Every finding on record at Mount Ascension Transitional Care of Cascadia

Based on observation, interview, and record review, the facility failed to implement and operationalize an effective grievance process and failed to thoroughly investigate, document, track, and resolve grievances, including failing to provide a written grievance decision upon request, for 1 (#10) of 11 sampled residents. The facility also failed to prominently post and include within the facility grievance policy the required contact information for the designated grievance official (name, business mailing address, business email, and business telephone number), which may affect any resident wishing to file a grievance at the facility. These failures resulted in a family member not receiving a timely written resolution to four grievances submitted to the facility. Findings include:Observations on 7/15/26 at 10:02 a.m. and on 7/16/26 at 12:30 p.m. revealed the facility did not prominently post the designated grievance official's required contact information. The posted information did not identify the grievance official by name and did not include a business mailing address, business email address, or business telephone number.During an interview on 7/16/26 at 1:22 p.m., NF1 stated she had submitted four written grievances to the facility on 6/26/26 regarding resident #10. NF1 stated she requested a written response on 7/6/26. NF1 said staff member A asked for her email address on 7/6/26 and informed her he was working on the grievances; however, as of the interview date, she had not received a written response or resolution. NF1 stated she continued to desire a written response from the facility.During an interview on 7/16/26 at 1:34 p.m., staff member A said he received the four grievances dated 6/26/26 from a former employee and was asked to address them. Staff member A said NF1 expected a response to the grievance(s) by the end of the week and admitted he had not yet responded, although it had been over two weeks from receipt of the grievance(s). Staff member A stated grievances should be addressed as soon as possible, although some become delayed, estimating they should generally be addressed within a week or two. Staff member A identified himself as the facility's grievance official but stated he did not know whether the grievance official's information was posted in the facility, stating, I don't know if the grievance officer is posted or not.Review of the facility's grievance log showed no documentation of the four grievances submitted by NF1 on 6/26/26 regarding resident #10.A request was made for NF1's four grievances submitted on 6/26/26 by NF1 on 7/16/26 at 12:46 p.m.Review of the grievance documents provided by the facility included four grievance forms with attached narratives describing the concerns. The records lacked evidence that grievances were processed according to the facility's grievance process, and showed: - No department or responsible staff member was assigned.- The section identifying What occurred? was blank.- The section documenting When and where did the event occur? was blank.- The section identifying a person with knowledge of the event was blank.- The section summarizing interviews conducted during the investigation was blank.- Additionally, the second page of the document titled Complaint/Grievance Follow-Up was entirely blank.- There was no documentation demonstrating the facility investigated the allegations, completed follow-up activities, reached findings, implemented corrective actions, communicated a resolution, or issued a written grievance decision.Review of the facility's policy titled Grievance Process, revised on 8/29/25 showed, Policy, .the Grievance program is utilized to address the concerns of Residents, family members and visitors and the facility should make prompt efforts to resolve grievances. Definitions, prompt efforts to resolve refers to a facility acknowledgment of a complaint/grievance and actively working toward resolution of that complaint/grievance.Procedure.3. The facility provides (or post in a prominent location), information on:.b. The contact information of the grievance official with whom grievance can be filed.c. A reasonable expected time frame for completing the review of the grievance.d. The right to obtain a written decision regarding his/her grievance.7. The Nursing Home Administrator/Designee is responsible for overseeing the grievance process; including receiving, tracking, and conclusion/resolution.8. The facility ensures that all written grievance decisions include:a. The date the grievance was received,b. A summary statement of the Resident's grievance,c. The steps taken to investigate the grievance,d. A statement as to whether the grievance was confirmed or not confirmed,e. Any corrective action/solution taken or to be taken by the facility to resolve the grievance,f. The date the written decision was issued.Responsibility of the Nursing Home Administrator and/or Designee:1. Overseeing the facility's grievance program2. Ensuring that all grievance reports have been reviewed and addressed in a timely and appropriate manner and that concerned individuals feel that some type of resolution has been communicated, achieved, and maintained. [sic]Review of the policy further showed it did not identify the designated grievance official by name and did not include the required business mailing address, business email address, or business telephone number for contacting the grievance official.

Based on observation, interview, and record review, the facility failed to ensure the provision of pharmaceutical services to ensure ordered medications were available which resulted in missed doses of prescribed pain medications, interruption in pain management, and delayed care, and resident medications were not acquired, received, dispensed and or administered as needed or ordered by the physician, for 2 (#s 2 and 3) of 11 sampled residents. This failure contributed to the ongoing risk for resident #2, who had a diagnosis of Stage IV cancer and required high-dose pain medication(s) for pain relief, and this increased the risk for uncontrolled symptoms of pain. Findings include: 1. During an interview on 7/15/26 at 4:01 p.m., staff member B said resident #2 was readmitted to the facility on [DATE] following a hospitalization. Staff member B explained that by the time the facility pharmacy received the readmission medication orders for the resident, the pharmacy's ordering cutoff time had passed. Most of the medication orders were submitted the following day; however, the narcotic prescriptions required physician confirmation before processing. Staff member B stated she was addressing resident #2's lack of narcotic pain medication since 6:00 a.m. that morning, and she had attempted to transfer the resident to the emergency department for pain control. Staff member B further stated resident #2 had exhausted her supply of hydromorphone, and the prescribed fentanyl patches were not received from the pharmacy yet.During an interview on 7/15/26 at 4:34 p.m., resident #2 reported she was experiencing pain. Resident #2 revealed she had Stage IV cancer and was recently hospitalized . Resident #2 stated her pain medication regimen had been changed during the hospitalization. When she was readmitted to the facility, she was informed the medications were not delivered from the pharmacy. Resident #2 said stated she had been without her pain medication and described it as though, My nerve endings are on fire.During an interview on 7/16/26 at 9:00 a.m., staff member I stated hospital discharge prescriptions for controlled substances were transmitted directly to the pharmacy. Staff member I explained that when urgently needed medications are unavailable, staff may contact the pharmacy, and if orders have been received before 3:30 p.m., they can obtain an access code to retrieve pain medications from the Omnicell (medication dispensing machine).Review of resident #2's hospital discharge orders dated 7/13/26 showed resident #2 was discharged with the following prescribed pain medications:- Gabapentin 300 mg oral capsule 3 times a day.- Hydromorphone 12 mg by mouth every 3 hours.- Fentanyl transdermal patches totaling 300 mcg every 72 hours, last placed on 7/11/26.Review of resident #2's medication administration record for July 2026 showed,- Gabapentin 300 MG: five scheduled doses were coded as not available.- Hydromorphone 4 MG: four scheduled doses were coded as not available.- Fentanyl patches: scheduled dose on 7/14/26 coded as not available.Review of resident #2's minimum data set pain questionnaire, dated 7/13/26, showed the resident experienced pain that was present almost constantly. The assessment included documentation that the pain almost constantly affected the resident's sleep, constantly interfered with day-to-day activities, and was rated by the resident as a 9 on a 0-10 numeric pain scale with 10 being the worst. Review of resident #2's electronic health record showed:- admission Note, effective 7/13/26 at 4:19 p.m., admission Clinical Evaluation Completed: [AGE] year old female admitted back to facility from [Acute Hospital] today after having left knee fracture repaired. Resident is continued on Palliative Care with [Hospice Provider]. Resident has discharged with more Opioids on board for better pain management of Cancer diagnosis and recent fracture. [sic]- Health Status Note, effective 7/15/26 at 1:23 p.m., Received phone orders from on-call provider [Provider Name] to send rsdt to ER for pain management/control as rsdt has no pain meds in facility to administer d/t receiving none from the pharmacy and has had nothing for pain since the evening of 7/14/26. Rsdt also agree to go to ER for pain management/control as she is in pain. [sic]- Health Status Note, effective 7/15/26 at 2:43 p.m., EMTs arrived at facility and discussed going to ER with rsdt. EMTs told rsdt that ER would do nothing for her but administer her Tylenol and send her back. EMTs stated that they do not administer opioids and the ER would not administer opioids either. That transferring rsdt to ER would cause her more pain than good, and it would be best to keep rsdt here in facility and wait for pain medications to arrive here. Rsdt became tearful, still in pain, and did not know what to do. After a bit more discussion, rsdt decided to remain in facility if ER/EMTs were not going to do anything to help her. [Hospice Provider] and on-call providers are sending in a satellite Rx to local pharmacy to get narcotics filled and available at pharmacy. [sic]2. During an interview on 7/15/26 at 3:01 p.m., resident #3 stated she had gone without her prescribed gabapentin for several days and experienced pain in her feet.During an interview on 7/15/26 at 2:40 p.m., staff member F stated the facility often ran out of medications, and the Omnicell (medication dispensing machine) routinely did not have medications needed for residents. During an interview on 7/15/26 at 2:43 p.m., staff member G said residents had experienced delays in receiving medications and stated those delays had affected resident care.During an interview on 7/15/26 at 4:01 p.m., staff member B stated nurses assigned to the medication cart were responsible for reordering medications. Staff member B stated medication deliveries occurred on Tuesdays and Thursdays and explained medication ordering by the night shift was inconsistent and required day shift nurses to complete missed reorders. Staff member B stated, Pills are kind of a struggle.During an interview on 4/16/26 at 10:11 a.m., staff member A said medication delays had occurred following the contracted pharmacy's software conversion. Staff member A stated residents had missed or received medications late and said there were occasions when medications that were expected to be available in the Omnicell were not, because the Omnicell had not been restocked. Staff member A further stated the facility's corrective action for the medication issues included changing pharmacy providers because the pharmacy's performance had not improved despite discussion that had occurred approximately one to two months earlier. Staff member A mentioned available options for pharmacy contractors and stated he had one in mind specifically that he was going to contact. During an interview on 7/16/26 at 1:11 p.m., staff member H said medication refill requests could be completed by fax, telephone, or through the electronic medical record. Staff member H explained the pharmacy relied on facility staff to notify the pharmacy when Omnicell medications required replenishment outside of the scheduled restocking and stated par levels (number of medications stocked/available) could be adjusted when medications routinely ran short.Review of resident #3's pain assessments showed the resident reported a pain level of 5 prior to the administration of as needed acetaminophen on 7/8/26. Additional documented pain assessments on 7/9/26 showed pain ratings of 10 and 6 on a 0-10 numeric pain scale prior to as needed acetaminophen administration. Review of resident #3's care conference review, dated 7/13/26 at 11:30 a.m., showed in the comments section: [Resident #3] is a long-term resident at the facility. Pain/Discomfort: [Resident #3] reported no current pain or discomfort at the time of the visit. However, she stated that she was without her gabapentin for approximately one week beginning in early July due to a facility-related issue. She reported that the pain became so severe that she felt like she wanted to amputate her feet. I confirmed that a total of nine doses were missed. This concern will be relayed to the ADON for follow-up. [sic]Review of resident #3's medication administration record for July 2026 showed the resident missed nine scheduled doses of gabapentin between 7/6/26 and 7/9/26.Review of resident #3's electronic health record showed,- EMAR progress note, effective 7/6/26 at 1:30 p.m., Gabapentin Oral Capsule 100 MG, give 2 capsules by mouth three times a day for neuropathy, was on order from the pharmacy.- EMAR progress note, effective 7/7/26 at 12:08 p.m., Gabapentin Oral Capsule 100 MG, give 2 capsules by mouth three times a day for neuropathy, was on order from the pharmacy.- EMAR progress note, effective 7/9/26 at 7:54 a.m., Effective Date: 07/09/2026 07:54 a.m., Gabapentin Oral Capsule 100 MG, Give 2 capsule by mouth three times a day for neuropathy.Medication not available, did not arrive from the pharmacy. Will call again today to find out where it is. Was told by [Provider Name] a new script was sent to pharmacy days ago.- EMAR Note, effective 7/9/26 at 11:37 a.m., Gabapentin Oral Capsule 100 MG, Give 2 capsules by mouth three times a day for neuropathy. This RN called pharmacy re medication. Pharmacist states that the provider sent in the wrong medication that the pharmacy does not carry. A message was sent to the main pharmacist asking if the medication could be changed to 2 (two) 100mg caps instead of what was ordered, they have not heard back from the pharmacist yet as to what to do, she said fax will also be sent to provider letting them know as well. So, still unable to pull any from omnicell as they cannot give me a code to pull because they do not have the accurate script also unable to administer any of this medication to rsdt as we have none [sic]- EMAR Note, effective 7/9/26 at 3:30 p.m., Rsdt requested tylenol for foot pain, Rsdt states her feet are very sore without having gabapentin for so long. [sic]Review of the facility's policy titled, Pharmacy Services, revised on 9/16/25, showed, Policy, This facility ensures the provision of pharmaceutical services through a contracted pharmacy to meet the medication-related needs of each resident. These services are delivered in accordance with 42 CFR S483.45, and applicable state laws. The facility collaborates with the pharmacy to ensure safe, timely, and compliant medication practices, including dispensing, .

Based on interview and record review, the facility failed to ensure residents received showers and assistance for their assessed needs and physician orders for 2 (#s 8 and 9) of 11 sampled residents. The deficient practice resulted in both residents going approximately 12 to 13 days without a shower. Resident #9 had a physician's order requiring a minimum of four showers per week due to colostomy care needs, and the lack of showering increased the risk of compromised personal hygiene and skin integrity concerns. Findings include:1. During an interview on 7/15/26 at 10:33 a.m., staff member B said resident showers are generally scheduled for two times per week.During an interview on 7/15/26 at 11:46 a.m., resident #8 stated she was scheduled to receive showers two times per week. Resident #8 stated approximately two week earlier, she did not receive a shower for about two weeks because of staffing shortages. Review of the facility's shower schedule showed resident #8 was scheduled to receive showers on Thursday and Sunday.Review of resident #8's shower documentation for June and July 2026 showed missed scheduled showers on:- 6/4/26- 6/18/26- 6/21/26- 6/25/26- 7/5/26.The documentation revealed resident #9 did not have a shower from 6/15/26 through 6/27/26, a period of 13 consecutive days, despite the established shower schedule.Resident #8's comprehensive care plan, last reviewed on 7/15/26, showed the resident required substantial to maximum assistance for bathing with the assistance of one staff member, showing the resident was dependent on staff for her care needs. 2. During an interview on 7/15/26 at 10:33 a.m., staff member B said some residents required more than the facility's routine shower schedule of two showers per week. Staff member B stated one resident had a physician order that required at least four showers per week.During an interview on 7/15/26 at 3:27 p.m., resident #9 said she preferred showers three times per week, and there were occasions when she did not receive them as often as she preferred. Resident #9 said she had a colostomy and this required more showers to maintain hygiene and care for the skin surrounding her stoma.Review of resident #9's comprehensive care plan, last reviewed on 6/30/26, showed she required set up assistance for bathing with the assistance of one staff member.Review of resident #9's physician orders showed an order dated 11/20/25 directing staff to provide the resident a minimum of four showers per week.Review of resident #9's shower documentation for June and July 2026 showed resident #9 missed showers on:- 6/4/26- 6/8/26- 6/13/26- 6/18/26- 6/20/26- 6/22/26- 6/25/26- 6/27/26- 7/9/26- 7/11/26The documentation further showed resident #9 did not receive a documented shower between 6/17/26 and 6/28/26, a period of 12 consecutive days, despite a physician's order requiring at least four showers each week.Review of the facility's policy titled, Activities of Daily Living, dated 9/8/25, showed, Policy, Residents receive assistance with activities of daily living (ADLs) based on their individual needs, preferences, and care plan goals. Staff provide support to maintain or improve the Resident's ability to perform ADLs and prevent avoidable decline.Procedure. 2. Staff help with the following ADLs as needed and in accordance with the Resident's care plan: I. Hygiene: Bathing . [sic]

Based on interview and record review, the facility failed to ensure nursing aides received performance evaluations that were completed and maintained, at least annually for 3 staff members (C, D, and E) of 3 employee files sampled. This resulted in the absence of documented assessments of employee performance, feedback, and opportunities to identify education or performance improvement needs. The deficient practice increased the risk that all residents receiving care from nurse aides could be affected by unrecognized performance deficits. Findings include:Review of staff member C's employee file showed the staff member was hired in 2024. The file contained no documented performance evaluations since the date of hire.Review of staff member D's employee file showed the staff member was hired in 2022. The file contained a blank performance review form, which was incomplete. There was no annual performance review in staff member D's file dating back to the staff member's hire. Review of staff member E's employee file showed the staff member was hired in February 2025. The file contained no documentation showing that a performance evaluation had been completed since the employee's hire.During an interview on 7/16/26 at 2:09 p.m., staff member A said the employee files did not contain performance evaluations because the previous employee responsible for the process and evaluations did not do them. Staff member A said the former employee was going to be placed on a performance improvement plan because the evaluations were not completed on an annual basis, but the employee resigned before that happened. Review of the facility's Employee Handbook, revised on 10/2025, showed, .Performance Evaluations, Performance evaluations are periodic supervisor appraisals of your job performance. Performance reviews are formal and in writing, .This documentation becomes a recorded part of the employment record.

