Every finding on record at Mission Valley Nursing and Transitional Care

Based on observation, interviews, 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 3 residents (Resident #1) reviewed for infection control. 1.The facility failed to ensure CNA B performed proper hand hygiene for at least 20 seconds during incontinent care for Resident #1 on 08/12/26. 2. CNA B failed to wash her hands or use hand sanitizer between change of gloves change while providing catheter care and perineal care for Resident #1 on 08/12/26. This failure could place residents at risk of infections, healthcare associated with cross contamination, and the spread of infection. Findings include: Record review of Resident #1's electronic face sheet, dated 08/12/2026, reflected a [AGE] year-old female who was originally admitted to the facility on [DATE]. Her diagnoses included Cerebral infarction (a type of ischemic stroke that occurs when a blocked or narrowed blood vessel cuts off blood flow to a region of the brain), muscle wasting and atrophy (the shrinking and loss of muscle tissue), need for assistance with personal care. Record review of Resident #1's quarterly MDS assessment, dated 6/12/26 reflected BIMS score of 7, indicated cognition was severe impaired. Section GG revealed Resident #1 was substantial/maximal assistance for toileting hygiene (Helper does MORE THAN HALF of the effort. Helper lifts or holds trunk or limbs and provides more than half the effort.) Record review of Resident #1's comprehensive person-centered care plan, dated 06/26/2026, reflected Focus [Resident #1] has a an ADL self-care performance deficit r/t Cerebral Infraction, need for assistance with personal care. Interventions: The resident requires assistance by 1 staff for toileting hygiene. During an observation on 08/12/26 at 11:10 a.m., CNA B washed hands before and after incontinent care was completed. CNA B did not sanitized hands in between glove changes. CNA B lathered her hands for 12 sec. During an interview on 08/12/2026 at 11:25 a.m., CNA B stated she should have lathered her hands for at least 20 seconds. CNA B stated I should have sanitize or washed my hands before putting new gloves. She stated she should have washed her hands or used hand sanitizer between glove changes. CNA B stated I forgot about it because I was nervous. She stated the potential negative outcome could be spread infection. During an interview on 08/13/2026 at 1:30 p.m., the DON stated the proper handwashing was to lather hands for at least 20 seconds. The DON stated if CNA B did not lather her hands for at least 20 seconds this would put Resident #1 at risk for infections. Record review of the facility's policy titled Hand Hygiene with an implemented date 10/24/22 reflected: All staff will perform proper hand hygiene procedures to prevent the spread of infection to other personnel, residents, and visitors. This applies to all staff working in all locations within the facility. 4. 4. Hand hygiene technique when using soap and water:a. Wet hands with water. A void using hot water to prevent drying of skin.b. Apply to hands the amount of soap recommended by the manufacturer.c. Rub hands together vigorously for at least 20 seconds, covering all surfaces of the hands and fingers.d. Rinse hands with water.e. Dry thoroughly with a single-use towel.f. Use clean towel to turn off the faucet.

Based on observations, interviews, and record review, the facility failed to ensure drugs and biologicals were stored and labeled in accordance with currently accepted professional principles for 1 (400 medication cart) of 9 medication carts. 1.The facility failed to ensure that the medication cart was secured and locked when it was left unattended by LVN A on 08/12/26. 2.LVN A failed to ensure that 400 medication cart keys were not left on top of medication cart on 08/12/26. This failure could place residents at risk of injury to other residents if medication left unsecured were consumed.Findings included: During an observation on 08/12/2026 at 08:45 AM the 400 medication cart was left unlocked and medication cart keys were in top of cart outside room [ROOM NUMBER]. During the observation LVN A came out of the room and surveyor informed him medication cart was unlocked and the LVN A secured the cart by locking it. During an interview on 08/12/2026 at 08:47 AM, LVN A stated he was responsible for the medication cart that was left unlocked. He stated he was expected to lock the medication cart when he walked away from it. He stated if it was left unlocked then a resident could open a drawer and take anything that was not for them. He stated he had left the cart unlocked because he just went to check a resident's blood pressure, and that he did not take long and forgot the keys in top of the cart. LVN A stated that he was supposed to keep the keys at all times with him. During an interview on 08/13/2026 at 1:30 PM, the DON stated her expectation of staff when they walk away from the medication cart was to lock it and staff should take the cart keys with them. DON stated that all staff were responsible for locking and monitoring the medication carts. DON stated that the negative outcome for leaving the cart unlocked and leaving the keys on top of the medication cart was that a resident or visitor could grab the medication from the cart, and it could harm them. Record review of facility's policy Medication Administration, Medication Carts with a revised date 10/01/19 revealed 1. Only a licensed nurse or certified medical aide may carry keys to the medication cart. 2. The medication cart is locked at all times when not in use.

Based on observation, interview and record review, the facility failed to review and revise the comprehensive care plan for 1 of 4 (Resident #1) residents reviewed for comprehensive care plan revisions. The facility failed to review and revise Resident #1's care plan to reflect his refusal to use his call light. This failure could place residents at risk of not receiving the appropriate care, service, or treatment needed in a timely manner. Findings included: Record review of Resident #1's admission record, dated 07/28/26, reflected a [AGE] year-old male readmitted on [DATE] and an initial admission date of 12/09/22. His relevant diagnoses included abnormalities of gait and mobility (limping, unsteady, shuffling patters), need for assistance with personal care (requiring hands-on help or supervision with basic daily self-care, such as bathing, dressing, and eating), weakness, and vascular dementia (a decline in thinking skills caused by conditions that block or reduce blood flow to the brain). Record review of Resident #1's quarterly MDS assessment, dated 06/11/26, reflected a BIMS score of 03, which indicated his cognition was severely impaired. Record review of Resident #1's quarterly care plan assessment, dated 06/05/256, reflected:Problem: [Resident #1] is a high risk for falls r/t age-related physical debility, muscle weakness, difficulty in walking. Date revised 04/23/26. Interventions included be sure [Resident #1's] call light is within reach and encourage the resident to use it for assistance as needed. During an observation and interview on 07/28/26 at 9:10 a.m., Resident #1 was observed sitting in his wheelchair in the activity room. Resident said he did not want to be interviewed. During an interview on 07/28/26 at 10:50 a.m., CNA A said she was assigned to Resident #1's hall. She said Resident #1 required extra supervision because he was a fall risk. CNA A said Resident #1 had dementia and was noncompliant in using the call light. She said Resident #1 continuously attempted to ambulate on his own without assistance causing him to fall. CNA A said she continued to re-educate Resident #1 in using his call light but thought he forgot due to his dementia. CNA A said she informed her charge nurse that Resident #1 did not use his call light. During an interview on 07/28/26 at 11:00 a.m., LVN B said Resident #1 was a considered a fall risk and required extra supervision. He said that was the reason Resident #1 was transferred to a room next to the nurse's station. He said Resident #1 suffered from dementia and was noncompliant in using the call light. LVN B said Resident #1 preferred to yell out for help rather than using his call light. LVN B said Resident #1 had repeated falls due to him still thinking he was able to ambulate on his own. He said Resident #1 was having a difficult time accepting his limitations due to his diagnosis of dementia. LVN B said CNAs and nursing staff provided frequent monitoring and encouraged Resident #1 to participate in daily activities. LVN B said staff (CNAs and nursing staff) knew he did not like to use his call light, therefore there were no negative outcome if his refusal to use his call light was not care planned. During an interview on 07/28/26 at 3:10 p.m., ADON C said Resident #1 had a diagnosis of dementia, and his cognition was deteriorating and his ability to ambulate was being affected. She said Resident #1 was having a difficult time coping with his memory loss. She said Resident #1 until recently was able to assist with his ADLs, walk and transfer on his own. ADON C said Resident #1 did not use his call light because he still thought he was independent and able to ambulate. She said Resident #1 was a fall risk and had several falls in the past. She said Resident #1 was continuously being monitored and supervised by all staff on his hall. She said the facility had interventions in place to prevent him from falling. ADON C said she had not been told by Resident #1's charge nurse(s) that he refused to use his call light but said it was a known issue. ADON C was not able to say if there was a negative outcome to Resident #1 not having his refusal to use his call light care planned. During an interview on 07/28/26 at 3:50 p.m., the MDS/LVN said Resident #1 was a fall risk and interventions were in place to prevent him from falling. She said she had not been told Resident #1 refused to use his call light. She said the facility's protocol for when there was a change of condition with a resident was for the CNAs to notify the chare nurse, the charge nurse would notify the ADON and the ADON would notify the DON. She said when the DON was informed, an IDT meeting would be held, and proper interventions would be care planned. The MDS LVN said if she was notified of Resident #1's refusal to use the call light, she would have created a new problem and interventions in the care plan. The MDS LVN was not able to say if there were any negative outcomes to Resident #1 not having his care plan include that he refused to use his call light. During an interview on 07/28/26 at 4:00 p.m., the DON said Resident #1 had a diagnosis of dementia. She said Resident #1 was pleasantly confused. She said Resident #1 thought he could still do things independently and was known to resist assistance with his ADLs. She said Resident #1 was monitored and supervised by all staff more frequently because he was a fall risk. She said Resident #1was having a difficult time accepting his cognitive limitations. She said she was not notified Resident #1 did not use his call light but was aware because she had read it on his progress notes. The DON said she had not care planned his preference of not using the call light. Record review of the facility's policy title, Care Plan Revisions Upon Status Change, dated 10/24/26, reflected: Policy: The purpose for this procedure is to provide a consistent process for reviewing and revising the care plan for those residents experiencing a status change. Policy Explanation and Compliance Guidelines: 1.The comprehensive care plan will be reviewed, and revised as necessary, when a resident experiences a status change. 2.Procedure for reviewing and revising the care plan when a resident experiences a status change: d. the care plan will be updated with the new or modified interventions.

Based on observations, interviews, 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 4 (Resident #13, Resident #116, Resident #10, Resident #79) of 8 residents observed for infection control. 1.The facility failed to ensure MA use proper infection control during her medication administration for Resident #13 on 02/10/2026. 2.The facility failed to ensure RN J changed gloves after touching the bed sheets and the bed remote during medication administration via Gastrostomy tube for Resident #116 on 02/11/2026. 3.The facility failed to ensure Resident #10 was placed under EBP due to a stage 3 sacral wound that started on 02/04/26. 4. CNA F failed to follow Enhanced Barrier Precautions for an indwelling medical device (indwelling catheter) for Resident #79 on 2/10/26. 5. CNA F did not remove their contaminated gloves after cleaning the posterior area and used the same gloves to don clean brief for Resident #79 on 2/10/26. These failures place residents at risk of healthcare associated with cross contamination and infections. The Findings included: 1.Record review of Resident #13's electronic face sheet dated 02/11/2026, reflected a [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses included Diabetes Mellitus (chronic condition where the body cannot properly manage blood sugar for energy, causing the buildup in the bloodstream), Hypertension (high blood pressure), Parkinsonism (progressive movement disorder of the nervous system), Peripheral Vascular Disease (a slow and progressive disorder of the blood vessels), Muscle Wasting and Atrophy (decrease in size or wasting away of muscle), and Quadriplegia (a severe medical condition characterized by the partial or total loss of function in all four limbs). Record review of Resident #13's quarterly MDS assessment dated [DATE] revealed she scored a 12 on her BIMS which indicated she was cognitively intact. During an observation on 02/10/2026 at 8:39 a.m., revealed during medication pass, MA placed her clean gloves inside her waistband of her scrub pant. She then proceeded to use the same pair of gloves to administer eye drops for Resident #13. In an interview on 02/10/2026 at 8:50 a.m., MA stated that she did not know that she was supposed to put them inside her waistband of her scrub pant. She stated that she had a lot of medications to administer on her tray and did not have room to put the gloves anywhere else. The MA stated that she should not have put the gloves on her waistband because the gloves were clean and once, they touch her pant, then they get contaminated. She stated the negative outcome would be that the patient can get an infection. The MA stated that she had an in service for infection control monthly. In an interview on 02/11/2026 at 11:00 a.m., ADON H stated that MA should not have put the clean gloves in her waistband of her scrub pant. He stated that this was to prevent contamination and infection control. ADON H stated that they have in-services for infection control frequently. In an interview on 02/11/2026 at 11:10 a.m., the DON stated that the MA should have grabbed the clean gloves and taken them with her on a clean surface. She stated since the MA had multiple medications that she should have cleaned the bedside table and placed her medications and gloves on the clean surface. 2. Record review of Resident #116's electronic face sheet dated 02/11/2026, reflected an [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses included Gastrostomy (a tube inserted through the belly that brings nutrition directly to the stomach), Type 2 Diabetes Mellitus (chronic condition where the body cannot properly manage blood sugar for energy, causing the buildup in the bloodstream), Pressure Ulcer of Sacral Region (area at the base of your spine), Vascular Dementia (group of thinking and social symptoms that interfere with daily functioning), Alzheimer's (a progressive brain disorder that slowly destroys memory and thinking skills, eventually making it difficult to carry out simple daily tasks), and Hypertension (high blood pressure). Record review of Resident #116's MDS assessment dated [DATE] revealed she scored a 0 on her BIMS which indicated she was cognitively severely impaired. During an observation on 02/11/2026 at 8:15 a.m., RN J donned gloves and touched multiple areas of the bed sheet and the bed remote. She then proceeded to touch Resident #116's G-tube and administered medication using the same pair of gloves. In an interview on 02/11/2026 at 8:25 a.m., RN J stated that after touching the bed sheets and the bed remote with gloves, she was to remove gloves and put on new pair of gloves. She stated that she forgot to change them. RN J stated that she was to change gloves every time she touches anything prior to starting the medication administration procedure. She stated that everybody touches the bed remote and it could be contaminated. RN J stated that it was important to change gloves to prevent infection. She stated that she had infection control in service about 2-3 weeks ago. In an interview on 02/11/2026 at 11:00 a.m., ADON H stated that staff were to change gloves after touching the bed remote when going to administer medications via G-tube. He stated that the G-tube was an opening and that it could get contaminated. ADON H stated that the negative outcome would be infection to the G-tube site or sepsis. In an interview on 02/11/2026 at 11:10 a.m., the DON stated that staff were to change gloves after touching the bed sheets and bed remote that was touched by staff, family, and resident. Their hands were dirty, and the staff should change gloves before touching the G-tube, syringe, and the medication. She stated that it was important to change gloves for infection control. The DON stated that they have annual skill check offs and as needed for medication administration. 3.Recod review of Resident #10's admission record dated 02/09/26, reflected a [AGE] year-old male with and admi date of 12/14/24 and an initial admission date of 12/07/24. His relevant diagnoses included vascular dementia (a decline in thinking skills caused by conditions that block or reduce blood flow to the brain, damaging brain tissue), Parkinsonism (a clinical syndrome characterized by motor dysfunction) and age-related physical debility (general physical deterioration, frailty, or senile asthenia). Record review of Resident #10's quarterly MDS assessment dated [DATE] reflected a BIMS score of 99, which indicated his cognition was severely impaired. His active diagnoses included a wound infection (other than foot). Record review of the Resident #10's quarterly care plan assessment dated [DATE] reflected a problem [Resident #10] (stage 3) pressure ulcer (sacrum) r/t immobility, incontinence. Date initiated 02/04/26. His interventions in part included cleanse coccyx with Daikin's (antiseptic wound cleanser) 0.125 pat dry pack with moist collagen sheets/powder and adaptic pack green foam and cover with drapes @125MMHG. There was no mention of EBP. Record review of Resident #10's order summary reflected no order for EBP. He had an order that reflected cleanse coccyx (tailbone) with Daikins 0.125 skin prep peri wound pat dry pack with moist collagen sheets or powder and adaptic pack green foam and cover with drapes @ 125MMHG as needed for stage 3 pressure injury date ordered 02/05/26. An observation on 02/09/2026 10:48 a.m., Resident #10 did not have an EBP sign on his door. In an interview on 02/09/26 at 5:00 p.m., LVN A said Resident #10 had a stage 3 ulcer to the sacral area that was covered with a wound vacuum. He said Resident #10 did not need to be under EBP because his wound was not open and was contained. LVN A said during peri-care, CNAs followed the facility's protocol and wore gloves. He said there was a possibility the wound vacuum could come off during peri-care and at that point the CNAs would notify the charge nurse. He said there were no negative outcomes to Resident #10 or other residents if he was not under EBP. LVN A said the facility's Wound Care Nurse was responsible for EBP. In an interview on 02/09/26 at 5:06 p.m., ADON B said Resident #10 had one wound to his sacrum. She said Resident #10's was not required to be under EBP because his wound was not open, was contained and had a wound vacuum. She said CNAs wore gloves during peri-care and that was sufficient. ADON A said if the vacuum came off during peri-care, the CNAs knew to notify the charge nurse. ADON A said there were no negative outcomes to Resident #10 not being under EBP because he did not need to be. In an interview on 02/10/26 at 10:00 a.m., the wound care nurse said Resident #10 had a stage 3 ulcer to his sacral area and had a wound vacuum to help it heal faster. He said he was not aware Resident #10 required to be under EBP since his wound was contained. The wound care nurse said a negative outcome Resident #10 not being under EBP could be cross contamination. In an interview on 02/10/26 at 2:13 p.m., the DON Resident #10 had a wound vacuum applied to a stage 3 sacral wound. She said the his wound was open but covered but nonetheless, he still needed to be under EBP. The DON said she was not sure why Resident #10 had not been under EBP since a negative outcome to Resident #10 not being under EBP would be possibly an infection. 4. Review of Resident #79's admission Record, dated 2/10/26, revealed she was a [AGE] year-old female originally admitted to the facility on [DATE] with diagnosis including Neuromuscular dysfunction of bladder (occurs when nerve damage from conditions like spinal cord injury, or Parkinson's disrupts signals between the brain and bladder), Parkinson's Disease (a progressive, neurodegenerative movement disorder caused by the loss of dopamine-producing brain cells). Review of Resident #79's quarterly MDS Assessment, dated 1/26/26 revealed her BIMS score was 7 meaning she was moderate cognitive impaired. Further review revealed she had a diagnosis of Parkinson's Disease; Resident #79 had a indwelling catheter while a resident. Review of Resident #79's Care Plan dated 11/26/24 revealed: Revised on 2/7/25 Focus: The resident has the need for Enhanced barrier precautions due to foley catheter. Goal: Resident will not experience signs or symptoms of depression as evidenced by no episodes of sad facial expressions or tearfulness secondary to Enhanced Barrier Precautions. Interventions included: Assess the resident for risk factors or current injuries or treatments that could put the patient at risk for infection (wounds, central lines, drains, catheters, tracheostomy). Review of Resident #79's Order Summary Report, dated 2/10/26, revealed Enhanced Barrier Precautions: Use gown and gloves for high contact resident care activities for those with known to be colonized or infected with a CDC targeted MDRO as well as those with increased risk of MDR. (Foley Catheter/Colostomy) every shift. During an incontinent care observation on 2/10/26 at 10:30 a.m. CNA F commenced incontinent care and indwelling catheter care of Resident #79. CNA F entered Resident #79's room after knocking. CNA F began with washing hands for 30 seconds, gloved up, and prepared table of needed supplies. CNA F continued by the raising bed and then discarded gloves. After discarding the gloves, CNA F continued with applying hand sanitizer and applied new gloves. CNA F proceeded with catheter care and cleaned the bowel movement. Once bowel movement was cleaned, using same pair of gloves, CNA F her removed brief, applied a new brief. CNA F did not use a gown during incontinent care. During an interview on 02/10/26 at 10:40 a.m. CNA F stated any resident with a indwelling catheter was required to be in enhanced barrier precautions. She stated she should have worn a gown and just overlooked it when she entered the room. She stated that she should have changed the gloves before placing the new brief. She stated the risk of not following Enhanced Barrier Precautions was the spread of infection. During an interview on 2/11/26 at 10:45 a.m. LVN C said that it was important to use the EBP to protect residents from whatever microorganisms that she could carry, and to protect other residents. LVN C said residents could be at risk of infection. During an interview on 2/11/26 at 2:20 p.m., the DON stated EBP was staff needing to wear a gown and gloves for individuals with a catheter, feeding tube, or wounds. DON said that it was important to use PPE to prevent introducing any kind of infection to residents. The DON said not using EBP could put residents at higher risk for infection. Record review of the facility's Infection Prevention and Control Program dated 05/13/2023 revealed Policy: This facility has established and maintains 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 as per accepted national standards and guidelines. Policy Explanation and Compliance Guidelines: .2. All staff are responsible for following all policies and procedures related to the program. 4. Standard Precautions: a. All staff shall assume that all residents are potentially infected or colonized with an organism that could be transmitted during the course of providing resident care services. Record review of the facility's Enhanced Barrier Precautions policy dated 11/24/25 reflected: Policy: It is the policy of this facility to implement enhanced barrier precautions for the prevention of transmission of multidrug-resistant organisms. Definition: enhanced barrier precautions (EBP) refer to an infection control intervention designed to reduce transmission of multidrug-resistant organism that employs targeted gown and gloves use during high contact resident care activities. Policy Explanation and Compliance Guidelines: 2. Initiation of Enhance Barrier Precautions: b. An order for an enhanced barrier precautions will be obtained for residents with any of the following: i. wounds (e.g., chronic wounds such as pressure ulcers.)

