Every finding on record at Monterey Care Center

Based on record review, interview, and facility policy review, the facility failed to ensure complete documentation of urinary output tracking as ordered by the physician. This affected one resident (#02) out of two reviewed for catheters. The facility identified nine residents with catheters. Additionally, the facility failed to ensure complete documentation regarding regular cleaning of a residents continuous positive airway pressure (CPAP) machine. This affected one resident (#101) of one resident reviewed for respiratory care. The facility census was 112.Findings Include: 1. Review of the medical record for Resident #02 revealed a re-admission date of 01/24/26 with diagnoses of but not limited to chronic kidney disease, obstructive and reflux uropathy, acute kidney failure, anemia. Review of Resident #02's active care plan revealed the resident had chronic renal failure with recent episodes of acute kidney disease related to kidney disease associated with type two diabetes and episodes of hydronephrosis. Further review of the care plan revealed the resident had a corresponding intervention to monitor/document/report for signs and symptoms of acute failure including urine output. Review of the Quarterly Minimum Data Set 3.0 assessment for Resident #02, dated 03/31/26, revealed a Brief Interview of Mental Status score of 15, indicating the resident was cognitively intact. Review of the Treatment Administration Record (TAR) revealed an order for foley catheter output every shift from 01/21/26 to 03/08/26. Review of the TAR further revealed the 7:00A.M. shift output was missing on 03/05/26, 03/14/26, and 03/18/26, and missing from the 7:00 P.M. shift on 03/03/26, 03/04/26, 03/09/26, 03/10/26, 03/11/26, and 03/18/26. Review of the TAR revealed an order for foley catheter output amount every shift from 03/22/26 to 05/09/26. Further review of the TAR revealed the 7:00 A.M. shift output was missing on 04/02/26, 04/04/26, 04/14/26, 04/15/26, 04/19/26, 04/20/26, 04/26/26 and the 7:00 P.M. shift on 03/25/26, 03/28/26, 04/07/26, 04/08/26, 04/10/26, 04/14/26, 04/15/26, 04/21/26, 04/22/26, 04/23/26, 04/28/26, and from 05/04/26 to 05/06/26. Interview on 06/03/26 at 2:23 P.M. with the Director of Nursing (DON) confirmed Resident #02 had orders for foley output tracking and that values were missing on the TAR's for the above identified days. The DON further reported the order had been discontinued due to the physician deeming it unnecessary to be tracking input and output for the resident but there was no documentation provided to confirm this nor to provide an explanation for missing output amounts on the various identified days. Review of the facility policy titled 'Catheter Care' issued 08/24/23 revealed catheter care will be performed every shift and as needed by nursing personnel. 2. Review of Resident #101's medical record revealed an admission date of 10/13/25 and medical diagnosis of type two diabetes, bipolar disorder, abnormal gate and mobility, morbid obesity, obstructive sleep apnea, asthma, chronic respiratory failure with hypoxia, dyspnea, shortness of breath, and acquired absence of right and left leg below the knee. Review of Resident #101's Minimum Data Set assessment last updated 02/25/26 revealed the resident had bilateral impaired bilateral extremities and required the use of a walker, wheelchair, and limb prosthesis for mobility. The resident required supervision with chair/bed-to-chair transfers. Review of Resident #101's care plan last revised 05/19/26 revealed the resident was at risk for altered respiratory status due to difficulty breathing related to chronic respiratory failure with hypoxia, obstructive sleep apnea, and cardiac issues and was at risk for activities of daily living self-care deficit related to poor balance, physical limitations, deconditioning, and mental health issues with interventions to have staff assist with personal care. Review of Resident #101's physician order dated 11/16/25 revealed orders to remove and cleanse the reservoir weekly with soap and water, air dry on the 7:00 A.M. to 3:00 P.M. shift, and to check and to clean CPAP/bilevel positive airway pressure (Bipap)/average volume-assured pressure (AVAP) filter weekly every day shift (Sunday) for equipment maintenance. Review of Resident #101's Treatment Administration Record revealed no documentation that the residents CPAP was cleaned as ordered for 04/19/26, 05/10/26, and 05/17/26. Interview on 06/02/26 at 2:23 P.M. with the Director of Nursing (DON) confirmed the facility did not have documentation showing that Resident #101's CPAP was cleaned as ordered and the expectation was for staff to follow the cleaning policy and to clean BPAP's as ordered. Review of the facility policy titled PAV (NIV) Equipment Sterilization and Maintenance last revised 04/03/25 and last reviewed 03/31/26 revealed, all CPAP/BIPAP/AVAPS equipment will be sterilized once a week using the sterilization machine to ensure tubing, humidifier, and face masks are kept clean.

Record review of the resident trust fund accounts and quarterly financial statements and staff interview revealed the facility failed to timely notify residents and/or responsible parties of the need to spend down excess resources to maintain Medicaid eligibility for three (Resident's #4, #55, and #56) out of four residents reviewed for personal funds. Findings Include:1. Review of the record for Resident #4 revealed the resident was admitted on [DATE] and had [NAME] Medicaid coverage. Review of the quarterly trust account statement for the period 01/01/26 through 03/31/26 revealed the resident's account balance exceeded the Medicaid resource limit of $2,000.00 from 01/01/26 through 02/12/26. The resident's balance decreased to $1,108.47 on 02/12/26. No documentation was provided evidencing the resident and/or responsible party were notified of the need to spend down excess resources during the period the resident's account exceeded the allowable limit. Further review revealed the resident's account balance was $2,141.97 on 06/01/26. No documentation was provided evidencing a spend-down notice had been issued. 2. Record review for Resident #55 revealed the resident was admitted on [DATE] and had [NAME] Medicaid coverage. Review of the quarterly trust account statement for the period 01/01/26 through 03/31/26 revealed the resident's account balance exceeded the Medicaid resource limit of $1,800.00 on 03/25/26, with a balance of $1,816.06. Further review revealed the resident's account balance remained above the Medicaid resource limit on 06/01/26, with a balance of $1,867.10. No documentation was provided evidencing the resident and/or responsible party were notified of the need to spend down excess resources when the account exceeded the allowable limit. 3. Record review for Resident #56 revealed the resident was admitted on [DATE] and was Medicaid pending. Review of the quarterly trust account statement for the period 01/01/26 through 03/31/26 revealed the resident's account balance exceeded the Medicaid resource limit of $2,000.00 throughout the entire quarter, ranging from $2,465.85 to $6,093.28. Documentation revealed a spend-down notice was issued on 03/18/26. Further review revealed the resident's account balance was $2,718.29 on 06/01/26. No documentation was provided evidencing any additional spend-down notice had been issued after 03/18/26 despite the resident's continued excess resources.During an interview on 06/04/26 at 2:45 P.M., Business Office Manager #166 confirmed the above findings. The Business Office Manager stated she provided spend-down notices at the end of the quarter and, if a resident's balance exceeded the resource limit during the quarter, she did not send a spend-down notice until the end of the quarter. The Business Office Manager confirmed no additional spend-down notices had been issued for the identified residents as noted above.

Based on medication regimen review, medical record review, staff interview, and facility policy, the facility failed to appropriately monitor adverse affects for psychiatric medications as ordered and failed to ensure a gradual dose reduction order was completed timely. This affected one resident (Resident #69) out of five reviewed for unnecessary medications.Findings include:1. Review of the medical record for Resident #69 revealed a re-admission date of 09/22/23 with diagnoses of cognitive communication deficit, suicidal ideations, depression, and dementia.Review of the active care plan for Resident #69 dated 09/22/23 revealed the resident may exhibit symptoms of psychosocial well-being problems related to their diagnoses of depression dementia with mood disorder, anxiety, insomnia, and a history of passive suicidal ideation, with an intervention to monitor, document, and report resident's feelings. Additionally, the care plan identified the resident as being at risk for adverse effects related to the use of antidepressants and antianxiety medication with interventions of monitoring for possible side effects of the medications, monitor the resident's mental status functioning on an on-going basis, and monitor/document/report any side effects or adverse effects of psychotropic medications.Review of Resident #69's quarterly Minimum Data Set assessment dated [DATE] revealed a Brief Interview of Mental Status score of 13, indicating the resident was cognitively intact.Review of physician orders for Resident #69 revealed the resident was prescribed buspirone 7.5 milligrams (mg) two times a day for anxiety beginning 12/18/25 and desvenlafaxine 100 mg one time a day for depression beginning 10/25/25. Continued review of the residents' orders revealed an order dated 10/25/25 for residents on psychoactive medications to identify targeted behaviors to be monitored with indicators zero for no behavior, one for restlessness, two for insomnia, three for easily annoyed, four for agitation, and five for anxiety. Buspirone and desvenlafaxine were listed as the medications triggering this prompt and it was scheduled to be completed twice daily.Review of Resident #69's Medication Administration Record's (MAR) for March 2026 to May 2026 revealed the prompt for monitoring side effects of psychiatric medications was signed off with check marks, not the identified numerical system in the order.Interview on 06/04/26 at 10:32 A.M. with the Director of Nursing (DON) confirmed staff were using a check mark system on the MAR for monitoring psychiatric medication side effects for Resident #69, instead of the ordered numerical system.Interview on 06/04/26 at 11:13 A.M. with Social Services #356 confirmed the nursing staff using a checking system on the MAR instead of the identified numerical system was not an appropriate way to monitor side effects for psychiatric medications.Review of the facility policy titled 'Psychotropic Medication Use' issued 12/01/16 revealed anti-depressants and anti-anxiety medications are considered psychotropic medications and are subject to monitoring. In addition, the policy revealed residents receiving these medications are to be monitored for effectiveness and adverse consequences.2. Review of the medical record for Resident #69 revealed a re-admission date of 09/22/23 with diagnoses of cognitive communication deficit, suicidal ideations, depression, and dementia.Review of the active care plan for Resident #69 dated 09/22/23 revealed the resident may exhibit symptoms of psychosocial well-being problems related to their diagnoses of depression dementia with mood disorder, anxiety, insomnia, and a history of passive suicidal ideation, with an intervention to monitor, document, and report resident's feelings. Additionally, the care plan identified the resident as being at risk for adverse effects related to the use of antidepressants and antianxiety medication with interventions of monitoring for possible side effects of the medications, monitor the resident's mental status functioning on an on-going basis, and monitor/document/report any side effects or adverse effects of psychotropic medications.Review of the physician orders for Resident #69 revealed on 08/08/24 the resident was ordered buspirone 5 mg three times a day. Review of the medication regimen reviews for Resident #69 revealed on 07/27/25 the pharmacy recommended a gradual dose reduction of buspirone 5 mg three times a day with the physician response to decrease buspirone 5 mg to twice a day and signed with the date 08/08/25.Review of the physician orders for Resident #69 revealed the facility did not decrease the buspirone from three times a day to twice a day until 09/08/25, one month later.Interview on 06/04/26 at 10:32 A.M. with the DON confirmed the physician signed the medication regimen review for 08/08/25 but the facility did not implement the change until 09/08/25.Review of the facility policy titled 'Psychotropic Medication Use' issued 12/01/16 revealed anti-depressants and anti-anxiety medications are considered psychotropic medications and are subject to monitoring. In addition, the policy revealed residents receiving these medications are to be monitored for effectiveness and adverse consequences.Review of the facility policy titled 'Physician and Practitioner Orders' issued 07/01/22 revealed the licensed nurse is responsible for administering medications and completing care per physician orders.