Based on interview and record review, the facility failed to ensure a timely, comprehensive interdisciplinary team (IDT) post-fall assessment, including root cause analysis, implementation of effective interventions, and care plan updates, was completed for avoidable falls, for 1 (#19) of 9 sampled residents. The failure resulted in the resident experiencing additional falls, and the resident had a major injury and was hospitalized . Findings include:During a telephone interview on 3/23/26 at 1:40 p.m., NF4 stated resident #19 had been declining for the past couple of months, with increased confusion, weight loss, agitation, and right hip and leg pain. NF4 stated resident #19 was transferred to the facility post-hospitalization with an iliac fracture after being found outside of her home in eight-degree weather. NF4 stated resident #19 continued to decline at the facility and fell once, then contracted COVID-19, and fell two additional times. NF4 stated resident #19 was placed on hospice at the hospital and passed away on 3/3/26.During an interview on 3/23/26 at 3:15 p.m., staff member B stated the facility completed an IDT post-fall assessment, typically within 24 hours of a resident's fall. The IDT meeting identified root causes for the falls and determined interventions to prevent additional falls. The resident's care plan was updated as needed. The IDT meetings were part of the morning meeting and therefore occurred every weekday. Staff member B stated the IDT meetings for resident #19 did not occur in a timely manner, stating, There was a lot going on here at that time.During an interview on 3/23/26 at 3:50 p.m., staff member A stated resident #19 had experienced three falls after her initial hospitalization, as she was declining mentally and physically prior to and while at the facility, and the hospital and radiology notes from 3/2/26 showed suspected bone malignancy.Review of resident #19's hospital discharge note, dated 2/6/26, showed diagnoses including osteopenia, degenerative changes, altered mental status, dementia, cognitive decline, right iliac crest fracture, weight loss, and lethargy. The discharge note also showed, Her cognitive decline has been present over months, however it sounds like it has progressed rather rapidly over the past month.Review of resident #19's nursing progress notes showed the resident experienced a total of three falls, and the notes showed: -On 2/23/26, resident #19 was observed attempting to park her wheeled walker and fell on her right knee and hip. No injuries were sustained at that time.-On 2/25/26, resident #19 was placed on palliative care services as recommended on discharge from the hospital on 2/6/26.-On 2/26/26, resident #19 tested positive for COVID-19.-On 3/1/26, resident #19 sustained an unwitnessed fall, resulting in bruising to the right elbow and right hip.-On 3/2/26, resident #19 sustained an unwitnessed fall with facial laceration and hematoma to the left brow region, skin tear to the left elbow, decreased level of consciousness, and the resident was transported to the hospital with emergency services.Review of resident #19's post-fall IDT note for the 2/23/26 fall, which was not dated until 3/5/26, showed: RCA: (Resident #19) attempted to park her walker without locking the brakes, her short-term memory contributing to the lack of completion of this safety step, which then resulted in the walker rolling away and causing the loss of balance and the fall. Parking the walker near the opposite bed created a situation in which this required her to step backwards, thus exceeding her functional abilities. Interventions: More frequent visual checks, consistent cuing and reinforcement for safe walker handling, evaluate walker for proper fit/function, OT/PT to continue with therapy with additional focus on fall prevention. [sic]Review of resident #19's electronic health record showed no evidence of the updated fall interventions implemented following the 2/23/26 fall, and the interventions identified by the IDT on 3/5/26 were not identified until after the resident was transferred to the hospital on 3/2/26.Review of resident #19's care plan, dated 2/6/26, and last updated on 3/9/26, showed no updated fall interventions between 2/6/26 and 3/9/26, when all care plan entries were cancelled due to resident #19's death. The facility failed to document and implement the interventions for falls on the resident's care plan, in an attempt to prevent future falls. The resident continued to have recurring falls and paired with her recent decline and Covid-19 illness, her risk was greater, highlighting the need for closer monitoring and oversight. Review of a facility document titled Fall Response & Management, last revised on 8/21/25, showed: PROCEDURES: . 5. Fall incident(s) will be evaluated to determine probable causal factors, including but not limited to environmental, medical, supervision, and/or assistive device needed.6. The Resident's care plan will be reviewed and updated following a fall incident, incorporating individualized measures to eliminate (if possible) or minimize risk of recurrence.7. The Interdisciplinary team (IDT) will review the fall incident and place intervention(s). The IDT will review and revise the care plan as needed.

Based on interview and record review, the facility failed to develop and implement an effective, comprehensive, data-driven Quality Assurance and Performance Improvement (QAPI) program. The facility identified multiple Performance Improvement Projects (PIPs); however, failed to implement, monitor, and sustain effective corrective actions. The failure resulted in ongoing quality of care and service concerns without resolution and placed all residents at risk for continued substandard care and negative outcomes. Findings include:During an interview on 3/23/26 at 2:30 p.m., staff member A stated the facility had a QAPI meeting system wherein each department manager would identify departmental updates and performance improvement projects for their department on a shared PowerPoint, which was then presented at the quarterly QAPI meetings. The department managers reported the progress and results in future meetings as appropriate. Staff member A stated each department had multiple PIPs in the past year. Staff member A stated QAPI meetings were held both quarterly and as needed, such as an Ad Hoc QAPI meeting after surveys.During an interview on 3/24/26 at 10:15 a.m., staff member K stated QAPI meetings were primarily informational and were not focused on problem-solving or process improvement. Staff member K stated the meetings consisted of reviewing departmental activities and did not consistently include follow-up on previously identified concerns. Staff member K stated she and staff member C had been discussing revising the format of the QAPI meetings to a more process-driven template, including identifying system failures, assigning responsibility, and establishing action items. Staff member K stated the facility had experienced ongoing system failures over the past year and QAPI meetings should occur more frequently to address new concerns and monitor progress of previously identified PIPs. Staff member K stated the QAPI committee .definitely needs to be more than it has been.Review of the facility's quarterly QAPI meetings in 2025 showed multiple quality concerns were identified, including infection control practices, housekeeping/environmental issues, care plans, pain management, and skin and wounds. The meeting documentation lacked evidence of the root cause being discussed or analyzed, lacked clearly defined action plans, and lacked documentation of the monitoring effectiveness or sustained improvement for identified issues.Review of the facility's PIP documentation for 2025 showed multiple projects were initiated; however, documentation did not include measurable goals, timelines for completion, or evidence of ongoing evaluation of interventions. Several issues were repeatedly identified across multiple meetings without documented resolution or progress.Review of a facility document titled Quality Assurance and Performance Improvement (QAPI), revision date 11/28/19, showed: . The committee meets at least monthly to:- a. Identify performance improvement opportunities through tracking and trending of data that necessitate quality assessment and assurance activities against state and national benchmarks;- b. Establish goals, thresholds, and performance indicators to advance quality;- c. Systematically analyze underlying causes of quality deficiencies;- d. Prioritize action plans through high volume, high risk, problem prone, and near miss review;- e. Develop appropriate plans of action to impact improvements opportunities;- f. Establish and implement process improvement strategies; .- i. Evaluate effectiveness of the process improvement activities, revise to achieve desired outcomes, monitor for sustained results.

Based on observation, interview, and record review, the facility failed to implement appropriate infection prevention and control practices, including hand hygiene, transmission-based precautions, and personal protective equipment (PPE), for 1 (#42) of 9 sampled residents. The failure placed residents, staff, and visitors at risk for transmission of COVID-19 and other infectious diseases. Findings include:During an observation on 3/22/26 at 8:58 a.m., a sign on the facility's public entrance door showed the facility had active resident cases of COVID-19 in the building.During an observation on 3/22/26 at 9:34 a.m., a sign was observed on resident #42's room, showing the resident was on Enhanced Droplet Precautions. The sign showed the use of an N95 face mask, gown, gloves, and eye protection was required. A PPE supply cart was observed outside of resident #42's room, which contained eye protection, masks, and gloves in the first drawer, and the second and third drawers were empty. The cart did not contain isolation gowns. Staff member E was observed entering and exiting resident #42's room wearing a face mask. No gown, gloves, or eye protection were observed in use by staff member E. Staff member E then returned to the medication cart to retrieve additional medications and then entered another resident's room wearing the same mask. No hand hygiene was observed at any time during the observation period. Staff member E failed to follow safe infection control precautions when completing tasks for the resident on Enhanced Droplet Precautions, and then went into another resident's room, increasing the risk of the spread of infection(s).During an observation on 3/22/26 at 9:40 a.m., no PPE was observed inside resident #42's room or in the trash receptacle inside the room.During an observation on 3/22/26 at 10:20 a.m., staff members E and F were observed entering resident #42's room wearing face masks. Both staff members exited the room several minutes later. No additional PPE was observed in use by either staff member E or F. No isolation gowns were observed in the PPE supply cart located outside the room. No hand hygiene was observed after exiting the room.During an observation and interview on 3/22/26 at 10:29 a.m., no used gowns were observed in the trash receptacle inside resident #42's room, and no gowns were observed on the PPE supply cart located outside the room. Resident #42 stated she was in isolation for 14 days after testing positive for COVID-19. Resident #42 stated the staff, don't always wear gowns or all that other isolation gear, maybe because I only have a couple of more days left on isolation.During an interview on 3/22/26 at 11:00 a.m., staff member E stated, I think we (staff) should be wearing PPE in (resident #42's) room. I guess I should have had it on, but I just went in quickly and dropped off her meds. She was in the shower.During an interview on 3/22/26 at 12:45 p.m., staff member B stated the facility had been experiencing a COVID-19 outbreak since 2/17/26.During an observation on 3/23/26 at 9:44 a.m., staff member F was observed standing in front of resident #42's door, reading the Enhanced Droplet Precaution sign. Staff member F was holding goggles in her hand and reading the instructions for PPE. Staff member F stated, It's been quite some time since we had training.During an interview on 3/23/26 at 1:19 p.m., staff member I stated she had been working at the facility for approximately 18 months through a contracted agency. Staff member I stated she had not received updated training on transmission-based precautions through her (contracted) agency since 2023. She stated she did not receive updated training by the facility. Staff member I stated, for Enhanced Droplet Precautions, eye protection was only required if there was a likelihood of splash contact. Staff member I also stated she did not understand when Enhanced Barrier Precautions would be used.A request was made on 3/23/26 for Enhanced Droplet Precautions and Enhanced Barrier Precautions staff education. The requested documentation was not provided by the end of the survey.Review of a facility document titled Special Droplet & Contact Precautions, dated 9/13/25, showed, This facility implements Special Droplet and Contact Precautions when a resident presents with signs or symptoms of a respiratory illness (until confirmation of diagnosis), or is diagnosed with a transmissible condition requiring the use of a NIOSH-approved particulate respirator (N95 or higher), gown, gloves, and eye protection (e.g., goggles or a face shield that covers the front and sides of the face), such as COVID-19.Review of Centers for Disease Control and Prevention (CDC) guidance located at https://www.cdc.gov/COVID, accessed on 3/26/26, showed, Infection Control Guidance: SARS-CoV-2 for Health Care Providers . Enhanced Droplet Precautions for COVID-19 are infection control measures used to prevent the spread of particles from coughing, talking, or touching contaminated surfaces. These protocols require hand hygiene, a surgical mask, eye protection, a gown, and gloves when in the patient's room, with all PPE removed upon exiting.

Based on observation, interview, and record review, the facility failed to provide a clean, sanitary, and homelike environment for 2 (#s 1 and 13) of 9 sampled residents. The failure placed residents at risk for exposure to unsanitary environmental conditions and diminished quality of life. Findings include: During an observation and interview on 3/23/26 at 1:05 p.m., resident #1's room was observed to have soiled window surfaces, visibly dirty windowsills, a paper wrapper and medicine cup on the floor near the trash can, and wall surfaces with holes, cracks, and missing paint. Resident #1 stated, They keep telling me this is my home, but my home wouldn't look like this . I have lived here two years, and the window curtains and privacy curtains have not been washed once since I have been here . When I asked the housekeepers about cleaning them, they told me they can't take either of them down for cleaning because of privacy concerns. They can take them down; it would only be temporary . Everyone has some excuses. Those (privacy curtains) are touched by everyone . They don't clean well. Yesterday I saw the housekeeper take a paper towel from the wall dispenser, wet it with some water in the sink, and wipe the mirror with it, and they call that cleaning . It's not sanitary. The place doesn't even smell clean . Look at my walls, no one seems to care that there are holes in the wall and missing paint and cracks everywhere . The windowsills are filthy, and the windows are too . They come in and do a little sweep and wipe, but definitely not every day, and it needs more than just a quick sweep and wipe. I don't think they have ever deep cleaned my room, like move the furniture and bed and stuff, never!During an observation and interview on 3/23/26 at 3:05 p.m., resident #13's room did not appear to have received basic daily cleaning. Dust and debris were observed under the bed, under the heat register, and on the dresser. A crumpled napkin was observed on the floor near the base of the bed. The trash can was overflowing. A discarded glove and a gown tie were observed on the floor near the trash can. Resident #13 stated, No one came in here to clean at all yesterday or today.During an interview on 3/22/26 at 1:31 p.m., staff member L stated no deep cleaning was being completed, and as many rooms as possible were being swept or mopped daily. Staff member L stated that housekeeping staff work until approximately 2:30 to 3:00 p.m., five days per week. Staff member L stated, We have one housekeeper per floor, and we can only do so much. I have 47 residents up here. It's too much. We don't have time to deep clean anything. Staff member L stated the CNAs cleaned, as needed, after housekeeping left for the day.During an interview on 3/23/26 at 9:05 a.m., staff member G stated, Every room gets deep cleaned every day . We have two housekeepers and myself . Well, downstairs rooms get deep cleaned every day, and upstairs the deep cleaning is done weekly.During an interview on 3/23/26 at 11:15 a.m., staff member G stated deep cleaning of resident rooms would take approximately 45 minutes to an hour for each room, and daily room cleaning typically would take 15 minutes or less. Staff member G stated, Some rooms don't take long because they don't really move around in there much, so we can do a quick sweep or mop, and that's all. Staff member G further stated, I have been here a year, and I don't even know if the (window and privacy) curtains are removable.During an interview on 3/23/26 at 3:50 p.m., staff member A stated there are three housekeepers because staff member G had only very minimal additional responsibilities. Staff member A stated staff member G would not know how often deep cleaning was completed, as she is new to her role. Staff member A stated that two rooms on each floor are deep-cleaned every day.During an interview on 3/24/26 at 8:50 a.m., staff member G stated, I am sorry you misunderstood me, and stated the facility was working on a deep cleaning schedule, which should occur monthly for every resident room. Staff member G stated she helped the housekeepers as able but was also responsible for overseeing laundry, ordering supplies, completing spreadsheets, and attending meetings. Staff member G stated she usually cleaned the dining room, public entrance areas, and the nurse's station every morning she was working, and then focused on her supervisory tasks unless there was a call-off or other fill-in staff need. Staff member G stated the housekeepers were responsible for cleaning on their assigned hall/floor; one housekeeper per floor.During an interview and record review on 3/24/26 at 9:30 a.m., staff member A stated, This is the deep clean log. What's the difference between a log and a schedule? Anyone can check something off. Resident #1's room was shown on the schedule for deep clean on 3/16/26, and resident #13's room was shown on the schedule for deep clean on 3/22/26.Review of QAPI meeting minutes for May through December 2025 showed the previous housekeeping manager was planning to start a privacy curtain cleaning rotation in June of 2025.A request was made for privacy curtain cleaning rotation documentation on 3/24/26. No documentation was provided by the end of the survey.Review of a facility document titled Position Description, undated, showed: Position Title: Housekeeping Manager . Essential Functions . - Manages team of housekeeping employees. - Ensures overall cleanliness and comfort of facility. - Assigns workers their duties and evaluates conformance to prescribed standards of cleanliness. - Schedules housekeeping employees based on facility census and other operating constraints. - Provides orientation, trains, evaluates of housekeeping employees. - Inventories stock to ensure adequate supplies and reports any ordering needs to Central Supply. - Issues supplies and equipment to workers. - Inspects and evaluates physical condition of establishment and submits recommendations for painting, repairs, and furnishings to management. - Investigates complaints regarding housekeeping service and equipment and takes corrective action. - Manages punctuality and regular attendance for all scheduled housekeeping shifts . [sic]Review of a facility document titled Complete Room Cleaning, undated, showed: PURPOSE: The Complete Room Cleaning Schedule ensures that each resident room is discharge-cleaned on a monthly basis 3.g. Windows - clean window tracks and check curtains. Report any soiled or damaged curtains to housekeeping supervisor. [sic]