Based on observation, interview and record review, the facility failed to ensure all drugs and biologicals were stored in accordance with currently accepted professional principles for 2 of 4 medication carts (400 Hall medication cart and 100/200 Hall medication cart) reviewed for pharmacy services.1.The facility failed to properly label the Med Plus 2.0 that was on the 400-Hall medication cart with an open date. 2. The facility failed to dispose of the medication from 400-Hall medication cart a blister pack of tamsulosin 0.4 MG (medication used to treat an enlarged prostate) capsules which had expired on 01/25/2026.3. The facility failed to dispose of the medication from Hall 100/200 Med-Cart a bottle of Over-the-Counter meclizine 12.5 MG (medication used to treat dizziness, nausea, and vomiting) tablets which had expired on January 2026 and had an opened date of 1/16/2026.These deficient practices could place residents at risk for adverse effects and not receiving the therapeutic effects of the medication or treatment.The Findings included: 1. An observation on 02/10/2026 at 8:05 a.m., revealed during medication pass, MA M opened a new bottle of Med Plus 2.0 that was placed on the 400 hall Medication Cart, and she did not write an open date. In an interview on 02/10/2026 at 8:50 a.m., the MA M stated the Med Plus 2.0 should have an open date written on it. She stated that she was focused on the medications and forgot to write the open date on the bottle. The MA M stated that the OTCs and liquids should have an open date. She stated that it was important to write the open date to know how long the bottle had been opened because the Med Plus 2.0 was milk and it can go bad. The MA M stated the negative outcome would be that it could upset the residents' stomach. In an interview on 02/11/2026 at 11:00 a.m., ADON H stated that the nurses and medication aides were responsible for writing the open date on OTC medications and Med Pass whenever they opened a new bottle. ADON H stated that the negative outcome would be that it could be expired not knowing when it was opened, and could cause stomach upset. He stated the in service for medication administration was done on 01/22/2026. In an interview on 02/11/2026 at 11:09 a.m., the DON stated that the MA M was responsible for writing the open date on the Med Plus 2.0. The DON stated that it was important for the open date to be on the bottles so that they do not administer anything that was expired. 2. In an observation on 2/10/206 at 2:55 PM of the Hall 400 Med-Cart, it was revealed that a blister pack of tamsulosin 04. MG had an expiration date of 1/25/2026. In an interview on 2/10/2026 at 3:05 PM with CMA D, she said she checked expiration dates on medications before administering them to the residents. She said that because the tamsulosin was given in the mornings, she did not see the expiration date. CMA D said that it was her responsibility to check all the medication for expiration dates and because she had been in charge of her Med-Cart during her shift, it was her responsibility to ensure no expired medications were in the cart. She said a negative outcome of administering expired medications was that it could be unsafe because it would be unknown the type of damage it could cause to the resident. CMA D said that Resident #23 had a history of refusing his medication and that it was documented on his MAR. She said the last training she received was about six months ago on medication administration which included checking for expired medication but received frequent reminders from management regarding expired and labeled medications. In an interview on 2/10/2026 at 3:11 PM with ADON H, he said that the medication aides were the ones who checked the Med-Carts for expired medications every morning. He said the pharmacy consultant performed monthly audits of the Med-Carts during their rounds. The ADON said he performed random spot checks to ensure expired meds were not in the carts. He said expired medication may not be as effective. The ADON said that the physician and family were aware of the continued refusal of medication by Resident #23. 3. In an observation on 2/10/2026 at 3:17 PM of the Hall 100/200 Med-Cart, it was revealed an Over-the-Counter bottle of meclizine, with an opened date of 1/16/2025, had an expiration date of January 2026. In an interview on 2/10/2026 at 3:17 PM with CMA E, he said he checked the Med-Cart daily for expired meds. He said that he pulled out expired medications from the carts and placed them in the designated spot for discontinued medication in the medication storage room. He said he remembered he had opened the over- the-counter bottle of meclizine and had labeled it with an open date of 1/16/2026. He said that administered expired medications would be less effective for the residents. In an interview on 2/22/2026 at 2:37 Pm with the DON, she said medication aides check the Med-Carts daily, the ADONs perform random spot checks, and the pharmacy consultant performed monthly audits. She said she personally made rounds throughout the day and saw medication aides clean the med-carts and pulled out discontinued medication in blister packs and given to her for destruction. She said the medication aides turned in expired medication to her or the ADON for destruction. She said monthly and PRN meetings were held with the clinical staff which included training in ANE and medication administration. Record review of the facility policy, Medication Administration dated 10/24/22, revealed Policy: Medications are administered by licensed nurses, or other staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice, in a manner to prevent contamination or infection. Policy Explanation and Compliance Guidelines: 2. Cover and date fluids and food. Record review of the facility's policy and procedure manual titled: Expiration Dating and Expired Medication with a revised date: 10/01/29 indicated .7. If the expiration date is expressed in terms of month and year only, the medication will not be utilized after the last day of the month. 8. It is the responsibility of all nurses who administer medications to monitor the expiration dates of the medications. Expired medications will not be administered in the facility. All expired medication will be disposed of per facility policy.

Based on observation, interview, and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident that included measurable objectives and time frames to meet resident's mental and psychosocial needs, for 1 Residents (Resident#73) of 3 residents reviewed for care plans. The facility did not develop and implement a comprehensive person-centered care plan to address Resident#73's behaviors. These failures could residents at risk for their mental and psychosocial needs not being met. The findings included: Record review of Resident#73's face sheet, dated 2/9/26, revealed Resident #73 was 66 years-old male and was initially admitted to the facility on [DATE]. Resident#73's diagnoses included: Muscle Weakness, Hemiplegia and Hemiparesis following cerebral infraction affecting right dominant side (long-term weakness or paralysis on the right side of the body caused by a previous stroke affecting the brain's dominant hemisphere). Record review of Resident#73's Quarterly MDS assessment, dated 12/2/25, revealed Resident#73had moderate cognitive impairment; was able to make self-understood; and was usually able to understand others. Record review of Resident #73's Comprehensive care plans dated 5/30/22 revealed no focus, goals or interventions/tasks related to Resident#73's behavioral issues, refusing using the plate guard while eating. Record review of Resident#73's Order Summary dated 2/9/26 revealed May use Sippy Cup and Plate Guard with meals. During an observation on 2/9/26 at 1:00 p.m., Resident #73 was in the dining room without the plate guard. During an interview on 2/9/26 at 1:01 p.m., Resident #73 stated that he did not want to use the plate guard. During an interview on 2/9/26 at 1:04 p.m., CNA I stated that Resident #73 refused to use the plate guard. She stated nurses were aware of Resident #72 refusing to use the plate guard. During an interview on 2/11/26 at 10:09 a.m., LVN C stated that he had seen Resident #73 refusing to use the plate guard. LVN C said when Resident #73 refused to use the plate guard they should have informed DON about the refusal to update the care plan. LVN C said that there was not a negative outcome for refused to use the plate guard because Resident #73 eat good without the plate guard. LVN C said that he should have called the doctor to get an alternative resolution, like occupational therapy for Resident #73. During an interview on 2/11/26 at 1:55 p.m., MDS nurse stated that nurses, ADONs and DON were responsible for updating the care plans. She said that she was not aware of Resident #73 refusing to use the plate guard. During an interview on 2/11/26 at 2:15 p.m., the DON said Resident #73 had refused to use the plate guard. DON said that MDS nurses and all nurses were responsible for updating the care plan. DON said that when a resident refused using the plate guard should have been care planned and nurse should have informed the doctor about the refusing. DON said that the negative outcome was that nurses and aides were not following the doctor's order. Record review of the facility's policy on, Comprehensive Care Plans, with an implemented date 10/24/2022, revealed:It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident's rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment.

Based on interviews, observations and record review, the facility failed to provide the right to personal privacy, which includes accommodations during medication administration for 1 (Resident #116) of 6 Residents reviewed for Privacy. The facility failed to ensure RN K closed the door or the curtain during medication administration via gastrostomy tube for Resident #116 on 02/10/2026. This failure could place the residents at risk of not having their personal privacy maintained during medical treatment.The Findings included: Record review of Resident #116's electronic face sheet dated 02/11/2026, reflected an [AGE] year-old female admitted to the facility on [DATE]. A diagnosis was Gastrostomy (a tube inserted through the belly that brings nutrition directly to the stomach). Record review of Resident #116's MDS assessment dated [DATE] revealed she scored a 0 on her BIMS which indicated she was cognitively severely impaired. Nutritional approach was feeding tube. During an observation on 02/10/2026 at 4:36 p.m., RN K kept the door and the curtain open during the medication administration procedure via G-tube (a soft, flexible tube into the stomach to deliver liquid nutrition, fluids, and medications directly to the digestive tract). Staff were seen passing by the room and looking in Resident #116's room while RN K was administering medication. RN K was having a difficult time administering medication via G-tube. He then went back out of the room a second time to get a new syringe. He then went back into Resident #116's room to continue with his medication administration and once again left the door and curtain open. In an interview on 02/10/2026 at 4:57 p.m., RN K stated that he was to close the door and the curtain before doing any care with Resident #116. He stated that he got nervous and forgot. RN K stated that he should have provided the resident with privacy. He stated that he had been trained on resident privacy and dignity. In an interview on 02/11/2026 at 10:50 a.m., ADON L stated that staff should provide privacy anytime they administer medications. She stated that all staff had been trained. ADON L stated that staff should close the door, the curtain, and close the blinds when providing care. She stated that this was important to provide privacy. In an interview on 02/11/2026 at 11:10 a.m., the DON stated that RN K should have closed the door and the curtain prior to administering medication to Resident #116. She stated that staff should provide privacy when providing care due to at times being exposed. The DON stated that in-services for privacy and dignity are done frequently. Record review of the facility's policy, Promoting/Maintaining Resident Dignity dated 01/13/23, revealed Policy: It is the practice of this facility to protect and promote resident rights and treat each resident with respect and dignity as well as care for each resident in a manner and in an environment, that maintains or enhances residents quality of life by recognizing each residents individuality. Compliance Guidelines: All staff members are involved in providing care to residents to promote and maintain resident dignity and respect resident rights. 12. Maintain resident privacy. Record review of the facility's policy, Enteral Tube Medication Administration revised date 10/01/19, revealedProcedure: Establish the privacy of the patient.

Based on observations, interviews and record reviews, the facility failed to ensure residents had the right to formulate an advance directive for 1 (Resident #57) of 6 residents reviewed for Advance Directives. The facility failed to ensure Resident #57's OOH-DNR form included a physician's signature. This failure could affect all residents who have implemented Advance Directives and established their choice not to be resuscitated at risk of receiving CPR against their wishes. The findings included: Record review of Resident # 57's admission record, dated [DATE], reflected a [AGE] year-old male with an admission date of [DATE], an initial admission date of [DATE], and an original admission date of [DATE]. His relevant diagnoses included anemia (lack of healthy blood cells or hemoglobin, reducing oxygen transported to body tissue), epilepsy (a chronic neurological disorder characterized by recurrent, unprovoked seizures caused by abnormal electrical activity in the brain), and atherosclerotic heart disease (caused by plaque in arterial walls). Record review of Resident #57's 5-day Medicare MDS assessment, dated [DATE] reflected a BIMS score of 02, which indicated his cognition was severely impaired. Record review of Resident #57's comprehensive care plan dated [DATE] reflected Problem: [Resident #57] is a DNR, date initiated [DATE], his interventions in part included ensure signed DNR is in medical record, date initiated [DATE]. Record review of Resident #57's order summary included an OOH-DNR order effective [DATE]. Record review of Resident #57's OOH-DNR form dated [DATE], reflected it had not been by the attending physician in section E, Physician's Statement: I am the attending physician of the above noted person and have noted the existence of this order in the person's medical records. I direct health care professionals acting in our-of-hospital settings, including a hospital emergency department, not to initiate or continue for the person: cardiopulmonary resuscitation (CPR), transcutaneous cardiac pacing, defibrillation, advanced airway management, artificial ventilation. It also revealed the physician had not sign section F, All persons who have signed above must sign below, acknowledging that this document has been properly completed. In an interview on [DATE] at 1:55 p.m., SW said it was her responsibility to discuss code status with all residents. She said if a resident or their RP opted to have a code status of DNR, she would initiate the process of completing the OOH-DNR form. She said she would first obtain the resident's or RP's signature, update their code status on their electronic medical record, and notified the charge nurse of their decision to have a code status of DNR. The SW said she would then forward the OOH-DNR form the facility's medical records department where they would notarize the form and forward the OOH-DNR form to the resident's physician to obtain their signature. The SW was observed as she reviewed Resident #57's electronic medical record and said he had been admitted several times to the facility's transitional unit (short-term). She said the OOH-DNR form on file was dated [DATE], which had been obtained during his previous admission. She said the OOH-DNR form did not have a physician's signature, but the facility would still honor his DNR code status because upon admission on [DATE], his RP opted for him to continue with a code status of DNR. In an interview on [DATE] at 2:07 p.m., Medical Records representative said if a resident requested a code status of DNR, the facility's SW initiated the process of getting the OOH-DNR form signed by the resident or their RP. She said once their signatures had been obtained, the SW would forward the OOH-DNR form to her. She said she notarized the OOH-DNR form and requested their physician's signature. She was observed as she reviewed Resident #57's electronic medical record and said the OOH-DNR form on file was dated [DATE] and had not been signed by his physician. She said even though Resident #57's OOH-DNR form had not been by his physician on [DATE], the facility would still honor Resident #57's RP wish for him to be a DNR. She said when a resident was sent to the hospital, the charge nurse would include their OOH-DNR form with the paperwork that was sent with the resident. She said a negative outcome to Resident #57 could be that the hospital would not honor his OOH-DNR form because it did not have a physician's signature and could possibly consider him a full code. In an interview on [DATE] at 2:13 p.m., the DON said it was the responsibility of the facility's SW to discuss code status with all residents. She said if a resident opted to be a DNR, the SW would ensure she got the resident's or their RP signature and then forward the OOH-DNR form to the medical records department. She said the medical records personnel notarized the OOH-DNR form and ensured a physician signed it. She said Resident #57 had been admitted several times to the facility's transitional unit. She said Resident #57's most recent admission was on [DATE] and prior to that was on [DATE]. The DON said Resident #57's RP had signed an OOH-DNR form on [DATE] and since his code status continued being a DNR for his [DATE] admission, the facility did not need to get a new OOH-DNR form. She said the OOH-DNR form followed the resident. The DON said it was the facility's ADONs and her responsibility to ensure all OOH-DNR forms were completed correctly. She said even though Resident #57's OOH-DNR form had not been signed by a physician, the facility would still honor his code status of DNR. The DON said there were no negative outcomes to Resident #57 not having his OOH-DNR form signed by a physician because his electronic medical records indicated he was a DNR. She said the facility did not have a policy related to code status.

Based on interviews and record reviews, the facility failed to maintain clinical records on each resident that were complete and accurately documented in accordance with accepted professional standards and practices for 1 (Resident #10) of 6 residents reviewed for administration. The facility failed to ensure Resident #10 had an order for EBP (refers to an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employs targeted gown and gloved use during high contact resident care activities). This failure could place residents at risk of not receiving nursing services by adequately trained nurses and could result in a decline in health.The findings included:Record review of Resident #10's admission record dated 02/09/26, reflected a [AGE] year-old male with and admi date of 12/14/24 and an initial admission date of 12/07/24. His relevant diagnoses included vascular dementia (a decline in thinking skills caused by conditions that block or reduce blood flow to the brain, damaging brain tissue), Parkinsonism (a clinical syndrome characterized by motor dysfunction) and age-related physical debility (general physical deterioration, frailty, or senile asthenia). Record review of Resident #10's quarterly MDS assessment dated [DATE] reflected a BIMS score of 99, which indicated his cognition was severely impaired. His active diagnoses included a wound infection (other than foot). Record review of the Resident #10's quarterly care plan assessment dated [DATE] reflected a problem [Resident #10] (stage 3) pressure ulcer (sacrum) r/t immobility, incontinence. Date initiated 02/04/26. His interventions in part included cleanse coccyx with Daikin's 0.125 pat dry pack with moist collagen sheets/powder and adaptic pack green foam and cover with drapes @125MMHG. There was no mention of EBP. Record review of Resident #10's order summary reflected no order for EBP. He had an order that reflected cleanse coccyx with Daikins 0.125 skin prep peri wound pat dry pack with moist collagen sheets or powder and adaptic pack green foam and cover with drapes @ 125MMHG as needed for stage 3 pressure injury date ordered 02/05/26. In an interview on 02/09/26 at 5:00 p.m., LVN A said Resident #10 had a stage 3 ulcer to the sacral area that was covered with a wound vacuum. He said Resident #10 did not need to be under EBP because his wound was not open and was contained. LVN A said during peri-care, CNAs followed the facility's protocol and wore gloves. He said there was a possibility the wound vacuum could come off during peri-care and at that point the CNAs would notify the charge nurse. He said there were no negative outcomes to Resident #10 or other residents if he was not under EBP. LVN A said it was the responsibility of the facility's wound care nurse to treat Resident #10's wound and obtain an order for EBP if one was needed.In an interview on 02/09/26 at 5:06 p.m., ADON B said Resident #10 had one wound to his sacrum. She said Resident #10's was not required to be under EBP because his wound was not open, it was contained and had a wound vacuum. She said CNAs wore gloves during peri-care and that was sufficient. ADON A said if the vacuum came off during peri-care, the CNAs knew to notify the charge nurse. ADON A said there were no negative outcomes to Resident #10 not being under EBP. She said there was no EBP order because one was not needed.In an interview on 02/10/26 at 10:00 a.m., the Wound Care Nurse said it was his responsibility to complete wound care to residents. He said if a resident required to be under EBP, he would notify their doctor to obtain an order. He said Resident #10 had a stage 3 ulcer to his sacral area and had a wound vacuum to help it heal faster. He said he was not aware; Resident #10 was required to be under EBP since his wound was contained. The Wound Care Nurse said a negative outcome Resident #10 not being under EBP could be cross contamination. In an interview on 02/10/26 at 2:13 p.m., the DON stated Resident #10 had a wound vacuum applied to a stage 3 sacral wound. She said, his wound was open and covered but nonetheless, he needed to be under EBP. She said she was not sure why he was under EBP. The DON said a negative outcome to Resident #10 not being under EBP would be possibly an infection. Record review of the facility's Enhanced Barrier Precautions policy dated 11/24/25 reflected:Policy: It is the policy of this facility to implement enhanced barrier precautions for the prevention of transmission of multidrug-resistant organisms. Definition: enhanced barrier precautions (EBP) refer to an infection control intervention designed to reduce transmission of multidrug-resistant organism that employs targeted gown and gloves use during high contact resident care activities. Policy Explanation and Compliance Guidelines:2. Initiation of Enhance Barrier Precautions:b. An order for an enhanced barrier precautions will be obtained for residents with any of the following:i. wounds (e.g., chronic wounds such as pressure ulcers.)