Based on resident record reviews, observations, staff interviews, and review of facility policy, the facility failed to ensure adequate activities of daily living (ADL) care was provided for two residents (#77 and 87). This affected two residents out of five residents reviewed for activities of daily living. Findings Include: 1. Review of a resident record revealed that Resident #77 was admitted to the facility on [DATE] and had diagnoses that included cognitive communication deficit, need for assistance with personal care and vascular dementia. Review of Resident #77's admission photo revealed that he was clean shaven. Review of Resident #77's Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed that he had a Brief Interview for Mental Status score of 03, indicative of severe cognitive impairment. Resident #77 required partial to moderate assistance with personal hygiene, such as shaving. Review of Resident #77's care plan dated 05/15/26 revealed that Resident #77 had an ADL self-care deficit related to weakness and dementia. A listed goal was that Resident #77 would receive the assistance necessary to meet ADL needs. An intervention listed was that Resident #77 would be assisted by a staff member for ADLs. Observation of Resident #77 on 06/02/26 at 2:00 P.M. and 06/04/26 at 9:33 A.M. and 11:27 A.M revealed that Resident #77 had long whiskers on his chin and had a sparse mustache with long whiskers. An interview with Resident #77 on 06/04/26 at 11:27 A.M. revealed that he preferred to be clean shaven. An interview with Licensed Practical Nurse #237 on 06/04/26 at 11:34 A.M. confirmed that Resident #77 had long whiskers on his chin and above his lip and he was not clean shaven. 2. Review of a resident record revealed that Resident #87 was admitted to the facility on [DATE] and had diagnoses that included Alzheimer's disease, cognitive communication deficit and dementia without behavioral disturbance. Review of Resident #87's MDS 3.0 assessment dated [DATE] revealed that Resident #87 had severely impaired cognitive skills for daily decision making. Resident #87 was assessed as needing partial to moderate assistance with personal hygiene. Review of Resident #87's care plan dated 12/17/25 revealed that Resident #87 had an ADL self-care deficit related to weakness and impaired cognition. A goal was that Resident #87 would receive assistance necessary to meet her ADL needs. Interventions included to assist with daily hygiene and grooming as needed and assistance from one staff member needed. Observation on 06/01/26 at 11:11 A.M. revealed that Resident #87 had facial hair approximately a half centimeter in length on her chin and above her lip. An interview with Certified Nurse Aide (CNA) #206 on 06/01/26 at 11:13 A.M. confirmed that Resident #87 had long facial hair on her chin and above her lip. Review of the facility policy titled, Activities of Daily Living, revised on 12/31/24 revealed that residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good grooming and personal hygiene. This deficiency represents non-compliance investigated under Complaint Number 2667104.

Based on observation, record review, interviews, and facility policy, the facility failed to ensure fall prevention interventions were implemented and maintained following a fall for two (Resident #07 and #84) out of two residents reviewed for falls. The facility census was 112.Findings Include: 1. Review of the medical record for Resident #07 revealed an admission date of 11/06/25 and re-entry date of 03/11/26. Diagnoses included Alzheimer's disease, fracture of neck of left femur with routine healing following surgical repair, type 2 diabetes mellitus with diabetic neuropathy, chronic kidney disease stage 3, and syncope and collapse.Review of the significant change Minimum Data Set assessment dated [DATE] revealed a Brief Interview for Mental Status score of 02 indicating severe cognitive impairment. The resident required extensive assistance with most activities of daily living and was dependent for ambulation beyond short distances. The resident utilized a wheelchair and had a history of falls including a fall with major injury on 03/07/26 resulting in a left hip fracture requiring surgical intervention.Review of the fall documentation revealed on 03/07/26 at 6:47 P.M. the resident was found on the floor near his bed after attempting to self-transfer from bed to wheelchair. The resident was assisted and no injury was initially noted. The resident later sustained a skin tear to the left arm with neuro checks initiated. Further documentation on 03/07/26 at 11:00 P.M. revealed the resident had a fall out of his wheelchair in the hallway with a skin tear noted and the resident stating he was looking for his mother. Neuro checks were initiated at that time.Review of the physician imaging report dated 03/09/26 revealed an intertrochanteric fracture of the left femur with displacement. The resident was sent to the emergency department for evaluation and subsequently underwent surgical repair of the hip fracture with return to the facility for long term care.Review of interdisciplinary team documentation dated 03/12/26 at 2:16 P.M. revealed the resident had a fall from attempting to self transfer from bed to wheelchair due to wheelchair not being within close proximity to the bed. The resident was found on the floor with no injury noted. An intervention was added for wheelchair placement at bedside and grippy strips were to be placed on the floor to reduce fall risk. Review of interdisciplinary team documentation dated 03/12/26 at 4:40 P.M. revealed care plan updates following the fall with major injury and identification that the resident was typically a walker user but required wheelchair use following injury.Review of the care plan revealed fall prevention interventions including bed in low position, call light within reach, nonskid footwear, assist with transfers, and grippy strips at bedside with an initiation date of 03/09/26. Observation on 06/01/26 at 2:20 P.M. revealed grippy strips were not in place at the bedside as an implemented fall prevention intervention.Interview with Licensed Practical Nurse (LPN) #162, on 06/01/26 at 2:35 P.M. confirmed the grippy strips were not implemented at bedside.2. Review of the medical record for Resident #84 revealed an admission date of 04/29/26. Diagnoses included methicillin resistant Staphylococcus aureus infection, need for assistance with personal care, unsteadiness on feet, other abnormalities of gait and mobility.Review of the Minimum Data Set assessment dated [DATE] revealed a Brief Interview for Mental Status score of 12 indicating moderate cognitive impairment. The resident required supervision to moderate assistance with transfers and ambulation and was identified as a fall risk with at least one fall documented.Review of the fall documentation dated 05/15/26 at 3:50 A.M. revealed the resident was found on the floor next to the bed with a laceration above the eye. The resident reported attempting to retrieve glasses from the floor and sliding from the bed. The resident was assessed and sent to the emergency department for evaluation.Review of interdisciplinary documentation dated 05/20/26 revealed the resident had a fall on 05/15/26 resulting in injury and care planned interventions were updated to include grippy strips at bedside and a reacher to assist with retrieval of items to prevent future falls. The resident returned from the hospital on [DATE] at 7:26 A.M. with neuro checks initiated following repair of a head laceration.Review of the care plan revealed fall prevention interventions including call light within reach, nonskid footwear, bed in low position, assist with transfers, and use of reacher and grippy strips at bedside with an initiation date of 05/20/26.Observation and interview on 06/01/26 at 3:51 P.M. revealed grippy strips were not in place at the bedside as ordered and the reacher was not present in the resident's room. At the time of the observation, LPN #162 confirmed grippy strips were not in place and the reacher was not in the room. The resident stated he did not receive a reacher following his prior fall. LPN #162 confirmed the reacher should have been provided per the care plan.Review of the facility policy titled Fall Management Guidelines, issued 12/13/23, revealed the purpose of the policy was to provide guidelines to assist with fall risk identification and fall management of residents in the facility. The policy defined a fall as unintentionally coming to rest on the ground, floor, or other lower level with or without injury and not as a result of an overwhelming external force. The policy indicated fall risk evaluations were to be completed upon admission, readmission, quarterly, and with a significant change in condition. The policy indicated the licensed nurse was to evaluate residents for intrinsic and extrinsic fall risk factors and that a comprehensive care plan was to be developed to include individualized interventions to address modifiable risk factors and reduce the risk of injury from falls. The policy further indicated the interdisciplinary team was to review care plans after a fall to ensure interventions were appropriate and reflective of the root cause of the fall event.This deficiency represents non-compliance investigated under Complaint Numbers 2682198, 2667104, 2666938, and 2664299.