Based on interview and record review, the facility failed to ensure physician ordered services were provided in accordance with professional standards for 1 (#99) of 9 sampled residents. The failure resulted in the resident not receiving ordered physical therapy services and placed the resident at risk for decline in mobility, strength, and functional status. Findings include:During an interview on 3/23/26 at 10:12 a.m., staff member D stated that when physical therapy orders were included in a resident's admission orders, the admitting staff member would forward a copy to the therapy department, and the physical therapist would complete the initial therapy assessment. Staff member D stated resident #99's initial therapy order may have been missed (not processed) by the admitting nurse or not forwarded to therapy; therefore, therapy staff would be unaware that services were ordered.During an interview on 3/23/26 at 10:25 a.m., staff member H stated that when a new therapy order was received, the initial evaluation would be completed by the physical therapist within a couple of days, and treatments would then be completed by the physical therapy assistants, in accordance with the treatment plan. Staff member H stated that resident #99 did not receive the ordered services, and he did not know how it occurred.During a phone interview on 3/23/26 at 1:15 p.m., NF1 stated resident #99 was admitted on [DATE] with therapy ordered for the resident, but the therapy was not provided during his stay. NF1 stated resident #99 was transferred to an assisted living facility, per her request, on 2/10/26.Review of resident #99's admission orders, dated 12/23/25, showed a physician's order for physical therapy services to evaluate and treat. The admission orders were signed off by NF2 on 1/1/26.Review of resident #99's admission MDS with an ARD of 12/29/25, showed none of the above in Section O0390, Therapy Services.Review of a facility document titled Census Details Report, dated 3/23/26, showed resident #99 was not enrolled in therapy services at any time during his stay.Review of National Council of State Boards of Nursing professional standards for nursing, located at www.ncsbn.org, accessed on 3/26/26, showed, Nurses are responsible for implementing orders for patient care unless they have reason to believe the order is inaccurate, not properly authorized, or harmful to the patient.

Based on observation, interview, and record review, the facility failed to ensure medications were not left at the bedside for resident self-administration without a physician order and safety assessment for 1 (#42) of 9 sampled residents. The failure placed the resident at risk for choking, aspiration, and medication errors. Findings include: During an observation on 3/22/26 at 9:45 a.m., resident #42 was lying in a recliner in her room. Resident #42 was observed to have neuromuscular spasticity of the bilateral upper extremities, weak vocal quality, a slowed speech pattern, and generalized neuromuscular weakness. Seven assorted colored and sized capsules were observed in a medicine cup on the table in resident #42's room. The medications were accessible to the resident without supervision.During an interview on 3/22/26 at 10:33 a.m., staff member E stated she went into resident #42's room earlier and left the medications at the bedside as the resident was in the shower. Staff member E stated that resident #42 probably did not have a physician's order for self-administration of medications.During an interview on 3/23/26 at 9:45 a.m., staff member B stated medications should not be left at the bedside unless an order and assessment supporting self-administration of medications was completed and in place. Staff member B stated that resident #42 did not have a medication self-administration order and stated she would educate staff member E.Review of resident #42's electronic health record showed diagnoses including oropharyngeal dysphagia, dysarthria, and anarthria (neuromuscular weakness affecting speech and swallowing), and conversion disorder with motor symptoms (involuntary neurologic motor symptoms).Review of resident #42's electronic health record showed no self-administration safety assessment or physician order for self-administration of medications.Review of resident #42's speech therapy note, dated 1/21/26 at 3:46 p.m., showed, Ptnt is permitted to have bread. Ptnt is on a regular diet. Her preference is for rye bread. [sic]No additional speech therapy notes or swallow evaluations were located in resident #42's electronic medical record to show the resident was safely able to swallow or self-administer medications.A written request for resident #42's medication self-administration safety assessment, speech therapy evaluation, and physician order for self-administration of medications was provided to the facility on 3/23/26. No documentation was provided by the end of the survey.

Based on interview and record review, the facility failed to maintain an infection surveillance and antibiotic stewardship program to ensure tracking of effective and efficient antibiotic therapies for residents residing in the facility. Findings include:During an interview on 2/26/26 at 10:12 a.m., staff member B stated she started in her position in mid-January (2026). Staff member B stated the previous director of nursing covered the infection preventionist role. Staff member B stated there were a lot of infection control areas of the program that needed to be caught up on. Staff member B stated she was working on the infection surveillance and antibiotic stewardship logs.Review of a facility document titled, Infection Control Log, dated January 2026, showed a list of 20 residents, with the names of the antibiotics they were taking. There was no tracking information on the log to show the associated room number, admit date , onset date, site, infection-related diagnosis, culture, organism, isolates, healthcare acquired infection status, date of re-culture, or resolution date. The total number of infections was blank at the bottom of the log, and there was no number in any of the categories of infections, to show the number of infections such as skin, eye, upper respiratory and others.Review of a facility policy titled, Antibiotic Stewardship Program, revised 8/10/25, showed: . f. Assess the response to antibiotic therapy, resident condition and review laboratory results as they become available to determine whether the current antibiotic remains appropriate or requires modification. 4. Tracking. b. Contain a system of reports related to monitoring antibiotic usage and resistance data. Examples may include the following:I. Summarizing antibiotic use from pharmacy data or electronic health records, such as the rate of new starts, types of antibiotics prescribed, or days of antibiotic treatment per 1,000 resident days.

Based on observations, interviews, and record reviews, the facility failed to ensure staff utilized personal protective equipment properly during care of residents who were positive with COVID-19, and for a resident who was on droplet precautions, for 3 (#s 7, 10, and 32) of 18 sampled and supplemental residents; and failed to maintain a system of communicable disease surveillance for tracking of active infections in the facility. The deficient practices placed residents, staff, and visitors at risk for the transmission of infections. Findings include:1. During an observation and interview on 2/24/26 at 9:52 a.m., staff member AA and staff member BB were inside resident #10's room, with the door open. The outside of the door had signage showing enhanced droplet precautions were in place for resident #10. The two staff members had respirators on but were not wearing an isolation gown, disposable gloves, or protective goggles. Staff member BB proceeded to reposition resident #10 in his bed, directly touching him with her own ungloved hands and clothing. Resident #10 was heard coughing several times while the two staff members were repositioning the resident. Staff member AA exited the room and stated she was shadowing staff member BB. Staff member BB stated they knew resident #10 was COVID-19 positive and saw the infection control precaution sign on his door. Staff member BB stated, I knew he was COVID positive, that's why we were wearing masks, I didn't think to put on a (isolation) gown and gloves. Staff member BB stated she usually looked at a resident's door to see what kind of infection control precautions to follow before entering the resident's room. During an interview on 2/26/26 at 10:12 a.m., staff member B stated she started in her position in mid-January (2026). Staff member B stated that the previous director of nursing covered the infection preventionist role. Staff member B stated there were areas of the infection control program that needed to be caught up on. Staff member B stated she was working on updating the infection surveillance logs. Staff member B stated she heard of staff in the facility, during the week of the survey, who did not wear personal protective equipment (PPE) when entering resident rooms when the resident was COVID-19 positive. Staff member B stated that all staff members in the facility, including hospice nurses, needed to wear the proper PPE for residents with droplet precautions. Review of resident #10's nursing progress notes, dated 2/21/26 at 3:28 p.m., showed: Note Text: Resident tested for COVID due to facility outbreak status. Resident tested positive today. Resident reports he's having body aches and increased fatigue. Resident's spouse. notified. PPE put in place. Review of resident #10's physician orders, dated 2/21/26 at 1:50 p.m., showed: Enhanced Droplet Precautions with contingency use PPE (Gown, N95 mask, eye protection, and gloves) for Dx of COVID-19. May re-eval after 10 days from symptoms onset/positive test, no fever for past 24-hours without the use of fever-reducing medication, and improvement of symptoms. every shift for covid for 14 Days. [sic] 2. During an observation and interview on 2/23/26 at 3:58 p.m., resident #32 was sitting in a wheelchair in his room. Resident #32 was heard exhibiting a frequent mucous-sounding cough. Two CNAs were observed going into resident #32's room. Resident #32's door had an infection control precaution sign posted on it showing that droplet precautions were to be used. The directions instructed the staff to wear eye, nose, and mouth coverings before entering the room. A second sign showed enhanced droplet precautions. This sign instructed the staff to wear full personal protective equipment (PPE). This included gowns, eye protection, N95 masks, and gloves. The sign also directed the staff to remove the gown and gloves and complete hand hygiene. When this surveyor heard resident #32 holler out, Ow! it was noted that the two CNAs were starting to transfer resident #32 back to bed. The two CNAs had masks and gloves on, but neither staff member was wearing eye protection or an isolation gown. After completing the resident's care, staff member V left resident #32's room without washing or sanitizing her hands. Staff member V said she removed her gloves and did not wash her hands, and she would use the hand sanitizer down the hallway from resident #32's room. Review of resident #32's lab report, dated 2/17/26, showed that resident #32 tested positive for Parainfluenza Virus 2. 3. On 2/24/26 at 9:13 a.m., the surveyor was in resident #7's room, and the resident was COVID-19 positive. A garbage can was observed across the resident's room, in the bathroom. As the surveyor was leaving the room, it was noted that there was no bin available for the soiled personal protective equipment. During an observation and interview on 2/24/26 at 9:16 a.m., staff member R brought two pairs of goggles to the isolation cart outside resident #7's room. Staff member R said there should be sanitizing wipes to clean the goggles off, but none were available at that time. Staff member R said she had to take her isolation gown off in the resident's bathroom and walk back through the resident room. Staff member R said she should not have done that, but there was no bin by the resident's door to place the used isolation supplies in. Staff member R said she told the nurse about the concern with the lack of a garbage bin by the resident's door. Staff member U said there should have been a garbage bag set inside the resident's door, so isolation gowns could be removed. Staff member U said the garbage bin should be in place for the disposal of used personal protective equipment. During an observation and interview on 2/26/26 at 11:20 a.m., staff member S was observed coming out of resident #7's room, and the resident was COVID-19 positive. Staff member S was all the way into the hallway with her gown, gloves, mask, and goggles on. Staff member S placed resident #7's food tray into a plastic bag. Staff member S then tied the plastic bag shut with her contaminated gloved hands. Staff member S then took off her isolation gown, removed her goggles and mask, and then removed her gloves without washing her hands. Staff member S used her contaminated hand to toss her hair, which was in a ponytail, over her head. She then went to the housekeeping cart and touched the surface of the cart and the supplies on the cart. Staff member S then went to the plastic bag on the floor near resident #7's room, which was full of garbage. She tied the bag closed. Staff member S said she had received training on COVID-19 and housekeeping practices. Review of a facility document titled Infection Control Log, dated January 2026, showed a list of 20 residents, including the names of the antibiotics they were taking. There was no tracking information on the log to show the resident's room number, admit date , onset date, site, infection-related diagnosis, healthcare-acquired infection status, or resolution date. The total number of infections was blank at the bottom of the log, and there was no information documented in any of the infection categories to show the number of the types of infection, such as skin, eye, upper respiratory, and or others. The January 2026 log had two pages of facility maps, with no tracking information for the infection types or the resident rooms identified for those who had active infections. Review of a facility policy titled Infection Control Surveillance Plan, revised 9/22/25, showed: . 3. Areas that facilities could consider for process surveillance include the following but are not limited to:. b. Appropriate use of personal protective equipment (PPE). h. Appropriate use of transmission-based precautions. 6. The Infection Preventionist (IP). reviews data by tracking and trending signs and symptoms of infection, as well as acute infections, to identify potential clusters and emerging trends. Review of a facility policy titled, Management of COVID-19, . revised 9/18/25, showed: .This facility is committed to protecting the health and safety of residents, staff, and visitors through proactive COVID-19 prevention and response measures.1. The facility should follow the Core Principles of COVID-19 Infection Prevention and Control:a. Hand hygiene (use of alcohol-based hand rub is preferred) practices .b. Face covering or masks (covering mouth and nose) . e. Appropriate staff use of Personal Protective Equipment (PPE). 6. Residents should be monitored for signs and symptoms of COVID-19. If noted, the facility should promptly place the resident on Special Droplet and Contract Precautions (formally referred to as Enhanced Droplet Precautions) . [sic]

Based on observation, interview, and record review, the facility's kitchen staff failed to handle food in a clean and sanitary manner during meal service to prevent potential contamination. These deficient practices were observed in the food preparation area during meal service and resulted in unsanitary conditions in the kitchen. These failures may affect any resident who received food from the kitchen when sanitation practices were not upheld. Findings include: During an observation on 2/23/26 at 1:13 p.m., during a COVID-19 outbreak at the facility, two dietary staff members, P and J, were observed to be in the food preparation area, and neither was wearing an infection control face mask. During an observation on 2/24/26 at 8:20 a.m., during breakfast meal service:Staff member Q was assembling the resident's breakfast trays with gloved hands. Staff member Q picked up trays and tray cards, then touched the food racks with gloved hands. Staff member Q then used her contaminated gloved hands to place her hand, in a cupped position, over the top of the open juice glasses. The staff member moved from clean to contaminated tasks without changing her gloves or washing/sanitizing her hands. Staff member K was not wearing gloves when observed. Staff member K was grabbing the link sausages with her bare hands, cutting the sausages, and placing them on the plates, which were to be served to the residents. Staff member K grabbed muffins with her bare hands and placed them on the plates, then moved eggs from one side of a plate to another with her bare hands to make room for the rest of the food on the plate. Staff member K then placed her fingers on the inside of the cereal bowls after touching the food and plates. She did not wash or sanitize her hands or put on gloves. Staff member K also touched the plate surfaces with her hands and fingers, where food would be placed before being served to the residents. Staff member K did not follow infection control precautions during the meal service tasks.During an interview on 2/25/26 at 11:44 a.m., staff member D said the kitchen staff should never touch the food with their bare hands. During an observation on 2/25/26 at 11:47 a.m., during lunch service, the following was observed:Staff member DD was observed cutting pizza, then placing the pizza on the resident's plate, with his bare hands. Staff member DD was observed scraping beans out of the serving spoon, then moving the beans around on the plate with his bare hands. Staff member DD placed buns on the resident's plate with his bare hands. Staff member DD did not follow infection control precautions during the meal tasks. Staff member K cut a sandwich, then placed the sandwich onto the resident's plate with her bare hands, not using proper infection control precautions.