Based on observation and interview, the facility failed to ensure nurse staffing data was posted daily and readily accessible to residents and visitors with all required information for 3 of 3 days reviewed (02/7/26, 02/8/26, and 02/9/26) for nurse staffing posting. The facility failed to post the daily staffing information in a prominent place on 02/7/26, 02/8/26, and 02/9/26. This failure could place residents, families, and visitors at risk of not being informed of the census and number of staff working each day to provide care on all shifts. Findings included: Upon observation during entrance to the facility on [DATE] at 8:39 am, State Surveyor observed a clear frame on the right side of the extended care nurses station, on the wall next to the dining area of the transitional care displaying name of facility and the total number of CNAs, LVNs, and RNs dated 02/6/26. An interview on 02/11/26 at 2:20 p.m., DON said she was in charge of posting the daily staff information. She said she would make sure the daily staff information were posted by 8:30 am on a daily basis. She said the negative outcome for not posting the staff information would be we would not have communication between residents/visitors and staff . An interview on 02/11/26 at 2:45 p.m., the Administrator said it was the responsibility of the DON to post the nursing staffing information. She said the daily postings should be up by 8:30 a.m. She said there were no negative outcome for not having the staff information posted just miscommunication between residents and staff. Record review of the facility's Nurse Staffing Posting Information policy dated 10/2022 reflected: Policy:It is the policy of this facility to make nurse staff information readily available in a readable format to residents and visitors at any given time. Policy explanation and compliance guidelines:1. The nurse staffing sheet will be posted on a daily basis and will contain the following informationb. the current date

Based on interviews and record reviews, the facility failed to ensure that each resident received adequate supervision and assistance devices to prevent accidents for 1 of 3 residents (Resident #1) reviewed for accidents hazards and supervision:1.The facility failed to ensure Resident # 1 was not left unattended in his wheelchair in his room by CNA A, which resulted in an unwitnessed fall. Resident #1 sustained a hip fracture from the fall. 2.The facility failed to ensure CNA A and Med-Aide B notified a nurse of Resident #1's fall and transferred Resident #1 to bed without being assessed. The non-compliance for Resident #1 was identified as Past Non-Compliance. The Immediate Jeopardy (IJ) began on 04/21/2025 and ended on 04/23/2025. The facility corrected the non-compliance before the investigation began. This failure could place the residents at risk for injury or death. Findings included:Record review of Resident #1's admission sheet dated 10/21/25, reflected an [AGE] year-old male with an admission date of 05/03/25 and an initial admission date of 07/30/23. His relevant diagnoses included hemiplegia (a condition that causes paralysis or weakness on one side of the body), hemiparesis (weakness on one side of the body that can affect the arm, leg, and sometimes the face), displaced intertrochanteric fracture of right femur ( a break in the femur (thigh bone) just below the femoral head and above the lesser trochanter), pain to right hip, Alzheimer's disease (a progressive brain disorder that causes memory loss, confusion, and other cognitive decline), lack of coordination, muscle weakness, and need for assistance with personal care. Record review of Resident #1's quarterly MDS assessment dated [DATE], reflected a BIMS score of 04, which indicated his cognition was severely impaired. Further review reflected Resident #1 was dependent ( helper does all of the effort. Resident does none of the effort to complete the activity. OR the assistance of 2 or more helpers is required for the resident to complete the activity) for transfers and used a wheelchair as a mobility device.Record review of Resident #1's quarterly care plan dated 09/23/25, reflected a:Problem: [Resident #1] is high risk for falls r/t unsteadiness on feet, other lack of coordination, other abnormalities of gait/mobility (dated initiated 07/30/23 and revised on 04/23/25)Interventions: in part included to anticipate and meet needs (date initiated 07/30/23 ad revised on 09/23/25), be sure the resident's call light is within reach and encourage/remind the resident to use call light for all assistance (dated initiated 07/30/23 and revised on 09/23/25), Ensure floor mats in place (dated initiated 08/25/25), provide resident with mobility device: WC, walker, or cane (date initiated 04/23/25), Pt evaluate and treat as ordered or PRN (date initiated 11/12/24)Problem: [Resident #1] has had an actual unwitnessed fall on: 03/26/25, 04/06/25, 04/09/25, 04/21/25 (date initiated 04/06/25 and revised on 04/23/25)Interventions: in part included, resident reminded to use call light for assistance when needed to avoid falls/injuries (date initiated 03/27/25), visual checks Q2 (date initiated 04/14/25), bed to lowest position w/safety pad on the floor (date initiated 04/22/25), and notify MD/RP of incident (date initiated 04/06/25)Record review of Resident #1's incident report dated 04/21/25 at 8:15 pm, reflected:Incident description: Around 8:00, CNA reported that upon entering the room, resident noted lying on the floor, left side of his bed, on his right-side position. Assisted X2 to bed, call light had not been triggered.Resident Description: [Resident #1] stated that he wants to walk. C/o pain to right hip/waist area when move/reposition. Denies of hitting his head.Record review on 10/21/25 of Resident #1's progress note dated 04/21/2025 at 8:24 pm, authored by LVN D reflected .notified NP. New orders for [pain medication], apply [pain gel] to affected area on right hip/waist, & x-ray hip/pelvis 2v in am. Will carry out orders.Record review on 10/21/25 of Resident #1's change in condition communication form dated 04/21/25 at 8:00 pm reflected: the change of condition was pain to right hip/waist area which started on 04/21/2025 Record review of Resident #1's x-ray results taken on 04/22/25 reflected a mildly displaced right hip fracture. This appears to be a inter trochanteric fracture.During a telephone interview on 10/21/25 at 1:04 pm, CNA A described Resident #1 as being a very anxious resident who frequently attempted to get up from his wheelchair and required constant supervision. She said when Resident #1 would be in his wheelchair, and he would be placed by the nurse's station so they could keep an eye on him. She said on 04/21/25 between 6:00 and 7:00 pm, she wheeled Resident #1 from the nurse's station back to his room. CNA A said she left him sitting in his wheelchair (wheels locked) while she went out to the hall to look for someone to help her transfer Resident #1 back to bed. She said while she was in the hall trying to motion for assistance from another CNA, the resident from across Resident #1's room asked her to take him to the restroom, and she did. CNA A said when she returned to Resident #1's room, she found him on the floor, lying on his right side between his bed and his wheelchair. She said she panicked and at that same moment, Med-Aide B walked into Resident #1's room. She said she asked Med-Aide B to help her transfer Resident #1 back to his bed. CNA A said Resident #1 did not complain of pain or had any facial grimacing during the transfer. CNA A said once Resident #1 was transferred back to bed, both she and Med-Aide B left his room. CNA A said Resident #1 looked ok. CNA A said she failed to notify Resident #1's charge nurse of the fall and Resident #1 was transferred back to bed without being assessed by a nurse. CNA A said she also forgot to notify anybody that Resident #1 had sustained an unwitnessed fall after she left his room. CNA A said that day, she had requested to leave early (8:00 pm) and CNA C had agreed to cover for her from 8:00 pm to 10 pm. CNA A said on her way home (not sure of the time) she received a telephone call from LVN D who told her Resident #1 was in pain and if she knew what had happened to him. CNA A said she told LVN D she did not know why Resident #1 was in pain and that nothing had happened to him during her shift. CNA A said around 9:30 pm, she called LVN D and told him Resident #1 had an unwitnessed fall in his room, was transferred back to bed by her and Med-Aide B, and that she had not reported it to anyone. CNA A said she had been regularly in-serviced on the topics of fall prevention which included notifying charge nurse of any falls and not moving a resident after they sustained a fall until they had been assessed by a nurse. She said a negative outcome of notifying a nurse that a resident had fallen and moving a resident before they were assessed could further injure a resident and cause more pain. CNA A said the next day, when she arrived at the facility to start her shift, she was called to the Administrator's office and was written up and suspended and days later was terminated. She said that it was the first time she had failed to report a fall.During a telephone interview on 10/21/25 at 3:31 pm, Med-Aide B said on 04/21/25 between 6:00 pm and 7:00 pm, she had been motioned by CNA A to assist her in transferring Resident #1 back to bed and at that moment she was busy. She said by the time she went into Resident #1's room to assist CNA A, Resident #1 on the floor. She said CNA A asked her to help transfer Resident #1 back to bed. She said they used a bed sheet to transfer Resident #1 back to bed and during the transfer, Resident #1 was moaning. Med-Aide B said after he was transferred back to bed, Resident #1 continued moaning but she and CNA A left his room, and she continued with her med-aide duties. Med-Aide B said she assumed CNA A had already notified Resident #1's charge nurse of the fall, had already been assessed, and it was safe to move him. Med-Aide B said her mistake was to assume CNA A had already notified Resident #1's nurse and that he had already been assessed. Med-Aide B said a negative outcome for not having a nurse assess Resident #1 before being transferred could have caused a fracture and made the pain worse. Med-Aide B said she had been in-serviced on the topic of fall preventions which included notifying a resident's nurse of a fall and not moving a resident after a fall until they had been assessed by a nurse. Med-Aide B said she received a write-up and was in-serviced on the topics of ANE and fall prevention.During a telephone interview on 10/22/25 at 3:45 pm, CNA C said that on 04/21/25, CNA A had asked her if she could cover the last two hours of her 2 pm to 10 pm shift. She said she agreed and punched in at around 8:00 pm. CNA C said the facility's protocol required the outgoing CNA to give report to the incoming CNA, but on that day, CNA A had not reported anything on Resident #1. CNA C said the only thing CNA A asked her to do was to help her make her end of shift round on Resident #1. CNA C said soon after she walked into his room, Resident #1, immediately told her his right leg was hurting. She said she noticed he had facial grimacing. She said Resident #1 told her he had a fall earlier in the day and his leg had been hurting since then. She said she immediately went to tell LVN D Resident #1 had pain in his right leg and asked him if it was true that he had fallen earlier in the day. She said LVN D told her that he had not been told Resident #1 had fallen earlier in the day. She said she and LVN D rushed back to Resident #1's room where LVN D assessed him.During a telephone interview on 10/22/25 at 4:00 pm, LVN D said on 04/21/25 between 8:00 and 8:20 pm, CNA C had reported to him that Resident #1 complained of pain in his right leg. He said he and CNA C rushed back to Resident #1's room and he noticed he had facial grimacing and voiced that his right leg was hurting. LVN D said he conducted a head-to-toe assessment, pain assessment (3/10) and notified Resident #1's NP/RP. LVN D said Resident #1's NP ordered pain medication and an x-ray of his right leg, stat. LVN D said after he had administered pain medication, called for an x-ray, and he called CNA A to ask her what happened to Resident #1. He said at first CNA A told him she did not know why Resident #1 was in pain and that nothing had happened to him during her shift. LVN D said CNA A called him 2 hours later and reported that Resident 1 had an unwitnessed fall and that she had failed to report it to anybody. LVN D said by the time CNA A called him back, he had already assessed Resident #1, called his NP, administered pain medication, and ordered x-rays to his right hip. LVN D said Resident #1's x-ray results showed he had sustained a right hip fracture as a result of the unwitnessed fall he had earlier that day. LVN D said a negative outcome for Resident #1 not having his unwitnessed fall reported and assessed before being moved could have worsened his fracture.During an interview on 10/22/25 at 4:20 pm, the DON said on 04/21/25, she had been informed by LVN D that Resident #1 had an unwitnessed fall sometime between 6:00 pm and 7:00 pm and was complaining of right hip pain. She said from what was reported to her, CNA A had wheeled Resident #1from the nurse's station back to his room to transfer him back to bed. She said while CNA A stood by Resident #1's door trying to motion another staff member to assist her in transferring Resident #1 back to bed, the resident directly across Resident #1's room called her to take him to the restroom. The DON said by the time CNA A came back to Resident #1's room, Resident #1 sustained an unwitnessed fall. The DON said Resident #1 was found on the floor and that's when CNA A and Med-Aide B transferred him back to his bed without him being assessed by a nurse or notifying anyone of the fall. She said that on 04/21/25, she had been informed by LVN D that between 8:00 pm and 8:15 pm, CNA C reported to him that Resident #1 had complained of right hip pain. She said LVN D immediately assessed Resident #1 and had notified his NP by 8:20 pm. She said LVN D later discovered CNA A had discovered Resident #1 lying on the floor in his room between 6:00 pm and 7:00 pm and that he had been transferred back to his bed by CNA A and Med-Aide B without being assessed by a nurse. She said the following day, CNA A was written up, suspended, and later terminated. The DON said it was her lapse in judgment that worried the facility's management that led to her termination. The DON said Med-Aide had received a write up for not reporting Resident #1's fall. The DON said the following interventions had been initiated between 04/21/25 through 04/23/25:100% of staff were in-serviced on the topic of ANE, timely reporting of incidents, direct care staff were in-serviced on the topic of fall prevention; the months of May 2025 to October 2025, direct care staff had been in-serviced on the topic of ANE, ADL accuracy, safe transfers, notification of changes, and fall prevention; ADONs had conducted weekly CNA observations of ADLs level assistance to ensure they followed proper procedures (started 08/2025 to present), nursing staff and CNAs had random check-offs performed from 08/2025 to 09/2025. The DON said the facility had what they called a watchlist which was a communication tool for nursing staff to communicate any changes in residents in their hall. She said during their morning and afternoon meetings, each charge nurse was called to attend and give report of any changes/concerns with any resident or CNAs not following protocols. The DON said CNAs have what they called handoff which meant the outgoing CNAs were supposed to relay any changes, and special instructions to the in-coming CNAs. She said the handoffs were supposed to occur at every shift. The DON said a negative outcome to Resident #1 of being moved without being assessed by a nurse or reporting the fall would be pain.Record review of the facility's Fall Prevention Program policy dated 08/15/22 reflected:Policy:Each resident will be assessed for fall risk and will receive care and services in accordance with their individualized level of risk to minimize the likelihood of falls.Definitions:A fall is an event in which an individual unintentionally comes to rest on the ground, floor, or other level, but not as a result of an overwhelming external force (e.g., resident pushes, another resident). The event may be witnessed, reported, or presumed when a resident is found on the floor or ground and can occur anywhere.Policy Explanation and Compliance Guidelines:8. When any resident experiences a fall, the facility will:Assess the residentComplete a post-fall assessmentComplete an incident reportRecord review of the facility's Safe Resident Handling/Transfers policy dated 02/19/25 reflected:Policy:It is the policy of this facility to ensure that residents are handled and transferred safely to prevent or minimize risk for injury and provide and promote a safe, secure, and comfortable experience for the resident while keeping the employees safe in accordance with current standards and guidelines. Policy Expectations:All residents require safe handling when transferred to prevent or minimize the risk of injury to themselves and the employees that assist them. While manual lifting techniques may be utilized dependent upon the resident's condition and mobility, the use of mechanical lift or other assistive devices could be used.Compliance Guidelines:13. Staff members are expected to maintain compliance with safe handling/transfer practices. Record review of the facility's Incidents and Accidents policy dated 08/15/22 reflected: It is the policy of this facility for staff to report, investigate, and review any accidents or incidents that occur or allegedly occur, on facility property and may involve or allegedly involve a resident.Definitions: Accident refers to any unexpected or unintentional incident, which results or may result in injury or illness to a resident.Policy Explanation:The purpose of incident reporting can include:Assuring the appropriate and immediate interventions are implemented and corrective actions are taken to prevent recurrences and improve the management of the resident care.Conducting root cause analysis to ascertain causative/contributing factors as part of the Quality Assurance Performance Improvement (QAPI) to avoid further occurrences.Alert administration of occurrences that could result in reporting requirements.Meeting regulatory requirements for analysis and reporting of incidents and accidents. Compliance Guidelines:6. Any injuries will be assessed by a licensed nurse or practitioner, and the affected individual will not be moved until safe to do so.Record review on 04/21/25 of Resident #1's change in condition dated 04/21/25 at 8:18 pm was done.Record review on 10/21/25 of Resident #1's progress notes dated 04/21/25 at 8:20 pm, reflected he had a head-to-toe assessment, pain assessment, NP notified, pain medication administered, and x-rays ordered.Record review on 10/22/25 of the facility's in-services reflected the following in-services were conducted on with staff after the incident on 04/21/25, 04/22/25, and 04/23/25 on the topics of ANE, timely reporting of an incident, and fall prevention.Record review on 10/22/25 of CNA A's Employee Counseling Report dated 04/21/25 reflected that she was written up on a Level two offense: Failure to report an incident.: On April 21, 2025, at approximately 8:00 pm, Resident #1 was found on the floor next to his bed. Staff member, CNA A failed to follow the appropriate incident reporting procedures. Upon further inquiry, the employee admitted to providing inaccurate information regarding the incident. This conduct constitutes violations of our Code of Conduct policy and proper reporting procedures.Record review on 10/22/25 of Med-Aide B's employee counseling report dated 04/23/25 reflected, she was counseled on a level two offense for failure to report an incident. On April 21, 2025, at approximately 8:00 PM, Resident #1 was found on the floor next to his bed. Staff member, [NAME] B. [NAME], was called by CNA A, to aid in transferring the resident from the floor to the bed. Employee failed to follow the appropriate incident reporting procedures. This conduct constitutes violations of our Code of Conduct policy and proper reporting procedures. Record review on 10/22/25 of the facility's in-service logs reflected during the months of May 2025 to October 2025, direct care staff had been in-serviced on the topics of ANE, ADL accuracy, safe transfers, notification of changes, and fall prevention program.Record review on 10/22/25 of the facility's Observation binder reflected weekly CNA observations conducted by the facility's ADONs from August 2025 to present, all CNAs had been observed on ADLs level of assistance to ensure they followed proper procedures.In interviews on 10/21/25 and 10/22/25, with CNAs B, C, E, F, G, H, I, J, K, P, Q, R, S, U, V, W, Y, Z, AA reflected all had been in-serviced on the topics of ANE, fall prevention, timely reporting of incidents, and fall prevention. All said they had been observed by ADONs during ADLs and random checkoffs had been done. All knew of the facility's protocol to give report to the in-coming CNA of any special instructions or changes with resident in their hall.In interviews on 10/21/25 and 10/22/25, with LVNs D, T, BB, and DD and RNs l, M, N, O, X, and CC reflected all had been in-serviced on the topics of ANE, fall prevention, timely reporting of incidents, and fall prevention. All knew of the facility's protocol to give report to the in-coming nurse to notify them of any special instructions or changes with resident in their hall. All said the facility had what they called watchlist which was a dashboard used as a communication tool for all nurses to report any change in conditions, special instructions, anything that is going on with a certain resident in their hall. They said the watchlist was updated as needed and they went over it during the morning and afternoon meetings. They all said that was a time also in which they were

Based on interview and record review, the facility failed to maintain clinical records in accordance with accepted professional standards and practices that are complete and accurately documented for 1 resident (Resident #3) of 5 residents reviewed for medical records accuracy, in that: The facility failed to document the doctor and RP had been notified of Resident #3's fall on 06/16/2025 at 05:07 am. This deficient practice could affect residents whose records are maintained by the facility and could place them at risk for errors in care and treatment.Findings included: Record review of Resident #3's admission Record dated 10/21/2025, revealed an [AGE] year-old male, admitted to facility on 06/06/2025. His diagnoses included: Wedge compression fracture of first lumbar vertebra (a type of spinal fracture where the front part of the vertebra collapses, creating a wedge-shaped deformity), dementia (a general term for a group of diseases that cause a loss of cognitive functioning, such as thinking, remembering, and reasoning, to the point that it interferes with daily life), heart disease, and hypertension (high blood pressure). Record review of Resident #3's Medicare 5-Day MDS dated [DATE] revealed Resident #3 had a BIMS score of 15, indicated cognitive function was intact. Resident #3 had clear speech, understood others and was able to be understood by others. Resident #3 was dependent on toileting hygiene and showers/baths requiring the assistance of two or more helpers. Record review of Resident #3's Care Plan dated 06/07/2025, revealed: FOCUS: Resident #3 has had an actual fall -06/16/25 UW fall Date Initiated: 06/16/2025 Revision on: 07/17/2025 Cancelled Date: 07/17/2025GOAL: The resident will resume usual activities without further incident through the review date. Date Initiated: 06/16/2025 Revision on: 07/17/2025 Target Date: 09/17/2025 Cancelled Date: 07/17/2025INTERVENTIONS/TASKS: 06/16/25 Encourage and educate resident on importance of using call light for all assistance. Date Initiated: 06/16/2025 Revision on: 07/17/2025 Cancelled Date: 07/17/2025 RN LN 07/17/2025 Monitor/document /report PRN x 72h to MD for s/sx: Pain, bruises, Change in mental status, New onset: confusion, sleepiness, inability to maintain posture, agitation. Date Initiated: 06/16/2025 Revision on: 07/17/2025 Cancelled Date: 07/17/2025 LN RN 07/17/2025 Neuro-checks x (72 hours) Date Initiated: 06/16/2025 Revision on: 07/17/2025 Cancelled Date: 07/17/2025 LN RN 07/17/2025 Notify MD/RP of incident Date Initiated: 06/16/2025 Revision on: 07/17/2025 Cancelled Date: 07/17/2025 RN LN 07/17/2025. Record review of Resident #3's Progress Notes on 06/16/2025 at 05:07 am written by LVN GG revealed, PATIENT WAS FOUND ON THE FLOR NEXT TO THE BED WITH PILLOW UNDER HIS HEAD. PATIENT STATES THAT HE WAS REACHING FOR THE BED SIDE TABLE WHEN THE AIR MATTRESS SHIFTED, CAUSING HIM TO LOSE BALANCE AND FALL ONTO THE FLOOR. PT DENIES HITING HIS HEAD AND DENIES PAIN AT THIS MOMENT. NEURO CHECKS PERFORMED AND WNL. PATIENT ASSISTED BACK TO BED WITH 3 STAFF AND STATED HE WAS COMFORTABLE WHEN FIXED INTO BED. EDUCATED THE PATIENT ON THE IMPORTANCE OF USING THE CALL LIGHT WHEN IN NEED OF ASSISTANCE. Record review of Resident #3's Progress Notes on 06/16/2025 at 04:35 pm written by PA HH revealed, No issues per nurse. During an interview on 10/21/2025 at 05:19 pm, PA HH stated she could not remember if she had been notified of Resident #3's fall on 06/16/2025, but she was pretty sure the nurse notified her of the fall. PA HH stated, If there are no notes on the fall, that's on me. I must have forgotten. PA HH stated she should have mentioned the fall in her notes. She stated again, If there are no notes on the fall or orders written in my notes, that is on me. I have a lot of patients I see. During an interview on 10/22/2025 at 02:36 pm, the DON stated the nurse should have documented the NP and RP were notified. The DON stated she did not know why PA HH did not document in her notes she was notified of the fall for Resident #3 when she came to see him that day of the fall (06/16/2025). During an interview on 10/28/2025 at 03:16 pm, LVN GG stated when a resident had a fall, she would notify the doctor, notify family, notify DON, and start the neuro checks. She said she did not know why her Progress Note did not show the notifications to the doctor and RP when Resident #3 fell on [DATE]. During an interview on 10/28/2025 at 05:15 pm, the DON stated the nurses should put all information in the Progress Notes when there was a fall. She said the nurse (LVN GG) should have documented the NP/PA and RP were notified. The DON stated she did not know why the PA did not document in her notes she had been notified of the fall for Resident #3 when she came to see him that day. During an interview on 10/29/2025 at 11:40 am, Doctor II stated it was their practice to document unwitnessed falls of residents. He stated Resident #3's unwitnessed fall should have been documented by his PA (PA HH). Doctor II stated he was looking at the notes from his PA who had seen Resident #3 the same day as his fall (06/16/2025). He stated PA HH would be counseled for not documenting that Resident #3 had an unwitnessed fall, the evaluation she had done, and orders she had given. Record review of facility's policy Physician Visits and Physician Delegation policy dated 10/24/2022 revealed: PolicyIt is the policy of this facility to ensure the physician takes an active role in supervising the care of residents.Policy Explanation and Compliance Guidelines:1.The Licensed Nurse should:h. Write a note to reflect the date and time of the physician visit, and indication as to whether new orders were written or no new orders were received and any special discussions between the resident and/or family and physician during the visit. Record review of facility's policy Documentation in Medical Record policy dated 10/24/2022 revealed: Policy:Each resident's medical record shall contain an accurate representation of the actual experiences of the resident and include enough information to provide a picture of the resident's progress through complete, accurate, and timely documentation.