Based on observation, record review, resident interview, staff interview, and facility policy, the facility failed to monitor and document fluid intake for Resident #08 who was on fluid restrictions. Additionally, the facility failed to monitor weights for Resident #01 with a significant weight loss. This affected two (Residents #01 and #08) out of three residents reviewed for nutrition. The facility census was 112.Findings Include: 1. Review of the medical record for Resident #08 revealed an admission date of 11/21/25. Diagnoses included congestive heart failure, chronic kidney disease stage 4, dependence on renal dialysis, chronic obstructive pulmonary disease, and type 2 diabetes mellitus. Review of the care plan dated 11/23/25 revealed interventions for fluid management related to congestive heart failure, chronic kidney disease, and dialysis dependence. Interventions included monitoring intake and adherence to fluid restrictions and ensuring compliance with physician ordered limitations. Review of the Minimum Data Set assessment dated [DATE] revealed the resident had a Brief Interview for Mental Status score of 15 indicating intact cognition. The resident required assistance with multiple activities of daily living and required dialysis services due to end stage renal disease. The resident was identified as being on a fluid restriction due to cardiac and renal conditions. Review of physician orders dated 06/01/26 at 07:00 P.M. revealed a fluid restriction of 1500 milliliters per 24-hour period. The order specified a structured allocation of fluids including 220 milliliters during the 11:00 P.M. to 7:00 A.M. shift, 220 milliliters during the 7:00 A.M. to 3:00 P.M. shift, and 220 milliliters during the 3:00 P.M. to 11:00 P.M. shift. The order further identified dietary allocation of 360 milliliters divided across meals including breakfast 240 milliliters, lunch 240 milliliters, and dinner 660 milliliters. The order indicated all fluid intake was to be strictly monitored, documented, and maintained within the prescribed daily limit of 1500 milliliters from all sources. Observation on 06/01/26 at 2:01 P.M. revealed the resident had a filled water container in her room measuring approximately 500 milliliters. The resident stated the container had originally been filled to approximately 800 milliliters and reported consuming approximately 300 milliliters earlier in the day. The resident further stated staff were not consistently tracking her fluid intake and that she attempted to manage her own intake but was unsure of exact amounts consumed. Interview with Director of Nursing (DON) on 06/02/26 at 4:18 P.M. revealed staff were expected to allocate fluids based on physician ordered limits and that intake was calculated through medications, meal consumption, and provided fluids during scheduled times. DON stated residents should not have additional fluids such as water pitchers in their rooms and confirmed that extra fluids were not accounted for in documented intake totals. Interview with Certified Nursing Assistant (CNA) #254 on 06/02/26 at 4:26 P.M. confirmed a full water container was present in the resident's room measuring approximately 800 milliliters. The aide stated she was unsure who had provided the water container during rounds. Interview with Resident #08 on 06/02/26 at 4:39 P.M. revealed the resident stated an aide had brought water into her room on both the current and previous day. The resident stated she was unsure of the exact staff member who provided the water and estimated she had consumed approximately half of the container. Review of the facility policy titled Hydration Program, dated 02/05/21, revealed the policy was intended to ensure residents receive adequate and appropriate fluids to maintain hydration status. The policy indicated fluid needs are individualized and that residents on fluid restrictions or with high risk conditions require interdisciplinary monitoring and accurate tracking of all fluid intake. The policy further indicated all fluids provided, including those in resident rooms, medication passes, and meals, are to be monitored and recorded to ensure compliance with physician orders. Review of the facility policy titled Nutritional Management, dated 10/2022, revealed the policy was intended to ensure residents maintain acceptable parameters of nutritional and hydration status. The policy indicated a systematic process is used to assess, implement, and monitor nutritional and hydration interventions. The policy further indicated that fluid intake is to be monitored and documented, and that the physician is to be notified of significant changes in intake or inability to meet ordered nutritional and hydration goals. 2. Record review for Resident #01 revealed this resident was admitted to the facility on [DATE] with diagnoses including: hypertension, osteoarthritis, anemia, gout, and adult failure to thrive. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed this resident had impaired cognition evidenced by a Brief Interview for Mental Status (BIMS) score of 12. This resident was assessed to require staff assistance with eating, dressing and bathing. Review of the care plan dated 01/21/26 revealed Resident #01 was at nutritional risk related to dysphagia, gout, hypomagnesemia, hypocalcemia, hypokalemia and chronic kidney disease stage 3. Interventions included monitoring resident weight as ordered and to notify dietician or significant weight changes. Review of the Resident #01's dietary note dated 01/27/26 revealed Resident #01 presented with a current body weight of 77 pounds, height of 58 inches, and a BMI of 17.3, consistent with underweight status. The resident was assessed as at risk for malnutrition. Recommendations included continuing House Med Pass three times daily, maintaining the current diet order, and obtaining weekly weights for four weeks. Review of Resident #01's recorded weights revealed a weight of 77 pounds (lbs) on 01/21/26 and a weight of 94.5 lbs on 01/29/26. The next recorded weight by the facility was 92.8 lbs on 02/26/26. During an interview with Regional Dietician #701 on 06/02/26 at 10:22 A.M. confirmed the weekly weights were not completed as ordered for Resident #01. Review of the facility's policy titled Weights, revised 02/04/26 revealed residents are weighed upon admission and then weekly for a total of four weeks. It also noted that weekly weights may continue based on interdisciplinary team review.

Based on review of resident records, interviews and review of facility policy, the facility failed to ensure appropriate pain management medications were administered per professional standards of practice, when parameters were not in place for as needed pain medications, including opioids, for two residents. This affected two residents (#21 and #101) of three residents reviewed for pain management. Findings include: 1. Review of a resident record revealed that Resident #101 was admitted to the facility on [DATE] and had diagnoses that included bipolar disorder and chronic pain syndrome. Review of Resident #101's Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed that Resident #101 received scheduled and as needed pain medication. Occasionally, pain interfered with therapy and day to day activities. Review of Resident #101's care plan dated 10/14/25 revealed that Resident #101's cognition fluctuated, as she initially had a Brief Interview Score of 12, indicative of a moderate cognitive impairment. Review of Resident #101's pain care plan dated 10/21/25 revealed that Resident #101 was at risk for pain related to mental and emotional health issues, and chronic medical conditions including bilateral below the knee amputations. Interventions include to administer pain medications as ordered and to implement non-pharmacological interventions per preferences to assist with pain. Review of Resident #101's physician orders dated 10/14/25 revealed that Resident #101 was prescribed acetaminophen, a non-opioid pain reliever, 325 mg, two tablets every six hours as needed for moderate pain and on 01/30/26 Resident #101 was ordered Oxycodone HCl, an opioid pain reliever, oral tablet 10 milligrams (mg), one tablet every four hours as needed for pain. No specific parameters were identified in the orders. Review of Resident #101's Medication Administration Record (MAR) revealed: On 05/02/26 she was administered Oxycodone HCl one tablet for a pain level of 4 (on a scale of zero to 10, zero being no pain and 10 being the worst pain); On 05/03/26 at 10:00 A.M. and 05/03/26 at 6:00 P.M., Resident #101 was administered Oxycodone HCl one tablet for a pain level of 4; On 05/04/26, Resident #101 was administered Oxycodone HCl 1 tablet for a pain level of 4; On 05/16/26, she was administered Oxycodone HCl one tablet for a pain level of 2; On 05/21/26, she was administered Oxycodone HCl one tablet for a pain level of 3 on two occasions; On 05/24/26, she was administered Oxycodone HCL one tablet for a pain level of 2; On 05/25/26, she was administered Oxycodone HCl one tablet for a pain level of 2; And on 05/30/26, she was administered Oxycodone HCl one tablet for a pain level of 4. Review of Resident #101's MAR revealed that Resident #101 was administered acetaminophen on 05/12/26 for a pain level of 8. An interview with the Director of Nursing (DON) on 06/04/26 at 3:40 P.M. revealed that she would expect acetaminophen to be given for pain levels of 1 through 5 and opioids to be given for pain levels of 6 through 10. The DON confirmed that Resident #101 received acetaminophen for a pain level of 8 and received as needed opioids for pain levels of less than 5. The DON further confirmed there were no parameters for the as needed pain medications. 2. Record review for Resident #21 revealed this resident was admitted to the facility on [DATE] with diagnoses including: nasal fracture, diabetes mellitus, osteoporosis, shortness of breath, dysphagia, encephalopathy, chronic kidney disease, collapsed vertebra, Review of Resident #21's pain care plan dated 03/06/26 revealed that Resident #21 was at risk for pain related to deconditioning, fatigue, malaise, uneasiness, chronic conditions including osteoporosis, aortic stenosis, seizures, asthma, osteoarthritis, dorsalgia, recent subdural hematoma, chronic obstructive pulmonary disorder, collapsed vertebra and electrolyte imbalance. Interventions include administering pain medications as ordered. Review of Resident #21's physician orders dated 04/01/26 revealed a prescription of acetaminophen, a non-opioid pain reliever, 325 mg, two tablets every six hours as needed for moderate pain. No specific parameters were identified in the order. Review of the 5-day Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had intact cognition evidenced by a Brief Interview for Mental Status (BIMS) score of 15. This resident was assessed to be dependent for toileting hygiene, bathing and mobility. Review of Resident #21's physician orders dated 04/28/26 revealed a prescription of Hydrocodone-Acetaminophen, an opioid pain reliever, one oral tablet 7.5 milligrams (mg) every six hours as needed for pain. No specific parameters were identified in the order. Review of Resident #21's Medication Administration Record (MAR) revealed: On 05/16/26 she was administered Oxycodone HCl one tablet for a pain level of 2/10. On 05/15/26, she was administered Oxycodone HCl one tablet for a pain level of 3/10. On 04/01/26, 04/17/26, 04/18/26, 05/21/26, and 05/30/26 she was administered Oxycodone HCl one tablet for a pain level of 4/10. On 04/10/26, 04/18/26, 04/20/26, 05/02/26, 05/03/26 and 05/09/26 she was administered Oxycodone HCl one tablet for a pain level of 5/10. During an interview with the Director of Nursing (DON) on 06/03/26 at 3:05 P.M. she confirmed there were no parameters on either of Resident #21's prescribed pain medications. On 06/04/26 at 3:40 P.M. she confirmed the expectation of acetaminophen to be administered for reported pain levels of one through five and opioids to be given for pain levels of six through 10. This deficiency represents non-compliance investigated under Complaint Number 2981805.

Based on observation, record review, resident interview, and staff interview, the facility failed to properly store medications. This affected two residents (#16 and #122) out of 28 residents in the survey sample.Findings Include: 1. Review of the medical record for Resident #131 revealed an admission date of 11/07/25. Diagnoses included type two diabetes mellitus without complications, essential (primary) hypertension, peripheral vascular disease, and acute kidney failure. Review of the quarterly Minimum Data Set assessment dated [DATE] revealed a Brief Interview for Mental Status score of 14 indicating intact cognition. The assessment indicated the resident required extensive assistance with activities of daily living and medication administration. Review of physician orders revealed an active order for Losartan Potassium 100 milligrams by mouth daily for hypertension. Review of the Medication Administration Record confirmed the medication was administered on 06/01/26. Review of nursing documentation revealed no documentation of medication omission, spill, or discrepancy on 06/01/26. Review of nursing documentation dated 06/02/26 at 08:25 A.M. revealed the resident stated medications had been dropped during administration on the prior evening and were not fully recovered at that time. Observation on 06/02/26 at 8:15 A.M. revealed an unknown pill was located on the floor of Resident #131's room. Observation and interview on 06/02/26 at 8:18 A.M. Licensed Practical Nurse (LPN) #362 confirmed observation of a pill on the floor and it was identified as Losartan Potassium. The medication was observed in plain view on the floor. The Licensed Practical Nurse confirmed the resident was not approved for self-administration and confirmed the medication was disposed of after discovery. During interviews at the resident council meeting on 06/04/26 from 1:50 P.M. to 2:11 P.M., residents stated that a pill had been observed on the floor by a council member several months prior, although the resident was unable to identify the medication source or affected resident. Review of the facility policy titled Medication and Treatment Storage, dated 08/07/23, revised 02/03/26, and reviewed 10/15/25 and 02/03/26, revealed the policy was intended to ensure accurate labeling and dating of medications and treatments and to provide safe and secure storage of all medications, including controlled access to medication storage areas. The policy indicated medications were to be stored in locked compartments with access limited to authorized licensed personnel and that medications must remain under direct observation during administration or secured in a locked storage area. 2. Review of a resident record revealed that Resident #122 was admitted to the facility on [DATE] and had diagnoses that included unspecified dementia, cognitive communication deficit and chronic obstructive pulmonary disease (COPD). Review of Resident #122's MDS 3.0 assessment dated [DATE] revealed that Resident #122 had a Brief Interview for Mental Status (BIMS) score of 13, indicative of intact cognition. Resident #122 was assessed as having no upper body impairments. Review of Resident #122's care plan dated 03/11/25 revealed that Resident #122 had altered respiratory status related to chronic obstructive pulmonary disease and interventions included to administer medication and puffers as ordered. Review of Resident #122's care plan dated 04/18/25 revealed that Resident #122 resided on a secure unit related to impaired safety awareness. Review of Resident #122's physician orders dated 12/12/25 revealed that he was prescribed Trelegy Ellipta Inhalation Aerosol Powder Breath Activated 100-62.5-25 micrograms per activation, a combination inhaled medication, one puff inhale orally one time a day for COPD. An observation on 06/01/26 at 11:00 A.M. revealed that Resident #122 was in his bed and his Trelegy Ellipta was within reach on Resident #122's bedside table. An interview on 06/01/26 at 11:02 A.M. with Registered Nurse Manager #323 confirmed that Resident #122's Trelegy Ellipta inhaler was not properly stored, and stated that she would secure it in the medication cart. Review of the facility policy titled, Medication and Treatment Storage, dated 08/07/23 revealed that all medications and biologicals will be stored in locked compartments such as medication carts. This deficiency represents non-compliance investigated under Complaint Number 2725964.