Based on interview and record review, the facility failed to ensure an investigation of a facility reported incident was completed with thorough documentation of the findings for 1 (#70) of 15 sampled residents. Findings include:Review of a Facility Reported Incident, dated 1/26/26, showed resident #70 was in a dining room and observed by staff to physically interact with a female resident, which included kissing her. The findings, submitted 2/2/26, showed female residents on the wing had been interviewed, and the female resident in the incident had been moved from the wing.During an interview on 2/26/26 at 10:22 a.m., staff member B stated resident #70's care plan should have been updated to include monitoring for recent changes in behavior after a physical incident with another resident. Staff member B stated the incident that occurred towards the end of January (2026) must have happened when she and staff member A were not in the facility, but out of town. Staff member B stated staff member A handled facility reported incidents. Staff member B stated if a resident-to-resident incident occurred, there was usually monitoring or alert charting started for both residents.Review of the event documentation showed the facility did not complete a thorough investigation, including interviews with other staff members, monitoring for awareness of details or ongoing patterns of behavior for those residents involved, a review or update to resident #70's care plan, and there were no interdisciplinary team event notes regarding the incident.Review of a facility policy titled, Event Management & Reporting, revised 9/16/25, showed: . 4. Investigation and Intervention. c. The Interdisciplinary Team (IDT) will conduct a thorough review to confirm or revise the initial findings.d. Based on the initial investigation, the nurse will implement an immediate intervention and update the resident's care plan. f. The IDT will determine whether the initial intervention is sufficient or requires adjustment. Any changes will be documented in the care plan.5. Resolution and Oversight. a. The Director of Nursing and/or Nursing Home Administrator is responsible for final resolution (locking) the event in the EMR.b. Sign-off by the Nursing Home Administrator confirms the investigation is complete and reviewed for abuse or neglect. If substantiated, the event will be reported to all required parties.

Based on interview and record review, the facility failed to ensure a baseline care plan was developed within 48 hours after a resident's admission, to reflect monitoring of high-risk medications used by the resident, for 1 (#79) of 15 sampled residents. Findings include:During an interview on 2/24/26 at 10:04 a.m., resident #79 stated she had just gotten to the facility and already wanted to go home. Resident #79 stated she wanted to speak with the staff about going home.Review of resident #79's February 2026 medication administration record showed an admission date of 2/20/26, and included physician orders for: - . Insulin Glargine Subcutaneous Solution 100 UNIT/ML. Inject 15 unit subcutaneously in the morning for DM (Diabetes Mellitus) ., - . Apixaban Oral Tablet 5 MG. Give 2 tablet by mouth two times a day for anticoagulant for 5 Days -Start Date- 02/20/2026.,- . Apixaban Oral Tablet 5 MG. Give 1 tablet by mouth two times a day for anticoagulant for 85 Days -Start Date- 02/25/2026. [sic]Review of resident #79's baseline care plan, initiated 2/20/26, showed pertinent diagnoses of Type 2 Diabetes Mellitus, other Pulmonary Embolism with acute Cor Pulmonale, and other symptoms and signs involving cognitive functions following Cerebral Infarction. It showed the focus area in the plan of care: Impaired mobility with risk for falls r/t, with no goals, and an intervention, PHARMACY: Pharmacist review of medications to address fall risk side effects. Develop plan with risks and benefits as indicated. [sic] Resident #79's baseline care plan did not include information about the prescribed high-risk medications of insulin and an anticoagulant, to include monitoring for signs and symptoms related to hypoglycemia with interventions, and monitoring for signs and symptoms associated with administration of an anticoagulant.Review of a facility policy titled Baseline Care Plans, revised 9/3/25, showed: . 1. A baseline plan of care is developed within 48 hours of admission to address the immediate needs of the residents and will be utilized/updated as needed until a comprehensive care plan can is developed and implemented.2. The baseline care plan should include the minimum healthcare information necessary to properly care for the resident upon their admission which includes the following, at a minimum:a. Initial goals based on admission orders and desired outcomesb. Physician orders .

Based on observation, interview, and record review, the facility failed to implement a care plan for individualized shower preferences to maintain resident cleanliness and ensure the resident felt their hygiene needs were met, for 1 (#42) of 15 sampled residents. Findings include:During an observation and interview on 2/24/26 at 8:55 a.m., resident #42 was sitting in her recliner. The resident's hair was braided and appeared disheveled with strands of hair hanging on both sides of her face. Resident #42 stated she was upset because she had not received a shower two times a week on Tuesday and Friday. She stated she needed assistance while showering, and the facility staff were too busy to get showers done. Resident #42 stated she did not feel clean when she did not receive her shower two times a week.During an interview on 2/26/26 at 8:35 a.m., staff member N stated the MDS nurse completes resident care plans. Staff member N stated, I think she does all the care plans.During an interview on 2/26/26 at 9:15 a.m., staff member E stated she was not certain who is responsible to complete a resident's plan of care, as it was already in the resident's electronic medical record. Staff member E stated she does not update care plans.During an interview on 2/26/26 at 9:30 a.m., staff member G stated that care plans are completed by the nurse managers. Staff member G stated she had not completed a resident care plan.Review of resident #42's care plan dated 1/21/26 showed the focus area as the resident had an ADL self-care deficit. The resident's care plan goal was to improve her current level of functioning in bathing. Resident #42's care plan did not have interventions related to the resident's bathing preferences of two times a week, or what bathing services were necessary, such as the frequency, to ensure the resident's hygiene needs were met. Review of a facility document titled Comprehensive Care Plans and Conferences, with a revision date of 9/3/25, showed: . The facility will ensure that each resident has a timely, person-centered comprehensive care plan developed and maintained in accordance with professional standards of practice. The care plan will reflect the residents' individual conditions, risks, needs, behaviors, cultural values, and preferences, and will include measurable goals, appropriate interventions, and realistic timeframes. The plan will be created, reviewed, and revised by an interdisciplinary team familiar with the residents' status and care needs, with active involvement from the residents and their representative, when applicable. Updates to the care plan will occur as needed based on the residents' response to interventions or changes in condition.

Based on interview and record review, the facility failed to update a resident care plan based on an individual resident's care needs related to behaviors exhibited, for 1 (#70) of 15 sampled residents. This deficient practice placed resident #70 at risk for unmet needs and or the lack of behavior monitoring to identify changes. Findings include:Review of resident #70's nursing progress notes, dated 1/26/26 at 3:48 p.m., showed: Note Text : CNA alerted this nurse to an occurrence in which rsdt walked behind another female rsdt who was sitting at the dining room table. Rsdt was witnessed rubbing female's shoulders and arms from behind, then bending over and giving the rsdt a kiss on the cheek. Female rsdt not of sufficient cognition to grant consent. Rsdt and female separated, but both still in the common area under supervision. DON and Administrator notified. [sic]During an interview on 2/26/26 at 10:20 a.m., staff member B stated resident #70's care plan should have been updated to include monitoring for recent changes in behavior after a physical incident with another resident. Staff member B stated the incident that occurred towards the end of January (2026) must have happened when she and staff member A were not in the facility, but out of town.Review of resident #70's comprehensive care plan, initiated 9/11/25, showed resident #70 had a diagnosis of unspecified Dementia, unspecified severity, with other behavioral disturbance. A problem included, [Resident #70] uses anti-psychotic medications r/t PTSD, antisocial personality disorder., with a goal of [Resident #70] will have behaviors managed for quality of life. Resident #70's comprehensive care plan did not include information about updated monitoring of physical behaviors towards other residents following the 1/26/26 incident in the dining room.Review of a facility policy titled Comprehensive Care Plans and Conferences, revised 9/3/25, showed: . The facility will ensure that each resident has a timely, person-centered comprehensive care plan developed and maintained. The care plan will reflect the residents' individual conditions, risks, needs, behaviors. and will include measurable goals, appropriate interventions, and realistic timeframes. Updates to the care plan will occur as needed based on the residents' response to interventions or changes in condition.

Based on observation, interview, and record review, the facility failed to provide ADL assistance to a resident who required staff assistance with bathing, for 1 (#42) of 15 sampled residents. The deficient practice resulted in a resident feeling unclean. Findings include:During an interview on 2/24/26 at 8:55 a.m., resident #42 stated she had requested a shower twice a week on Tuesday and Friday. Resident #42 stated she very rarely received two showers a week. Resident #42 stated she did not feel clean due to the lack of showers provided.During an interview on 2/26/26 at 8:25 a.m., staff member L stated a bath aide was scheduled later in the morning to complete resident showers. Staff member L stated she tried to get some resident showers completed before the bath aide arrived to begin their shift. She stated that if a resident refused a shower, staff would re-approach the resident later and extend the offer again. Staff member L stated that if a resident refused a shower after a second attempt, she would report the refusal to the nurse, and the resident would sign a shower refusal form. Staff member L stated she was not sure if residents scheduled for the evening showers had been completed. Staff member L stated residents who were scheduled for evening showers often asked for a shower the following day, after their scheduled shower.During an interview on 2/26/26 at 9:15 a.m., staff member E stated she went by a list at the nurse's station to identify what residents were scheduled for a shower during the week. Staff member E stated if a resident refused a shower, she would ask again later or try on a different day.During an observation and interview on 2/26/26 at 9:30 a.m., staff member G stated if a resident refused to take a shower, she would have a different CNA offer the resident a shower. Staff member G stated if the resident continued to refuse a shower, a refusal sheet would be completed, and the resident would sign the form. Staff member G stated the shower refusal forms were located at the nursing station in a notebook. When checked, there was one shower refusal form observed in the notebook.Review of resident #42's care plan, dated 1/21/26, showed the resident was dependent on staff for bathing, and this was with the assistance of one staff member.Review of resident #42's bathing records, dated 12/1/25 through 2/26/26, showed the resident was scheduled to receive showers on Tuesday and Friday each week. Resident #42 did not receive a scheduled shower on 12/5/25, 1/6/26, 1/20/26, 2/3/26, 2/10/26, 2/13/26, and 2/17/26. Resident #42 had 24 opportunities for a shower and received 17 showers during the months of December 2025, January 2026, and February 2026. Based on resident #42's electronic medical record, the resident went without a shower for more than six days, four times, and one time, with 13 days between showers from December 2025 through February 2026. The documents supported the resident's claim of not receiving the preferred showers two times a week. Review of a facility document titled Activities of Daily Living, dated 9/8/25, showed: POLICYResidents receive assistance with activities of daily living (ADLs) based on their individual needs, preferences, and care plan goals. Staff provide support to maintain or improve the Resident's ability to perform ADLs and prevent avoidable decline. Any change in a resident's ability to perform ADLs is documented and reported to the licensed nurse for evaluation and care plan review .2. Staff help with the following ADLs as needed and in accordance with the Resident's care plan:I. Hygiene: Bathing, dressing, grooming, oral care .4. Documentation and ReportingI. ADL assistance and resident response are documented in the medical record .

Based on interview and record review, the facility failed to provide a written notice of the reason for a facility-initiated transfer or bed hold to the resident or the resident's representative, for 1 (#74) of 15 sampled residents. Findings include:Review of resident #74's electronic medical record showed a discharge date of 12/28/25 to a local hospital. There were no transfer or bed hold notices in resident #74's electronic medical record. Resident #74 did not return to the facility following the transfer on 12/28/25.During an interview on 2/26/26 at 10:12 a.m., staff member X stated residents who transferred to the hospital for urgent evaluation would sign a bed hold and transfer notice form. Staff member X stated the nurse who was transferring the resident to the hospital would fill it out. Staff member X stated she did not know if a form was filled out for resident #74.During an interview on 2/26/26 at 10:21 a.m., staff member Y stated that residents who transferred from the facility signed a transfer notice and a bed hold notice form. Staff member Y stated the 100 wing had residents coming and going a lot because it was a rehab wing. Staff member Y stated nurses would assist the resident to sign the form if they could not.A request was made on 2/25/26 at 10:50 a.m. for resident #74's transfer and bed hold notice. The facility provided a document which showed, There is no bed hold present for [Resident #74]'s transfer dated 12/28/25.Review of a facility document, titled Discharge or Transfer, revised 8/30/25, showed: .1. The facility must provide the resident, the resident's representative. with a written notice at least 30 days before the resident is transferred or discharged , except when:c. The resident's urgent medical needs require an immediate transfer.2. The written notice must include:a. The reason for transfer or discharge;b. The effective date of transfer or discharge;c. The location to which the resident is being transferred or discharged .3. A copy of the notice shall be maintained in the resident's clinical record.Review of a facility document, titled Bed-Hold, revised 9/9/25, showed: . The facility issues two notices related to bed-hold policies. The notices will be provided in writing in a manner that resident/representative understands:a. First notice is given well in advance of any transfer.b. The second notice is provided to the resident, and if applicable the resident's advocate, at the time of the transfer, or in cases of emergency transfer, within 24 hours. [sic]

Based on observation and interview, the facility staff failed to ensure a resident was assisted with maintaining a dignified existence when the staff did not identify and provide personal care to a female resident who had dark facial hair that she wanted shaved off, and the facial hair bothered the resident, for 1 (#71) of 15 sampled residents. Findings include:During an observation and interview on 2/24/26 at 8:37 a.m., resident #71 was sitting at the breakfast table. Resident #71 was observed to have lots of dark chin and upper lip hair. Resident #71 said she wished the staff would shave her facial hair because it bothered her.During an observation and interview on 2/25/26 at 3:30 p.m., resident #71 was lying in bed. Resident #71 was observed to be pulling at her chin hairs. Residents #71's facial hair was unchanged from 2/24/26. Resident #71 said she would like to be shaved.During an interview on 2/25/26 at 3:33 p.m., staff member M said she takes care of resident #71. Staff member M said she gives resident #71 a bath on Mondays and shaves her facial hair during the bath. Staff member M said she was not here this Monday, and she did not know if resident #71 had been shaved.

Based on observations, interviews, and record review, the facility failed to provide adequate assistance to prevent injury for 1 (#1); and ensure the residents' environment was free from smoking and vapes creating accident hazards for 3 (#s 1, 2, and 3) of 10 sampled residents investigated regarding smoking and falls. This deficient practice resulted in a fractured hip for resident #1, and created an accident hazard for the residents. Findings include: 1. During an interview on 10/15/24 at 9:25 a.m., resident #1 stated he had a broken hip because a CNA dropped him when transferring him on the toilet. Resident #1 stated he was supposed to have two people for transfers but only one person the night he fell . Resident #1 stated the one CNA stood behind him, and he fell because no one was in front of him to provide support. Resident #1 stated he was flown out to [City] and had surgery to repair the hip. Resident #1 stated he was fearful the facility staff would drop him again. During an interview on 10/15/24 at 11:32 a.m., NF1 stated, He worries too much about the past, the accident happened and sounds like an error occurred. During an interview on 10/16/24 at 3:00 p.m., with staff member B and C, staff member B stated the investigation file into resident #1's fall was missing. Staff member B stated only one CNA was assisting resident #1 when the, bump on his hip occurred. Staff member C stated the education was also located in the investigation file and was not available for review. Review of a facility, Risk management form, dated 3/28/24, reflected resident #1 had, . bumped his hip on the toilet riser when transferring. and When the CNA was helping me to the toilet, my hip bumped the toilet riser. The report reflected no predisposing factors. Review of resident #1's EHR Care Plan, dated 11/23/23 with a revision date of 2/22/24, reflected: - [Resident #1] has an ADL Self Care Performance Deficit r/t multiple sclerosis, myoneural disorder, ataxia.TOILET TRANSFER: Dependent for toileting with assist of 2 staff. Two attempts were made on 10/15/24 at 9:55 a.m. and 10:16 a.m., with voicemails left to call back. As of the end of the survey, no response to voicemails were received cna involved. 2. During an observation and interview on 10/15/24 at 9:25 a.m., resident #1's room had an odor of marijuana. Resident #1's roommate was in bed sleeping. Resident #1 was noted to have a marijuana vape pen in bed with the resident, during the interview, which was by his hip under edge of blanket, on his left side. Resident #1 stated he had the vape pens sent to him by mail. Resident #1 stated he smoked the vape (pen) in bed exclusively. Resident #1 stated he used the pen to calm himself throughout the day. Resident #1 stated all the staff knew about him vaping and said the staff could not smell the marijuana. During an interview on 10/15/24 at 8:04 a.m., staff member P stated resident #1 had a vape pen in his room. Staff member P stated the staff were told not to hand it to him, and he had to get the vape pen on his own. Staff member P stated management told the staff to not hand resident #1 the vape pen. During an interview on 10/15/24 at 8:22 a.m., staff member B stated she had talked to resident #1 about the vape pen when she heard a rumor he had one, and he denied having the vape pen. Staff member B stated they did not do anything further since it was against the resident's rights to search the rooms. Staff member B stated if a staff member was to find a vape pen, they should take it, then bring the vape pen to management. During an interview on 10/15/24 at 8:49 a.m., staff member H stated management was aware resident #1 had a vape pen and chose to not do anything, so she told her staff to not touch the vape pen or hand it to resident #1. Staff member H stated resident #1 had refused a shower last week because he stated he was too high to shower. Staff member H stated the shower aide had found the vape pen in his bed and did not touch it. During an interview on 10/15/24 at 11:32 a.m., with staff members B and C, staff member C stated they went together to resident #1's room a few minutes ago to talk to him about the vape pen. Staff member C stated she could smell the marijuana as she entered the room. Staff member B stated resident #1 consented to a room search, and the vape pen was found tucked under him in his bed. 3. During an interview on 10/15/24 at 1:20 p.m., resident #3 stated she smoked regularly. Resident #3 stated, I go outside by the trash can area to smoke 4x every night. I'm a night owl, so I sleep during the day. I go by myself, with my walker. Staff know I go out. I keep my own cigarettes and lighter in my purse, my daughter brings in more when I need them. 4. During an observation and interview on 10/15/24 at 10:01 a.m., resident #2 had a strong odor of cigarette smell on him and stated he smoked cigarettes, mostly in his car in the parking lot, or out by dumpster. Resident #2 stated he smoked on the facility property at night, mostly. During an interview on 10/15/24 at 4:18 p.m., staff member H and I both stated resident #s 1, 2, and 3 were the only smokers they were aware of in the facility at the time. During an observation on 10/15/24 at 4:20 p.m., there were, No smoking Oxygen in use signs on the doors of every room going down the hall. During an observation and interview on 10/15/24 at 1:35 p.m., staff member Q stated she regularly saw resident #2 and #3 outside smoking by the dumpsters, around 8:00 p.m., when she would pick up a co-worker. Multiple employees were standing and smoking at the dumpsters. During an interview on 10/16/24 at 2:17 p.m., staff member B stated she was not aware residents #2 and 3 were also smoking on the property. Review of the facility's policy, Smoke Free Campus, revised on 10/15/22, reflected: - 3. Upon admission the resident/family sign acknowledgement form to demonstrate their understanding the resident will not smoke anywhere in the facility or on the premises . - . b. Non-exempt employees wishing to use tobacco products may do so upon clocking out for a meal break and leaving facility premises . - . 11. It is the responsibility of the CEO/CNO to monitor compliance of the staff, residents, visitors, and other people entering the facility premises with the Tobacco-Free policy . Review of a facility policy, Prohibition of Medical Marijuana Use, dated 11/28/17, reflected: - [Facility Name] prohibits the use of marijuana as a medical treatment until such time the Attorney General establishes an accepted medical use under the Controlled Substance Act (CSA). The Department of Health and Human Services (DPHHS) has concluded that marijuana has a high potential for abuse, no accepted medical use in the United States, and lacks an acceptable level of safety for use even under medical supervision . A review of the US Food and Drug Administration Website, dated 4/12/24, showed the following safety concerns with vape pen use, and this is located at the following website, https://www.fda.gov/tobacco-products/products-ingredients-components/tips-help-avoid-vape-battery-fires-or-explosions: . vape fires and explosions are dangerous to the person using the vaping product and others around them. There may be added dangers, for example, if a vape battery catches fire or explodes near flammable gasses or liquids, such as oxygen, propane, or gasoline. The exact causes of vape fires or explosions are not yet clear, but some evidence suggests that battery-related issues may be a cause.