Based on interviews and record reviews, the facility failed to provide Accuracy in service delivery. A facility must provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident for 2 (Resident #2 and Resident #3) of 5 residents reviewed for medication.1.The facility failed to administer Morphine Sulfate as ordered by the physician on two different occasions.2.The facility failed to document the pain level 0-10 on the physician's order to monitor for pain every shift for Resident #3. These deficient practices could place residents at risk of not receiving therapeutic doses of their medication.The Findings included:1.Review of Resident #2's face sheet reflected a [AGE] year-old female with an initial admission date of 07/14/2018 with a diagnosis of Parkinsonism (Umbrella term for conditions that cause symptoms similar to Parkinson's disease, including tremors, stiffness, and slow movement), Alzheimer's Dementia (Brain disorder that causes memory loss, confusion, and other cognitive decline), Atherosclerotic Heart Disease (Plaque buildup in arterial walls), Atrial Flutter (a heart rhythm problem where two upper chambers of the heart beat too fast, causing them to flutter instead of beating in a strong steady rhythm).Review of Resident #2's MDS dated [DATE] reflected a Brief Interview for Mental Status (BIMS) of 99 (Resident was unable to complete the interview).Review of Resident #2's Care Plan dated 7/28/2025 reflected resident was under hospice care with listed interventions as: medications as ordered and notify physician immediately if there is breakthrough pain. Work cooperatively with hospice team to ensure the resident's spiritual, emotional, intellectual, physical and social needs are met.Review of Resident #2's active orders as of 8/01/2025 OK to admit resident to hospice under physician DX: Alzheimer's / DementiaReview of Resident #2's active orders as of 8/01/2025 for Morphine Sulfate (Concentrate) Solution 20 MG/ML Give 0.5 mL by mouth every 4 hours as needed for Pain.Review of Resident #2's Individual Resident's Controlled Substance Record dated 8/2/25 reflected Morphine Sulf 100 MG/5 ML administer 0.5 ML by mouth as needed every 4 hours for shortness of breath or pain.Review of Resident #2's Individual Resident's Controlled Substance Record reflected Morphine Sulfate 0.25 mL was given on 8/10/20 at 10:00 PM by LVN EE and the same dose of 0.25 mL given on 8/11/25 at 7:00 AM by LVN FF.Review of Resident #2's Medication Administration Record reflected Morphine Sulfate 0.5 mL was given on 8/10/25 at 10:00 PM by LVN EE.Review of Resident #2's Medication Administration Record reflected Morphine Sulfate 0.5 mL was given on 8/11/2025 at 7:01 AM by LVN FF.Review of Resident #2's Nursing Progress Note reflected an entry made on 8/10/2025 at 10:00 PM by LVN EE Note Text: Morphine Sulfate (Concentrate) Solution 20 MG/ML Give 0.5 ML by mouth every 4 hours as needed for painReview of Resident #2's Nursing Progress Note reflected an entry made on 8/10/2025 at 10:39 PM by LVN EE Note Text: Morphine Sulfate (Concentrate) Solution 20 MG/ML Give 0.5 ML by mouth every 4 hours as needed for Pain PRN Administration was: Effective Follow-up Pain Scale was: 0Review of Resident #2's Nursing Progress Note reflected an entry made on 8/11/2025 at 6:17 AM by LVN FF Note Text: Received shift with resident in bed with irregular breathing between 24-32 per minute with Pulse of 110. Patient not on O2 per family request as endorsed by LVN EE. At 7 AM administered Morphine Sulfate 0.25 ML only per family due to patient moaning when repositioned. Kept HOB elevated and comfort measures provided. Family at bedside.Review of Resident # 2's Nursing Progress Note reflected an entry make on 8/11/2025 at 8:50 AM by LVN FF Note Text: Morphine Sulfate (Concentrate) solution 20 MG/ML Give 0.5 ML by mouth every 4 hours as needed for Pain Patient moaning and having SOB.In an interview on 10/21/2025 at 3:41 PM with LVN FF stated he had received a report from LVN EE not to give the whole dose (Morphine) as family requested. LVN FF said I asked the family member out of respect and gave 0.25 mL of morphine as the family requested. LVN FF said he had not called the doctor to inform him of the request made by the family to decrease the dosage of the morphine because he was busy and he knew he should have called. LVN FF said he documented on his progress notes the dose of 0.25 ML given as requested by the family.In a phone interview on 10/22/2025 at 11:42 AM with the Branch Manager of hospice, she stated Coordination of Care is done between hospice and facility staff upon admission and facilities are good in communicating with us. She said the facility did inform hospice of a lowered dose requested by the family after the medication was given. She said The facility was supposed to notify hospice of a request for a lowered dose so that we can document and let the doctor know. We would have to maybe send out our nurse to speak to the family and provide re-education.In a phone interview on 10/23/2025 at 1:14 PM with the pharmacy consultant, she said she was not informed that the nurses had given a lesser dose of the prescribed medication (morphine) to resident #2. She said administering a lesser dose of morphine may cause less drowsiness and may not manage pain as effectively.In an interview on 10/23/2025 at 3:42 PM with LVN BB stated if there are any changes to a resident's condition or meds, I would coordinate with hospice. If a family decided to give less or more of a medicine, we would have to coordinate with hospice and let them know so they can give us an order and speak to the family for further assessment. He said he would notify the family of the need to coordinate with hospice for changes in dosage. LVN BB said his last in-service on medication administration was about 2 weeks ago and an in-service from hospice was about 2 weeks ago.In an interview on 10/23/2025 at 3:57 PM with LVN ADON GG stated Resident # 2's pain was being managed because she was noted to be calm and there was no distress that he noted as he would make his rounds. He said a lesser dosage of morphine given than what was ordered would possibly affect pain management. In an interview on 10/23/2025 at 4:22 PM with the DON, she said 2-3 weeks ago hospice training was done by the hospice. We spoke to all staff and reminded them to provide compassionate care. We also communicated and met with the hospice DON and Administrator for training. Re-education and in-services were started and were still ongoing.In an interview on 10/23/2025 at 4:39 PM with the Administrator, she said there is a communication binder that hospice nurses and aides use when they check in and out after the visit was completed. She said the pharmacy consultant comes in every month and does entrance and exit with the DON and the Administrator. She said the facility's QAPI is reviewed for trends monthly. The administrator said reeducation and mandatory meetings were held continuously. She said daily morning meetings are held Monday-Friday that consisted of 3 different types. The first meeting held was and IDT (Interdisciplinary Team) meeting which consisted of all departments to discuss problems and resolutions, 2nd meeting was a clinical meeting held with the charge nurse to discuss all nursing related topics and reviewed the 24 hour. The 3rd meeting was a discharge planning meeting which involved the clinical care team and social services to review long-term/short-term residents and what residents may need upon discharge.2.Record review of Resident #3's admission Record dated 10/21/2025, revealed an [AGE] year-old male, admitted to facility on 06/06/2025. His diagnoses included: Wedge compression fracture of first lumbar vertebra (a type of spinal fracture where the front part of the vertebra collapses, creating a wedge-shaped deformity), dementia (a general term for a group of diseases that cause a loss of cognitive functioning, such as thinking, remembering, and reasoning, to the point that it interferes with daily life), heart disease, and hypertension (high blood pressure). Record review of discharge revealed Resident #3 was discharged from the facility to the hospital on [DATE] and did not return to the facility. Record review of Resident #3's Medicare 5-Day MDS dated [DATE] revealed Resident #3 had a BIMS score of 15, indicated cognitive function was intact. Resident #3 had clear speech, understood others and was able to be understood by others. Resident #3 was dependent on toileting hygiene and showers/baths requiring the assistance of two or more helpers. Record review of Resident #3's Care Plan dated 06/07/2025, revealed: FOCUS: Resident #3 is on pain medication therapy (Tylenol) r/t pain. Date Initiated: 06/09/2025 Revision on: 07/17/2025 Cancelled Date: 07/17/2025.GOAL: Resident #3 will be free of any discomfort or adverse side effects from pain medication through the review date. Date Initiated: 06/09/2025 Revision on: 07/17/2025 Target Date: 09/17/2025 Cancelled Date: 07/17/2025.INTERVENTIONS/TASKS: Administer ANALGESIC medications as ordered by physician. Monitor/document side effects and effectiveness Q-SHIFT. Date Initiated: 06/09/2025 Revision on: 07/17/2025 Cancelled Date: 07/17/2025 LN RN 07/17/2025 Ask physician to review medication if side effects persist. Date Initiated: 06/09/2025 Revision on: 07/17/2025 Cancelled Date: 07/17/2025 LN RN 07/17/2025. Record review of Resident #3's 06/01/2025 to 07/01/2025 Order Summary revealed Monitor for pain every shift use 0-10 scale (A) for alert residents use pain ad (B) for confused residents document which pain scale used to assess residents pain rating. Every shift. Record review of Resident #3's June 2025 Medication Administration Record revealed check marks only for monitoring dayshift pain level and nightshift pain level from 06/07/2025 through 06/26/2025 and a check mark only for dayshift pain level 06/27/2025 with no pain level documented.In an interview on 10/28/25 at 12:52 pm, RN M stated Resident #3 always had complaints of pain to his back. She said they always had to be gentle moving him. She said he was almost always in like a fetal position. In an interview on 10/28/25 at 02:45 pm, LVN GG stated Resident #3 was always in pain. She said his pain level would go from a 3 to where he was yelling at times. LVN GG stated Resident #3 was alert but then there were times when he was confused. She said he was a fragile man. LVN GG stated he had to be turned every so often. LVN GG stated Resident #3 would complain of pain when he was turned here and there. She said pain medication was always offered because he was always had pain. During an interview on 10/28/25 at 05:15 pm, the DON stated Resident #3 had an order to monitor for pain every shift and for them to document the pain scale using 0 out of 10. She said Resident #3's June 2025 MAR showed check marks with no documentation of pain level. The DON stated the MAR should have had the pain level documented on the monitoring order. She said the PRN Tylenol order had pain levels on administration, but that was not the pain monitoring order. The Tylenol order was another order. She said if the pain level number was not there, they would not know if the resident's pain was being controlled. Record review of facility policy titled: Medication Administration, Revised Date 10/01/19 reflected 2. Administration B. Medications are administered in accordance with written orders of the prescriber.Record review of facility policy titled: Pain Management, Date Implemented: 8/15/22 reflected 1. In order to help a resident attain or maintain his/her highest practicable level of physical, mental, and psychosocial wee-being and to prevent or manage pain, the facility will: c. Manage or prevent pain, consistent with the comprehensive assessment an plan of care, current professional standards of practice, and the resident's goals and preferences.Record review of Hospice Service Agreement dated June 1, 2018, reflected Article IV. Services to be provided by Nursing Facility. 4.3 Coordination with Hospice regarding Plan of Care. (ii) Modification. The Nursing Facility will assist with periodic review and modification of the Plan of Care. Nursing Facility will consult with Hospice, as reasonably necessary, with respect to any modification of the Plan of Care. Hospice retains the sole authority for determining the appropriate level of hospice care provided to each Hospice Patient. Any modification to the Plan of Care must be approved by Hospice.Record review of facility's policy Pain Management dated 08/15/2022 revealed: Policy:The facility must ensure that pain management is provided to residents who require such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goal and preferences.Policy Explanation and Compliance Guidelines:The facility will utilize a systematic approach for recognition, assessment, treatment and monitoring of pain.Recognition:1. In order to help a resident attain or maintain his/her highest practicable level of physical, mental and psychosocial well-being and to prevent or manage pain, the facility will:a. Recognize when the resident is experiencing pain and identify circumstances when the pain can be anticipated.b. Evaluate the resident for pain upon admission, during ongoing scheduled assessments, and when a significant change in condition or status occurs (e.g., after a fall, change in behavior or mental status, new pain or an exacerbation of pain).c. Manage or prevent pain, consistent with the comprehensive assessment and plan of care, current professional standards of practice, and the resident's goals and preferences.

Based on interview and record review, the facility failed to inform residents in advance about any care and treatment for 1 of 5 residents (Resident #3) reviewed for resident rights, in that: The facility failed to ensure consent forms were properly completed or signed by a responsible party prior to administration of a psychotropic medication (Remeron) for Resident #3. This failure could place residents at risk of not being aware of changes related to their care/treatment. Findings include: Record review of Resident #3's admission Record dated 10/21/2025, revealed an [AGE] year-old male, admitted to facility on 06/06/2025. His diagnoses included: Wedge compression fracture of first lumbar vertebra (a type of spinal fracture where the front part of the vertebra collapses, creating a wedge-shaped deformity), dementia (a general term for a group of diseases that cause a loss of cognitive functioning, such as thinking, remembering, and reasoning, to the point that it interferes with daily life), heart disease, and hypertension (high blood pressure). Resident #3 was discharged from the facility to the hospital on [DATE] and did not return to the facility. Record review of Resident #3's Medicare 5-Day MDS dated [DATE] revealed Resident #3 had a BIMS score of 15, indicated cognitive function was intact. Resident #3 had clear speech, understood others and was able to be understood by others. Resident #3 required supervision or touching assistance with eating. Resident #3 was dependent on toileting hygiene and showers/baths requiring the assistance of two or more helpers. Record review of Resident #3's Order Summary dated 06/01/2025 to 07/01/2025 revealed, Resident #3 had the following order written by PA HH:Start Date: 06/18/2025 Remeron Oral Tablet 30 MG (Mirtazapine)Give 1 tablet by mouth one time at bedtime for appetite stimulant.Medication Class: Tetracyclic antidepressants. Record review of Resident #3's consent form for Remeron (Mirtazapine) dated 06/18/2025 revealed no resident/responsible party signature or verbal consent was obtained to give Remeron. Record review of Resident #3's June 2025 MAR revealed Resident #3 had received Remeron Oral Tablet 30mg at bedtime for appetite stimulant from 06/18/2025 through 06/26/2025. Record review of Progress Notes dated 06/18/2025 at 12:09 pm written by PA HH revealed PA HH ordered Remeron Oral Table 30mg at bedtime for appetite stimulant. In an interview on 10/28/2025 at 03:16 pm LVN GG stated the nurse who received the psychotropic order from the physician would be responsible for getting signatures or verbal consent for the consent form. The nurse would explain to the family the medication and side effects and the family would decide if they wanted the resident to have it or not. She said if the family wanted the resident to take the medication, the nurse would either get verbal consent documented on the consent form or the Responsible Party would sign the consent form for the psychotropic. LVN GG stated the medication was not given to the resident until the consent for the psychotropic was signed or verbal consent was documented on the consent form. LVN GG stated the resident had the right to take the medication or refuse it. She said it was a patient's right. In an interview on 10/28/2025 at 05:15 pm The DON stated the nurse who took the order for a psychotropic or antipsychotic was the one responsible for getting signatures of the doctor and RP. The DON stated the nurse was not to give the medication until signatures were on the consent form. She said the negative effect of not getting signatures on the consent form would be that it would not show the RP or resident was informed of the side effects of the medication and the consent to give the medication. She said it was a resident's right to accept the medication or refuse it. Review of facility's policy Use of Psychotropic Medication(s) dated 03/05/2025 revealed:Policy Explanation and Compliance Guidelines: 9. Prior to initiating or increasing a psychotropic medication, the resident, family, and/or resident representative must be informed of the benefits, risks, and alternatives for the medication, including any black box warnings for antipsychotic medications, in advance of such initiation or increase.10. The resident has the right to accept or decline the initiation or increase of psychotropic medication.11. The facility will document that the resident or resident representative was informed in advance of the risks and benefits of the proposed care, the treatment alternatives or other options and the preferred option to accept or decline in a format the facility deems to use (e.g., written consent form, narrative note, etc.).