Based on observations, record review, interviews, and review of facility policy, the facility failed to ensure a physician-ordered pressure reducing mattress was functioning as intended for Resident #131 who had multiple pressure ulcers requiring pressure relieving interventions. This affected one (Resident #131) out of four residents reviewed for pressure ulcers. Findings Include:Review of the medical record for Resident #131 revealed an admission date of 05/22/26. Diagnoses included cognitive communication deficit, disorder of muscle, rhabdomyolysis, chronic pain syndrome, spinal stenosis of the lumbar region without neurogenic claudication, peripheral vascular disease, osteoarthritis, other specified disorders of bone density and structure, idiopathic scoliosis, and macular degeneration.Review of the admission skin assessments revealed the resident was admitted with multiple areas of skin impairment. Documentation identified a Stage III pressure ulcer to the left gluteus present on admission, a Stage III pressure ulcer to the right gluteus present on admission, and an unstageable pressure ulcer to the left heel present on admission. Documentation also identified a left elbow wound which later resolved.Review of the Braden Scale assessment completed upon admission revealed a score of 16, indicating the resident was at risk for the development of pressure ulcers.Review of the 5-Day Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had intact cognition with a Brief Interview for Mental Status (BIMS) score of 15. The assessment revealed the resident required moderate assistance with bed mobility and transfers and was dependent upon staff for toilet transfers. Additionally, it identified the resident had two unhealed Stage III pressure ulcers, he utilized a pressure reducing device for the bed and received pressure ulcer dressings.Review of the care plan dated 05/27/26 revealed the resident was at risk for alteration in skin integrity related to actual impairment to a left elbow skin tear and pressure ulcers to the right buttock, left buttock, and left heel. Interventions included administering treatments as ordered, applying barrier cream as needed, completing Braden Scale assessments per facility policy, providing diet and supplements as ordered, elevating heels, utilizing an air mattress, encouraging and assisting with turning and repositioning, providing incontinence care as needed, utilizing a low air loss mattress, and observing skin condition daily during activities of daily living care.Review of the physician order dated 06/01/26 at 7:00 A.M. revealed an order to monitor low air-loss mattress functioning and check that settings were appropriate for the resident every shift and to replace the mattress if malfunctioning.Observation and interview on 06/04/26 at 10:51 A.M. with Resident #131 revealed the low air-loss mattress pump was not operating and the electrical cord was unplugged from the wall outlet. Resident #131 stated the mattress was unplugged but she was not sure what the pump at the end of her bed was used for. Resident #131 stated she had utilized the air mattress since admission.Observation and interview on 06/04/26 at 11:03 A.M. with Registered Nurse (RN) #207 confirmed the low air-loss mattress was unplugged and not functioning. RN #207 further confirmed the mattress was utilized for the resident's buttock pressure ulcers. RN #207 further confirmed the resident had no history of unplugging the mattress.Interview on 06/04/26 at 11:50 A.M., revealed Resident #131 stated she never unplugged or tampered with the low air-loss mattress.Review of the facility policy titled Skin and Wound Guidelines, dated 03/05/24, revised 03/20/24, and reviewed 02/04/26, revealed the policy was intended to describe the process required for identification of residents at risk for pressure injuries and the interventions used to assist with management of pressure injuries and skin alterations. The policy indicated treatment options were selected based on the type of wound and resident needs and that treatments were ordered by the medical practitioner.This deficiency represents non-compliance investigated under Complaint Numbers 2725964

Based on observation, interview, and review of Centers for Disease Control (CDC) guidance, the facility failed to ensure glucometers were sanitized/disinfected between resident use. This affected one resident (#05) and had the potential to affect four residents the facility identified as residents who utilized the facility glucometer. Findings Include: Review of the medical record for Resident #69 revealed the resident was originally admitted on [DATE] with the diagnosis of diabetes type two. Review of Resident #69's physician orders revealed an order for Humalog insulin 100 units per milliliter per sliding scale (a specific dose of insulin per the residents blood glucose reading). Review of the medical record for Resident #05 revealed the resident was admitted on [DATE] with the diagnosis of diabetes mellitus. Observation on 06/04/26 at 11:15 A.M. revealed Licensed Practical Nurse (LPN) #238 used a facility owned glucometer (a small, portable electronic device used to measure how much sugar (glucose) is in the residents' blood. The process of blood glucose testing consisted of inserting a drop of blood, generally obtained via a finger prick, on a test strip and into the glucometer.) to check the blood glucose level of Resident #69. LPN #238 then did not sanitize or disinfect the glucometer and used the same glucometer to check the blood glucose level of Resident #05.During an interview with LPN #238 on 06/04/26 at 11:28 A.M. confirmed that she did not clean and disinfect the glucometer between residents and that she did use the glucometer to check the blood glucose levels of multiple residents. She stated she would disinfect the glucometer following every two residents.Review of guidance issued from the Centers for Disease Control (CDC) and Prevention effective 08/07/24 revealed facility staff must clean and disinfect blood glucose meters after every use, per the manufacturer's instructions.

Based on review of resident records, staff interviews, and review of facility policy, the facility failed to provide documented evidence of good faith efforts to notify a former resident of an active urinary tract infection. This affected one former resident (Former Resident #115) out of four residents reviewed for urinary tract infections. The facility census was 113 residents. Findings include: Review of the medical record for Former Resident (FR) #115 revealed he was admitted to the facility on [DATE] with diagnoses including retention of urine and presence of urogenital implants. Review of FR #115's Minimum Data Set (MDS) 3.0 comprehensive assessment dated [DATE] revealed that he was cognitively intact and that he had an indwelling catheter. Review of FR #115's nursing progress notes dated 06/22/25 revealed that FR #115 was observed with intermittent confusion. The physician was called, and a new order was made to obtain a urinalysis and culture and sensitivity (UA C&S). Nursing progress notes dated 06/24/25 revealed that the urine was collected and picked up by the laboratory. Review of FR #115's social work progress notes dated 06/24/25 revealed that FR #115 desired to leave the facility Against Medical Advice (AMA). Review of nursing progress notes dated 06/25/25 revealed that FR #115 left the facility AMA. Review of FR #115's labs that resulted on 06/26/25 at 1:16 P.M. revealed that his urine growth was over 100,000 Escherichia coli (E. coli) bacteria, which was indicative of a urinary tract infection, and that it was susceptible to many options of antibiotics. Review of FR #115's medical progress notes and medical record revealed no documented evidence of facility notification to the resident or family regarding FR #115's UTI/laboratory results. Interview with the Administrator on 07/09/25 at 9:52 A.M. revealed that if a former resident decided to leave the facility AMA prior to receiving their laboratory (lab) results, if the facility received the labs back after the resident discharged , she would expect that the former resident would be notified of abnormal results. Interview with the Director of Nursing on 07/09/25 at 10:36 A.M. revealed that if a resident left the facility AMA, when they received lab results that resulted after the resident left the facility, the results would be sent to the physician for review. The DON indicated that it would be no different for a current resident that received abnormal lab results, than it would be for a former resident who had left the facility AMA and that they would be informed of the results. Interview with DON on 07/09/25 at 10:43 A.M. stated that FR #115 left AMA when he had a urinalysis pending. DON confirmed on 07/09/25 at 10:43 A.M. that FR #115's chart did not have documentation that FR #115 was informed of his lab results and that he had a urinary tract infection. Interview with Unit Manager #161 on 07/09/25 at 11:00 A.M. confirmed that she did not speak with FR #115 or FR #115's resident representative about the abnormal urinalysis report or urinary tract infection. Unit Manager #161 confirmed that she did not document that she attempted to contact FR #115 or FR #115's resident representative about his urinary tract infection. Review of a facility policy titled, Change in Condition, dated 08/09/23, revealed that a nurse will notify the resident and/or resident representative and physician about changes in a resident's medical condition which includes conditions that potentially need physician intervention. Review of facility policy titled, Transfers and Discharges, dated 04/18/25, revealed that if a resident discharges AMA, the facility will attempt to obtain physician orders and complete referrals for post-discharge care and attempt to obtain physician orders including discharge medications and follow up appointments. This deficiency represents non-compliance investigated under Complaint Number OH00167445.