Based on observation, interview, and record review, the facility failed to ensure 2 (#s 6 and 15) of 4 sampled residents did not develop a new pressure ulcer or have worsening of pressure ulcers. Outcomes included: Resident #6 developed a sacral pressure ulcer in eight days, which worsened to a Stage IV, the pressure ulcer was avoidable, and the resident had pain from the wound. The staff failed to identify, report, and assess the skin as necessary, failed to develop and implement interventions to reduce skin pressure timely, and failed to complete dressing changes as ordered once the wound developed, for #6. For resident #15, the resident developed a Stage III pressure ulcer resulting from a skin tear caused during the provision of care. The facility failed to develop and implement pressure ulcer prevention strategies staff failed to follow physician orders for wound care. Findings include: 1. During an interview on 5/20/24 at 1:30 p.m., staff member D stated pressure relieving interventions included turning and repositioning, placing a cushion in their (resident's) wheelchair, and a the resident having a different mattress. During an interview on 5/20/24 at 1:40 p.m., staff member E stated residents with wounds were to be turned and repositioned every two hours. Staff member E stated changes in a resident's skin would be reported to the nurse right away, so the skin could be assessed. During an interview on 5/20/24 at 1:45 p.m., staff member F stated residents with wounds were to be turned and repositioned every two hours, or as ordered, they were to off load pressure areas (to skin) when the resident was in bed, place heel protectors at all times, and complete wound assessments as ordered. Review of resident #6's admission Skin Inspection and Admission Clinical Evaluation, dated 2/6/24, showed the resident's skin was intact with pink areas on the pannus and sacrum areas. Review of resident #6's Progress note, dated 2/6/24, showed the resident was at high risk for developing pressure ulcers with a score of 12. Review of resident #6's progress notes, dated 2/6/24 to 5/20/24, showed the resident started on admission with intact skin, and then developed a Stage III pressure ulcer. The progress notes showed a progression from a Stage III to a Stage IV from 2/14/24 to 3/13/24. Review of resident #6's Wound Care Notes, Nursing Progress Notes, and Wound Clinic Documentation, dated 2/6/24 through 5/17/24, showed 17 missed dressing changes. The resident went to the wound clinic two times without a dressing on the wound. Review of resident #6's Nursing Progress Notes, for wound care from 2/15/24 to 5/15/24 showed: - 2/6/24 skin intact with pink areas to the pannus and sacrum - 2/13/24 dressing on buttocks intact - 2/14/24 nursing alerted to worsening wound to left buttock by the CNA and PT. Large open area noted to left buttock approximately 7.0 cm x 5.3 cm. Current wound orders to apply barrier cream to sacrum two times daily. Provider notified. Review of resident #6's physician orders, dated 2/16/24, showed dressings changes were to be done daily. There were six days with missed dressing changes. The dressings were changed on 2/18/24, 2/23/24, 2/26/24, and on 3/1/24 the dressing was changed and the Weekly Pressure Ulcer Report showed it was a Stage III severity. Review of resident #6's physician orders from the wound clinic, dated 3/1/24, showed the resident was to have dressing changes every other day. There was one dressing change missed. The documentation showed: - 3/3/24; Large amount of tan/red odorous drainage noted on old dressing. Resident reported the area was very sore. - 3/5/24 at 4:31 a.m.; There was old dressing saturated with tan and bloody very foul-smelling discharge. Wound bed has clump of tan slough tissue that appears to be loosening off of wound bed. Tolerated dressing change, reported the area is very painful. - 3/5/24 at 5:05 p.m., wound care was provided three times as resident was wet, and dressing was soiled. - 3/7/24 - Pressure injury to buttocks is very painful and increasing in depth. - 3/12/24 through 3/28/24 - A wound vac was in place on the resident's coccyx - 3/15/24 - The resident was to have the wound vac changed three times weekly. There were four missed dressing changes. Review of resident #6's physician orders from the wound clinic showed: - 3/22/24 - Continue the wound vac and keep it set at 125mm/hg pressure and dressing changes were to be done three times weekly. - On 3/29/24 the wound vac was discontinued. - 3/29/24 - The resident was to have daily dressing changes. There were four missed dressing changes. The facility progress notes showed: - 4/1/24 - Wound showed signs of improvement. - 4/8/24 at 4:18 a.m. wound vac in place. At 6:54 a.m. wound vac on hold. - 4/29/24 - Readmission to the facility, as she was transferred to ER after a fall. - 4/29/24 through 5/2/24 dressing changed per orders - 5/3/24 and 5/10/24 no dressing on wound on arrival to the wound clinic. The resident was yelling out in pain. Review of resident #6's physician orders from the wound clinic, dated 4/5/24, showed dressings were to be done three times weekly with the facility doing dressing changes on Mondays and Wednesdays. There were three missed dressing changes following the receipt of the orders. Review of resident #6's wound care notes showed the following: - 2/14/24 Stage III pressure ulcer measured 7 cm x 5.31 cm. Alerted to change by PT and CNA. Resident reports significant pain. - 2/21/24 Stage III pressure ulcer on sacrococcygeal area. Measured 7.62 cm x 5.86 cm. Dressing changes daily with wound clinic one time per week - 2/29/24 Stage III pressure ulcer, no measurements. Large amount of slough in wound bed made it difficult to assess and measure. - 3/7/24 Stage III. Measured 5.97 cm x 3.94 cm. - 3/13/24 Stage IV. Measured 6.13 cm x 4.36 cm. - 3/20/24 Stage IV. Measured 6.03 cm x 4.89 cm. Wound vac in place. - 3/27/24 Stage IV. Measured 4.84 cm x 3.8 cm. - 4/3/24 Stage IV. Measured 4.66 cm x 3.96 cm. - 4/10/24 Stage IV. Measured 3.69 cm x 2.22 cm. - 4/18/24 Stage IV. Measured 4.17 cm x 3.02 cm. - 4/30/24 Stage IV. Measured 3.1 cm x 2.32 cm. - 5/8/24 Stage IV. Measured 2.56 cm x 1.99 cm. - 5/15/24 Stage IV. Measured 4.37 cm x 1.55 cm. Review of the Wound Clinic documentation showed the following: - 2/16/24 Stage III pressure ulcer of the sacral region. Date acquired 1/24/24. It is unclear when the pressure ulcer developed or what treatment the resident had received thus far. Review of the nursing home H&P did not indicate the resident had a pressure ulcer on admission. The wound measured 6.1 cm x 5 cm x 0.1 cm depth. There was a large amount of serosanguineous drainage noted. The physician noted the wound was a fairly large and devastating pressure injury. I diagnosed at least Stage III. - 2/23/24 Stage III pressure ulcer of sacral region. Patient wound is worse. Concerns of infection are noted. Wound measurements were 5.4 cm x 5 cm x 0.1 cm depth. - 3/1/24 Stage III pressure ulcer on the left gluteus. Wound showed progress. - 3/8/24 Stage III pressure ulcer of sacral region. Pre debridement measurements were 5.2 cm x 4.7 cm x 4 cm depth and post debridement measurements were 4.7 cm x 4.7 cm x 4 cm depth. Post debridement noted as Stage IV. Wound was making progress and had some tunneling. - 3/15/24 Measurements were 5.2 cm x 5 cm x 2.8 cm depth. Stage IV pressure ulcer. Patient continues with some depth and undermining to this wound. The depth has improved; however, it does have some twists and turns in deeper area. Continue with wound vac. - 3/22/24 wound vac in place. Facility nursing removed a white foam from the tunnel area, which was not on the original orders for the wound vac. The white foam was covered with a small piece of black foam which extended onto the right buttock, and the right side now showed breakdown with texture potentially from the wound vac sponge. Facility nursing reported a foul odor when the wound vac sponge was removed. Stage IV pressure ulcer and measured 4.4 cm x 4.3 cm x 2.8 cm depth. There is muscle and fat layer visible with undermining noted. - 3/29/24 Ordered for a break in the wound vac. Wound measured 5 cm x 4.1 cm x 2.8 cm. Stage IV. There was a foul odor following cleansing. Patient's wound has again worsened this week. She has also not yet started her antibiotics. She has a wound vac on which appears to be doing more harm at this point related to malposition of the vac sponge during dressing changes or movement of the sponge after it was placed. She also has a positive wound culture result, not currently on antibiotics, placing her in unnecessary danger by this intervention. Wound cultures had been reviewed by the provider ,and the resident was to be on an antibiotic. - 4/5/24 Stage IV pressure ulcer. Wound measured 3.4 cm x 3.7 cm x 1.1 cm depth. The resident's wound had made good progress. - 4/12/24 Stage IV pressure ulcer. Wound vac discontinued. The wound measures 3.3 cm x 3.7 cm x 0.3 cm depth. There was muscle and fat layer exposed. There was no tunneling or undermining noted. The wound continues to make slow progress. - 5/3/24 Stage IV pressure ulcer. The resident did not have a dressing on her wound when she arrived at the wound clinic. - 5/10/24 Stage IV pressure ulcer. Patient again had NO dressing on wound bed and was yelling out in pain. There was an order to give the resident pain medication 30 minutes prior to her appointment. The wound measured 1.8 cm x 2.2 cm x 0.3 cm. 2. During an interview on 5/20/24 at 8:54 a.m., NF2 stated it seemed like resident #15 was getting more wounds after admission. NF2 stated there was to be an evaluation of size of sling to use, but it had not occurred yet. During an interview on 5/20/24 at 9:53 a.m., resident #15 stated she sustained a skin tear to her left mid back related to the sling from the Hoyer lift. The sling was pulled from under her instead of rolling her side to side. Resident #15 stated after that it was classified as a Stage III pressure ulcer. Resident #15 stated NF1 came to the facility to change her dressings on her back and foot (had wound treatment experience). Resident #15 stated she started going to the wound clinic on 5/15/24, and she started wound care at the Wound Care Clinic the week prior. During an observation on 5/20/24 at 3:17 p.m., NF1 removed the dressing from resident #15's left mid back. The wound was large and covered with eschar with a moderate amount of serosanguineous drainage. During an interview on 5/21/24 at 4:31 p.m., NF1 stated an assessment of the proper sling to use for #15 had not been completed. NF1 stated the facility had used several different slings. During an interview on 5/21/24 at 5:15 p.m., staff members A, B, and C stated resident #15 came into the facility with left lateral foot diabetic ulcer, and multiple areas of scrapes due to falls at home. Staff members A, B, and C stated the resident developed a blister on her right heel on 3/20/24 with a small, opened area at the bottom of the blister. The blister opened up on 4/16/24. Staff members A, B, and C stated the resident's partner began doing dressings on her right foot. Staff members A, B, and C stated the skin tear from the sling happened on 4/30/24, and a foam dressing was applied. On 5/7/24 the skin tear on the left mid back worsened to a Stage III. The provider was notified, and a new order was placed and referral made to the wound clinic as soon as possible. Staff members A, B, and C stated at that point the staff of the facility were doing dressing changes to the resident's back. On 5/15/24, NF1 began doing dressing changes to the resident's wound on her back. Review of resident #15's Braden Scale for Predicting Pressure Sore Risk, dated 3/13/24, showed a score of 15 which showed the resident was at risk for developing pressure ulcers. Review of resident #15's Care Plan, dated 3/13/24, failed to show problems, goals and interventions for prevention of pressure ulcers. The resident had a diabetic ulcer on her left heel, and a pressure ulcer to the right heel and left mid back. Review of resident #15's Foot and Ankle Clinic physician order, dated 5/1/24, showed NF1 was to do all dressing changes to the resident's feet. No staff at the facility were permitted to perform dressing changes. Review of resident #15's Wound Clinic documentation, dated 5/15/24, showed the resident had a Stage III [NAME] ulcer to the left upper back. Review of the orders showed NF1 was to change the dressing on the resident's back. At the time of the appointment at the Wound Clinic, the wound was currently Unstageable/unclassified due to the 67-100% necrotic tissue. There was no tunneling or undermining noted. Post debridement of the wound showed it was classified as a Stage III pressure ulcer, measuring 4.8 cm x 4.8 cm x 0 depth. The dressing was to be changed three times per week. It was a full thickness and required surgical debridement. The resident refused to be referred to a surgeon. There was one facility assessment, dated 4/30/24, which showed a new blister to #15's lateral left side, related to friction from the Hoyer sling, during transfers. There was a scant amount of drainage present. The wound was cleansed and covered with a 4x4 Opti foam for protection.

