improper position to be documented on the 24 hour report for nursing management follow up and validation. The expectation of repositioning the resident when identified prior to administration of medication. Expectation that if resident position changes during the administration of medications or enteral nutrition the administration will be stopped and the resident will be properly positioned prior to continuation of administration. Additionally, the resident will be evaluated for signs and symptoms of aspiration if found improperly position with intervention as indicated. Residents who require Gastrostomy Tube for medications and/or nutritional supplements will be observed every 15 minutes for 4 hours. Then every 30 minutes for 4 hours starting at 7:15 PM on 02/05/16. Moving forward, we will monitor resident positioning once an hour while enteral nutrition is being administered to ensure proper body position. Resident(s) found slumping e.g.: body angle not within 30-40 degree range will be repositioned, assessed and monitored every 15 minutes for two hours to ensure proper body position is maintained. If positioning is not maintained, 15 minute checks will resume until positioning intervention is initiated and resident maintains a position of 30-40+ degree during feeding and medication administration. Additionally, CNA's and MA's will be educated to notify the nurse to pause Gastrostomy Tube feeding to deliver care to the resident and resuming the feeding once care is complete so the resident is properly positioned with Head of Bed elevated 30 to 40+ degrees and resident is positioned upright and not slumping. --The DON will be responsible for monitoring re-education compliance and will validate that no employee returns to work prior to completing the required re-education. --Members of Nursing Management will perform rounds each shift to observe residents who require Gastrostomy tube for medications and/or nutritional supplements. These rounds will begin on second shift on 02/05/16 and will continue for 4 weeks. These rounds will be monitored through daily clinical meetings Monday through Friday. The process will also be analyzed through the monthly Quality Assurance and Performance Improvement meeting until significant compliance is achieved and maintained. --The MD was notified by the ADM of the facility's IJ status on 02/06/16. --The ADM will be responsible for the overall implementation and validations of this plan. 11) To verify implementation of the plan the following was conducted: Routine Check Sheets were provided for all residents with a Gastrostomy Tube that reflected monitoring every 15 minutes, 30 minutes, then every hour which began on 02/05/16, and was still ongoing at the time the POR was accepted on 02/07/16. A copy of the facility's education for Gastrostomy Tube Resident Positioning for CNAs and Licensed Nurses along with the post-test was received from the ADM on 02/07/16 at 3:30 PM. --Evidence revealed 17 of 29 nurses and 18 of 48 CNAs and MAs had received the required re-education at the time of the POR acceptance on 02/07/16. During individual interviews with the following RNs they each answered all questions on the positioning of resident's with a Gastrostomy Tube correctly. The interviews were conducted on the following day: --On 02/07/16 at 11:24 AM and 1:20 PM with RN G and RN H. During individual interviews with the following LVNs they each answered all questions on the positioning of resident's with a Gastrostomy Tube correctly. The interviews were conducted on the following day: --On 02/07/16 at 12:35 PM, 3:05 PM, 3:25 PM, 3:29 PM, 3:50 PM, 4:08 PM, and 4:11 PM with LVN I, LVN J, LVN K, LVN L, ADON B, ADON A, and LVN M. During individual interviews with the following CNAs they each answered all questions on the positioning of resident's with a Gastrostomy Tube correctly. The interviews were conducted on the following day: --On 02/07/16 at 10:45 AM, 11:00 AM, 11:34 AM, 11:40 AM, 12:30 PM, 2:25 PM, 2:35 PM, 3:45 PM, 3:50 PM, and 3:55 PM with CNA N, CNA O, CNA P, CNA Q, CNA R, CNA S, CNA T, CNA U, CNA V, and CNA W. During individual interviews with the following MAs they each answered all questions on the positioning of residents with a Gastrostomy Tube correctly. The interviews were conducted on the following day: --On 02/07/16 at 12:25 PM and 4:05 PM with MA X and MA Y. Follow-up observations were made of the residents with gastrostomy tubes on the following day: --On 02/07/16 at 10:50 AM, 10:54 AM, 10:56 AM, 11:06 AM, 11:07 AM, 11:09 AM, and 11:12 AM of Resident #22, #26, #25, #27, #21, #8, and #28. All residents were positioned in the bed at or above 30 degrees, with the exception of Resident #21 who was positioned in the bed at 15 to 20 degrees. Resident #21 had no fluids or formula running in his gastrostomy tube at that time. Review of the facility's Nursing Policy and Procedure titled, Gastrostomy Tube Management Policy Addendum, revised on 02/07/16 and provided by the ADM on 02/07/16 at 4:00 PM revealed the following: Subject: Required body positioning monitoring for patient(s) who receive enteral nutrition via gastrostomy tube. Policy: Residents who require Gastrostomy Tube for medications and/or nutritional supplements will be monitored for resident positioning once an hour while enteral nutrition is being administered to ensure proper body position. Resident(s) found slumping e.g. body angle not within 30-40 degree range will be repositioned, assessed and monitored every 15 minutes for two hours to ensure proper body position is maintained. If positioning is not maintained, 15 minute checks will resume until positioning intervention is initiated and resident maintains a position of 30-40+ degree during feeding and medication administration. 