THIS IS AN INCIDENCE OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on medical record review, review of facility incident report, resident and staff interview, and facility policy review, the facility failed to ensure a resident was safely transferred by a mechanical lift. This resulted in Actual Harm on 05/27/25 when one staff attempted to transfer Resident #103 from the wheelchair to the bed with the mechanical lift and the strap to the lift pad tore and Resident #103 dropped to the floor. Resident #103 was observed by staff to have one missing tooth, and one tooth was broken in half at the time of the incident. Resident #103 was sent to the hospital and returned to the facility with no other injuries noted. The resident has a follow up appointment with the emergency dentist. This affected one resident (#103) of three residents reviewed for mechanical lift transfers. The facility census was 117. Findings Include: Resident #103 was admitted to the facility on [DATE]. His diagnoses included but were not limited to absence of right leg and left leg above knee, multiple sclerosis, disorder of muscle, muscle wasting, morbid obesity, legal blindness, schizoaffective disorder, paraplegia, and weakness. Review of his Minimum Data Set (MDS) assessment, dated 03/04/25, revealed he was cognitively intact and dependent on staff for transfers. Review of Resident #103's care plan, dated 11/19/24, revealed a care area of Resident #103 having an activity of daily living (ADL) deficit. An intervention within this care plan revealed he needed two-person assistance due to having to use a mechanical lift for transfers. Review of Resident #103 Incident Report and Progress Notes, dated 05/27/25, confirmed that Resident #103 was being transferred from his wheelchair to his bed via mechanical lift. It was confirmed that Resident #103 was being transferred by CNA #148 alone; she did not have a second nursing staff with her while performing the transfer. During the transfer, the mechanical lift pad strap broke on one side, causing Resident #103 to fall from the mechanical lift to the floor. Resident #103 was assessed by the nurse for injury and found that he had one tooth missing and another tooth was broke in half. He was sent to the emergency room for further evaluation. In review of the findings, the facility confirmed CNA #148 should have had a second staff person with her while transferring Resident #103, and there should have been a better assessment of the mechanical lift pad prior to using it; which contributed to Resident #103 fall. Interview with Resident #103 on 06/04/25 at 9:30 A.M. confirmed he fell from the lift about a week ago. He confirmed there was only one staff member transferring him in the mechanical lift. He stated he wasn't sure why she was doing that, because all staff know he is a two-person transfer. He confirmed he fell to the ground while he was in the air, and knocked one tooth out and broke a second tooth due to the fall. He confirmed he went to the emergency room after the fall to ensure there were no further injuries. Interview with Director of Nursing (DON) on 06/04/25 at 12:10 P.M. confirmed they completed an investigation regarding the fall/accident that occurred with Resident #103 on 05/27/25. She confirmed CNA #148 was transferring Resident #103 via mechanical lift by herself, when she should have had a second staff person with her. She also confirmed there was evidence the mechanical lift pad failed/broke, which contributed to Resident #103 falling to the ground while in the air during the transfer. She confirmed they immediately started the quality assurance process to ensure an incident like this did not occur again. Interview with CNA #148 on 06/04/25 at 1:40 P.M. via telephone confirmed she transferred Resident #103 by herself. She confirmed she should not have done that. She confirmed the front part of the mechanical lift pad failed as well, which contributed to Resident #103 falling to the ground. She was unsure if the pad hooks broke or if they came off the lift itself, but after Resident #148 fell, she noticed that one side of the lift pad was no longer attached to the mechanical lift. Review of facility Hoyer Lift/Mechanical Lift policy, dated 05/13/24, revealed it is the responsibility of the RN, LPN, and/or STNA to follow manufacturer's guidelines. Please utilize two staff members. To transfer a patient/resident back to bed, you should attach the hooks to the sling. Be sure the hooks are placed so that they are facing away from the patient/resident. Bring the lift into position over the resident. Be sure the lift is in the low position and the legs of the lift are spread appropriately to balance the lift. Attach the hooks to the sling. Be sure the hooks are placed so that they are facing away from the patient/resident. Instruct the resident to fold both arms over his or her chest if possible. Using the crank/power button, raise the resident from the chair. Assist the resident in guiding his/her legs. Move the lifter away from the chair. Be sure the resident is turned in such a manner that the resident is facing you. Do not pull the resident backwards. Position lift over the bed. Lower the resident into the center of the bed. Remove the hooks from the lift. Remove the hooks from the sling. Remove the sling from under the resident. Remove the lift. Position the resident in a comfortable position that promotes good body alignment. Place the call light within easy reach of the resident. The deficient practice was corrected on 06/03/25 when the facility implemented the following corrective actions: • On 05/28/25, Director of Nursing (DON) or designee assessed all residents who use a mechanical lift for injuries. • On 05/28/25, DON or designee audited all mechanical lift pads for safety and functionality. Those that were deemed unsafe were discarded and new pads were issued. • On 05/28/25, DON or designee audited the mechanical lift assessments and care plans reviewed; of all residents who utilize a mechanical lift and updates were made as necessary. • From 05/27/25 to 05/29/25, DON or designee educated all nursing staff except for five as needed nursing staff who have not worked since the incident. The education included operating a mechanical lift in a safe/proper manner and assessing/removing mechanical lift pads if they are deemed unsafe. None of the five nursing staff who have not received education will work in the facility until the education has occurred. The following nursing staff were interviewed on 06/04/25 and confirmed they received education and were aware of the proper procedures to follow regarding mechanical lifts: Unit Manager #155, CNA #148, CNA #103, and CNA #225. Observation completed on 06/04/25 with CNAs #103 and #225 performing a resident transfer via mechanical lift safely and appropriately. • On 05/28/25, all laundry staff were re-educated by Housekeeping and Laundry Manager #110 about inspecting/ assessing/removing mechanical lift pads if they are deemed unsafe. The following laundry staff were interviewed on 06/04/25 and confirmed they received education and were aware of the proper procedures to follow regarding mechanical lift pads: Laundry Staff #250. • On 05/29/25, Certified Nursing Aide (CNA) #148 was provided education by DON about using a mechanical lift with two staff and assessing the mechanical lift pads to ensure they are safe. She also received a final written warning as discipline by DON and Administrator. • On 05/30/25, DON ensured all nursing staff except for five as needed nursing staff who have not worked since the incident, received and passed competency training regarding the proper assessment of mechanical lift pads and properly transferring a resident within the mechanical lift. None of the five nursing staff who have not received education will work in the facility until the education has occurred. • Starting 05/29/25, nursing managers/designees will assess mechanical lift pads at least three times weekly for four weeks, and then on a monthly basis there after. Audits were completed on the following dates: 05/29/25, 05/30/25, 05/31/25, 06/01/25, 06/02/25, 06/03/25, and 06/04/25 with no negative findings. • Starting 06/03/25, all laundry staff will complete a daily assessment/review of mechanical lift pads taken to the laundry room, to review their condition and remove if they are deemed to be unsafe. This will continue indefinitely. Audits were completed on the following dates: 06/03/25 and 06/04/25 with no negative findings. This deficiency represents non-compliance investigated under complaint number OH00166132.

Based on observation, record review, and staff interviews, the facility failed to store, prepare, distribute, and serve foods in accordance with professional standards for food service safety. This had the potential to affect all residents in the facility except one (Resident #34) who was ordered nothing by mouth (NPO) and didn't receive food from the kitchen. The facility census was 111. Findings include: Observation of the kitchen on 03/31/25 at 11:20 A.M. revealed Staff #41 was preparing lunch trays without wearing a beard restraint over his beard. Interview on 03/31/25 at 11:20 A.M. Staff #41, verified he wasn't wearing a beard restraint, and one was required when preparing food for the residents. Interview on 03/31/25 at 11:26 A.M. with the Dietary Manager #500, verified Staff #41 was preparing lunch plates without a beard restraint in place. Dietary Manager #500 stated it was the facility's policy for all food service employees to wear hair and beard restraints while working in the food preparation and service areas of the kitchen. Review of the facility's policy titled Employee Sanitary Practices dated 06/26/20 revealed all nutrition and food service employees would practice good personal hygiene and safe food handling procedures. It was the responsibility of the Food Service Manager or designee to ensure all employees complied with the facility's procedures and all federal, state and local requirements. Food service employees would wear hair restraints such as hairnets, hats, and beard restraints to prevent hair from contacting exposed foods.

Based on record reviews, staff interview, review of the Centers for Disease Control and Prevention, and review of the facility policy, the facility failed to ensure the Water Management Program was timely and appropriately implemented to prevent the spread of Legionella. This had the potential to affect all 108 residents residing in the facility. Findings include: Review of the facilities Water Management Program logs revealed no evidence of testing or interventions to prevent Legionella were present prior to 10/2024. Interview with the Administrator on 11/19/24 at 10:27 A.M. confirmed there was no record of water testing, flushing, or any other Legionella prevention measures being conducted prior to 10/2024. The Administrator stated there was a new Maintenance Director in place who had begun implementing the Water Management Plan in 10/2024. Review of the facility policy titled Legionella Policy/Procedure - Environmental, reviewed 12/26/23, revealed the facility would implement control measures to reduce the potential for the growth and spread of Legionella as identified int he Legionella Management Plan. Control measures would include, but were not limited to routine testing of chlorine levels, routine testing of water temperature levels, monitoring and flushing pipes in rooms and/or areas of the building that were not in use, monitoring decorative fountains and water fountains for use and evidence of debris and biofilm, and monitoring for conditions that may increase the risk of Legionella. Review of the CDC guidance titled Overview of Water Management Programs, dated 03/15/24, revealed water management programs identify hazardous conditions and take steps to minimize the growth and transmission of Legionella and other waterborne pathogens in building water systems. Developing and maintaining a water management program is a multi-step process that requires continuous review. Further review revealed the seven key elements of a Legionella water management program included: establish a water management program team, describe the building water systems, identify areas where Legionella could grow and spread, decide where control measures should be applied and how to monitor them, establish ways to intervene when control limits are not met, ensure the program runs as designed and is effective, and document and communicate all the activities.

Based on observation and staff interview, the facility failed to ensure the kitchen was maintained in a clean and sanitary manner. This had the potential to affect all residents who received food from the kitchen. The facility identified one resident (#60) who consumed nothing by mouth. The facility census was 108. Findings include: Observations and interview on 11/18/24 at 9:30 A.M. with Dietary Manager (DM) #118 revealed an area in the center of the kitchen was about an inch lower than the rest of the kitchen. This area contained cooking equipment such as the oven, fryer, and soup kettle. In this area, the floor (which was supposed to be a red tile) had a thick black build up, and had a large amount of food and other debris including a dome lid, plastic utensils, and French fries. There was a large amount of dirt-like material behind and around the soup kettle. DM #118 verified the observation. Subsequent observations on 11/18/24 from 11:05 A.M. to 11:35 A.M. revealed the area in the center of the kitchen, that was about an inch lower than the rest of the kitchen, had been somewhat cleaned. It was clear someone had started to get the unidentifiable black residue up. However, there were still large sections of the black residue and some of the food debris remained and the pile of dirt-like material behind the soup kettle remained. Continued observations and interview on 11/18/24 from 11:05 A.M. to 11:35 A.M. with DM #118 revealed the ceiling had multiple spots throughout the kitchen with a thick build up of dust-like particles and spots of food splatter. Additionally, there were two racks of three to four shelves that had a large amount of dust-like particles stuck to them and hanging from them. These racks had items including bowls, lids, stainless-steel cooking containers and a variety of other food service items. At 11:35 A.M., DM #118 verified the observation.