Based on observation, interview, and record review it was determined there was a system failure for the prevention of infections. The facility failed to identify and protect residents from infection of Influenza A. There were 13 residents in transmission-based precautions for positive or presumed positive Influenza A (#s 10, 15, 17, 21, 22, 29, 32, 33, 34, 42, 53, 66, and 68) during the survey. The first resident was positive for Influenza A on 12/22/22, and within one week, there were 13 residents positive for Influenza A. Resident #10 was admitted to the hospital. This failure had the potential to cause a widespread Influenza outbreak throughout the facility. The facility failed to adhere to proper infection control practices of hand hygiene, during the administration of medications, for 3 (#s 38, 53, and 64) of 6 sampled residents. Findings include: IMMEDIATE JEOPARDY: On 1/5/23 at 10:38 a.m., the facility management was notified that an Immediate Jeopardy existed in the area of F880 - Infection Control. The Severity and Scope for the Immediate Jeopardy was identified to be the level of L, and upon removal of immediacy, lowered to an H. Influenza: Upon entrance to the facility on [DATE] at 12:45 p.m., staff member A stated there were seven residents positive for influenza. 1. During an observation on 1/4/23 at 10:25 a.m., resident #10's door was open to her room. There was a sign on the door showing droplet precautions were in place and precautions were required to enter the room. The garbage can on the floor was overflowing with used PPE. The hand sanitizer in her room was empty, and the hand sanitizer across the hallway, was also empty. Record review of a progress note, dated 12/23/22 at 9:38 a.m., for resident #10, showed, Patient present [sic] with persistent, non-productive cough, and O2 sats between 80-84% on RA. Abnormal sounds, in all lung fields. Patient sent to [ Health Facility Name ] ER . Record review of a progress note, dated 12/23/22 at 11:55 p.m., for resident #10, showed, This nurse was informed by [ Health Facility Name ] that resident was hospitalized r/t influenza type A. This date was two days earlier than the date the facility's infection preventionist identified there was the first positive case of influenza in the facility. 2. During an observation and interview on 1/4/23 at 10:33 a.m., the door to resident #17's room was open to the hallway. There was a sign on the door showing droplet precautions were in place and necessary to enter the resident's room. The resident was sitting on her bed next to the door. Resident #17 was coughing. Resident #17 stated, I have no idea what I've got or why I have to be shut in like this. 3. During an observation on 1/3/23 at 3:35 p.m., the door to resident #21's room was closed, there was a sign on the door showing droplet precautions were in place and necessary to enter the resident's room. There was a PPE cart outside of room. 4. During an observation on 1/4/23 at 10:11 a.m., the door to resident #33's room was open to the hallway. There was a sign on the door showing droplet precautions were necessary to enter the room. There was a PPE cart outside the room. The cart did not contain any gowns or gloves. 5. During an observation on 1/4/23 at 8:11 a.m., the door to resident #42's room was open to the hallway. There was a sign on the door showing droplet precautions were in place and necessary to enter the room. There was a PPE cart in the hallway by the door. The cart did not contain isolation gowns or gloves. None of the PPE carts observed on the 1st floor hallway had disinfecting wipes or any other method to clean the face shields used by staff or other healthcare supplies. There was a waste bin by the door for used PPE, and it was overflowing onto the floor, and in the residents room. Record review of resident #42's care plan, dated 12/29/22, failed to show a request to leave the resident's room door open, while in isolation, for the resident's infection of influenza A. 6. During an observation on 1/4/23 at 12:38 p.m., the door to resident #66's room was open to the hallway. There was a sign on the door showing droplet precautions were in place and necessary to enter the room. Inside the room, the garbage can used to dispose of PPE already used by staff, was full. 7. During an observation on 1/4/23 at 10:36 a.m., the door to resident #68's room was open to the hallway. There was a sign on the door showing droplet precautions were in place and necessary to enter the room. The garbage can used to dispose of PPE was full and spilling onto the floor, of the room, next to the door. During an interview on 1/4/23 at 10:13 a.m., staff member A stated the doors to TBP rooms should be closed. Staff member A stated some residents have requested their doors be open, but the request should be on the resident's care plan. Staff member A stated the PPE should not be reused including the eye protection. Staff member A stated the eye protection was reusable, but her expectation was the staff would not reuse the eye protection. During an interview on 1/5/23 at 8:51 a.m., staff member G stated she was notified of the the first positive case of Influenza on 12/26/22. She stated the last positive or presumed positive was on 12/29/22, and there had been 13 total positive or presumed positive cases of influenza in the facility. 32998 8. During an observation on 1/3/23 at 3:00 p.m., the door to resident #15's room was open to the hallway. There was a sign on the door which showed the resident was on droplet precautions, with instructions to see the nurse, prior to entering the resident's room. There was an isolation cart outside the resident's room. There were no face shields in or on top of the cart. During an observation on 1/4/23 at 8:04 a.m., the door to resident #15's room was open to the hallway. There was a sign which showed the resident was on droplet precautions, and to see the nurse prior to entering the room. Staff member F entered resident #15's room with a gown, gloves, and face mask on. Staff member F did not have a face shield or goggles on. Staff member F began to clean resident #15's room. Staff member F entered and exited the resident's room three times, wearing PPE, to get supplies from the cart. Staff member F did not remove the PPE prior to exiting the room to get needed supplies. The cart was placed across the hall from resident #15's room, near resident #29's room. 9. During an observation on 1/4/23 at 8:12 a.m., a staff member entered resident #22's room. The staff member was wearing full PPE. The staff member was observed changing linens. When the staff member exited the room, the face shield was placed on the hand railing outside the resident's room. The face shield was not cleaned, although the resident had been identified as having influenza A. During an observation on 1/4/23 at 8:26 a.m., another staff member entered room resident #22's room and used the face shield located on the hand railing outside the room, which had already been worn by an alternate staff member, and not cleaned prior to use. 10. During an observation on 1/3/23 at 3:07 p.m., the door to resident #29's room was open to the hallway. There was a sign on the door which showed the resident was on droplet precautions, and anyone entering should see the nurse prior to entering the room. There was an isolation cart located outside the resident's room. During an observation on 1/4/23 at 8:06 a.m., the door to resident #29's room was open to the hallway. There was a sign on the door which showed the resident was on droplet precautions, and anyone entering should see the nurse prior to entering the room. During an observation on 1/5/23 at 12:50 p.m., the door to resident #29's room was open to the hallway. There was a sign on the door which showed the resident continued to be on droplet precautions. 11. During an observation on 1/3/23 at 3:05 p.m., the door to resident #32's room was open to the hallway. There was a sign on the door, which showed the resident was on droplet precautions, and those entering should see the nurse prior to entering the room. There was an isolation cart located outside the resident's room. During an observation on 1/4/23 at 8:05 a.m., the door to resident #32's room was open to the hallway. The sign continued to be on the door showing droplet precautions were in place. During an interview on 1/5/23 at 8:50 a.m., staff member G stated it was the expectation for staff to follow the precautions for residents identified to be in isolation. Staff member G stated education should have been done by the DON. Staff member G stated all staff entering rooms were to check carts to ensure enough PPE was available. 47752 12. During an observation on 1/3/23 at 2:12 p.m., resident #53's room had the door open to the hallway. The sign on the door showed resident #53 was in droplet precautions, and those entering should see the nurse prior to entering the room. An isolation cart was located outside of resident #53's room, and a trash can in the room was overflowing with used PPE and trash. Resident #53 was on oxygen via nasal canula at 7 L/m. During an observation and interview on 1/4/23 at 8:30 a.m., staff member F was seen entering and exiting multiple residents' rooms without using proper hand hygiene techniques or proper use of donning and doffing PPE. Staff member F stated she was never trained on how to use PPE properly. During an interview on 1/4/22 at 12:50 p.m., staff member A stated, I do not have any staff training on PPE and have started educating this morning when we realized there was a problem. During an observation on 1/5/23 at 7:55 a.m., resident #53's door was open to the hallway, and the isolation trash can located inside the room, was spilling onto the floor. The isolation cart outside the resident's room, which was to hold PPE supplies for staff use, was empty and did not contain PPE. Multiple face shields, already worn by staff, were observed along the handrail. A staff member came out of resident #53's room, stepped over the PPE trash, and placed his face shield on the handrail without sanitizing it. During a record review on 1/5/23 at 8:00 a.m., nurses notes stated that resident called this nurse into room due to increased SOB. He was leaning forward in his stand up chair with his feet on the floor, breathing heavily. Resident provided with albuterol nebulizer .O2 sats 89% on 7 L/m. Increased flow to 10 [sic] . 13. During an observation on 1/3/23 at 2:00 p.m., resident #34's door was open to the hallway. There was a droplet precautions sign on her door. The resident could be heard coughing in her room. There was a PPE cart for PPE supplies outside her door. During an interview on 1/5/23 at 8:51 a.m., staff member G stated, The expectation for precautions is that everybody follows the instructions on the door, and if there are any questions, ask nursing. Staff member G stated, The DON was to have done all of the education on precautions. Record review of a Facility Policy and Procedure, titled Transmission-Based Precautions Conventional Plan, revised 10/15/22, showed: Droplet Precautions .4. Goggles/face shield are required if exposure is anticipated . .5. Frequent hand hygiene is the most important method of control to prevent transmission . Hand Hygiene: 1. During an observation and interview on 1/4/23 at 11:07 a.m., staff member D was passing medications. Staff member D opened the medication cart, located the correct medication, and dispensed the medication into a medication cup for resident #38. Staff member D closed and locked the medication cart, picked up the medication cup and the cup of water, and entered the resident's room. Resident #38 was not in his room. Staff member D went down to the medication cart and back up the hallway. At this time staff member D located resident #38. Resident #38 took the medication, and the cup of water, and swallowed the medication. Hand hygiene was not preformed prior to giving the resident his medication. Staff member D stated that hand hygiene was to be done prior to resident care, after resident care, and if hands are soiled. 2. During an observation on 1/4/23 at 12:15 p.m., staff member L opened the medication cart and took out a plastic container containing a blood glucose machine, with resident #64's name on it. Staff member L donned proper PPE for transmission-based precautions and went into resident #64's room to check her blood glucose level. Staff member L doffed her PPE and came back to the medication cart. The staff member did not perform hand hygiene after doffing PPE. 3. During an observation and interview on 1/4/23 at 12:20 p.m., staff member L was donning PPE to enter resident #53's room. Hand hygiene was not done prior to donning or doffing PPE. Staff member L stated she was not sure what happened. The staff member stated that the policy for hand hygiene was to perform hand hygiene before and after resident cares, between residents, and when hands are soiled.

Based on observation, interview, and record review, the facility failed to maintain enough staff to effectively manage the care needs of the residents, which lead to a delay in response for resident call lights for 8 (#s 10, 12, 25, 36, 41, 42, 44, and 52) of 8 sampled residents; failed to provide adequate wound care for 1 (#68) of 6 sampled residents; failed to provide physical therapy as ordered for 2 (#s 37 and 52 ) of 5 sampled residents; failed to weigh residents as ordered to monitor for weight loss for 2 (#s 9 and 52) of 5 sampled residents; and failed to provide showers as scheduled for 1 (#23) of 5 sampled residents. These failures had residents feeling mad, frustrated, stranded and unworthy, and for some, they struggled with incontinence due to long wait times. Findings include: Call lights: 1. During an observation on 1/4/23 at 8:16 a.m., the call light came on for resident #10 in room [ROOM NUMBER]. Staff member K looked at the light and walked by the room. Two more staff members walked by room [ROOM NUMBER] without answering the light. Staff member K walked by room [ROOM NUMBER] three more times and did not answer the call. The call light was answered at 8:23 a.m. The resident wanted assistance with getting out of bed, using the restroom, getting dressed, and ready for breakfast. 2. During an interview on 1/4/23 at 1:15 p.m., resident #12 and NF2 were sitting in her room. NF2 stated, the facility had been shorthanded, and there had been some long wait times when she pushed her call light. NF2 stated resident #12 has had accidents in her bed from waiting too long. 3. During an interview on 1/4/23 at 12:42 p.m., resident #25 stated, I really need a shower at least twice a week. I get an infection on my legs that I get if I am not kept clean. There is one nurse that puts an ointment on me, but she is the only one that does it. It depends on the staff. Sometimes when they are really short on staff we don't get showers. One time my O2 got unhooked and it took 20-30 minutes before someone came. It was really critical because my oxygen drops real fast. I couldn't get to the machine to fix it myself. They did not check my oxygen level or anything when they finally came in to answer my call light. That was about a week ago. During an observation on 1/4/23 at 7:50 a.m., the breakfast cart was delivered to the 1st floor. There was a call light on for resident #25. There was a nurse outside of the room with her med cart, but she did not answer the light. There were two staff members delivering trays, the CNO, and an aide. The call light was answered at 8:21 a.m. 4. During an observation on 1/4/23 at 8:35 a.m., resident #42 had his call light on. After waiting 32 minutes, the surveyor found a staff member to help the resident. The resident needed help repositioning. He was too low in the bed and could not eat his breakfast from that position. He was also complaining of pain on his coccyx from sitting on his pressure ulcer for too long. Wound care: 5. During an interview on 1/4/23 at 10:36 a.m., resident #68 said there was limited staffing, and staff were tense and overworked. She stated, The big thing is my wound care. I feel like I really need to press them (staff). It is really detrimental to my healing; it should have been done in the morning, but it took until 8:00 p.m. to get it done. My antibiotics are way late most of the time. There is always trouble with the pump. Sometimes they don't use the pump at all. It was like 3:45 a.m., in the morning, before I got to bed after all my meds. I feel like I can't get a shower because they don't have time, and they don't have the things to cover my bandages and IV. During an interview on 1/4/23 at 10:05 a.m., staff member L stated she had worked at the facility since October 2022. Staff member L stated, Staffing is horrible, I'm down here by myself sometimes. Sometimes I have a med aide, sometimes I don't, it is just horrible. It makes it very hard to take good care of the residents. 45448 Call lights 6. During an interview on 1/3/23 at 2:27 p.m., resident #52 said it took staff a long time to answer the call light. Resident #52 said, The staff will often tell you they will be right back, and they don't return. It makes me mad and frustrated. Resident #52 said she was waiting for the staff to finish with report today to come and help her to the bathroom. She stated, I nearly have an accident. 7. During an interview on 1/3/23 at 2:34 p.m., resident #44 said, Staff here treat each other better than they treat the residents. It will take them half an hour to 45 minutes to come and assist me off of the toilet. 8. During an interview on 1/3/23 at 3:42 p.m., resident #41 said, A couple of the nurse's rush and are not too kind. They make me feel unworthy. Resident #41 said sometimes she waits for quite a while for assistance. She said the staff will say they need to go and get help and never come back. Resident #41 said, I had a shower yesterday and was supposed to have my legs re-wrapped. I had my shower at 10:00 a.m. and buzzed at 10:45 a.m. to have them wrapped. I was told I would have to wait until they got around to it. It was 3:15 p.m. before they returned to wrap my legs. By the time they came, my feet were freezing. I have neuropathy. 9. During an interview on 1/3/23 at 3:56 p.m., resident #23 stated he was working on a bowel program and now had a commode in his room. Resident #23 stated, I don't have much warning, and it (bowel movement) is pretty loose. When I ring the call light, it takes a while for someone to respond. I have to go with an urgent nature. I transfer myself to the commode and clean myself up. 10. During an interview on 1/4/23 at 9:50 a.m., resident #36 said the facility needed more staff, and she had timed the staff, and it took 30 to 40 minutes before staff answered her call light. Resident #36 said staff had asked her not to time them anymore. Resident #36 said she felt like she was stranded in bed when she waits that long. During an interview on 1/5/23 at 12:18 p.m., staff member B said the acuity of the residents has changed, since taking a large number of residents into the facility in November 2022, and more staffing is needed. Physical Therapy 11. During an interview on 1/3/23 at 2:53 p.m., resident #35 said the weakness of the facility has been the physical therapy. The facility does not have enough occupational therapy or physical therapy staff. Resident #35 said when the residents arrived from [another facility name], the facility did not increase the physical therapy staff. Resident #35 said he had not been to physical therapy in three weeks and would like to get stronger so he could go home with his wife. 12. During an interview on 1/3/23 at 3:37 p.m., resident #37 said he had been at the facility for a month. He said he was receiving physical therapy but not as much as he thought he was to receive. Resident #37 said the facility could use more physical therapists and more therapy staff. Record review of resident #37's Physical Therapy order, dated 12/7/22, showed resident #37 was to be evaluated and treated for six months. Record review of resident #37's Treatment Encounter Notes, showed resident #37 received treatment five times in a four-week period. 13. During an interview on 1/4/23 at 3:36 p.m., staff member E said the biggest problem with providing therapy was staff. Staff member E said the facility has one physical therapist and one therapy aide for the resident population that has almost doubled since November of 2022. Staff member E said the 16 rehab residents must be seen first and if there is time, the long-term residents are worked into the schedule. Staff member E said, The facility had a restorative program in the past, when it had staffing. It would be helpful because a lot of the long-term care residents don't really need skilled care. Staff member E said resident #52 has not received therapy in three weeks. Record review of resident #52's physical therapy order, dated 11/30/22, showed resident #52 was to be evaluated and treated for six months. Record review of resident #52's Treatment Encounter Notes, showed resident #52 received treatment three times over a four-week period. Weights During an interview on 1/5/23 at 4:26 p.m., staff member I said she expects staff to document weights as ordered and to notify her if a significant change occurred. Staff member I said the facility had identified a problem with weighing residents and documentation. If a resident refused to be weighed, it was not being documented. 14. Review of resident #52's physician orders, dated 11/1/22, showed: . Weight weekly x4 weeks upon admission every day shift every 7 day(s) for Weight Baseline for 4 weeks Weight daily x3 days upon admission every day shift for Establish Baseline Weight for 3 days . Review of resident #52's weight record showed staff did not weight the resident per the physician's order. Review of the resident's weight documentation showed: -11/1/22 144.2 Lbs -11/3/22 143.0 Lbs -11/22/22 136.6 Lbs -11/29/22 135.4 Lbs 15. Review of resident #9's physician orders, dated 2/14/22, showed: . Weight Weekly One time a day every Mon for Routine Monitoring Review of resident #9's weight record showed the resident was not weighed per the physician's order: -9/2/22 186.0 Lbs -9/14/22 186.3 Lbs -10/3/22 178.6 Lbs -10/14/22 183.8 Lbs -10/15/22 184.6 Lbs -11/29/22 177.8 Lbs Review of a facility document, Weight Measurement, release date 11/28/2017, showed: .12. Monitor residents' weight: -On admission -Weekly for 4 weeks -Monthly when stable -As needed .2. If a resident refuses weighing or circumstances prevent weighing a resident, document the reason in the resident's medical record. Reschedule the weight for another time . Showers 16. During an observation and interview on 1/3/23 at 3:56 p.m., resident #23 stated he had not had a shower in three weeks, and it made him angry. Resident #23 said, I am getting semi-adept at taking a sponge bath from the sink. Upon entering resident #23's room, a strong urine odor was noticed. Resident #23 was seated in his wheelchair and had a bandana wrapped around his hair. He had long hair that hung to his shoulders, and a long beard. Resident #23's hair appeared greasy, and he had debris in his beard. Resident #23 had a strong urine odor coming from his person. Record review of resident #23's shower schedule, dated 11/2/22, showed resident #23 was scheduled for a Bath/Shower & Shampoo on Tuesday and Friday afternoons. Record review of a facility document, ADLs- AM Cares, revision date 11/14/2017, showed: . 1. Provide shower, tub bath, or bed bath as scheduled .