Based on interviews and record reviews, the facility failed to review and revise comprehensive care plans for 1 (Resident #3) of 5 residents reviewed for comprehensive care plan revisions. The facility failed to review and revise Resident #3's comprehensive person-centered care plan from Full Code Status to DNR Status in a timely manner reflecting both Full Code and DNR status on the care plan. This failure could affect residents and place them at risk of not receiving appropriate interventions to meet their current needs. Findings include: Record review of Resident #3's admission Record dated [DATE], revealed an [AGE] year-old male, admitted to facility on [DATE]. His diagnoses included: Wedge compression fracture of first lumbar vertebra (a type of spinal fracture where the front part of the vertebra collapses, creating a wedge-shaped deformity), dementia (a general term for a group of diseases that cause a loss of cognitive functioning, such as thinking, remembering, and reasoning, to the point that it interferes with daily life), heart disease, and hypertension (high blood pressure). Resident #3 was discharged from the facility to the hospital on [DATE] and did not return to the facility. Record review of Resident #3's Medicare 5-Day MDS dated [DATE] revealed Resident #3 had a BIMS score of 15, indicated cognitive function was intact. Resident #3 had clear speech, understood others and was able to be understood by others. Resident #3 was dependent on toileting hygiene and showers/baths requiring the assistance of two or more helpers. Record review of Resident #3's Care Plan dated [DATE], revealed: 1: FOCUS: Resident #3 is a full code Date Initiated: [DATE] Revision on: [DATE] Resolved Date: [DATE] GOALS: Facility will comply with resident/family wishes Date Initiated: [DATE] Revision on: [DATE] Target Date: [DATE] Resolved Date: [DATE] INTERVENTIONS/TASKS: If resident has a cardiac arrest, initiate CPR and call 911. Notify MD/RP and follow MD orders after notification. Date Initiated: [DATE] Revision on: [DATE] Resolved Date: [DATE] LN [DATE] Keep emergency cart well supplied and ready for use at all times Date Initiated: [DATE] Revision on: [DATE] Resolved Date: [DATE] LN [DATE] [NAME] chart and all pertinent documents with FULL CODE Date Initiated: [DATE] Revision on: [DATE] Resolved Date: [DATE] LN SS [DATE] FOCUS: Resident is a DNR Date Initiated: [DATE] Revision on: [DATE] Cancelled Date: [DATE] GOAL: Facility will comply with resident/family wishes Date Initiated: [DATE] Revision on: [DATE] Target Date: [DATE] Cancelled Date: [DATE] INTERVENTIONS/TASKS: Ensure signed DNR is in medical record Date Initiated: [DATE] Revision on: [DATE] Cancelled Date: [DATE] LN SS [DATE] If resident has a cardiac arrest, do not call 911 or initiate CPR. Notify MD/RP and follow instructions after notification Date Initiated: [DATE] Revision on: [DATE] Cancelled Date: [DATE] LN [DATE] [NAME] chart and all pertinent documents with DNR status Date Initiated: [DATE] Revision on: [DATE] Cancelled Date: [DATE] LN [DATE] Send copy of DNR paperwork upon transfer from facility Date Initiated: [DATE] Revision on: [DATE] Cancelled Date: [DATE] LN [DATE] Record review of Resident #3's OOH-DNR signed by RP, witnesses, physician, and notary was signed on [DATE]. In an interview on [DATE] at 12:52 pm, RN M stated that the admitting nurse was responsible for putting the code status of a resident in the care plan. She said if the resident code status changed to DNR after the admitting care plan, the nurse who was notified of the change of code status would put it in the Care Plan and remove the Full Code status. RN M stated she would want to see the signed DNR with signatures before she changed the code status on the Care Plan. RN M stated that usually the nurse who took the psychotropic order was the one who put the psychotropic or antipsychotic in the care plan. RN M stated for psychotropic medication orders, she would let the Care Team know, and they would put it in the care plan. In an interview on [DATE] at 01:40 pm, RN X stated that the admitting nurse was the one who completed the care plan on admission. She said the admitting nurse adds the code status of a resident on admission and if their code status changed, the nurse who received the change in code status was the one who updated the care plan with the change in code status and discontinued the full code status to DNR. RN X stated that the nurse who received the order for a psychotropic was responsible for getting the signed consent for psychotropics. She said the medication was not to be put in the computer until the family had signed consent for the psychotropic. She said that way, the order would not show up on the MAR and the medication would not be given until the consent was signed. In an interview on [DATE] at 03:16 pm, LVN GG stated that the admitting nurse completed the initial care plan and the RN reviewed the care plan then signed off on them. She said the admitting nurse was responsible for entering the code status on admission. LVN GG stated if the resident's code status changed, the Social Worker would let the nurse know of the change in code status and the nurse changed the status, discontinued the original code status, and in the comments, the nurse would document the resident's code status had been changed to DNR. LVN GG stated that the nurse who received the order for a psychotropic or antipsychotic was responsible for updating the care plan with goal and interventions. In an interview on [DATE] at 05:15 pm, the DON stated the Care Plan for Resident #3 showed his status code as Full Code on [DATE] which was the date his DNR was signed. She said the Care Plan was not updated with the DNR until [DATE]. She said it should have been updated sooner. The DON stated it would not have been clear if the resident was DNR if anything had happened to the resident between [DATE] and [DATE]. Resident #3 had an unwitnessed fall on [DATE] with no obvious injury. Record review of facility's policy Care Plan Revisions Upon Status Change dated [DATE] revealed: Policy: The purpose of this procedure is to provide a consistent process for reviewing and revising the care plan for those residents experiencing a status change. Policy Explanation and Compliance Guidelines: d. The care plan will be updated with the new or modified interventions. h. The Unit Manager or other designated staff member will conduct and audit on all residents experiencing a change in status, at the time the change in status is identified, to ensure care plans have been updated to reflect current resident needs.

Based on interview and record review, the facility failed to ensure adequate supervision was provided for 1 of 4 residents (Resident #1) reviewed for accidents and supervision. The facility failed to ensure Resident #1 was provided with adequate supervision and assistance while provided incontinent care on 08/20/25. Resident#1 suffered a fall that resulted in a subdural hematoma (a collection of blood that forms on the surface of the brain, between the brain and its outermost protective covering). Resident#1 was discharged to hospital on [DATE] and passed away on 08/21/25. The facility did not have consistent procedures for floor staff to establish level of need for residents requiring 1-2 person assist for ADLs. An Immediate Jeopardy was identified on 08/22/2025. The Immediate Jeopardy template was provided to the facility on [DATE] at 5:37 p.m. While the Immediate Jeopardy was removed on 08/23/2025 at 3:30 p.m. The facility remained out of compliance at a scope of isolation and a severity of harm with potential for more than the minimal harm that was not an immediate jeopardy because of the facility's need for continued monitoring of implemented procedures. This failure could prevent residents from receiving appropriate supervision which could lead to resident sustaining serious injury, harm, or death. Findings included: Record review of Resident#1 electronic admission record dated 08/21/2025, revealed a [AGE] year-old female with an admission date of 12/11/2022 and an original admission date of 04/09/2021. Resident #1's pertinent diagnosis included Dementia, Cerebral Vascular Accident (stroke) with right sided weakness, epilepsy (seizures), Heart Failure, and Atrial Fibrillation (irregular heartbeat). Record review of Resident #1's Comprehensive MDS dated [DATE], revealed a BIMS score of 02, indicating severe cognitive impairment. Resident #1 was noted in section GG- Functional Abilities coded as a 03 (Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds, or supports trunk or limbs, but provides less than half the effort) for self-care tasks and transfers. Resident #1 was noted to be bowel and bladder always incontinent. Record review of Resident #1's comprehensive care plan dated 05/22/2025, revealed Resident#1 had an ADL self-care performance deficit related to CVA with hemiplegia, Dementia. Interventions: BED MOBILITY: The resident requires (extensive assistance) by (1-2) staff to turn and reposition in bed daily and as necessary. Care needs may vary. TOILET USE: The resident requires extensive assistance by 1-2 staff for toileting. Care needs may vary. Record review of Resident #1' s Order Summary Report revealed Apixaban (anticoagulant) tablet 2.5 mg for A Fib and Keppra (anticonvulsant) tablet 500 mg for Seizures. Record review of Resident #1's narrative of the incident dated 08/20/2025, revealed the resident was receiving perineal care from CNA A. As CNA A turned to dispose of the soiled brief in the trash can at bedside, the resident rolled over onto the floor mat at bedside. Charge nurse was immediately notified and performed a head-to-toe assessment prior to bed transfer. Resident #1 was initially able to communicate and stated she had right sided shoulder pain. Family and NP were informed. Neuro checks were initiated, and a change of condition with AMS was noted approximately 20 minutes into the neuro checks, 911 call was activated and resident was transferred to hospital. Record review of Resident #1's Final report from the Hospital revealed Resident #1 suffered a subdural hematoma (a collection of blood that forms on the surface of the brain, between the brain and its outermost protective covering) secondary to anticoagulant therapy and recent fall with head injury. In an interview on 08/21/2025 at 11:06am, CNA A stated the incident happened around 10:45ish but not before 11am. She stated she went in and notified Resident #1 that she would be doing perineal care. She then proceeded to clean her. She turned her on the right side. She then removed the dirty brief and as she turned halfway to throw it away in the trash can that was beside her, Resident#1 did a quick movement and fell. She was not able to grab her because it happened so quickly. She notified charge nurse immediately. In an interview on 08/21/2025 at 12:30pm LVN B stated that she was called by CNA A to go to Resident #1's room. Resident #1 was awake, alert, and responsive. No visible injuries noted. She stated Resident #1 answered yes when asked if rolled off the bed. Resident#1 was immediately assessed for injuries, no visible injuries were noted. LVN B stated Resident #1 complained of pain to the right-side right shoulder, no swelling or redness noted to affected area. Neuro checks initiated. She stated the NP and RP were notified. LVN B stated Resident #1 was a 1-2 person assist depended on the task. She stated Resident #1 was a one person assist the day of the incident, 08/20/2025. LVN B stated that the CNAs that provided the care would determine if the patient cooperated. The CNAs were more hands-on with them. Then they would report to her if they were transferred well. In an interview on 08/21/2025 at 2:44 p.m., the DON stated she was at the facility at the time of the incident. She stated she was informed about the incident right away. She stated she did her own head to toe assessment. The DON stated Resident #1 was initially responding, then she had a decline. She stated everything happened fast, within minutes. The DON stated that she was familiar with her care and the staff were as well. She stated Resident #1 had been there for a while. The CNA had worked with her for a long time. The DON stated that because Resident #1 was doing so well yesterday morning, 08/20/2025, that was why CNA A provided care alone at that moment. In a follow up interview on 08/22/2025 at 10:44 a.m., the DON stated that the charge nurse did daily rounds first thing at the beginning of their shifts. She stated the charge nurse would determine if the resident would be a one or two person assist and verbally communicated this with the CNAs. Record review of the facility's policy dated 02/19/2025 titled Turning and Repositioning revealed: Policy Explanation and Compliance Guidelines:2. Turning and repositioning is a primary responsibility of nursing assistants. However, all nursing staff are expected to assist with turning and repositioning. 3. Turning and positioning includes using both side lying and back positions, alternating from the right, back, and left side.5. Use the appropriate number of staff to perform the tasks safely. Record review of the facility's policy dated 02/19/2025 titled Safe Resident Handling/Transfers Policy revealed: Policy: It is the policy of this facility to ensure that residents are handled and transferred safely to prevent or minimize risks for injury and provide and promote a safe, secure and comfortable experience for the resident while keeping the employees safe in accordance with current standards and guidelines. Compliance Guidelines: 1. The interdisciplinary team or designee will evaluate and assess ach residents' individual mobility needs, taking into account other factors as well, such as weight and cognitive status. 13. Staff members are expected to maintain compliance with safe handling/transfer practices. Record review of the facility's policy dated 08/15/2022 titled Fall Prevention Program Policy revealed: Policy: Each resident will be assessed for fall risk and will receive care and services in accordance with their individualized level of risk to minimize the likelihood of falls. An Immediate Jeopardy was identified on 08/22/2025. The Immediate Jeopardy template was provided to the facility on [DATE] at 5:37 p.m. The Immediate Jeopardy template was provided to administrator. The following Plan of Removal was accepted on 08/23/2025 at 10:50 a.m.: PLAN OF REMOVALDate: 08/22/2025Issue: F689: Free of Accident Hazards/Supervision/Devices: 483.25(d)(2)The facility failed to develop and implement processes and procedures to ensure adequate staff is provided to meet the needs of residents that require increased supervision, and that staff provide this supervision were trained and familiar with the resident's supervision needs.Actions Taken:For those Identified: Resident #1 was discharged from the facility and admitted to the hospital on [DATE].To Identify Other Residents: On 8/22/25, the MDS Nurses completed 100% review of residents to assess level of supervision required. Based on the assessment the Plan of Care was updated as needed to reflect the level supervision required. The level of ADL assistance is clarified to one (1) or two (2) person assist. The updated level of ADL assistance is reflected in the Point of Care nurse aide task list.The Interdisciplinary Team (IDT) i.e. MDS nurse, Director of Nursing, Director of Rehab, Social Services, Activities, Dietary will determine the initial level of ADL assistance based on admission Assessments. The IDT will no less than quarterly assess and update the level of ADL assistance required and update the Plan of Care, Kardex and Point of Care nurse aide tasks. The charge nurse will continuously evaluate the resident's status to determine whether the current level of assistance remains appropriate.The charge nurse will review the 24h report during the change of shift to identify any changes in conditions were identified for any resident. The nurse will review the level of assistance required and determine if this remains appropriate. If the charge nurse determines that a higher level of assistance is required, the nurse will arrange for additional support to meet the resident's need and communicate this change to the nurse aide. If a permanent change in level of assistance is identified this will be reflected in the Point of Care nurse aide task listing.The nurse will report any changes in level of assistance during the Clinical Morning Meeting. Monday-Friday with the Interdisciplinary Team present. The IDT will further assess to determine if the change in level of assistance is permanent. lf this is determined in the positive the Plan of Care, Kardex and tasks will be updated to reflect the change.Education / System Change: Effective immediately on 8/22/25, the Administrator/ DON and/ or designee began reeducation to 100% of direct care staff on the following:o Abuse, Neglect & Exploitationo Fall Preventiono Safe Handling of Residentso Perinea! Careo Turning and Repositioningo Process for Level of Assistance Required Effective immediately on 8/22/25, the Administrator/ DON and/ or designee beganreeducation to 100% of non- direct staff on the following: Abuse, Neglect & Exploitation The completion date of education of direct care staff will be 8/22/25, in person or via telephone. Those that were not scheduled on 8/22/2025 will have the education completed prior to accepting assignment for their next scheduled work. Any direct care staff not re­ educated in person or via phone today (8/22/2025), will be removed from providing care until education is provided. Verification of 100% of direct care staff education will be verified by the Director of Nursing/ designee. On 8/22/25, an Ad Hoc QAPI meeting was held with the Medical Director, facility Administrator, Director of Nursing, and the Regional Clinical Specialist to review the IJ Template and the Plan for Removal. Monitoring: Beginning 8/22/25, and going forward, the Director of Nursing/designee will review the 24 Hour Report to identify residents who may have had a change in condition that may require increased level of supervision in facility Clinical Morning Meeting, attended Monday-Friday. The Director of Nursing/designee will ensure that the residents' Plan of Care and Kardex is updated to reflect the change in level of supervision and the Point of Care nurse aide task list is updated. The DON/designee will conduct daily observations for all shifts for 5 days, then 5 days on random shifts to ensure the level of ADL assist is being followed as care planned. DON/designee will complete weekend rotations on random shifts to ensure the level of ADL assist is be followed as care planned. Administrator and DON will monitor compliance with the facility process implemented. The Director of Nursing will monitor to ensure the process is in place daily (Monday-Friday) for three months. Trends will be presented and discussed in the monthly QAPI meeting for three months. Monitoring: Started on 08/23/2025 at 11:00 a.m. and included: Record review of an In-Service with subject of Turning and Repositioning, dated 08/22/2025, indicated that working staff signed the in-service record on 08/22/2025 and 08/23/2025. Record review of an In-Service with subject of Safe Resident Handling/Transfers, dated 08/22/2025, indicated that working staff signed the in-service record on 08/22/2025 and 08/23/2025. Record review of an In-Service with subject of Fall Prevention, initiated date 08/22/2025, indicated that working staff signed the in-service record on 08/22/2025 and 08/23/2025. Record review of an In-Service with subject of Perineal Care, dated 08/22/2025, indicated that working staff signed the in-service record on 08/22/2025 and 08/23/2025. Record review of an In-Service with subject of ADLs, dated 08/22/2025, indicated that working staff signed the in-service record on 08/22/2025 and 08/23/2025. Record review of an In-Service with subject of Abuse, Neglect, and Exploitation, dated 08/22/2025, indicated that working staff signed the in-service record on 08/22/2025 and 08/23/2025. Record review of the Process for Level of Assistance Required dated 08/23/2025 revealed, The staff providing direct care to residents must be aware of the level of assistance required by the resident. The nurse will assess the patient's current condition and overall needs and provide direction to the nurse aide regarding the appropriate level of supervision require to ensure safe and effective care. The nurse will continuously evaluate the patient's status to determine whether the current level of assistance remains suitable. If the patient exhibits signs of agitation, fatigue, or any indication of a change in conditions (note: this is not an exhaustive list), the nurse will promptly inform the nurse aide. If it is determined by the nurse that a higher level of assistance is necessary, the nurse will arrange for additional support to meet the patient needs and communicate this change to the nurse aide accordingly. The aide will refer to the Kardex daily, or as needed, and follow any special instructions provided by the nurse to confirm the appropriate level of care for tasks such as Activities of Daily Living (ADLs). If a permanent change in the patients required level of assistance is identified, the Plan of Care will be updated accordingly, and the changes will be reflected in the Kardex. At no time will the nurse aide unilaterally determine the level of assistance required by the resident. The nurse will have the sole responsibility to assess and determine the level of assistance required by the resident. Record Review of the QAPI meeting was held on 08/22/2025 QAPI documentation reviewed. During interviews on 08/23/2025 at 11:29 a.m. - 08/23/2025 at 2:09 p.m., 8 CNAs were all knowledgeable of the of the expectation that at no time would they determine the level of assistance required by the resident. They stated that the nurses will have the sole responsibility to assess and determine the level of assistance required by the resident. The CNAs stated that the level of assistance would be reflected in the residents Kardex. They were to refer to the Kardex daily, or as needed, and if they had any questions then they would ask the nurse to confirm the appropriate level of care for tasks such as ADLs. During interviews on 08/23/2025 at 1:26 p.m. - 08/23/2025 at 2:44 p.m., 5 LVNs and 1 RN were aware of the expectations to review the 24-hour report during the change of shift and identify any changes in conditions the residents might have. They will review the level of assistance required and determine if this remains appropriate. If they determine that a higher level of assistance was required, they would arrange for additional support to meet the residents needs and communicate the change to the nurse aides. If the change were permanent in the level of assistance, then it would be reflected in the point of care nurse aide task listing. They would report any changes in level of assistance during the clinical morning meeting with the IDT team present. They were knowledgeable of the process for the determination of level of assistance required and having reeducation of the following policies and procedure- Abuse, neglect, and exploitation, Falls, Safe Handling of residents, Turning and reposition, and Perineal care. In an interview on 08/23/2025 at 3:00 p.m., MDS F stated that they completed 100% reviews of the residents to assess level of supervision required. She stated that the Plan of Care was updated to reflect the level of supervision required, based on the assessment. MDS F stated that there were about 75% of care plans that had 1-2 person assist for the level of ADL assistance and were clarified to reflect either a one or two person assist. She stated the updated level of ADL assistance was reflected in the Point of Care nurse aide task list. On 08/23/25 at 12:33 an Observation of peri care revealed CNAs reviewed the cardex before providing the care to verify the level of assistance required by the resident. On 08/23/25 from 1:26 p.m., to 1:42 p.m., two observations were done for two LVNs reviewing care plans to make sure the care plans were updated to reflect a one or two person assist. Record review of six care plans and 6 cardex were reviewed to verify that the information was the same in both records.The Administrator was informed that the Immediate Jeopardy was removed on 8/23/2025 at 3:30 p.m., however, the facility remained out of compliance at a severity of no actual harm with potential for more than minimal harm that is not an immediate jeopardy and a scope of isolated due to the facility need to evaluate the effectiveness of the corrected system.