Based on observation, interview, and medical record review, the facility failed to ensure nail care was provided for dependent residents. This affected four residents (#75, #91, #95, #104) of six residents reviewed for activities of daily living (ADL). The facility census was 108. Findings include: 1. Review of Resident #104's medical record revealed an admitted [DATE] with diagnoses including bipolar disorder, secondary parkinsonism, schizoaffective disorder, mild cognitive impairment, and disorientation. Review of Resident #104's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed she had intact cognition. She required partial to moderate assistance with personal hygiene. Review of Resident #104's care plan dated 08/01/24 revealed she had an Activity of Daily Living (ADL) self-care deficit related to decreased mobility, use of assistive device, need of staff assistance, weakness, and diagnoses. Interventions included assisting with daily hygiene as needed, therapy evaluation as needed, and adjusting level of care as needed. Review of Resident #104's monthly summary dated 10/24/24 revealed she was disoriented. Observation on 11/18/24 at 10:09 A.M. revealed Resident #104 had long dirty nails. On 11/20/24 at 1:10 P.M. and 1:47 P.M. her nails were noted to remain long and appeared to be caked in food. Observation on 11/21/24 at 10:56 A.M. revealed Resident #104's fingernails remained long and dirty. Interview attempts on 11/18/24 at 10:09 A.M. and on 11/20/24 at 1:47 P.M. revealed Resident #104 was unable to answer questions. Interview on 11/21/24 at 10:56 A.M. with Certified Nurse Assistant (CNA) #197 verified Resident #104's nails were long and dirty. She indicated the resident required assistance and did not refuse nail care. 2. Review of Resident #95's medical record revealed an admitted [DATE] with diagnoses including protein-calorie malnutrition, bilateral age-related nuclear cataracts, Alzheimer's disease, anxiety disorder, adult failure to thrive, cognitive communication deficit, depression, and bilateral sensorineural hearing loss. Review of Resident #95's quarterly MDS assessment dated [DATE] revealed his cognition was not assessed. He required supervision or touching assistance with personal hygiene. Review of Resident #95's plan of care dated 11/13/23 revealed the resident had an ADL self-care performance deficit related to cognitive status, decreased mobility, and weakness. Interventions included adjusting care level as needed, assisting with ADLs as needed, and encouraging the resident to participate in activities. Review of Resident #95's monthly summary dated 10/24/24 revealed he was disoriented. Observation on 11/18/24 at 11:31 A.M., 11/20/24 at 8:16 A.M., and 11/21/24 at 10:09 A.M. of Resident #95 revealed he had long nails extending past the end of his fingertips, and they appeared to be dirty. Interview on 11/21/24 at 10:56 A.M. with CNA #197 verified Resident #95's nails were long and dirty. She indicated the resident required assistance and did not refuse nail care. 3. Review of Resident #91's medical record revealed an admitted [DATE] with diagnoses including moderate protein-calorie malnutrition, Alzheimer's disease, adult failure to thrive, aphasia, rheumatoid arthritis, fibromyalgia, pick's disease, anorexia, and depression, Review of Resident #91's quarterly MDS assessment dated [DATE] revealed she had a short term and long-term memory problem. The resident was dependent on staff for personal hygiene. Review of Resident #91's plan of care dated 07/21/23 revealed she had an ADL self-care performance deficit related to disease process, weakness, and need for staff assistance to maintain safety at times. Interventions included approaching in a calm manner, collaborating with hospice, discussing any concerns related to decline in function, monitor for decreased activity tolerance, assisting with ADLs as needed and providing one person assistance with personal hygiene and encouraging nail care as needed. Observation on 11/18/24 at 10:03 A.M. and 11/21/24 at 10:56 A.M. revealed Resident #91 had contracted hands in a tight fist. Her nails were observed to be long with some of them having dirt underneath them. Interview on 11/21/24 at 10:56 A.M. with CNA #197 verified Resident #91's nails were long and dirty. She indicated the resident required assistance and did not refuse nail care. 4. Review of Resident #75's medical record revealed an admitted [DATE] with diagnoses including Alzheimer's disease, bilateral nuclear cataracts, cognitive communication deficit, dementia, alcohol use, anxiety disorder, depression, and tremor. Review of Resident #75's comprehensive MDS assessment dated [DATE] revealed the resident was rarely or never understood. He required supervision or touching assistance with personal hygiene. Review of Resident #75's plan of care dated 02/19/23 revealed the resident had an ADL self-care performance deficit related to his diagnoses. Interventions included assisting with ADLs as needed and providing one person assistance with personal hygiene. Observation on 11/18/24 at 10:00 A.M., 11/19/24 at 8:12 A.M., and 11/21/24 at 9:32 A.M. and 10:56 A.M. revealed Resident #75 had long dirty fingernails. Resident #75's nails were so long they could be seen from across the dining room. Interview on 11/21/24 at 10:56 A.M. with CNA #197 verified Resident #75's nails were dirty and long enough that they could be seen from a distance. She indicated the resident required assistance and did not refuse nail care. Review of the policy, Nail Care, dated 04/16/23 revealed it was the responsibility of nursing staff to provide appropriate nail care as needed.

Based on interview and record review, the facility failed to ensure there were sufficient activities in the memory care unit especially in the evening and weekend. This affected four residents (#75, #91, #95, and #99) of four residents reviewed for activities and had the potential to affect all 25 residents residing in the memory care unit. The facility census was 108. Findings include: 1. Review of Resident #95's medical record revealed an admitted [DATE] with diagnoses including protein-calorie malnutrition, bilateral age-related nuclear cataracts, Alzheimer's disease, anxiety disorder, adult failure to thrive, cognitive communication deficit, depression, and bilateral sensorineural hearing loss. Review of Resident #95's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed his cognition was not assessed. Review of Resident #95's plan of care dated 06/10/24 revealed the resident was sometimes dependent on staff for cognitive stimulation related to cognitive deficits. The resident could make their own decisions as to which programs they would like to attend. Review of Resident #95's recreational assessment dated [DATE] revealed the resident had interest in arts and crafts, cards, bingo, puzzles, cooking, exercise, music, outside, pet therapy, reading, writing, and watching television. He was somewhat interested in spiritual activities. He wished to attend group activities, special events, one on ones, and independent activities. Review of Resident #95's monthly summary dated 10/24/24 revealed the resident was disoriented. Review of Resident #95's activities from 10/20/24 to 11/17/24 revealed he had no independent activities. His intellectual activities included sensory stimulation on 10/25/24, and current events on 11/04/24 and 11/11/24. He had no physical activities. His social activities included snacks on 11/06/24 and 11/08/24, bingo on 11/07/24, and arts and crafts on 11/13/24. He had no spiritual activities. His special activities included holiday parties on 11/11/24, special events on 10/31/24, pet visits on 10/22/24, 10/29/24, 11/05/24, and 11/12/24, music therapy on 10/21/24, 11/04/24, 11/05/24, 11/14/24, 11/18/24, and entertainment on 11/15/24. There were no activities listed on the weekend. Observation on 11/18/24 at 10:01 A.M., 10:51 A.M., 11:41 A.M., 2:19 P.M., 3:10 P.M., and 4:18 P.M. revealed Resident #95 sitting in the dining room. The television was on but the volume was down very low. Observation on 11/19/24 at 9:59 A.M. and 2:55 P.M. revealed Resident #95 in the lounge with the television on, he was not paying attention to the television. At 4:17 P.M. he was in the dining room and again the television was on but the volume was down low. Observation on 11/20/24 at 8:16 A.M. revealed activities was passing out the daily chronicle. Resident #95 shuffled the papers but did not read them. Observations at 9:21 A.M., 1:10 P.M., and 1:47 P.M. revealed Resident #95 in the lounge with the television on, he did not appear to be watching it. 2. Review of Resident #91's medical record revealed an admitted [DATE] with diagnoses including moderate protein-calorie malnutrition, Alzheimer's disease, adult failure to thrive, aphasia, rheumatoid arthritis, fibromyalgia, pick's disease, anorexia, and depression, Review of Resident #91's MDS assessment dated [DATE] revealed she had a short term and long-term memory problem. Review of Resident #91's plan of care dated 03/22/24 revealed the resident was encouraged to engage in leisure preferences to promote socialization and provide physical and mental stimulation. Interventions included honoring music and hobby preferences, introducing to other residents with similar interests, provide with assistance during programing if needed, and provide one on one programming. Review of Resident #91's recreational assessment dated [DATE] revealed the resident liked music, outside or gardening, reading or writing, watching television, and bible study. She wished ot have independent activities, one on ones, and group activities. Review of Resident #91's activities from 10/20/24 to 11/17/24 revealed her independent activities included a one on one visit, with a room visit and winding down on 10/24/24 and one on one on 11/11/24. Her intellectual activities included current events on 11/04/24, and sensory stimulation on 11/07/24 and 11/12/24. She had no physical activities. Her social activities included arts and crafts on 11/06/24, games and snacks on 11/07/24, and snacks on 11/08/24. Her spiritual activities included bible study and spiritual services on 10/23/24 and 10/30/24. Resident #91's special activities included pet therapy on 10/22/24, 11/05/24, 11/12/24, music therapy on 11/05/24 and 11/15/24, and entertainment on 11/15/24. There were no activities listed on the weekend. Observation on 11/18/24 at 11:41 A.M. and 2:19 P.M. revealed Resident #91 in the lounge, she was at a table facing the wall. Observation on 11/20/24 at 8:16 A.M. revealed Resident #91 facing the wall, the chronicle was passed out by activities and she did not get one. Observations of the resident at 9:19 A.M., 1:10 P.M., and 1:47 P.M. revealed the resident was now facing the television. 3. Review of Resident #75's medical record revealed an admitted [DATE] with diagnoses including Alzheimer's disease, bilateral nuclear cataracts, cognitive communication deficit, dementia, alcohol use, anxiety disorder, depression, and tremor. Review of Resident #75's comprehensive MDS assessment dated [DATE] revealed the resident was rarely or never understood. Review of Resident #75's plan of care dated 03/14/24 revealed he was dependent on staff for some cognitive stimulation due to cognitive deficits. Interventions included assisting off unit for strolls or special events, assisting with radio or television in room as needed, assuring activities are compatible with capabilities, encouraging participating in groups, monitoring for changes in activities, and providing with one on one as needed. Review of Resident #75's activities assessment dated [DATE] revealed he had interest in cards, bingo, puzzles, listening to music (used to play guitar), going outside, gardening, pet therapy, light reading, watching television and bible study. He had interest In group activities, independent activities, and one on ones. Review of Resident #75's activities from 10/20/24 to 11/17/24 revealed the resident had no independent, intellectual or physical activities. He had one spiritual service on 10/30/24. His social activities included games, reminiscing, and snacks on 11/07/24, arts and crafts on 11/13/24 and 11/15/24, and music groups on 11/15/24. He had no activities on the weekends. 4. Review of Resident #99's medical record revealed an admitted [DATE] with diagnoses including dementia, neuromuscular dysfunction of bladder, dysphagia, encephalopathy, anxiety disorder, chronic diastolic heart failure, cognitive communication deficit, and edema. Review of Resident #99's quarterly MDS 3.0 assessment dated [DATE] revealed her cognition was not assessed. Review of Resident #99's plan of care dated 03/06/24 revealed the resident was dependent on staff for activities, cognitive stimulation, social interaction due to cognitive deficits. The family was involved in Resident #99's care. Interventions included assisting off the unit for strolls or special events, assisting with radio or television in room as needed, assuring that activities were compatible with physical and mental capabilities, attempting to redirect when the resident becomes tearful, introducing to peers near resident, place close to the facilitator, one on one as needed, redirect when yelling out, and redirect as needed when distracted. Review of Resident #99's recreational assessment dated [DATE] revealed her only activity interest was listening to music. Activities needed to be modified to accommodate her cognitive deficits and she required cueing and assistance with activities. Review of Resident #99's activities from 10/22/24 to 11/17/24 revealed her spiritual activities included spiritual service and bible study on 10/30/24. Special activities included pet therapy on 11/05/24 and 11/12/24, special events on 10/29/24, music therapy on 11/15/24, and entertainment on 11/15/24. Her social activities included arts and crafts and music group on 11/15/24. Her independent activities included one on one or room visits on 10/23/24, 10/24/24, 11/05/24, 11/11/24, 11/13/24, and 11/14/24, watching television on 11/11/24 and 11/14/24, and winding down on 10/23/24, 10/24/24, 11/11/24, and 11/13/24. She had no intellectual or physical activities. She had no weekend activities. Review of Resident #99's monthly summary dated 11/19/24 revealed the resident was disoriented. Interview on 11/20/24 at 1:57 P.M. with State tested Nursing Assistant (STNA) #162 verified that the television was not catching all the residents' attention. She reported the residents really liked music however, they no longer had a way to play it on the unit. She reported Resident #75 was especially interested in music. She revealed occasionally there were activities in the afternoon. Interview on 11/21/24 at 3:31 P.M. and 11/24/24 at 10:58 A.M. with Activities Director #231 revealed they had activity staff that came in on the weekends and a part-time staff member who did some activities in the evening. She reported activities in the memory care unit varied in length but she would like each activity to last over a half an hour. She was unaware they did not have a radio on the unit. She verified there had not been many evening activities in October and November. Activities Director #231 verified that some activities were documented twice under different areas. [NAME] down was something done during one on ones. Activities Director #231 was unable to provide evidence Residents #75, #91, #95, and #99 received activities on the weekends. Review of the activity calendar in the memory care unit for October 2024 revealed activities only occurred after 2:00 P.M. on 10/02/24, 10/09/24, 10/16/24, 10/23/24, and 10/29/24. The Sunday activities for 10/06/24, 10/13/24, 10/20/24, and 10/27/24 included one activity at 1:00 P.M. called word searches, coloring pages, and sensory stimulation. Saturday activities on 10/05/24, 10/12/24, 10/19/24, and 10/26/24 included two activities at 12:00 P.M. and 2:00 P.M. Review of the activity calendar in the memory care unit for 11/01/24 to 11/17/24 revealed activities only occurred after 2:00 P.M. on 11/06/24 and 11/13/24. The Sunday activities for 11/03/24, 11/10/24, and 11/17/24 included one activity at 1:00 P.M. called word searches, coloring pages, and sensory stimulation. Saturday activities on 11/02/24 and 11/09/24 only included two activities at 12:00 P.M. and 2:00 P.M. The activities on Saturday 11/16/24 included activities at 9:00 A.M. and 10:30 A.M.