Based on observations, interviews, and record reviews, the facility failed to provide services that met professional standards of quality as nursing staff were not following the physician order's, for 2 (#53 and#164) of 2 sampled residents. Findings include: 1. During an interview on 1/3/23 at 2:15 p.m., resident #164 was observed lying in bed with his forearm covering his forehead. He was moving from side to side and appeared to be experiencing discomfort. Resident #164 stated the facility staff had some confusion regarding his fentanyl patches. Resident #164 said the patches were to be changed every three days and were due to be changed on 1/3/23. Resident #164 said his patches had not been changed, and he had not heard anything about the patches that day. He said he was in pain and needed the nurse for more pain medication. During an interview on 1/4/23 at 10:13 a.m., staff member C said he called the hospice provider to clarify the fentanyl patch orders for resident #164. The order was for a fentanyl 50 mcg patch, and the facility was directed by hospice to hold the order and use resident #164's oral pain medication for pain control. He placed the order in the facility medical record system to hold the fentanyl 50 mcg patch on 1/2/23 through 2/2/23. Staff member C said he meant to only hold the medication for the one dose on 1/3/23, and then hospice was going to evaluate the resident on 1/3/23. Staff member C stated the facility did not have any fentanyl 50 mcg patches for resident #164. During an interview on 1/4/23 at 10:15 a.m., staff member D said the fentanyl patch order for resident #164 had not been popping up for him in the medical record for him to administer. He said he did not know anything about fentanyl patches ordered for resident #164 and did not have any fentanyl patches in his medication cart. Staff member D said, As far as I know, [Resident #164] does not have a fentanyl patch on at this time. During an interview on 1/4/23 at 12:38 p.m., NF1 said resident #164 was admitted to hospice on 12/28/22, and was at his home. It was determined that resident #164 could not be managed at home, and he was transferred to the facility on [DATE]. Resident #164 had two fentanyl 25 mcg patches placed on 12/31/22 to make the 50 mcg order. The pharmacy was out of 50 mcg patches and placed an order for resident #164. The facility called on 1/2/23 to clarify the medication order, as the facility did not have any fentanyl patches, specifically for resident #164. NF1 said the facility was directed to leave the fentanyl patches in place on resident #164 because they were not due to be changed until 1/3/23 and to use oral medication for pain control. Hospice was told by nursing staff the facility had pain patches to cover the resident's pain needs until resident #164's patches arrived. NF1 said no order was given by the physician to hold the fentanyl patches. During an observation on 1/4/23 at 1:06 p.m., resident #164 was observed to have two fentanyl patches in place on his right upper arm. Record review of resident #164's Medication Administration Record (MAR), dated January 2023, showed: . fentaNTL Patch 72 hour for MCG/HR Apply 1 patch transdermally every 72 hours for Pain related to MALIGNANT NEOPLASM OF UPPER LOBE, LEFT BRONCHUS OR LUNG; SECONGARY [sic] MALIGNANT NEOPLASM OF BONE, and remove per schedule Start Date - 12/30/2022, 1615 (4:15 p.m.), and a Hold Date - from 1/02/2023 1658 (4:58 p.m.) to 2/01/2023 . The MAR showed the medication was held on 1/2/23. The MAR also showed resident #164's fentanyl patches were changed on 1/4/23 at 1:52 p.m. Record review of resident #164's hospice note, dated 1/2/23, showed: Call from [staff member C] at [facility name] to request 50 mcg fentanyl patch for new order. (The) 37 mcg not due to be removed unit tomorrow so verbal order given to keep current patch on and utilize morphine and oxycodone as directed for pain control until 50 mcg patch can be supplied. [Staff member C] reports that patient is not in pain currently, and he believes pain can be managed effectively with current methods. [sic] 2. During an observation on 1/3/23 at 3:34 p.m., resident #53 had oxygen on via nasal annular at 7.5 liters per minute, and the oxygen tubing was not high flow tubing. During an interview on 1/4/23 at 12:20 p.m., staff member L stated, Earlier today I increased resident #53's oxygen to 10 liters via nasal cannula for shortness of breath. Staff member L stated she did not use high flow tubing, or a non-rebreather mask. She stated she was not sure what the oxygen policy was regarding tubing. Staff member L stated hospice was not notified of the incident. During an interview on 1/4/23 at 1:09 p.m., NF1 stated there was an issue where resident #53 called hospice himself complaining of shortness of breath. NF1 stated the on-call nurse came to the facility and found resident #53's oxygen was at nine liters per minute via nasal cannula. The hospice nurse was able to calm resident #53 down and returned his oxygen down to the prescribed amount. During a record review on 1/4/23 at 2:54 p.m., resident #53's hospice care plan showed oxygen orders and it was to be at three liters. A review of resident #53's monthly facility visit, by NF4, showed, . He reports he is using 5L of oxygen . Review of resident #53's care plan did not address how many liters of oxygen resident #53 was on. During a record review of resident #53's oxygen information, and interview with staff member L, on 1/5/23 at 11:19 a.m., a nurses note showed the resident was, .breathing heavy. Resident provided with albuterol nebulizer . O2 sats 89% at 7 L/m. increased flow to 10 L until stable. Staff member L stated she did not notify hospice. During an interview on 1/5/23 at 2:03 p.m., staff member B stated she was unaware the staff were increasing resident #53's oxygen with out physician orders, and not notifying hospice, of any changes. A review of the facility Policy and Procedure, titled Oxygen Therapy, revised 11/14/17 showed: .a. Nasal Cannula- can provide 24-40% oxygen with flow rates up to 6 L/min . .b. High flow Nasal Cannula- on average can provide 60-70% FiO2 with flows greater than 10L/min . .c. Simple oxygen mask-can provide 35-50% oxygen at flow rates from 5-10 L/min. Flow rates should be maintained at 5 L/min or more in order to avoid exhaled CO2 that can be retained. .Procedure: 1. Verify physician orders prior to initiating oxygen therapy.

Based on observation, interview, and record review, the facility failed to prevent and treat a pressure injury for 2 (#s 18 and 42) of 21 sampled residents. Findings include: 1. During an interview on 1/4/23 at 8:35 a.m., resident #42 stated he had a sore on his butt. He stated it was hurting, and he was having a hard time changing his position to get off of the wound. Resident #42 stated he did not know what the facility was doing to treat the wound. He denied the staff have him change position frequently or that they come help him change position frequently. Resident #42 stated he was usually on his back or sitting on his tailbone. During an interview on 1/4/23 at 3:44 p.m., staff member J stated he helped resident #42 with positioning, but there wasn't a set schedule to turn or reposition resident #42. During an observation on 1/4/23 at 3:44 p.m., resident #42 had a dressing on his coccyx. The dressing was intact with the exception of a small area at the bottom. There was brown colored drainage coming from the opening in the dressing. There was a 3 inch by 3 inch area of drainage that could be visualized through the dressing. The drainage was dark in color. The dressing was not dated. During an interview on 1/5/23 at 1:35 p.m., staff member H stated she found a blanchable red area of skin on resident #42's coccyx in October 2022. She stated she was told not to put blanchable wounds on her wound tracker, so she only took the one picture of the wound at that time. Staff member H stated she was unaware that resident #42 now had a dressing on his coccyx or that there was a draining wound. Staff member H stated, It is hard for me to know about wounds if nobody tells me about them. Staff member H stated the nurses were supposed to chart wounds under the wound progress note in the resident's chart. She stated she was the only one who takes pictures and documents wound staging. Staff member H stated her expectation for the nurses was for them to call her at any time to report a new wound or change in skin condition, even if it was at 2 a.m. During an interview on 1/5/23 at 3:25 p.m., staff member H stated, The last time I saw it (resident #42's wound) was blanchable skin, nothing open. During an observation and interview on 1/5/23 at 4:34 p.m., the dressing was removed on resident #42's coccyx. The dressing was the same as the previous days dressing, and there was still drainage coming from the bottom of the dressing. There were two open wounds, one was approximately 1.5 inches in diameter, and the other was 1 inch diameter. Both wounds were surrounded by a reddened area of skin that was three inches in diameter. There was brownish drainage on the dressing. Upon removing the dressing staff member L stated, Oh my gosh, I need to contact his doctor. Review of resident #42's care plan showed, Risk for alteration in skin/tissue integrity, and the goal on the care plan showed, skin will remain intact. The interventions included weekly skin checks and applying barrier cream. The care plan failed to show resident #42 had a pressure ulcer on his coccyx. Review of resident #42's TAR showed an order for Optifoam to top of coccyx Q 3day for protection, and of 22 oportunities from 11/1/22 through 1/5/23, 9 were missed. Review of resident #42's TAR showed an order for weekly skin check, and of 9 opportunities from 11/1/22 through 1/5/23, 6 were missed. Review of resident #42's EMR showed: -Progress note dated 12/18/22, showed Bandage applied to coccyx for protection, -Skin assessment dated [DATE], showed small reddened area to coccyx on bony prominence [sic] -Skin assessment dated [DATE], showed Redness to sacral and coccyx region. Covered with optifoam dressing. -Skin assessment dated [DATE], showed area of reddened skin on coccyx. Blanchable, non tender. [sic] -Skin assessment dated [DATE], showed Coccyx area remains red, blanchable. -Skin assessment dated [DATE], showed small non blanchable areas on coccyx. -Skin assessment dated [DATE], showed reddened breakdown on coccyx. Hydrogel applied and optifoam covering The EMR failed to show any physician notes addressing the wound on resident #42's coccyx or a note showing the physician was informed of the wound. 32998 2. During an interview on 1/5/23 at 1:36 p.m., staff member H stated the resident often refuses wound treatment. Staff member H stated staff try to get him to allow staff to assess the wound. Staff member H stated there is an order to pre-medicate the resident prior to any wound care or turning and repositioning. Staff member H stated the facility had just started a wound program, and she is still learning what needs to be done with wounds. Review of resident #18's Treatment Administration Record (TAR), dated 12/1/22 through 12/31/22, showed skin assessments were to be done weekly. There were no skin assessments done on the following dates: 12/2/22, 12/9/22, 12/16/22, 12/23/22, and 12/30/22. Review of resident #18's Skin Inspection Evaluations showed skin assessments for the following dates for 12/1/22 through 12/31/22: 12/2/22 and 12/9/22. The facility did not provide evidence of skin assessments for the remainder of December 2022. Review of resident #18's Skin Inspection Evaluation assessments showed the following: - 10/5/22: Small open areas, posterior thighs. Bilateral posterior thighs are red, and have dry patches. Mid-lower back and bilateral buttocks have open areas with red wound beds and scant bloody drainage, - 10/14/22: Small open areas, posterior thighs. Bilateral posterior thighs are red, and have dry patches. Mid-lower back and bilateral buttocks have open areas with red wound beds and scant bloody drainage, - 10/19/22: Small open areas with scabs to bilateral thighs. Lower back and bilateral buttocks had open areas with blood tinge drainage, - 10/26/22: Bilateral buttocks breakdown. Refused to turn so skin could be assessed by nursing and hospice staff, - 11/2/22: Bilateral buttocks breakdown, - 11/10/22: Bilateral buttocks breakdown. Skin dry. Rash on back, - 11/18/22: Bilateral buttocks breakdown. Skin dry. rash on back from top of coccyx to mid back, - 12/2/22: Left ankle small amount of reddish discharge. Buttocks/lower back red with red drainage on bilateral buttocks, - 12/9/22: Left heel open area with small amount of red drainage. Lower back/bilateral buttocks red with moderate amount of red drainage. There was not any additional skin inspection documentation provided by the facility. Review of resident #18's Skin and Wound Evaluation, dated 11/2/22, showed a pressure injury to the coccyx at a Stage 3. The wound had been present 1-2 years. The wound was in-house acquired. The resident had pain at dressing changes. Review of resident #18's Weekly Skin Alteration Report, dated 10/5/22, showed small open areas on both the resident's buttocks, lower and mid back,and bilateral posterior thighs. Resident did not always tolerate and allow for repositioning. Continue with current care orders to protect area from worsening and infection. The report showed the resident had pain during treatments and with movement. Review of resident #18's Weekly Skin Alteration Report, dated 10/12/22, showed large open areas to bilateral buttocks. Small open areas to lower and mid back, bilateral posterior thighs. It was noted the resident did not always tolerate and allow for repositioning. And staff were to continue with current care orders to protect resident #18's wound from worsening and infection. Review of resident #18's Order Summary Report as of 1/4/23, showed the following treatments: - Use Skintegrity wound spray cleanser, mix Calazime with ostomy powder and apply liberally to open areas. Clean buttocks often and do not allow product to build up where skin is not open. Apply nystatin ointment BID (two times daily) to groin area for rash every shift for wound care. Clean off BM (bowel movement) off skin if present. Do not scrub off Calmoseptine or Calazime. - Cleanse and flush open area with Dakins solution. Crush Flagyl tablet and sprinkle to ABD that covers open areas. Cover all wound with ABD pads and secure with kerlix gauze. Change 3 times per week on Monday, Wednesday, and Friday with a start date of 11/21/22. - Right heel: cleanse area with NS (normal saline) or wound cleanser. Pat dry. Apply Opti foam every Monday, Wednesday, and Friday with a start date of 12/19/22. Review of resident #18's Progress Notes, dated 12/1/22 through 12/29/22, showed the resident was given Morphine prior to turning and repositioning during night shifts. The progress notes did not show administration of pain medication prior to skin assessments and dressing changes. Review of resident #18's TAR, dated 12/1/22 through 12/31/22, showed four out of six opportunities for wound care to the resident's right heel were blank, with no initials or evidence the resident refused. Review of resident #18's TAR, dated 12/1/22 through 12/31/22, showed 23 out of 62 opportunities for wound care to the resident's buttocks and groin were blank. The medical record did not show refusals for missed opportunities.