12) On 02/07/16 at 4:40 PM the ADM, DON, and CSD were notified the IJ was removed. While the IJ was removed on 02/07/16, the facility remained out of compliance at a severity level of No actual harm with potential for more than minimal harm, and a scope of pattern because the staff were still being trained and the facility was monitoring the effectiveness of the POR. 13) The facility's enteral feeding list provided by the DON on 02/04/16 reflected there were seven residents with a gastrostomy tube.

Based on observation, interview and record review, the facility failed to ensure residents with gastrostomy tubes received appropriate treatment and services to prevent aspiration, pneumonia, diarrhea, vomiting, dehydration, and metabolic abnormalities for two (Residents #21 and #22) of seven residents reviewed for gastrostomy (tube inserted through the abdomen into the stomach for the purpose of administering liquid nutrition and medications) care. 1. LVN C failed to ensure Resident #21 was positioned with his head at a 35 to 40 degree angle prior to and during administration of medication through his gastrostomy tube causing him to gag/choke. 2. The facility failed to ensure Resident #22 was positioned with her head at a 35 to 40 degree angle while receiving her continuous enteral tube feeding which could cause her to gag/choke. An Immediate Jeopardy was identified on 02/05/16. While the IJ was removed on 02/07/16, the facility remained out of compliance at a severity level of No actual harm with potential for more than minimal harm, and a scope of pattern because the staff were still being trained and the facility was monitoring the effectiveness of the Plan of Removal. This failure affected Resident #21 causing him to gag/choke during the administration of medication and fluids through the gastrostomy tube and had the potential to affect the facility's six other residents who received medication, fluids, and enteral feeding through the gastrostomy tube causing them to gag/choke and/or to aspirate, possibly causing aspiration pneumonia, hospitalization or death. Findings included: 1) The Resident Admission Record dated 02/04/16 reflected Resident #21 was a [AGE] year-old male admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The MDS assessment, dated 01/31/16, reflected Resident #21 had a feeding tube and received 51% or more of calories through the feeding tube. His BIMS (Brief Interview for Mental Status) reflected a 14 indicating he was cognitively intact. Resident #21's January 2016 Consolidated Physician order [REDACTED]. Observation of the medication pass on 02/04/16 at 8:27 AM, revealed LVN C administered medications to Resident #21 through his gastrostomy tube. Resident #21 was lying on his right side and had slid down in the bed upon entering the room. During the administration of the second crushed medication, Resident #21 began to gag as if he were about to vomit. LVN C paused the medication administration and asked if Resident #21 was alright, then once he cleared his throat, LVN C continued with the administration. Resident #21 stated, It's a good thing I have a strong gag reflex. Observation and interview on 02/04/16 at 8:55 AM, with LVN C revealed the facility policy for positioning of a resident with a gastrostomy tube was 30 to 45 degrees. LVN C then returned to Resident #21's room with the medication. LVN C was asked if she felt Resident #21 was positioned at 30 to 45 degrees. LVN C walked around each side of the bed looking at the sides, but did not respond. LVN C did not assess the position of Resident #21. She then administered the final medication to Resident #21 and flushed the gastrostomy tube with 60 cc water while Resident #21 was positioned less than 30 degrees. On 02/04/16 at 9:04 AM, the surveyor summoned the DON. The DON entered the room of Resident #21. Observation and interview with the DON revealed Resident #21 was not positioned appropriately. She said Resident #21 needed to be up in the bed a little bit with his head up a little more. The DON instructed LVN C to assist her and they repositioned Resident #21, pulling him up in the bed. The DON then took LVN C's stethoscope and assessed Resident #21's lung sounds and said they sounded clear. The DON said she would have LVN C in-serviced on [DEVICE] medications and positioning and she would have a nurse call the physician to report the choking episode to him. She also stated she would have a nurse call [MEDICAL TREATMENT] and let them know to monitor Resident #21 when he was in [MEDICAL TREATMENT] as he was scheduled to go there. An interview with LVN C on 02/05/16 at 2:45 PM revealed during the medication pass, she felt she could have raised Resident #21 up higher or turned him to the side, but it sounded like he was going to vomit. LVN C said she still had the gastrostomy tube in her hand, but she could have dropped it and grabbed the remote for the bed. LVN C said since Resident #21 was slid down in the bed, the head of the bed was elevated at 35 to 40 degrees, but the resident was not. She further said if she went in to perform a medication administration in the future and Resident #21 was slid down in the bed, she would get another aide to go with her and help adjust him to the proper position before beginning the administration of the medications. During an interview with Resident #21 on 02/05/16 at 3:15 PM he said the nurses sometimes do not position him properly and that he had choked on the feeding before. During an interview with Resident #21 on 02/05/16 at 4:15 PM he said he felt afraid he might die during times when he gags/chokes. 