Based on observations, interviews, and record reviews, the facility failed to ensure Thrombo-Embolic Deterrent (TED) hose were applied as ordered by the physician. This affected one resident (#57) of the eight residents reviewed for skin conditions during the annual survey. Additionally, the facility failed to timely collect urine and treat a urinary tract infection (UTI) for Resident #86. This affected one resident (#86) of one reviewed for UTI. The facility census was 108. Findings include: 1. Record review for Resident #57 revealed the resident was admitted to the facility on [DATE] and had diagnoses including history of venous thrombosis and embolism, chronic pain, and muscle weakness. Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed the resident was assessed to be rarely/never understood. Review of the active physicians order dated 06/25/24 revealed the resident was to have knee high TED hose applied every morning and removed at bedtime for edema. Observation on 11/19/24 at 8:25 A.M. revealed Resident #57 was up in his wheelchair in the dining room eating the breakfast meal. The resident did not have TED hose applied as ordered. Observation on 11/20/24 at 8:12 A.M. revealed Resident #57 was up in his wheelchair in the dining room eating the breakfast meal. The resident did not have TED hose applied as ordered. Observation on 11/20/24 at 11:00 A.M. revealed Resident #57 was up in his wheelchair in his room. The resident did not have TED hose applied as ordered. Interview with Unit Manager #144 at the time of the observation confirmed Resident #57 did not have TED hose applied as ordered. 43064 2. Review of Resident #86's medical record revealed an admitted [DATE] with diagnoses including Alzheimer's disease, dysphagia, dementia, type two diabetes mellitus, cognitive communication deficit, depression, and insomnia. Review of Resident #86's quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident was rarely or never understood. Review of Resident #86's plan of care dated 04/15/24 revealed she was at risk for alteration in elimination related to incontinence of bowel and bladder due to impaired cognition. Interventions included assisting with toileting and hygiene as needed, incontinence care per protocol, and monitoring for signs of UTI. Review of Resident #86's progress note dated 10/02/24 revealed Psych 360 had given new orders to obtain a urinary analysis with culture and sensitivity. Review of Resident #86's progress notes dated 10/02/24 to 10/04/24 revealed no evidence there had been attempts to collect urine. Review of Resident #86's progress note dated 10/05/24 revealed the nurse obtained a urine sample via straight catheter. Review of Resident #86's progress note dated 10/07/24 revealed the initial urinary analysis had been received indicating trace amounts of blood and protein in the urine and a moderate amount of bacteria. They were awaiting the culture and sensitivity. Review of the culture and sensitivity dated 10/09/24 revealed the presence of Klebsiella pneumoniae in the urine and the susceptibility of the specimen was verified on 10/09/24. Review of Resident #86's progress note dated 10/14/24 revealed a new order was given for Keflex 500 milligrams (mg) for seven days for UTI. Interview on 11/21/24 at 10:15 A.M. and 1:44 P.M., the Director of Nursing (DON) was unable to explain why the urine was not collected until 10/05/24. She reported the urine was not collected until 10/07/24 because the lab did not pick up samples over the weekend. She verified the delay in treatment. She reported she believed the laboratory had been having a glitch and that they received the culture back by 10/10/24 but not the sensitivity.

Based on observations, interviews, and record reviews, the facility failed to ensure resident dignity was maintained during dining experiences. This affected two residents (#35 and #103) observed for dining during the annual survey. The facility census was 108. Findings include: Observation on 11/20/24 at 8:05 A.M. revealed Resident #35 and Resident #103 were lying in bed and did not have breakfast meal trays. A newly admitted resident residing in the room with Resident #35 and Resident #103 was sitting up in bed consuming breakfast from a meal tray set up in front of her. Resident #35 and Resident #103 both confirmed they were hungry and would like a meal tray. Observation on 11/20/24 at 8:19 A.M. revealed Resident #35 and Resident #103 had still not been served a breakfast meal tray. Three unknown facility employees were standing at the end of the hall by the breakfast meal cart discussing who was responsible for Resident #103. All three employees stated the resident was not on their assignment and walked away. Observation on 11/20/24 at 8:29 A.M. revealed Registered Nurse (RN) #198 entered the room of Resident #35 and Resident #103 to provide care. RN #198 confirmed Resident #35 and Resident #103 had yet to receive their breakfast meal but would find out why. Observation on 11/20/24 at 8:40 A.M. revealed Certified Nurse Assistance (CNA) #133 entered the room of Resident #35 and Resident #103 and served the residents the breakfast meal. CNA #133 confirmed he was assisting another CNA to get a resident ready for dialysis and had not had time to serve the breakfast meals to the two residents. CNA #133 confirmed the newly admitted resident residing in the same room as Resident #35 and Resident #103 had already been served and eaten her breakfast meal.

Based on record review and interview, the facility failed to provide residents with a bed hold notification prior to hospital stay. This affected two (Residents #15 and #39) of four residents reviewed for notification of bed hold. The facility census was 108. Findings include: 1. Review of the medical record for Resident #15 revealed an admitted [DATE] with diagnoses including epilepsy, clavicle fracture, humerus fracture, dysphagia, Alzheimer's disease, dementia, Lennox-Gastaut Syndrome, convulsions, idiopathic progressive neuropathy, anxiety, depression, cervical vertebrae fracture, and nontoxic thyroid nodule. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #15 had severe cognitive impairment. Resident #15 was sent to the hospital on 08/30/24 following a fall with a laceration to her forehead. Review of the Notification of Bed Hold form with this resident's name written at the top revealed the form did not provide the total amount of bed hold days left. Interview with the Administrator on 11/21/24 at 2:18 P.M. verified by the actual bed hold days were not captured at the time of the notice. 2. Review of the closed medical record for Resident #39 revealed an admitted [DATE] with diagnoses including hallucinations, cognitive communication deficit, obesity, Hepatitis B and C, hypertension, asthma, irritable bowel syndrome, anemia, restless leg syndrome, constipation, anxiety, depression, fibromyalgia, and rheumatoid arthritis. Review of the quarterly MDS revealed Resident #39 had minimal cognitive impairment. Resident #39 was sent to the hospital on 11/12/24 due to abnormal lab work and complications to her PICC line. Review of the Notification of Bed Hold form with this resident's name written at the top revealed the form did not provide the total amount of bed hold days left. Interview with the Administrator on 11/21/24 at 2:18 P.M. verified by the actual bed hold days were not captured at the time of the notice.