Based on interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan that described the services to be provided to attain or maintain the residents' highest practicable physical, mental, and psychosocial needs, for 1 of 4 residents (Resident #1) reviewed for care plans in that: The facility failed to ensure an individualized care plan to address Resident #1's level of assistance that was required for ADLs by a 1 or 2 person assist. The CNA made the determination to provide perineal care by herself, resulting in Resident #1 to fall and was discharged to the hospital on [DATE]. An Immediate Jeopardy was identified on 08/22/2025. The Immediate Jeopardy template was provided to the facility on [DATE] at 12:20 p.m. While the Immediate Jeopardy was removed on 08/23/2025 at 3:30 p.m. The facility remained out of compliance at a scope of isolation and a severity of not actual harm with potential for more than the minimal harm that was not an immediate jeopardy because of the facility's need for continued monitoring of implemented procedures. This failure could place residents at risk of injuries and their individual medical, physical and psychosocial needs not being met. The findings were: Record review of Resident#1 electronic admission record dated 08/21/2025, revealed a [AGE] year-old female with an admission date of 12/11/2022 and an original admission date of 04/09/2021. Resident #1's pertinent diagnosis included Dementia, Cerebral Vascular Accident (stroke) with right sided weakness, epilepsy (seizures), Heart Failure, and Atrial Fibrillation (irregular heartbeat). Record review of Resident #1's comprehensive MDS dated [DATE], revealed a BIMS score of 02, indicating severe cognitive impairment. Resident #1 was noted in section GG- Functional Abilities coded as a 03 (Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds, or supports trunk or limbs, but provides less than half the effort) for self-care tasks and transfers. Resident #1 was noted to be bowel and bladder always incontinent. Record review of Resident #1's comprehensive care plan dated 05/22/2025, revealed Resident#1 had an ADL self-care performance deficit related to CVA with hemiplegia, Dementia. Interventions: BED MOBILITY: The resident requires (extensive assistance) by (1-2) staff to turn and reposition in bed daily and as necessary. Care needs may vary. TOILET USE: The resident requires extensive assistance by 1-2 staff for toileting. Care needs may vary. Record review of Resident #1's narrative of the incident dated 08/20/2025, revealed the resident was receiving perineal care from CNA A. As CNA A turned to dispose of the soiled brief in the trash can at bedside, the resident rolled over onto the floor mat at bedside. Charge nurse was immediately notified and performed a head-to-toe assessment prior to bed transfer. Resident #1 was initially able to communicate and stated she had right sided shoulder pain. Family and NP were informed. Neuro checks were initiated, and a change of condition with AMS was noted approximately 20 minutes into the neuro checks, 911 call was activated and resident was transferred to hospital.In an interview on 08/21/2025 at 11:06 a.m., CNA A stated that she was the one who determined if the resident would be a one or two person assist. She stated that she would determine this by seeing if the resident was cooperative and followed commands, prior to starting the task. If they were, then she would proceed with doing the task on her own. If they do not want to cooperate and assist, then she would get another staff member to assist. She stated that the Kardex (summary of a patients care plan and needs during their shift) had Resident #1 as a 1-2 person assist. CNA A stated that she normally does Resident #1's perineal care on her own.In an interview on 08/21/2025 at 11:43 a.m., CNA C stated that she was familiar with Resident #1's care and that she would normally do perineal care on her own. She stated that she looked in the computer Kardex to see if the resident would be a one person or two person assist. If the resident was a 1-2 person assist, then she determined if she could do it on her own or if she would need assistance. She would determine this after she talked to the resident and informed them of the task. If the resident was cooperative then she would continue to do the task on her own. If she saw that they were not, then she would get another person to assist. In an interview on 08/21/2025 at 12:30 p.m., LVN B stated that Resident #1 was a 1-2 person assist depended on the task. She stated Resident #1 was a one person assist the day of the incident, 08/20/2025, because she was cooperative. LVN B stated that the CNAs that provided the care would determine if the patient cooperated. The CNAs were more hands-on with them. Then they would report to her that they were transferred well. In an interview on 08/22/2025 at 2:25 p.m., CNA G stated that she worked at the facility for about ten months. She stated that she was familiar with Resident #1's care. She stated that Resident #1 would assist with moving her around in the bed, she followed commands. CNA G stated that she would know if a resident was a one or two person assist by looking in the computer, the Kardex. She stated that if showed 1-2 person assist, then she would determine if the resident was going to be a one or two person by seeing if the resident had been cooperative and followed commands. If not cooperative and were sleepy, then she would get someone to assist. She stated it depended on the state that the resident was in, but she would make that decision if she would need the extra help. She would document afterwards when she had time, if the task was done with a one or two person assist.In an interview on 08/25/2025 at 1:56 p.m., RN D stated that she and the MDS nurse were responsible for completing the care plans. She stated that when a resident was admitted , she performed a head-to-toe assessment. They gather all that information, and she communicated this with the CNAs. She would then talk to MDS and formulated everything on the care plan. RN D stated that it was important for the care plans to be person centered for each resident for their safety and the safety of the staff. She stated that they could have something general for everybody. The staff or resident can hurt themselves if it was supposed to be a 2 person and was done by a 1 person. She stated that it was important for the care plan to be individualized with their specific needs for safety and to prevent accidents. In an interview on 08/22/2025 at 10:39 a.m., MDS E, stated that she coded Resident #1 as 03. Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds, or supports trunk or limbs, but provides less than half the effort under the Functional Abilities was because the patient could be 1 or 2 person assist. She stated the patients in the morning could be extensive and, in the evening, they could be total assist. It all depended on what they needed at that moment. The CNA and the charge nurse would be the ones who determined the level of assistance. MDS E stated that changes in condition were communicated every day in the IDT morning meeting. She stated that they were responsible for care planning. In a follow up interview on 08/25/2025 at 2:20 p.m., MDS E, stated that person centered care plan meant it was an individualized care plan with their specific needs based on the patient's diagnoses, their functions, limitations, goals, and their preferences. It focused on them as a whole. MDS E stated that the process for care planning was if it was an admission, the nurse would go assess the patient. The initial baseline care plan would be started. She stated once that was closed, it imported to the system. In the morning meetings, they go over our patients and make any changes to the care plan that were needed. She stated she would then have 14 days to complete the comprehensive. If any changes were made in their 24-hour reports, they reviewed them in the morning meetings. MDS E stated that it was important for the care plans to be person centered for each resident because nobody was the same, everybody has different limitations. She stated, What can work for someone, does not work for others; they all have different preferences. The negative outcome of the care plan not being individualized with their specific needs and being a 1 -2 assist would be that incidents can happen. The care of the patient can be at risk and the safety of both the patient and staff. In an interview on 08/21/2025 at 2:44 p.m., the DON stated that the MDS nurses formulated the care plan, but it was a team collaboration. She stated the therapist, charge nurses, ADON, and she were all involved. It was a holistic approach from the staff if a resident would be a one or two person; it takes a team. She stated the 1-2 person assist depended on the time of the day. In the morning, Resident #1 does well, she followed commands. There were other moments that she might need two person assist, this would be when Resident #1 was more tired or fatigued towards the end of the day. The CNAs would not begin care on their own if they knew she needed a two person assist. In a follow up interview on 08/25/2025 at 2:35 p.m., the DON stated the charge nurse was responsible for starting the care plan. She stated that a head to touch assessment was done upon admission. This was considered a mini care plan. She stated the nurse and MDS nurse can update and change interventions. The DON stated that it was important for the care plans to be person centered for each resident because every patient was different. She stated every care plan needed to be specific to that patient's needs. The DON stated the negative outcome of not having an individualized care plan would be that the patient or the staff could get hurt. Record review of facility's policy for Comprehensive Care Plans date implemented 10/24/2022 revealed: It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment.Policy Explanation and Compliance Guidelines: 3.The comprehensive care plan will describe, at a minimum, the following:f. Resident specific interventions that reflect the residents needs and preferences and align with the residents cultural identify, as identified.8. Qualified staff responsible for carrying out interventions specified in the care plan will be notified of their roles and responsibilities for carrying out the interventions, initially and when changes are made. An Immediate Jeopardy was identified on 08/22/2025. The Immediate Jeopardy template was provided to the facility on [DATE] at 12:20 p.m. The Immediate Jeopardy template was provided to administrator. The following Plan of Removal was accepted on 08/23/2025 at 10:50 a.m.: PLAN OF REMOVALDate: 08/22/2025Issue:F 656 Comprehensive Patient Centered Care Plan The facility failed to develop and implement a comprehensive specific person-centered care plan for each resident to ensure adequate staff is provided to meet the needs of residents that require increased supervision.Actions Taken:For those Identified: Resident #1 was discharged from the facility and admitted to the hospital on [DATE].To Identify Other Residents: On 8/22/25, the MDS Nurses completed 100% review of residents to assess level of supervision required. Based on the assessment the Plan of Care was updated as needed to reflect the level supervision required. The level of ADL assistance is clarified to one (1) or two (2) person assist. The updated level of ADL assistance is reflected in the Point of Care nurse aide task list.The Interdisciplinary Team (IDT) i.e. MDS nurse, Director of Nursing, Director of Rehab, Social Services, Activities, Dietary will determine the initial level of ADL assistance based on admission Assessments. The IDT will no less than quarterly assess and update the level of ADL assistance required and update the Plan of Care, Kardex and Point of Care nurse aide tasks. The charge nurse will continuously evaluate the resident's status to determine whether the current level of assistance remains appropriate.The charge nurse will review the 24h report during the change of shift to identify any changes in conditions were identified for any resident. The nurse will review the level of assistance required and determine if this remains appropriate. If the charge nurse determines that a higher level of assistance is required, the nurse will arrange for additional support to meet the resident's need and communicate this change to the nurse aide. If a permanent change in level of assistance is identified this will be reflected in the Point of Care nurse aide task listing.The nurse will report any changes in level of assistance during the Clinical Morning MeetingMonday-Friday with the Interdisciplinary Team present. The IDT will further assess to determine if the change in level of assistance is permanent. lf this is determined in the positive the Plan of Care, Kardex and tasks will be updated to reflect the change.Education / System Change:Effective immediately on 8/22/25, the Administrator/ DON and/ or designee began reeducation to 100% of direct care staff on the following:o Abuse, Neglect & Exploitationo Fall Preventiono Safe Handling of Residentso Perineal Careo Turning and Repositioningo Process for Level of Assistance Required Effective immediately on 8/22/25, the Administrator/ DON and/ or designee beganreeducation to 100% of non- direct staff on the following: Abuse, Neglect & Exploitation The completion date of education of direct care staff will be 8/22/25, in person or via telephone. Those that were not scheduled on 8/22/2025 will have the education completed prior to accepting assignment for their next scheduled work. Any direct care staff not re­ educated in person or via phone today (8/22/2025), will be removed from providing care until education is provided. Verification of 100% of direct care staff education will be verified by the Director of Nursing/ designee. On 8/22/25, an Ad Hoc QAPI meeting was held with the Medical Director, facility Administrator, Director of Nursing, and the Regional Clinical Specialist to review the IJ Template and the Plan for Removal. Monitoring: Beginning 8/22/25, and going forward, the Director of Nursing/designee will review the 24 Hour Report to identify residents who may have had a change in condition that may require increased level of supervision in facility Clinical Morning Meeting, attended Monday-Friday. The Director of Nursing/designee will ensure that the residents' Plan of Care and Kardex is updated to reflect the change in level of supervision and the Point of Care nurse aide task list is updated. The DON/designee will conduct daily observations for all shifts for 5 days, then 5 days on random shifts to ensure the level of ADL assist is being followed as care planned. DON/designee will complete weekend rotations on random shifts to ensure the level of ADL assist is be followed as care planned. Administrator and DON will monitor compliance with the facility process implemented. The Director of Nursing will monitor to ensure the process is in place daily (Monday-Friday) for three months. Trends will be presented and discussed in the monthly QAPI meeting for three months. Monitoring: Started on 08/23/2025 at 11:00 a.m. and included: Record review of an In-Service with subject of Fall Prevention, initiated date 08/22/2025, indicated that working staff signed the in-service record on 08/22/2025 and 08/23/2025. Record review of an In-Service with subject of Safe Resident Handling/Transfers, dated 08/22/2025, indicated that working staff signed the in-service record on 08/22/2025 and 08/23/2025. Record review of an In-Service with subject of Turning and Repositioning, dated 08/22/2025, indicated that working staff signed the in-service record on 08/22/2025 and 08/23/2025. Record review of an In-Service with subject of Perineal Care, dated 08/22/2025, indicated that working staff signed the in-service record on 08/22/2025 and 08/23/2025. Record review of an In-Service with subject of ADLs, dated 08/22/2025, indicated that working staff signed the in-service record on 08/22/2025 and 08/23/2025. Record review of an In-Service with subject of Abuse, Neglect, and Exploitation, dated 08/22/2025, indicated that working staff signed the in-service record on 08/22/2025 and 08/23/2025. Record review of the Process for Level of Assistance Required dated 08/23/2025 revealed, The staff providing direct care to residents must be aware of the level of assistance required by the resident. The nurse will assess the patient's current condition and overall needs and provide direction to the nurse aide regarding the appropriate level of supervision require to ensure safe and effective care. The nurse will continuously evaluate the patient's status to determine whether the current level of assistance remains suitable. If the patient exhibits signs of agitation, fatigue, or any indication of a change in conditions (note: this is not an exhaustive list), the nurse will promptly inform the nurse aide. If it is determined by the nurse that a higher level of assistance is necessary, the nurse will arrange for additional support to meet the patient needs and communicate this change to the nurse aide accordingly. The aide will refer to the Kardex daily, or as needed, and follow any special instructions provided by the nurse to confirm the appropriate level of care for tasks such as Activities of Daily Living (ADLs). If a permanent change in the patients required level of assistance is identified, the Plan of Care will be updated accordingly, and the changes will be reflected in the Kardex. At no time will the nurse aide unilaterally determine the level of assistance required by the resident. The nurse will have the sole responsibility to assess and determine the level of assistance required by the resident. Record Review of the QAPI meeting was held on 08/22/2025 QAPI documentation reviewed. During interviews on 08/23/2025 at 11:29 a.m. - 08/23/2025 at 2:09 p.m., 8 CNAs indicated they were all knowledgeable of the expectation that at no time would they determine the level of assistance required by the resident. They stated that the nurses would have the sole responsibility to assess and determine the level of assistance required by the resident. The CNAs stated that the level of assistance would be reflected in the residents Kardex. They were to refer to the Kardex daily, or as needed, and if they had any questions then they would ask the nurse to confirm the appropriate level of care for tasks such as ADLs. During interviews on 08/23/2025 at 1:26 p.m. - 08/23/2025 at 2:44 p.m., 5 LVNs and 1 RN indicated they were aware of the expectations to review the 24-hour report during the change of shift and identify any changes in conditions the residents might have. They would review the level of assistance required and determine if this remains appropriate. If they determine that a higher level of assistance was required, they will arrange for additional support to meet the residents needs and communicate the change to the nurse aides. If the change were permanent in the level of assistance, then it would be reflected in the point of care nurse aide task listing. They would report any changes in level of assistance during the clinical morning meeting with the IDT team present. They were knowledgeable of the process for the determination of level of assistance required and having reeducation of the following policies and procedure- Abuse, neglect, and exploitation, Falls, Safe Handling of residents, Turning and reposition, and Perineal care. In an interview on 08/23/2025 at 3:00 p.m., MDS F stated that they completed 100% reviews of the residents to assess level of supervision required. She stated that the Plan of Care was updated to reflect the level of supervision required, based on the assessment. MDS F stated that there were about 75% of care plans that had 1-2 person assist for the level of ADL assistance and were clarified to reflect either one or two person assist. She stated the updated level of ADL assistance was reflected in the Point of Care nurse aide task list.On 08/23/25 at 12:33 an Observation of peri care revealed CNAs reviewed the cardex before providing the care to verify the level of assistance required by the resident. On 08/23/25 from 1:26 p.m., to 1:42 p.m., two observations were done for two LVNs reviewing care plans to make sure the care plans were updated to reflect a one or two person assist. Record review of six care plans and 6 cardex were reviewed to verify that the information was the same in both records.The Administrator was informed that the Immediate Jeopardy was removed on 8/23/2025 at 3:30 p.m., however, the facility remained out of compliance at a severity of no actual harm with potential for more than minimal harm that is not an immediate jeopardy and a scope of isolated due to the facility need to evaluate the effectiveness of the corrected system.

Based observations, interviews, 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 (Resident #115) of 3 residents observed for Infection Control. CNA A failed to follow proper hand hygiene and cleansing of perineal area while providing incontinent care to Resident #115. These failures could place the residents at risk of cross-contamination and development of infections. Findings included: Review of Resident #115's Face Sheet, dated 11/14/2024, reflected that the resident was an [AGE] year-old male admitted on [DATE]. Resident #115 was diagnosed with urinary tract infection, benign prostatic hyperplasia (the prostate gland grows in size due to overgrowth in cells) with lower urinary tract symptoms, and need for assistance with personal care. Review of Resident #115's Admission MDS Assessment, dated 07/21/2024, reflected that Resident #115 had a BIMs score of 10 which suggested moderate impairment of cognition. Resident #115's Admission MDS Assessment indicated that the resident was incontinent for bowel and bladder. Review of Resident #115's Comprehensive Care Plan, dated 07/16/2024, reflected that Resident #115 required (dependent assist) for toileting hygiene. Observation on 11/14/24 at 4:05 PM revealed during incontinent care of Resident # 115, after CNA A placed resident in comfortable position, she removed her gloves and applied clean gloves. CNA A did not sanitize between glove changes. CNA A retracted the foreskin of the penis, wiped half circle to tip of the penis, then crumpled and re-wiped the same area using the same wipe. CNA A then wiped the opposite half circle to tip of the penis and re-wiped using same wipe. She did not use one wipe per swipe. She then replaced the foreskin, CNA A then proceeded to clean the catheter tubing from the urethra outward for about three inches of tubing, then wiped again using the same wipe. She did not use one wipe per swipe. CNA A then finished cleaning the scrotum and outward to the thighs properly. She then assisted Resident #115 to his left side to begin cleaning the buttocks area. CNA A did not remove gloves, sanitize hands, and apply clean gloves after cleansing front genitalia and prior to touching Resident #115 to assist him to his left side. In an interview with CNA A on 11/13/24 at 4:40 pm CNA A said she didn't recall doing anything incorrect when performing incontinence care with Resident #115. She said she must sanitize her hands every time she changed her gloves. She said she knew when the state was here, they need to be very strict with hand hygiene. She then said, she always performed hand hygiene per protocols. She said she did not remember the last time the facility assessed her skills for incontinent care or foley care. She said she knew every time she changed her gloves, she must sanitize her hands, but she just got confused. CNA A said at every in-service or training for infection control, they train them on when to wash their hands and when to gown up. She did not remember when the last infection control in-service was done, but they go over infection control daily. In an interview with CNA B on 11/24/25 at 1:22 pm she said the last infection control in-service she received was about 2 weeks ago. She said hand hygiene must be performed before entering a resident's room, between glove changes and as needed. She said they must remove gloves, sanitize hands, and apply clean gloves. She said when providing incontinent care to a resident, they must use one wipe per swipe when cleaning both the front and back areas. She said they must change gloves and sanitize hands after cleaning the front area and before continuing with the rest of the incontinent care. In an interview with CNA C on 11/14/24 at 1:42 pm she said she did not remember when the last infection control in-service was. She said they go over hand hygiene and PPE. She said hand hygiene must be done every time they provide care to a resident. She said they perform hand hygiene before entering a resident's room and when leaving a resident's room. She said they must sanitize hands between glove changes. She said when performing incontinent care on a resident, they must use one wipe per swipe. She said they must change gloves and sanitize hands when moving from front to back. She said they completed an incontinent care check off at hire and periodically by one of the ADONs. In an interview with LVN D on 11/14/24 at 1:53 pm he said the last infection control training he completed was also about one month ago. He said they go over hand hygiene, PPE, and contact precautions. He said they performed hygiene before and after care with a resident. He said they must complete hand hygiene between glove changes. He said when performing incontinent care, they must use one wipe per swipe. He said he tried to ensure the CNAs were performing correctly. In an interview LVN E on 11/14/24 at 2:25 pm she said she was one of the ADONs who conducted in-services for staff. She said for infection control in-services they go over new policy on enhanced barrier precautions (EBP), hand hygiene and incontinent care. She said the staff were told perform hand hygiene before performing resident care, when going in and out of resident's rooms and between glove changes. She said staff were instructed to use one wipe per swipe, not to fold or roll, when incontinent care was provided to residents. In an interview with the DON on 11/14/24 at 5:05 pm, she said one of the ADONs does the monthly hand hygiene and PPE in-services as well as skills checklist for incontinent care and foley care. The DON said all staff must perform hand hygiene between glove changes. She said when performing incontinence care on a resident, staff must use one wipe per swipe. The DON also said staff must change gloves and perform hand hygiene when peri care was completed and before touching a resident. She said if they did not, it would cause cross contamination. Review of the facility's Infection Control Policy implemented 5/13/23 revealed, Policy: This facility has established and maintains 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 as per accepted national standards and guidelines. Policy Explanation and Compliance Guidelines: . 4. Standard Precautions: a. All staff shall assume that all residents are potentially infected or colonized with an organism that could be transmitted during the course of providing resident care services. b. Hand hygiene shall be performed in accordance with our facility's established hand hygiene procedures. c. All staff shall use personal protective equipment (PPE) according to established facility policy governing the use of PPE. Review of the facility's Hand Hygiene policy implemented 10/24/22 revealed, Policy: All staff will perform proper hand hygiene procedures to prevent the spread of infection to other personnel, residents, and visitors. This applies to all staff working in all locations within the facility. Definitions: Hand hygiene is a general term for cleaning your hands by handwashing with soap and water or the use of an antiseptic hand rub, also known as alcohol-based hand rub (ABHR). Policy Explanation and Compliance Guidelines: 1. Staff will perform hand hygiene when indicated, using proper technique consistent with accepted standards of practice. 2. Hand hygiene is indicated and will be performed under the conditions listed in, but not limited to, the attached hand hygiene table. 6. Additional considerations: a. The use of gloves does not replace hand hygiene. If your task requires gloves, perform hand hygiene prior to donning gloves, and immediately after removing gloves. Policy for Incontinent Care requested on 11/13/2024 at 5:30 pm and the Administrator provided a copy of pages from Lippincott Nursing Procedures, 11th Edition. The Administrator said they follow Lippincott Nursing Procedures. Review of documents revealed, When caring for a patient with an indwelling urinary catheter, follow infection-prevention practices, such as performing hand hygiene, . Implementation: Gather the equipment and supplies at the patient's bedside. .Advise the patient to remind staff members to perform hand hygiene before and after handling the catheter if they fail to do so. Perform hand hygiene. Put on gloves and other personal protective equipment, as needed, to comply with standard precautions. Reviewed Incontinent Care Proficiency Checklist provided by Administrator for CNA A dated 8/30/24. The checklist revealed the following: .Put on gloves. Use more than one washcloth, if needed . Wash hands before performing peri care. Use hand gel between glove changes. If heavily soiled, wash hands with soap and water. Wash hands after cleaning the resident and before touching clean linens. Wash hands after peri care is completed and before leaving the room. Wash hands any time you are unsure if you touched something dirty.