2) Review of Resident #22's facility Face Sheet, dated 02/06/16, revealed she was a [AGE] year-old female admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #22's care plan, dated 11/01/15, reflected she required tube feeding related to dysphagia and nothing by mouth (NPO). The long-term goal was that she would not exhibit signs of complications from the feeding tube or enteral feeding solution. The care plan also reflected to Elevate HOB 30-45 degrees .Resident needs to be kept at 45 Degree Angle due to risk for Aspiration at all times. Resident #22's MDS assessment, dated 11/30/15, reflected she was severely impaired cognitively. She required extensive assistance from two plus people for bed mobility and was total assist from one person for eating. She had a feeding tube ([DEVICE]) and received 51% or more of her nutrition and 501 cc/day or more of her fluid intake per her tube feeding. Resident #22's current Physician orders, dated 02/06/16, reflected she was to have her enteral feeding solution at 45 cc/hr for 22 hours via her gastric tube ([DEVICE]). It further reflected to Elevate HOB 30-45 degrees during feeding and one hour after . 3) On 02/05/16 at 2:20 PM, Resident 22 was observed in her room, in bed. She was awake and alert. Resident #22 had slid down in the bed. Resident 22's [DEVICE] was attached to the feeding pump and was running an enteral feeding solution at 46 cc/hr. 4) Review of the facility's Nursing Policy and Procedure titled, Medication Management Program, revised 07/24/14, reflected the following: .13. The authorized licensed or certified/permitted medication aide or by state regulatory guidelines staff member administers enteral medications as follows: A. Check position of patient/resident (forty (40) + degrees) 5) Review of the facility's Nursing Policy and Procedure, titled Gastrostomy Tubes, dated 02/24/12, revealed aspiration as a complication; however, there were no guidelines regarding the proper positioning of a resident during enteral feeding and/or medication administration. Keep patients sitting upright at 30 to 45 degrees during tube feeding and for one to two hours afterward to minimize incidence of nosocomial aspiration pneumonia and to allow gravity to help propel the food. This information was retrieved on 02/12/16 from: www.merckmanuals.com/professional/nutritional-disorders/nutritional-support <http://www.merckmanuals.com/professional/nutritional-disorders/nutritional-support> 6) An Immediate Jeopardy was identified on 02/05/16 at 4:55 PM. The ADM was notified of the IJ on 02/05/16 at 4:55 PM. The ADM, DON, and CSD were notified of the IJ on 02/05/16 at 5:00 PM. A Plan of Removal for the IJ was requested at that time. 7) The facility's POR was accepted on 02/07/16 at 3:20 PM. The plan reflected the following: --On 02/05/16 each resident with a Gastrostomy Tube was observed for proper positioning in bed with HOB 30-40 degrees with resident pulled up in bed and without slumping. There were none identified to be improperly positioned. Each resident with Gastrostomy Tube was evaluated for signs and symptoms of aspiration. --On 02/04/16 LVN C was given a 1 on 1 in-service by ADON A on proper medication administration via gastrostomy tube and resident positioning. LVN C was suspended pending investigation. --Licensed Nursing staff, Certified Nursing Assistants, and Medication Aides will be re-educated by CSD and members of Nursing Management beginning on 02/05/16 and ending on 02/06/16. After 02/06/16, no licensed nurse, certified nursing assistant, or medication aide will be allowed to work their scheduled shift until they have completed the required re-education. The re-education process will be validated using a post test. --The training will also be included in New Hire orientation and then annually thereafter. Re-education included: Facility policy and procedure for proper positioning of resident who requires a Gastrostomy Tube for medications and/or nutritional supplements. Identification of resident slumping in bed and not positioned 30-40+ degrees upright and expectation of repositioning properly. Documentation of improper position to be documented on the 24 hour report for nursing management follow up and validation. The expectation of repositioning the resident when identified prior to administration of medication. Expectation that if resident position changes during the administration of medications or enteral nutrition the administration will be stopped and the resident will be properly positioned prior to continuation of administration. Additionally, the resident will be evaluated for signs and symptoms of aspiration if found improperly position with intervention as indicated. Residents who require Gastrostomy Tube for medications and/or nutritional supplements will be observed every 15 minutes for 4 hours. Then every 30 minutes for 4 hours starting at 7:15 PM on 02/05/16. Moving forward, we will monitor resident