Based on closed record review, review of hospital records, review of facility notification of change policy, and staff interviews, the facility failed to appropriately assess, monitor, and seek timely medical attention for one resident (Resident #141) of nine residents reviewed for a change in condition. This resulted in actual harm and Immediate Jeopardy when no medical attention was given to Resident #141 when she exhibited grumbling sounds when breathing, was anxious, and shaking the side rails of her bed during the evening. Approximately five hours later the resident was found with wet lung sounds and expired during a breathing treatment. The facility census was 137. On [DATE] at 11:05 A.M., the Licensed Nursing Home Administrator (LNHA), Director of Nursing (DON), and Registered Nurse (RN) Corporate Director of Nursing Services #11 was notified Immediate Jeopardy began on [DATE] when Resident #141 suffered harm when a high blood pressure was obtained by State tested Nursing Assistant (STNA) #3 on [DATE] at 12:09 P.M. The reading was documented as ,[DATE] millimeters/mercury (mmHG). Normal blood pressure readings are ,[DATE] mmHG. The STNA reported the reading to RN #2. RN#2 told the STNA to keep an eye on the resident and documented the resident was more tired and lethargic, however, RN#2 did not obtain a formal assessment, or report the change in the resident ' s status to the nursing supervisor. Subsequently, later in the shift, Resident #141 was found with grumbling sounds when she breathed, was very anxious and shaking the side rails. No formal assessment was completed until five hours later (7:00 P.M.) when RN #4 documented wet lung sounds. The physician was notified and orders were received for a breathing treatment and [MEDICATION NAME] (a diuretic medication) and [MEDICATION NAME] (anxiety). The resident never received the [MEDICATION NAME] and expired during the breathing treatment. The Immediate Jeopardy was removed on [DATE] when the facility completed the following corrective actions: · On [DATE], immediate re-education was given to all RN ' s and Licensed Practical Nurse (LPN) staff on the following: Shift to shift report, the Situation Background Assessment Recommendations (SBAR) tool which included nursing assessment and Notification Policy and Do Not Resuscitate Comfort Care (DNRCC). This re-education was completed by 8:00 P.M., on [DATE] by the DON, Staff Development LPN #14 and RN Corporate Director of Nursing Services #11. · Facility audits will be conducted every shift daily until Immediate Jeopardy is resolved for the following areas: SBAR will be completed for all change in resident status/condition, physician notification, nursing assessment, DNRCC, and notification of DON/Designee. Any concerns, will be forwarded to the Quality/Assurance and Performance Improvement (QAPI) committee and the Medical Director for immediate follow up. · Audits will be conducted daily for five weeks, then three times a week for five weeks, then random to ensure compliance. The audits will be completed by the DON/Designee. · During interviews on [DATE] at 12:50 P.M., RN #31, LPN #30 and RN #21 all stated they had training on notification of change, completing the SBAR form and gave examples and great detail of the training provided last week. Although the Immediate Jeopardy was removed, the facility remained out of compliance at Severity Level 2 (no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) as the facility is still in the process of implementing their corrective action plan and monitoring to ensure on-going compliance. Findings include: Review of the closed medical record revealed Resident#141 was admitted to the facility on [DATE] from an acute care hospital with [DIAGNOSES REDACTED]. Review of hospital records dated [DATE] to [DATE] revealed a peg tube was placed on [DATE] due to the resident ' s dysphagia (swallowing difficulties). Review of speech therapy notes dated [DATE] revealed the resident remained nothing by mouth (NPO) now due to severe dysphagia, with peg tube for alternative means of nutrition/hydration. Review of STNA #3 ' s vital sign documentation dated [DATE] at 12:09 P.M., revealed a blood pressure (B/P) measurement of ,[DATE] mmHG. No other vital signs were documented until RN #4 ' s nurse ' s note dated [DATE] at 2:33 A.M., after the resident had expired. Review of the nurse ' s note dated [DATE], revealed RN #2 documented the resident seemed more tired and lethargic and was being monitored. No formal assessment of the resident was completed. No notification to the physician was noted. The RN placed the resident ' s name on the doctor notification clipboard to be seen. Nurse ' s note dated [DATE] at 2:33 A.M. documented resident had a change of status with a blood pressure reading of ,[DATE] mmHG, pulse 60 beats per minute, respirations 24, oxygen saturation 92% and temperature 98.1 degrees Fahrenheit and had wet lung sounds. The family and doctor were notified of status. At this time, the daughter clarified with the nurse and nurse supervisor the resident ' s code status was do not resuscitate, comfort care (DNRCC, no chest compressions or breathing tubes). New orders were obtained for [MEDICATION NAME] 40 milligrams (mg), [MEDICATION NAME] (for anxiety) one mg, and a breathing treatment. Review of further documentation revealed when the nurse went to complete the breathing treatment the resident was absent of any vital signs and pronounced expired at 1:11 A.M. Review of the Physician order [REDACTED].M., revealed the resident was to receive a chest x-ray, [MEDICATION NAME] 40 mg per tube times one, [MEDICATION NAME] nebulizer treatment every three hours for shortness of breath, and [MEDICATION NAME] one mg by mouth times one. A telephone interview on [DATE] at 1:04 P.M. with the daughter of Resident #141 revealed her mother did not look right all day (Sunday) [DATE], which was a huge change from the day before. She stated an STNA, (who she was unable to identify), had gotten a high blood pressure reading on her mother earlier in the morning and noises were heard when she would breathe. She was very anxious and kept shaking the side rails on the bed. She then found another STNA who came in and took another blood pressure reading who said it was a little high, however better than what it was earlier. The daughter then asked the STNA to alert the nurse of the audible noises during breathing and how anxious she was. The daughter stated she never did see the nurse. She stated they left for the evening around 9:00 P.M., and let them know at the nurse ' s station to keep an eye on her due to her breathing. During an interview on [DATE] at 1:55 P.M. with the Administrator and DON they stated they did not do an investigation into the death because she was comfort care and they did not think anyone was unhappy. A telephone interview on [DATE] at 2:13 P.M. revealed RN #4 stated he had gotten report when he arrived for his shift on [DATE] at 7:00 P.M. and Resident #141 was not doing well and to monitor her. He stated he was told by STNA #7 the resident was having breathing problems. He further stated he did not see the resident until between 10:00 P.M. and 11:00 P.M., and she was making rattling noises while breathing and was not good. There was no formal assessment or notification to the physician at this time. During an interview on [DATE] at 2:24 P.M., LPN #5 stated she was the supervisor on day shift on [DATE]. She stated nothing was mentioned to her about the change in the resident ' s status; however it should have been if she was having any problems. She further stated she should have been notified about the blood pressure and if she was placed on the doctor notification clipboard. A telephone interview on [DATE] at 2:48 P.M. revealed RN #2 remembered the resident was smiling on Saturday [DATE] and then Sunday [DATE] she was tired and sleepy. She stated she could have asked STNA #3 to retake the resident ' s blood pressure because she remembered it being high. She stated it was facility protocol if a STNA got an abnormal blood pressure reading the nurse was supposed to retake the blood pressure manually to verify. She did not retake the resident ' s blood pressure. During a telephone interview on [DATE] at 3:04 P.M., STNA #3 stated she took care of Resident #141 on [DATE] and [DATE]. She further stated she got a high blood pressure reading earlier in the morning on [DATE] and reported it to RN #2 who asked her to keep an eye on the resident. Telephone interview on [DATE] at 3:42 P.M. revealed STNA #6 worked on [DATE] and started her shift at 7:00 P.M. STNA #6 stated during the first round she made shortly after the start of her shift she found Resident #141 was red, hot, and sweaty. She stated the resident was also grabbing the side rails on the bed. The STNA turned down the heat and opened a window. She notified RN #8 (night shift supervisor) of the resident ' s status. At 9:00 P.M., the resident ' s daughter put the call light on. When STNA #6 went in the room she stated the resident was making grumbling noises when she breathed, was anxious, and grabbing the bars on the bed. The STNA reported these changes to RN #4 who stated he would see her as soon as he could. It was an hour later before he did. The STNA then stated the resident ' s oxygen saturation level began to drop and she was placed on oxygen around 11:00 P.M. The STNA stated she knew they got orders for a breathing treatment and when RN #4 went to turn the breathing treatment of [REDACTED]. Interview on [DATE] at 7:34 A.M. with RN #4 revealed around 11:00 P.M., the resident ' s oxygen saturations were dropping and he put oxygen on her, as it was a standing order. He stated he did not give the ordered [MEDICATION NAME]. He stated the resident had wet lung sounds and gave her a breathing treatment. He stated the nursing supervisor called the doctor. When he went to take her off the breathing treatment she had passed away. During a telephone interview on [DATE] at 10:07 A.M. with supervisor RN #8 she stated she started her shift on [DATE] at 3:00 P.M. She was unaware of issues with the resident until sometime between 9:00 P.M. and 10:00 P.M. She stated she did not assess the resident because she thought RN #4 had already done so. She stated the physician was not notified. She further stated she looked at Resident #141 ' s medical record and saw her code status was DNRCC and since she looked like she was dying, they gave the breathing treatment, however the [MEDICATION NAME] was not given. During an interview on [DATE] at 11:16 A.M., Certified Nurse Practitioner (CNP) #9 stated she did not give the orders for Resident #141 as she had only signed the telephone orders. She stated the collaborating physician, Medical Doctor (MD) #10, who was on call for the night shift, was the one who gave the order. She stated [MEDICATION NAME] worked pretty fast and she would have expected the nurses to implement the orders. Review of the policy titled Notification of Change dated [DATE] documented it is the center ' s policy to manage the residents ' clinical needs, signs and symptoms of an impending change of condition according to the clinical best practice. It is the clinical team ' s responsibility to be proactive with change of condition scenarios and manage the symptoms with the Primary Care Provider (PCP)/Certified Nurse Practitioner (CNP). The nursing staff will be alerted to any slight alteration in the residents ' physical or mental clinical condition. STNA's are to report any change no matter how slight (small) to the charge nurse. The charge nurse needs to review and assess the residents ' clinical condition. The policy further documented the nursing staff will make every effort to manage the residents ' change in condition at the center. If the PCP determines it is in the best interest of the resident to be sent to an acute hospital for evaluation please complete transfer form. Review of the policy titled SBAR Tool dated [DATE] documented the nursing staff must be very proactive in managing signs and symptoms and contacting the PCP for immediate interventions before the situation gets out of hand. The nursing staff will be alerted to any slight alteration in the resident ' s physical condition or mental condition and then begin completing the SBAR Tool. The SBAR Tool has four separate areas and to please complete all the areas (of which one is an assessment). This deficiency substantiates Complaint Number OH 558.