Based on observation, interview, and record review the facility failed to ensure that all alleged violations involving exploitation were thoroughly investigated and results reported of all investigations to the State Survey Agency, within 5 working days of the incident for 1 (Resident #49) of 5 residents reviewed for exploitation. The facility Abuse Coordinator/Administrator failed to thoroughly investigate a reported allegation of exploitation of Resident #49 by CNA A. This failure could place residents at risk of exploitation. Findings included: Record review of Resident #49's face sheet indicated she was a [AGE] year-old female admitted to the facility on [DATE]. Her diagnosis included spinal stenosis (lumbar and thoracic region), paraplegia, type 2 diabetes, hyperlipidemia, morbid (severe) obesity. Record review of Resident #49's Quarterly Minimum Data assessment dated [DATE], revealed Resident #49's Brief Interview for Mental Status score was 13 (cognitively intact). Resident #49 required extensive assistance for bed mobility, dressing, locomotion on/off unit, and personal hygiene. Record review of Resident #49's Comprehensive Care Plan initiated 06/26/23 revealed she had little, or no activity involvement related to immobility preferring to spend most of her time in her room. Observation of Resident #49 on 09/06/23 at 9:15 a.m., revealed Resident #49 was in her room lying in bed. She was awake, alert and in her own personal clothing. Room was clean and well lit. During an interview on 09/06/23 at 09:21 a.m., Resident #49 said sometime in 03/2023, while CNA A was in her room providing care, she complained about having money issues. Resident #49 said she does not remember the reason CNA A needed the money, but she said she offered to help with her with $40. Resident #49 said she told CNA A she could pay her back in payments and she agreed. Resident #49 said the next day CNA A paid her back $20. Resident #49 said she voluntarily loaned her the $40. out of the kindness of her heart. Resident #49 said after making 1 payment of $20. CNA A had not made any other payments until 2 months ago (did not remember the exact month or day) Resident #49 said CNA A sent the remaining $20. with another CNA (last name unknown). She said she had not told anyone of the loan she made to CNA A but had a strange feeling someone had recorded their conversation. Resident #49 said she did not have any ill feelings towards CNA A saying it was just money and wanted to help her out. Resident #49 said about two months ago, the administrator, the social worker and ADON 1 went to her room to ask about the loan she had made to CNA A. Resident #49 said the administrator asked if it was true, she had loaned CNA A money and why. Resident #49 said the administrator told her she was not supposed to be lending staff money and told her not do it again. Resident #49 said she had not seen CNA A in two months because she was transferred to another hall. During an interview on 09/06/2023 at 1:30 p.m., CNA A said sometime in March 2023, while in Resident #49's room she noticed bottles of perfume on Resident #49's dresser. She said Resident #49 said her sister brought them and were for sale. CNA A told Resident #49 she was interested in buying two bottles of perfume for a total of $200. Resident #49 agreed and told her she could pay her back in payments. CNA A said she told Resident #49 she would make a $20.00 to $25.00 payment each time she got paid, so she agreed. CNA A said she kept her word and made bi-weekly payments until she paid off the entire balance (sometime in 06/2023). She said she would give Resident #49 the money for her to give to her sister. CNA A said sometime in 07/ 2023, Resident #49 told her she still owed her sister $60.00. CNA A said she told Resident #49 she had already paid her $200. She said Resident #49 insisted CNA A owed her money and that she was going to talk to her sister about it. CNA A said sometime in mid-August 2023 the administrator approached her and asked her if she owed Resident #49 money. CNA A said she told the administrator she had purchased two bottles of perfumes from Resident #49's sister back in 03/2023 but had already finished paying her back. CNA A said she told the administrator Resident #49 was saying she still owed her money but was not true. CNA A said she was counseled, in-serviced on resident rights and was moved to a different hall. CNA A said the administrator reminded her not to be buying anything from residents. CNA A said the administrator reminded her if she was offered a gift, it must be less than $25.00 and it must be shared with all staff. CNA A said the administrator told her she was going to conduct her own investigation into the matter. CNA A said 3 days after she was counseled, she asked the administrator what the outcome of her investigation was and was told by the administrator the investigation was complete and closed but did not give her any details. CNA A said has not had any contact with Resident #49 since August 2023. CNA A said she had been trained in resident rights when she was hired and said I made a mistake in buying the perfume bottles from Resident #49. She said, I learned my lesson and it was a big error on my part. CNA A said she did not feel she was doing anything wrong because she bought the perfumes from Resident #49's sister and not the resident. During an interview on 09/06/2023 at 2:00 p.m., Resident #49 was asked about the perfume bottles. She said her sister came to visit her and brought her one bottle of perfume. Resident #49 said her sister expected her to pay her back. She said she left the perfume bottle on her bedside table and when CNA A came into her room and asked if she was selling the perfume. Resident #49 said she told CNA A she would sell it to her for $120.00 and CNA A agreed to buy it from her. Resident #49 said she agreed to sell the bottle of perfume to CNA A because she did not have the money to pay her sister back. Resident #49 said CNA A paid her the $120.00 on her next payday (not sure of date). Resident #49 said the administrator wanted to make it seem like the money CNA A owed her was for the perfume, but it was not. Resident #49 said she loaned CNA A the $40.00 after she purchased and paid off the perfume. During an interview on 09/06/2023 at 2:07 p.m. The Social Worker said Resident #49 was saying something about a CNA I don't remember the name of the cna's name The Social Worker said the information received was third party and did not remember the details but said it was about money being owed to Resident #49. The Social Worker said during a care plan meeting The administrator, ADON 2 and himself met with Resident #49 to discuss the allegations. The social worker said it was not really care planned as the facility uses the word care plan loosely he said it was not an official care plan meeting they had but an informal meeting. The social worker though he had taken some notes regarding the meeting with Resident #49, after about 5 minutes, the social worker said he was not able to find any notes saying he must have forgotten take any notes. He said the administrator had done all the talking. The social worker said he does not speak Spanish and did not remember any details of the meeting but did say it was determined Resident #49 did not lend money to CNA A. Interview on 09/06/2023 at 2:30 p.m., The administrator said she was approached by CNA B (former employee) that while she was providing care to Resident #49, she made an outcry about CNA A owing her money. The administrator said she immediately got together with, ADON 1, and the social worker all went to talk to Resident #49. The administrator said she asked, Resident #49, I understand you told CNA B, one of our CNA's (CNA A) owed you money (between $30.00-$60.00) The administrator said Resident #49's response was CNA A said she needed money, and I offered to help her out. The administrator said after meeting with Resident #49, she brought CNA A to her office and advised her there was an allegation of her owing money to a resident. The administrator said CNA A immediately asked, are talking about Resident #49. She said CNA A told her Resident #49's sister sells perfumes and had brought perfume bottles to Resident #49 for her to sell. She said CNA A confessed to buying 2 bottles and offered sell them to other CNA's at the facility. CNA A said she purchased 2 bottles and the transaction had taken place in Resident #49's room. The administrator said she got upset with CNA A and told her that could be considered exploitation/solicitation and said she would be conducting her own investigation into the matter. The administrator said she went back to Resident #49 and told her CNA A had said the money owed was for a perfume bottle and not a loan. She said the resident agreed. The administrator said she in-serviced CNA A on the topic of resident rights/solicitation and transferred CNA A to a different hall just in case Resident #49's memory was triggered if she saw her again. The administrator said Resident #49 wanted to make money as she believes prior to being admitted to the facility Resident #49 used to sell at local flea markets. The administrator said she did not remember the exact date of the allegation or when she conducted her own investigation. During an interview via phone on 09/06/2023 at 3:30 p.m., CNA #2 said she was busy and would call back after 5:00 p.m. Interview via phone on 09/06/2023 at 5: 15 p.m., CNA B (former employee) called back and said she was no longer employed at facility but remembered the incident. She said Resident #49 was alleging CNA A was exploiting her. She said Resident #49 said the first time she loaned CNA A money was $100.00 and claimed there were two other times for a total of $500.00. She said Resident #49 was told by CNA A she needed the money to bail her son out of jail, pay her light bill, and fix her truck. She said Resident #49 told her CNA A had been making payments but still owed her money. She said she recorded Resident #49 while she was telling her about CNA A because she knew the administrator would not believe her because CNA A had been working at the facility longer than her. CNA B said she only recorded Resident #49's voice and did it without knowledge/consent. I immediately told my supervisor, ADON 2 and asked him what I needed to do. He said, let us go to the administrator's office to let her know. Once we were in the administrator's office, I advised the administrator what Resident #49 had told me. CNA B said the administrator told her she did not need to do a statement because she was going to do it. CNA B said that was a mistake she made of not writing her own statement within her own words because I do not know what she wrote or even if she made a statement. CNA B said the only thing the administrator did was to move CNA A to a different hall. CNA B said the weekend before she reported the incident to the administrator Resident #49 told me to call CNA A to her room and I did. CNA B said she went to assist another resident right across Resident #49's room and overheard CNA A yelling at Resident #49 telling her No te vas hacer [NAME] con el dinero que te estoy pagando, ya [NAME] de pagarte y no te [NAME] a seguir pagando (you are not going to get rich with the money I'm paying you, I already finished paying you and I don't plan on paying you anymore). CNA B said she could hear CNA A yelling at Resident #49 from across the hall. CNA B said there were nurses out in the hall, but no one went to check on Resident #49. CNA B said she had advised the administrator. she had recorded the conversation between Resident #49 and herself and she said yes. CNA B said the administrator was surprised to know she had a recording and asked to her if she could listen to the recording. After listening to the recording CNA B said the administrator questioned her saying she did not hear any names being mentioned and did not believe the voice in the recording belonged to Resident #49. Interview on 09/07/2023 at 9:43 a.m., ADON B said he recalled CNA B came to him with an allegation regarding money owed to Resident #49. He said he did not remember the exact date but said he immediately escorted CNA B to the administrator/abuse coordinator to inform her of the situation. He said he does not know what the outcome was since he let the administrator manage the situation. Interview on 09/07/2023 at 3:30 p.m. During resident council meeting, Resident #2, Resident #3, Resident #4, and Resident #5 were interviewed regarding staff asking them for money or voicing they had money issues, and all said they had not experienced any staff members asking them for money or voicing they had money issues. Interview via phone on 09/07/2023 at 4:20 p.m. CNA C (former employee) said she was the person CNA A asked to give the remaining $20.00 to Resident #49. According to her, CNA A told her Resident #49 had loaned her $40.00 and still owed her $20.00. She said CNA A sent her $20.00 via cash app and she in turn gave Resident #49, $20.00 in cash. As per CNA C she said Resident #49, later told her she had voluntarily loaned CNA A $40.00 because she had voiced, she was having money issues. CNA C said she personally knows of staff members who have purchased perfume bottles from Resident #49's sister. She said Resident #49 keeps the perfume bottles in her room and collects the money for her sister. Interview via phone on 09/08/2023 at 8:05 AM, Resident #49's sister said she has never sold any perfume bottles in the facility. She said she did take a couple perfume bottles to Resident #49 but were bottles she had requested for her grandchildren but has never told Resident #49 to sell them to staff at the facility. Interview on 09/08/2023 at 8:30 am., ADON A said she remembers meeting with Resident #49, the administrator, and the social worker to discuss about a CNA owing her money. She said she does not speak Spanish, so she did not know the outcome of the meeting. Interview on 09/08/2023 at 2:04 p.m., The administrator said she had investigated the possible exploitation allegation (selling perfumes/loan) which involved Resident #49 and CNA A. She said she had only spoken to CNA A, CNA B (former employee who reported the allegation) and Resident #49. The administrator said she did not request a written statement from CNA B when she informed her of the alleged allegation of exploitation, the administrator said no. The administrator said just recently she was told by her management they no longer needed a written statement from the person making an allegation. She said she was told she just needed to write a summary of what they were alleging. The administrator said she did not have a written summary of what CNA B had alleged. The administrator said there are time in which she does request a written statement from the person making allegations and sometimes she doesn't. The administrator was not able to say under what circumstances she does request a written statement. The administrator said had not interviewed other staff members and/or staff to see if they had purchased any perfumes from Resident #49 and/or her sister and she said no. The administrator said by not conducting a thorough investigation, Resident #49 could negatively be affected by it could worry the resident by thinking staff owes her money. She said she in-serviced all staff members on Abuse, Neglect, and exploitation on 07/18-20/2023. Record review of Complaint/Grievance Follow-Up Report dated 07/12/2023 (completed by the administrator) revealed Receipt of Concern/Grievance: Name of person contacted: The social worker The nature of the complaint: Resident is alleging a CNA (CNA A) owes her money Documentation of facility follow-up: date: 0712/23, Name of person notified: The social worker, Comments: Care Plan will be held. Resolution of concern/grievance: Date received: 07/12/2023 Date of notification: 07/12/2023 Person notified of resolution: Resident #49 Final resolution: ADON, SW, & Admin spoke to resident about money owed. Resident denied giving or receiving money. Stated her sister was the one selling perfumes. Resident was encouraged to speak to any of us about any further incidents. Resident was in good spirits. Record review of Employee Counseling Report dated 07/12/2023 completed by the Administrator. Verbal Warning Level two Offenses: accepting gifts from residents or visitors/buying or purchasing gifts from visitors. Other offenses: Violation of any other policy or procedure contained in Employee's Manuall: Resident Rights/Solicitation Incident Description: A resident told a CNA, that CNA A owed her money from a personal loan. Upon investigation, it was determined that (she) CNA A had bought a perfume from the resident's sister but had paid the sister directly. CNA A should not be conducting transactions with visitors, family members or residents. Record review of the facility's Employee's Handbook revised 02/2019 #6-solicitation revealed: #6-Solicitation No employee shall solicit for any cause or organization during his or her working time or during the working time of the employee or employees at whom such activity is directed. No employee shall distribute, circulate, or post any printed material in work areas at any time, or during his or her working time or during the working time of the employee or employees at whom such activity is directed. Work areas include resident care areas, resident waiting areas, resident lobby areas, nurse's stations, resident corridor, and in any areas where medical services are provided. Under no circumstances will non-employees be permitted to solicit or to distribute written material for any purpose or Employer property. Record review of the facility's policy on abuse, neglect and exploitation implemented on 08/15/2022 revealed: Policy: It is the policy of this facility to provide protections for the health, welfare, and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation, and misappropriations of resident property. Policy Explanation and Compliance Guidelines: 1. The facility will develop and implement written policies and procedures that: a. Prohibit and prevent abuse, neglect and exploitation of residents and misappropriation of property; b. Establish policies and procedures to investigate any such allegations; and c. Include training for new and existing staff on activities that constitute abuse, neglect exploitation, and misappropriate of resident property, reporting procedures, and dementia management and resident abuse prevention; 2. The facility will designate and Abuse Prevention Coordinator in the facility who is responsible for reporting allegations or suspected abuse, neglect, or exploitation to the state survey and other officials in accordance with state law. The components of the facility abuse prohibition plan are discussed herein: II. Employee Training A. New employees will be educated on abuse, neglect, exploitation, and misappropriation of resident property during initial orientation. B. Existing staff will receive annual education through planned in-services and as needed. III. Prevention of Abuse, Neglect and Exploitation The facility will implement policies and procedures to prevent and prohibit all types of abuse, neglect, misappropriation of resident property, and exploitation that achieves: B. Identifying, correcting, and intervening in situations in which abuse, neglect, exploitation, and/or misappropriation of resident property is more likely to occur with the deployment of trained and qualified registered, licensed, and certified staff on each shift in sufficient numbers to meet the needs of the residents, and assure that the staff assigned have knowledge of the individual residents' care needs and behavioral symptoms. V. Investigation of Alleged Abuse, Neglect and Exploitation A. An immediate investigation is warranted when suspicion of abuse, neglect or exploitation, or reports of abuse, neglect or exploitation occur. B. Written procedures for investigations include: Investigating different types of alleged violations. Identifying and interviewing all involved persons, including the alleged victim, alleged perpetrator, witnesses, and other who might have knowledge of the allegations. Focusing the investigation on determining if abuse, neglect, exploitation, and/or mistreatment has occurred, the extent, and cause; and Providing complete and thorough documentation of the investigation. A. The administrator will follow up the government agencies, during business hours, to confirm the initial report was received, and to report the results of the investigation when final within 5 working days of the incident, as required by state agencies.

Based on observation, interviews and record reviews, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, that include measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment for one of eight residents (Resident #48) reviewed for comprehensive care plans, in that: Resident #48's last fall was not reflected in her comprehensive care plan. This failure could place residents at risk for not receiving necessary care and services. The findings were: Record review of Resident #48's admission record dated 09/07/23 reflected she was readmitted to the facility on [DATE] with diagnoses of hemiplegia and hemiparesis (weakness of one entire side of the body) ,epilepsy (condition with recurring seizures), and dementia (decline in cognitive abilities). Record review of Resident #48's quarterly MDS assessment dated [DATE] reflected indicated Resident #48 had severe cognitive impairment and a fall since admission or re-entry, with no injury Record review of Resident #48's comprehensive care plan initiated on 04/12/21 and revised on 01/09/23 reflected is at high risk for falls r/t unsteadiness, other lack of coordination weakness, history of falls with interventions that included to ensure floor mats in place. Resident had an actual fall, unwitnessed with no injury, as per resident, she had rolled over from bed. This care plan was dataed 04/06/23. Interventions included to ensure bed to lowest position for safety with floor mats in place, dated 04/05/23. Record review of the Incident Report dated 08/02/23 for Resident #48 reflected Resident #48 Was noted sitting on floor on top of the pad, on the right side of the bed, bed was at lowest position. Resident unable to give description. No injuries observed at time of incident. Observation and interview on 09/05/23 at 2:12 pm with Resident #48 revealed Resident #48 was in low bed, awake, with call lights in her hand and floor mats on each side of bed. Resident #48 was not able to respond to greeting from surveyor due to cognitive impairment. Interview on 09/07/23 at 3:00 pm with MDS/LVN D revealed as an IDT staff collaborate information to determine what could be done as a preventive for falls. MDS/LVN D said the resident's care plans were updated for falls as they occurred and added new interventions as needed to help prevent further falls. The MDS /LVN D said the IDT reviewed incident reports during their morning meetings to ensure if there was a need to update care plans. MDS/LVN D said she should have updated Resident #48's care plans in the concern area of falls. MDS/LVN D said it was her responsibility to update Resident #48's care plans to include the last unwitnessed fall on 08/02/23. Interview on 09/07/23 at 3:33 pm with CNA E revealed Resident #48 tried to get up from bed without calling for help and was very forgetful. Interview on 09/08/23 at 9:46 am with ADON 1 revealed all nurses had access to the care plans. ADON 1 said staff had meetings every morning with the IDT group and they reviewed falls, behaviors, etc. to determine if a care plan needed to be updated or revised. Interview on 09/08/23 at 9:53 am with the DON revealed all staff had access to care plans in their computers. Resident #48 had a fall on 08/03/23 that had not been care planned or new interventions added to prevent further falls. The DON said the IDT met as a group to determine if care plans needed to be updated or revised. The last fall for Resident #48 had not been care planned to add a new intervention. The DON stated it was his responsibility to ensure care plans were updated or revised as needed. Record review of the facility policy titled Fall Prevention Program dated 08/15/22 reflected Each resident will be assessed for fall risk and will receive care and services in accordance with their individualized level of risk to minimize the likelihood of falls. Each resident's risk factors, and environmental hazards will be evaluated when developing the resident's comprehensive plan of care. When any resident experiences a fall, the facility will review the resident's care plan and update as indicated.