positioning once an hour while enteral nutrition is being administered to ensure proper body position. Resident(s) found slumping e.g.: body angle not within 30-40 degree range will be repositioned, assessed and monitored every 15 minutes for two hours to ensure proper body position is maintained. If positioning is not maintained, 15 minute checks will resume until positioning intervention is initiated and resident maintains a position of 30-40+ degree during feeding and medication administration. Additionally, CNA's and MA's will be educated to notify the nurse to pause Gastrostomy Tube feeding to deliver care to the resident and resuming the feeding once care is complete so the resident is properly positioned with Head of Bed elevated 30 to 40+ degrees and resident is positioned upright and not slumping. --The DON will be responsible for monitoring re-education compliance and will validate that no employee returns to work prior to completing the required re-education. --Members of Nursing Management will perform rounds each shift to observe residents who require Gastrostomy tube for medications and/or nutritional supplements. These rounds will begin on second shift on 02/05/16 and will continue for 4 weeks. These rounds will be monitored through daily clinical meetings Monday through Friday. The process will also be analyzed through the monthly Quality Assurance and Performance Improvement meeting until significant compliance is achieved and maintained. --The MD was notified by the ADM of the facility's IJ status on 02/06/16. --The ADM will be responsible for the overall implementation and validations of this plan. 8) To verify implementation of the plan the following was conducted: Routine Check Sheets were provided for all residents with a Gastrostomy Tube that reflected monitoring every 15 minutes, 30 minutes, then every hour which began on 02/05/16, and was still ongoing at the time the POR was accepted on 02/07/16. A copy of the facility's education for Gastrostomy Tube Resident Positioning for CNAs and Licensed Nurses along with the post-test was received from the ADM on 02/07/16 at 3:30 PM. --Evidence revealed 17 of 29 nurses and 18 of 48 CNAs and MAs had received the required re-education at the time of the POR acceptance on 02/07/16. During individual interviews with the following RNs they each answered all questions on the positioning of residents with a Gastrostomy Tube correctly. The interviews were conducted on the following day: --On 02/07/16 at 11:24 AM and 1:20 PM with RN G and RN H. During individual interviews with the following LVNs they each answered all questions on the positioning of residents with a Gastrostomy Tube correctly. The interviews were conducted on the following day: --On 02/07/16 at 12:35 PM, 3:05 PM, 3:25 PM, 3:29 PM, 3:50 PM, 4:08 PM, and 4:11 PM with LVN I, LVN J, LVN K, LVN L, ADON B, ADON A, and LVN M. During individual interviews with the following CNAs they each answered all questions on the positioning of residents with a Gastrostomy Tube correctly. The interviews were conducted on the following day: --On 02/07/16 at 10:45 AM, 11:00 AM, 11:34 AM, 11:40 AM, 12:30 PM, 2:25 PM, 2:35 PM, 3:45 PM, 3:50 PM, and 3:55 PM with CNA N, CNA O, CNA P, CNA Q, CNA R, CNA S, CNA T, CNA U, CNA V, and CNA W. During individual interviews with the following MAs they each answered all questions on the positioning of residents with a Gastrostomy Tube correctly. The interviews were conducted on the following day: --On 02/07/16 at 12:25 PM and 4:05 PM with MA X and MA Y. Follow-up observations were made of the residents with gastrostomy tubes on the following day: --On 02/07/16 at 10:50 AM, 10:54 AM, 10:56 AM, 11:06 AM, 11:07 AM, 11:09 AM, and 11:12 AM of Residents #8, #21, #22, #25, #26, #27, and #28. All residents were positioned in the bed at or above 30 degrees, with the exception of Resident #21 who was positioned in the bed at 15 to 20 degrees. Resident #21 had no fluids or formula running in his gastrostomy tube at that time. Review of the facility's Nursing Policy and Procedure titled, Gastrostomy Tube Management Policy Addendum, revised 02/07/16, and provided by the ADM on 02/07/16 at 4:00 PM, revealed the following: Subject: Required body positioning monitoring for patient(s) who receive enteral nutrition via gastrostomy tube. Policy: Residents who require Gastrostomy Tube for medications and/or nutritional supplements will be monitored for resident positioning once an hour while enteral nutrition is being administered to ensure proper body position. Resident(s) found slumping e.g. body angle not within 30-40 degree range will be repositioned, assessed and monitored every 15 minutes for two hours to ensure proper body position is maintained. If positioning is not maintained, 15 minute checks will resume until positioning intervention is initiated and resident maintains a position of 30-40+ degree during feeding and medication administration. 9) On 02/07/16 at 4:40 PM the ADM, DON, and CSD were notified the IJ was removed. While the IJ was removed on 02/07/16, the facility remained out of compliance at a severity level of No actual harm with potential for more than minimal harm, and a scope of pattern because the staff were still being trained and the facility was monitoring the effectiveness of the POR. 10) The facility's enteral feeding list provided by the DON on 02/04/16 reflected there were seven residents with a gastrostomy tube.