Based on observations, interview and record review the facility failed to ensure that a resident who needs respiratory care, including [CONDITION(S)] care and tracheal suctioning, is provided such care, consistent with professional standards of practice for one (Resident #1) of 2 residents reviewed for [CONDITION(S)] care. LVN A, RN B and LVN C failed to provide prompt care to Resident #1 who was dependent on a [CONDITION(S)] (surgical procedure which consists of making an incision on the anterior aspect of the neck and opening a direct airway through an incision in the trachea) when resident had removed her [CONDITION(S)] tube and was in respiratory distress. LVN A, RN A and LVN C failed to attempt to re-insert a new [CONDITION(S)] tube during the CPR process. EMS arrived at the facility and pronounced Resident #1 had expired. This failure resulted in an identification of an Immediate Jeopardy at 5:11 p.m. on [DATE]. While the IJ was removed on [DATE], the facility remained out of compliance at a severity level of actual harm with a scope identified as isolated until all staff were in-serviced. This failure placed residents at risk for incorrect [CONDITION(S)] care and [CONDITION(S)] related complications. Findings included: Record review of the Admission Record dated [DATE] indicated Resident #1 was [AGE] years old, admitted to the facility on [DATE] from hospital with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of the Order Summary Report dated [DATE] for Resident #1 indicated orders: -change disposable [CONDITION(S)], [NAME] #8, inner cannula for copious secretions, start date of [DATE]. -change disposable [CONDITION(S)], [NAME] #8, inner cannula, every day at each shift, start date [DATE]. - [CONDITION(S)] care, cleanse with normal saline with 4 x 4 around [CONDITION(S)] stoma, pat dry, apply T-drain sponge and secure with [CONDITION(S)] collar as needed for copious secretion. -[CONDITION(S)] care, cleanse with normal saline with 4 x 4 around [CONDITION(S)] stoma, pat dry, apply T-drain sponge and secure with [CONDITION(S)] collar, every shift. -[CONDITION(S)] humidification with air compressor at (specify) PSI with continuous O2 at (specify) LPM via concentrator every shift. Record review of the MDS dated [DATE] indicated Resident #1 BIMS score was 8 (moderate cognitive impairment), required extensive assistance by two persons for bed mobility, transfers, dressing and personal hygiene. Resident #1 was total dependent on two persons for locomotion on unit (how resident moves between locations in his/her room and adjacent corridor on same floor), toilet use and had an indwelling catheter. Active diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Other health conditions included shortness of breath or trouble breathing when lying flat. Resident #1's height was 66 inches and weight of 286 pounds. Resident #1 had two pressure ulcers stage 2 (partial thickness loss of dermis presenting as a shallow open ulcer with a red or pink wound bed, without slough) and one stage 3 (full thickness tissue loss). MDS indicated Resident #1 received insulin and diuretic medications. Resident #1 received respiratory treatments that included oxygen therapy and [CONDITION(S)] care. Record review of the Initial Baseline Care Plan for Resident #1 indicated Resident #1's code status was full code and was alert and cognitive. Initial Baseline care plan was completed by RN D, effective date [DATE]. Record review of the nursing progress note dated [DATE] for Resident #1 and completed by LVN A indicated: At 8:15 pm went to patient's room when heard feeding pump machine beeping. Arrived in patient's room, patient in bed awake and alert with no signs of any distress. Noted rattling [MEDICATION(S)] on [CONDITION(S)]/airway and able to obtain moderate amount of [MEDICATION(S)] amount of [MEDICATION(S)] upon suctioning via [CONDITION(S)]. At 8:20 pm while attempting to disconnect the feeding tube for replacement, I noticed a physician, outside patient's room waiting for me to come out, so I went to approach him so I went out approach him and handed me stat orders for another patient. At 8:25 pm left patient in bed with [CONDITION(S)] equipment and safety measures in place, patient appears alert and awake. At 8:28 pm walked with the physician to the main nurse's station, ordered and called mobile x-ray for stat orders received, then came to med room to get patient's feeding supplies needed. At 8:45 pm arrived back in patient's room, found patient unresponsive, absence of breathing, performed chest rub while talking to patient but continues with no response. Noticed patient's [CONDITION(S)] cannula completely dislodged with no strap in place, unable to find [CONDITION(S)] upon searching, so then I called 911 and called other staff for help. At 8:48 pm CPR initiated by four staff, applied AED and continued with compressions until EMS arrived and took over at 9:05 pm, police officer and Justice of the Peace also in facility. At 9:45 pm the DON arrived stated patient has history of self-decannulation at the hospital. Justice of the Peace pronounced time of death at 10:03 pm. At 12:30 am family and body remains left facility with funeral home. Interview on [DATE] at 10:30 am with the DON revealed Resident #2 was the only resident with a [CONDITION(S)] currently in the facility. Resident #2 was in the same hall as Resident #1 had been. On [DATE] at 10:56 am observation of Resident #2 revealed resident was in bed, head elevated, alert and oriented with a [CONDITION(S)] and receiving oxygen. Extra supplies for [CONDITION(S)] were observed stored in a bin in resident's room. Resident #2 said she had been at facility for almost a month. She said she received oxygen with the [CONDITION(S)]. Resident #2 said staff would come and provide her with care for her [CONDITION(S)] several times a day. Resident #2 said she had no concerns with the care provided and had been told she was going to be discharged to go home on [DATE]. Interview on [DATE] at 11:14 am with LVN H revealed she provided [CONDITION(S)] care to Resident #2. LVN H said if the tracheotomy tubing was blocked by mucous, she would remove the inner cannula which was inserted in the [CONDITION(S)] tube, clean and re-insert into the [CONDITION(S)] tube. LVN H said there were extra supplies in resident's room in a storage bin. On [DATE] at 2:32 pm interview with LVN A via telephone revealed he began work at 6 pm on [DATE] with Resident #1. He entered the room to go and check on Resident #1 and he saw Resident #1 had removed her tracheotomy tube with strap and was unresponsive. LVN A said he did not know how Resident #1 had removed the [CONDITION(S)] with strap and he could not immediately see it by the resident's bed or floor. Extra supplies for [CONDITION(S)] items were stored in Resident #1's room in a bin. LVN A said he called for help from other staff who arrived right away, and he called 911 on his cell phone. CMA F brought the emergency cart with the AED (an automated external defibrillator, portable electronic device that automatically diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . RN B and LVN C assisted with the CPR process, compressions and rescue breathing on Resident #1. LVN A said he started doing CPR on Resident #1 right away. LVN A said he had not attempted to re-insert a new [CONDITION(S)] tube into Resident #1 because he did not want to waste time and needed to do the CPR as needed. LVN A said everything happened so fast that instead of re-inserting a new [CONDITION(S)], he started applying CPR doing compressions while LVN B began rescue breaths with ambu bag. LVN B used the ambu bag over mouth and nose while covering the stoma opening. When EMS arrived within minutes, they took over and continued with CPR, but they stopped and said resident had expired. The police came and investigated the incident while all facility staff stepped out of the room. The police officers found the [CONDITION(S)] tube with strap on bedside table close to resident's bed. LVN A observed the [CONDITION(S)] tube on Resident #1 looked like it had been physically pulled out. LVN A said the DON had informed him on [DATE] after the incident that Resident #1 had a behavior of decannulation at the hospital from where she had been transferred. On [DATE] at 2:44 pm interview with RN G revealed she was charge nurse for Resident #1 during the day shift from 6am to 6pm on [DATE] and [DATE]. RN G said she was the admitting nurse for Resident #1 who was admitted on [DATE] at approximately 5:00 pm. RN G said Resident #1's family was with the resident during the whole day. At 6pm, LVN A came to his shift, from 6 pm to 6 am and took over Resident #1's care. Family did not verbalize to her that Resident #1 had taken off her [CONDITION(S)] at the hospital where she had been transferred from the previous day. On [DATE] at 3:06 pm interview with RRT E revealed Resident #1 was a [CONDITION(S)] patient and he was in a supervisory position to provide care to residents with [CONDITION(S)] status. On approximately [DATE] he went to the hospital where Resident #1 was receiving [CONDITION(S)] care to evaluate the resident for transfer to this facility. On that day, RRT E spoke to the respiratory therapist in charge of Resident #1's [CONDITION(S)] care at the hospital. The hospital respiratory therapist stated Resident #1 had decannulated (removed [CONDITION(S)], including inner cannula and collar) earlier in the morning. A hospital staff saw Resident #1's O2 levels were low and saw she had removed the [CONDITION(S)] and had re-inserted a new [CONDITION(S)] tube to the patient. The hospital staff was alerted to Resident #1's O2 levels through monitoring by equipment at the hospital. RRT E said this facility did not have the type of monitoring equipment to detect low O2 levels. Resident #1 was not able to be transferred to this facility until [DATE] due to her declining status and no rooms were available for this resident. When Resident #1 was admitted on [DATE] at about 5:00 pm, he assessed and evaluated Resident #1 on [DATE]. RRT E said the facility had no policy for [CONDITION(S)] care. He said he used the facility procedures titled Pulmonary Program to in-service staff on providing [CONDITION(S)] care to residents. Record review of the procedure titled Pulmonary program signed and dated by RRT E on [DATE] indicated the procedures on [CONDITION(S)] care that included procedures on [CONDITION(S)] Care with Knowledge Based Competency; Is able to verbalize steps to take when there is an accidental decannulation; Call for assistance and assess your patient Replace the old [CONDITION(S)] tube with the new tube that is the same size Be prepared to manually ventilate the resident in whom respiratory distress develops Notify emergency personnel, if necessary Continue to manually ventilate until emergency personnel arrives and takes over ventilation Notify physician and follow any orders, if applicable Notify family/responsible party of accidental decannulation and transfer to acute care, if applicable. Make sure extra [CONDITION(S)] tubes, obturator and resuscitation bad are readily available in case of emergency. Record review of Respiratory Therapy Certificate for LVN A dated [DATE] indicated LVN A had received the training that included the Knowledge Based Competency on [CONDITION(S)] Care. On [DATE] at 9:24 am interview with RRT E revealed he had informed the DON on [DATE] that Resident #1 had decannulated at the hospital when he went to do his assessment of the resident on [DATE]. During the assessment of Resident #1 on [DATE] at this facility, Resident #1 was alert and oriented and FM I was with the resident in her room. RRT E said he had not seen the resident attempt to remove the [CONDITION(S)] while he did his assessment. RRT E said he did not communicate to any other staff any issues with decannulation on his assessment on [DATE]. On [DATE] in the evening, Resident #1 decannulated (removed [CONDITION(S)] tubing, inner cannula and collar) and was found unresponsive. RRT E said in this situation, he would have attempted to re-insert a new [CONDITION(S)] during the CPR process by first initiating CPR and then try to re-insert a new [CONDITION(S)] tube. In this incident, first initiate CPR, with other staff assistance providing oxygen with an ambu bag (a handheld device used to provide pressure ventilation to patients who are not breathing or not breathing adequately) while covering the stoma (opening for [CONDITION(S)] tube). Record review of the respiratory assessment tool dated [DATE] and completed by RRT E indicated Resident #1 had a [CONDITION(S)]. The respiratory assessment tool developed by RRT E notes indicated no sob or distress at this time. Shiley size 6 [CONDITION(S)] tube in place. Stoma site clean, dry and intact. Cool aerosol therapy via [CONDITION(S)] collar with 8L of O2 and nebulizer treatments scheduled Q6 and will continue to monitor. RP Interview on [DATE] at 9:51 am with RN B revealed she answered LVN A's call for assistance during the incident on [DATE] with Resident #1. RN B said she arrived and began to assist LVN A with CPR. RN B said she began with CPR compressions while LVN C used the ambu bag over Resident #1's mouth and nose and applying a gauze to close the stoma while pressing with his hand to prevent air from flowing out of stoma. RN B said she did not think to re-insert a new [CONDITION(S)] to Resident #1 because she, LVN A and LVN C were already using CPR and providing oxygen to the resident. Record review of Code Blue Mock Drill Evaluation dated [DATE] indicated RN B received training on CPR. On [DATE] at 10:01 am the DON said he thought LVN A had panicked because the incident occurred so fast after LVN A had just provided care to Resident #1 a few minutes earlier. LVN A started CPR with the ambu bag while getting assistance from two other staff, RN B and LVN C. If the [CONDITION(S)] had been dislodged for more than five minutes, it would have been difficult to re-insert a new [CONDITION(S)]. Resident #1 was obese and weighed approximately 265 pounds and had recovered from COVID-19. Resident #1's neck was heavy with extra fat. Resident #1 would not have recovered even with compressions during CPR. There had been extra [CONDITION(S)] supplies in resident's room to use. Staff including LVN A, RN B and LVN C used an ambu bag (a handheld device used to provide pressure ventilation to patients who are not breathing or not breathing adequately over the mouth and nose while covering the stoma). When the EMS came in, they did not do any more CPR because they saw Resident #1 had expired. Investigators were called to come investigate after police officers saw they needed more assistance with the investigation. The Justice of the Peace indicated no autopsy was needed and pronounced the resident with cause of death was of natural causes at 10:03 pm. The DON provided a document with progress notes and a timeline of the incident. The DON said he had started mock drill in-services on CPR to all nursing staff in [DATE]. This CPR trainings did not include CPR with [CONDITION(S)] residents. The DON said the pulmonary physician had assessed Resident #1 earlier in the day on [DATE]. The pulmonary physician said resident still had fluid and physician would be monitoring. The pulmonary physician saw no other concerns or voiced any other instructions. Record review of the Pulmonary Consult for Resident #1 dated [DATE] by the Pulmonologist indicated; Chest x-ray done at this institution, shows haziness in the left lung, complete. The plan is best for therapy and continue with nebulization q 6 h. To repeat she has x-ray in one day, if she continues to have complete opacification of the lung, she is going to need fluoroscopy or sonogram to look for possible pleural effusion. Record review of the timeline of the incident written by the DON indicated: at 8:15 pm LVN A entered resident's room, at 8:28 pm LVN A exited resident's room. At 8:45 pm LVN A entered residents' room, which was 17 minutes later after LVN A left the resident's room. Resident was found unresponsive and with absence of breathing. Resident's [CONDITION(S)] was completely dislodged and LVN A was unable to locate [CONDITION(S)] tubing. LVN A called 911 immediately. At 8:48 pm facility started CPR and AED. At 9:05 pm, EMS arrived. At 10:03 pm, death was pronounced by Justice of the Peace. On [DATE] at 1:19 pm interview with LVN A revealed on day of incident, LVN C placed ambu bag over Resident #1's mouth and nose and closed the airway with a gauze to prevent air from flowing out of stoma. LVN A said he was doing the compressions after the board had been placed underneath Resident #1. LVN A said he did not see resident's chest rise during compressions. LVN A said he thought Resident #1 was already gone, meaning expired. LVN A said Resident #1 was cold to the touch. Resident #1's RP said during interview via telephone on [DATE] at 1:54 pm that Resident #1 had removed her [CONDITION(S)] tube several times while she was a patient at the hospital for approximately four to five weeks. Resident #1's RP had requested staff use mittens or gloves on resident's hands to prevent resident from pulling out oxygen, [CONDITION(S)] tubing and IVs. RP said Resident #1 would get anxious and pull on these devices. Resident #1's RP said she was upset that the hospital had not sent this facility the information about Resident #1's behaviors of removing her [CONDITION(S)] tube to this facility. Resident #1's RP had not informed this facility that Resident #1 had behaviors of pulling out tubing. The Administrator was notified on [DATE] at 5:11 pm that an Immediate Jeopardy situation had been identified due to the above failures. The IJ template was provided to the Administrator on [DATE] on 5:11 pm. A Plan of Removal was first submitted by the Administrator on [DATE] at 8:00 am and the POR was accepted on [DATE] at 3:33 pm. Facility would like to submit this plan for removal for an Immediate Jeopardy that was cited by Investigation, on [DATE]: Issue: The facility staff failed to re-insert a [CONDITION(S)] cannula prior to initiating CPR. Resident expired. -When the resident's [CONDITION(S)] tube was accidentally decannulated and was noted unresponsive, the facility staff immediately started CPR, applied AED, and activated 911. When the paramedics arrived, the decision was made to stop the CPR efforts and the resident expired. Death was pronounced by the Justice of the Peace. Immediate Action: -On [DATE] and 6, 2021 the facility Respiratory Therapist completed an in-service training on Emergency [CONDITION(S)] Tube Change to all 29 active Licensed Nurses. The training included; 1. A return demonstration on how to reinsert an outer and inner [CONDITION(S)] tube or cannula during an accidental decannulation. 2. The Respiratory Therapist also reviewed the following; a. CPR procedure and the use of AED following BLS guidelines b. CPR procedure with a [CONDITION(S)] resident c. Emergency [CONDITION(S)] Airway Management including checking for [CONDITION(S)] placement and patency. -On [DATE] (7:,d+[DATE]:30 PM) The Director of Nursing, Assistant Director of Nursing, and facility Respiratory Therapist reassessed the current resident who has a [CONDITION(S)] and re-educated the assigned nurses on: 1. [CONDITION(S)] care 2. Emergency [CONDITION(S)] management during an accidental decannulation. 3. Ensured that [CONDITION(S)] supplies are available and at bedside. -On [DATE] (7:,d+[DATE]:30 PM) The Director of Nursing instructed the nurses assigned to increase the rounding and frequent monitoring of the current resident who has a [CONDITION(S)]. 1. Staff will ensure [CONDITION(S)] is in place and airway is patent. 2. Monitor patient's behavior (comfort level) 3. Check vital signs, oxygen saturation level and patient's clinical status to ensure patient is not in distress. 4. Documentation of clinical observation and findings will be done every shift using the Nursing Respiratory Progress Notes. -On [DATE] (7:00 -7:30 PM) The Director of Nursing reviewed the incident with LVN A, RN B, and LVN C and re-emphasized the need to re-insert the [CONDITION(S)] tube before attempting CPR. Facility's Plan to Ensure Compliance -The Respiratory Therapist will assess new [CONDITION(S)] resident's prior to and upon admission and will document any concerns noted during the evaluation and share the findings with the nursing staff. -The charge nurses will utilize the nursing respiratory evaluation form to assess all new [CONDITION(S)] admissions and concerns will be addressed and resolved immediately. Concerns will be shared using the 24-hour reporting system. The Respiratory Therapist and the assigned charge nurses will re-assess residents with [CONDITION(S)] daily to determine if concerns are present. The Director of Nursing, the Respiratory Therapist and Assistant Director of Nursing are responsible in ensuring any concerns stemming from the assessment are followed-up on and resolved. -The facility updated the Mock Code Blue Drill on [DATE] to include emergency [CONDITION(S)] management during an accidental decannulation. The mock code blue drill includes performing CPT with a [CONDITION(S)] resident. The mock code blue drills have been ongoing every month since [DATE] and will continue and increase the frequency to weekly for the next 3 months beginning [DATE]. This will be provided to all shifts. -All licensed staff have completed the in-services on [DATE]. The facility will ensure all licensed staff receive the mandatory training and check on the employee roster that all have been in-serviced. This will be monitored by the Director of Nursing and reported to the Administrator. -The Administrator and DON conducted an Ad-Hoc Performance Improvement Meeting to discuss the above plan with the charged nurses on [DATE]. It is the opinion that this facility has addressed and re-educated the staff regarding Emergency [CONDITION(S)] Management. The facility respectfully requests that the plan of removal be accepted, and the immediate jeopardy be lifted effective [DATE]. The survey team monitored the plan of removal on [DATE] and [DATE] as follows: On [DATE] beginning at 4:28 pm seven nurse staff from different shifts were interviewed on effectiveness of in-services on providing CPR to residents with [CONDITION(S)] that were found unresponsive and with dislodged [CONDITION(S)]. All seven staff indicated the in-services on conducting CPR with [CONDITION(S)] patients had been effective. On [DATE] beginning at 7:57 am 14 nurse staff from different shifts were interviewed on effectiveness of in-services on providing CPR to residents with [CONDITION(S)] that were found unresponsive and with dislodged [CONDITION(S)]. All 14 staff responded being knowledgeable on conducting CPR with [CONDITION(S)] patients. Interview on [DATE] at 8:16 am with LVN C revealed he had received in-service training on [DATE] on providing CPR to a [CONDITION(S)] patient who was unresponsive and responded he was knowledgeable in the steps to be taken to insert a new [CONDITION(S)]. Interview on [DATE] at 8:52 am with RN B revealed she had received in-service training on [DATE] on providing CPR to a [CONDITION(S)] patient who was unresponsive and responded she was knowledgeable in the steps to be taken to insert a new [CONDITION(S)]. Interview on [DATE] at 10:00 am with LVN A revealed he had received in-service training on [DATE] on providing CPR to a [CONDITION(S)] patient who was unresponsive and responded she was knowledgeable in the steps to be taken to insert a new [CONDITION(S)]. On [DATE] at 11:20 a.m. the Administrator was informed the IJ was removed. However the facility remained out of compliance at a severity level of actual harm with a scope identified as isolated until all staff were in-serviced.