Based on observation, interview, and record review, the facility failed to ensure a safe mechanical lift transfer, which resulted in a resident's fall with a fracture and [MEDICAL CONDITION] for 1 (#1); and failed to provide adequate supervision to prevent six falls, five of which were unwitnessed, with one fall resulting in a fracture for 1 (#7) of 17 sampled residents. Findings include: 1. During an interview and observation on 3/4/20 at 10:14 a.m., staff members G and H transferred resident #27 from his chair, to the bed, using the mechanical stand-lift. Staff member H stated all mechanical lifts were two person transfers. Staff members G and H placed leg straps behind the resident's lower legs. Staff member H stated leg straps should always be used for stand-lift transfers. Review of resident #1's Fall Witnessed Report, dated 10/18/19, showed, CNA reported resident's legs buckled and her arms slid off of lift and the resident slid to the floor. The resident stated her legs gave out. Resident #1 was sent to the emergency room for a [MEDICAL CONDITION] and fractured left arm. Review of resident #1's nursing Progress Note, dated 10/19/19, showed the resident's legs buckled, and it appeared that she lost consciousness during the transfer, slid out of the sling and fell face forward. Review of resident #1's Weekly ID Team Fall Review committee, dated 10/23/20, showed interventions to prevent accidents included: - Move resident closer to the nurses station. - Two staff are required for the use of the sit to stand lift. - Educate the resident on call light use. - Staff will utilize the hoyer lift for transfers until injury healed. - Employee training and counseling. During an interview on 3/3/20 at 4:44 p.m., resident #1 stated she knew she felt weak the day of the transfer, and was afraid to step on to the lift. She knew she was going to pass out and her legs buckled. She stated the CNA drug her to the bed while she hung onto the lift. She said the leg straps were not used, and the transfer was with NF2 only. The next thing she remembered, she was on the floor. I can't even see those machines any more. I just want to feel safe. It was their negligence. During an interview on 3/3/20 at 11:12 a.m., staff member K stated the resident had not gotten out of bed since she hurt her arm in October. Review of a handwritten note from the facility showed resident #1 got out of bed twice in December 2019, for orthopedic appointments. During an interview on 3/3/20 at 3:54 p.m., staff member A stated the facility should have a statement from the CNA involved in the transfer. The statement was not provided because the facility could not find it. Evidence of staff training for NF2 was not provided. NF2 no longer worked at the facility. During an interview on 3/4/20 at 9:20 a.m., staff member I stated there were some missing pieces of documentation for the fall, and the facility was looking for them. During a phone interview on 3/4/20 at 10:29 a.m., NF2, the staff member who provided the transfer for resident #1 on 10/18/19, stated she had already written a statement about the transfer, and the facility should take care of the incident. NF2 did not provide information regarding the transfer and fall for resident #1. During an interview on 3/4/20 at 2:25 p.m., staff member A stated the facility did not conduct a Fall Scene Investigation Report, took the nurses note at face value, and did not go any further with the investigation. Staff member A stated she did not know what NF2's statement said, and did not know if leg straps were used for the transfer. Review of resident #1's Care Plan for transfers, dated 3/19/19, showed I need extensive assistance of 2 staff persons with bed mobility and transfers. During an interview on 3/4/20 at 9:14 a.m., staff member L stated resident #1 was an unhappy person. She said getting out of bed depended on resident #1's mood, but I do think the fall scared her. During an interview on 3/5/20 at 12:30 p.m., staff member A stated the facility reviewed all falls at the daily stand-up meeting. The Interdisciplinary Team reviewed the falls to implement immediate interventions. The interventions were reviewed for three weeks to monitor for effectiveness. 2. During an interview on 3/5/20 at 4:13 p.m., NF1 stated resident #7 puts her call light on and has to wait a long time for help. A few months ago, the call light took staff 1/2 hour to provide assistance. She said the facility was short of help, and this caused resident #7 to fall and break her back. During an interview with resident #7 on 3/4/20 at 1:24 p.m., she stated her back always hurt, and she would probably keep on falling. She did not say why she felt that way. Review of the facility Incident By Incident Type report, dated 3/3/20, showed resident #7 had six falls from 10/3/19 through 2/9/20. Five of the six falls were in the resident's room, and unwitnessed. One of the six falls resulted in a vertebral fracture. Review of resident #7's Fall Report, dated 10/3/19, showed the resident attempted to self transfer from bed to wheelchair, and the wheelchair rolled out from under her. The fall was unwitnessed. Anti-rollback bars were to be placed on her wheelchair. Review of resident #7's Fall Scene Investigation Report, dated 10/21/19, showed the resident had improper foot wear as a contributing factor to the fall. The fall was not witnessed. The resident was barefoot. The report identified the use of gripper socks. Review of resident #7's Fall Scene Investigation Report, dated 12/9/19, showed the resident stated the chair moved as she was getting out of it to go to her bed. The resident was drowsy in wheelchair and not assisted to bed. The fall was not witnessed. The CNAs reported the last time they viewed the resident, she was dozing off in her wheelchair. The CNAs were assisting other residents at the time resident #7 was found on the floor. Review of resident #7's Fall Scene Investigation Report, dated 2/2/20, showed she was trying to get to the bathroom, and did not have appropriate foot wear on. She was barefoot. The bed was placed in the lowest position. The resident was reminded to use the call light, and staff to round frequently. Review of resident #7's 24 hour Incident Review, dated 2/10/20, showed the resident attempted to transfer self into the bathroom, and was found sitting on the floor between the toilet and wheelchair. The wheelchair brakes were not locked. The intervention to be implemented was toileting schedule. The toileting schedule was not documented in the care plan, which would consist of an individualized program for resident #7. Review of resident #7's Care Plan, dated 2/10/20, showed, I need assistance with toileting. Please ask me before and after meals if I need to use the bathroom and before bed. When you see me headed to my room ask me if I need to use the restroom. During an interview on 3/4/20 at 8:20 a.m., staff member H stated resident #7's fall interventions were to toilet her before and after each meal. She stated resident #7 has to use the bathroom frequently. Staff member H also made sure her call light was in reach. Review of the Fall Scene Investigation Report for the six falls showed resident #7 did not use her call light for assistance. During an interview on 3/4/19 at 12:40 p.m., staff member J stated fall interventions for resident #7 were call light in reach, gripper socks, and checking on her. She stated the CNA's should be putting on the resident's gripper socks. During an interview on 3/5/20 at 9:33 a.m., staff member G stated some CNAs were not aware of resident #7's routine. Staff member G did not know how her routine should be communicated to other staff members. She said the staff go out to smoke after the meals are done, and this is when resident #7 toilets herself.

Based on observation, interview, and record review, the facility failed to control a resident's pain due to a lack of pain medication for 1 (#7) of 14 sampled residents. Findings include: During an interview on 8/26/19 at 8:29 p.m., staff member G said resident #9 had fallen several days ago. She said the resident was sent to the emergency room several days after her fall and returned to the facility wearing a splint on her right arm. The staff member said she had heard the resident crying earlier that night. She said she went to the resident's room to see what was wrong. Staff member G said resident #9 told the staff member her arm hurt. Staff member G said she told the floor nurse the resident was in pain and crying. During an observation on 8/26/19 at 9:03 p.m., resident #9 was in bed. Her right lower arm was covered with a splint and was elevated on a pillow. During an interview on 9/11/19 at 9:02 a.m., NF1 said the facility did not manage resident #9's pain appropriately after her fall on 8/16/19. She said resident #9 had called NF2 several days after her fall, and was crying and told NF2 her arm hurt so bad. NF1 said NF2 called her, and NF1 called the facility. She spoke with the nurse, asking the nurse to check on resident #9. The nurse told NF1 she had given the resident a pain pill about an hour before and she was fine. NF1 said she told the nurse the resident had just called NF2 and was crying because her arm hurt so bad. NF1 said she got a phone call from the nurse a short time later to tell her the resident was being sent to the emergency room . NF1 said she went to the hospital to be with resident #9. NF1 said the resident was taken to X-ray. When the resident returned to the room, the doctor told the resident and NF1 the resident had a fracture just above the wrist. NF1 said the resident was placed in a splint, given some pain medicine, and sent back to the facility. During an interview on 9/11/19 at 11:53 a.m., NF2 said resident #9 called her on 8/19/19. She said the resident was crying and saying her arm hurt. NF2 said she called NF1 and told her of the phone call. NF2 said NF1 told her she would take care of it. Review of resident #9's physician orders [REDACTED]. - 2/19/18, [MEDICATION NAME] HCI Tablet 50 mg, Give 1 tablet by mouth every 4 hours as needed for pain. - 1/9/19, [MEDICATION NAME] HCI Tablet 50 mg, Give 50 mg by mouth at bedtime for pain related to displaced intertrochanteric fracture . Review of resident #9's nursing progress notes dated 8/27/19 to 8/29/19 showed: - 8/27/19 C/O pain 6/10 scale at hs. Is out of [MEDICATION NAME] as needs a new script, so gave 650 mg APAP of c/o pain. Later pain decreased to 4/10 scale. - 8/28/19 1830 writer phoned (Pharmacy Name) to see if they had received script from MD for residents [MEDICATION NAME], (pharmacy name) (pharmacy tech) states they have not received a script and that the pharmacy has also faxed MD to get script for the [MEDICATION NAME] but they have not received it as of this time. 2046 since resident is out of [MEDICATION NAME], Tylenol 650 mg given . - 8/29/19 [MEDICATION NAME] has not arrived from pharmacy at this time, given Tylenol 650 mg instead . Review of resident #9's Medication Administration Record [REDACTED] - [MEDICATION NAME] HCI 50 mg by mouth at bedtime for pain . The resident did not receive the scheduled doses on 8/26/19, 8/27/19, and 8/28/19. It was noted the medication was unavailable. - [MEDICATION NAME] tablet give 500 mg by mouth every 6 hours as needed for pain . The resident received this medication on 8/26/19 with a noted pain level of 7, and she received another dose on 8/27/19 with a noted pain level of 6. - [MEDICATION NAME] HCI 50 mg Give 1 tablet by mouth every 4 hours as needed for pain. The dates for 8/26/19, 8/27/19, and 8/28/19 were blank. Review of resident #9's care plan with a print date of 9/11/19 showed: - Focus: Comfort/Pain: I have pain/discomfort related to hx of knee pain and abdominal pain. - Goal: I want to keep my pain between a pain score of 1-4. - Interventions: Please provide me with pain medications as ordered. During an interview on 9/11/19 at 11:05 a.m., staff member N said the facility had been having problems with the pharmacy providing medications in a timely manner. She said she talked to the pharmacist on or about 8/28/19 regarding the [MEDICATION NAME] for resident #9. The pharmacist told her the pharmacy had not received a script from the physician's office for the [MEDICATION NAME]. Staff member N said she went back and forth with the doctor's office and the pharmacy on this issue. The doctor's office told staff member N the script had been faxed to the pharmacy several times over several days. Staff member N said the matter was finally taken care of but resident #9 did not receive her scheduled or PRN [MEDICATION NAME] for several days.

Based on observation, interview, and record review, the facility failed to ensure 1 (#1) resident was safe, had visible safety accessories on his wheelchair, when leaving the premises to smoke cigarettes on a nearby busy street used by hospital patrons and an ambulatory surgical center, requiring cars to stop or swerve to avoid hitting the resident parked on the roadway; and failed to ensure 1 (#1) of 8 sampled residents was not smoking near oxygen equipment affixed to the wheelchair. Findings include: On 6/6/19 at 1:08 p.m., the facility Administrator in Training, was notified that an Immediate Jeopardy situation had been identified in the areas of deficient practice 483.25; F 689 Accidents and Hazards which affected 1 (#1) of 8 sampled residents. The severity and Scope was identified at the level of J, and upon the removal of the immediacy for the deficient practices, the severity and scope would be lowered to a D. Findings include: During an observation on 6/5/19 at 8:47 a.m., resident #1 exited the facility in a motorized wheelchair. A small oxygen cylinder, with tubing, was attached to the back of the resident's wheelchair. Resident #1 drove to the end of the facility driveway, exited the facility property, and parked on the street next to the curb. Resident #1 began smoking a cigarette. Several vehicles drove past the resident and even came to a stop when two vehicles were passing resident #1 at the same time. The resident was not wearing reflective gear and did not have any safety accessories visible. There was no sidewalk between the facility and the street. Resident #1 was admitted to the facility in (MONTH) (YEAR) with [DIAGNOSES REDACTED]. The resident was oxygen-dependent and used 3 liters per minute, continuously, with a nasal cannula. An Admission MDS, with an ARD of 2/11/19, showed the resident had a BIMS of 15; cognitively intact. Review of resident #1's Smoking Assessment, dated 11/28/18, read, .smoker up to the time of admit .(Facility name) policy is NO SMOKING UNLESS admitted [DATE] OR BEFORE. we are beyond that time. no smoking, and patient is receptive to cessation. (sic) During an interview on 6/5/19 at 8:56 a.m., staff member A stated resident #1 was independent and was the only active smoker at the facility. Staff member A stated resident #1 had been assessed for smoking, which included updating his care plan, and the resident was required to sign out each time he went outside to smoke. During an interview and record review on 6/5/19 at 9:29 a.m., staff member A stated resident #1's care plan lacked documentation showing a focused area for smoking (cigarettes) with goals and interventions had been initiated. A copy of resident #1's care plan was provided and reviewed. During an interview on 6/5/19 at 10:33 a.m., staff member D stated resident #1 did not require assistance from the facility staff, with oxygen, when the resident exited the facility to smoke. Staff member D stated resident #1 should not be wearing an oxygen tank on his wheelchair when going to the street to smoke. Staff member D stated it was, Not safe. The staff member stated resident #1 was required to leave the facility premises because it was a no smoking facility. During an interview on 6/5/19 at 1:05 p.m., staff member I stated resident #1 often went out to the street to smoke because the facility was non-smoking. Staff member I stated she had heard of concerns with resident #1 being out in the road, but nobody approached the resident because he was off the facility premises. Staff member I stated it was concerning to her that resident #1 would be in the street and smoking with an oxygen tank attached to his wheelchair. Staff member I stated it was known throughout the facility that resident #1 would exit the facility, go to the street, and smoke cigarettes. During an interview on 6/5/19 at 2:15 p.m., staff member F stated resident #1 had begun going outside several times an hour, around the clock, to the street to smoke cigarettes. Staff member F stated resident #1 had a BIMS of 15 and he was cognitively intact. Staff member F stated other staff members did not approach or attempt to redirect resident #1 when on the street smoking, for fear of the resident becoming angry with staff. During an interview on 6/5/19 at 2:26 p.m., staff member [NAME] stated resident #1 was constantly outside, on the street, smoking, including at night. Staff member [NAME] stated resident #1 often wore his oxygen tubing while smoking. Staff member [NAME] stated when approaching resident #1 to assist with removing, or turning off the oxygen, resident #1 would say, I will do it myself. During an observation and interview on 6/5/19 at 3:10 p.m., resident #1 was smoking a cigarette while parked out on the shoulder of a busy street. Resident #1 stated he was not allowed to smoke on the facility premises and that was why he would drive onto the shoulder of the street with his motorized wheelchair. Resident #1 stated he used to smoke in the drive way of the facility but was told that vehicles entering and exiting the facility had to go around him. He stated he had no fears about being on the street and that vehicles often, crossed the middle line to avoid hitting him. Resident #1 stated some vehicles would stop, and passengers would ask if he were ok, when they saw him on the shoulder of the street. Resident #1 stated he was required to smoke on the street, in the parking lane, because there was no sidewalk in front of the facility for him to use. The oxygen tank on the back of the wheelchair was on, set to 3 liters per minute, and had 1700 PSI of oxygen remained in the tank. Resident #1 stated he kept his smoking paraphernalia with him at all times but had a lock box in his room. He pulled a lighter out of the top pocket of his shirt and a box of cigarettes from behind an unopened button of his shirt. During an interview on 6/5/19 at 3:40 p.m., staff member C stated she was afraid resident #1 would get hit by a car. Staff member C stated the street used by resident #1 to smoke on, was very busy. Staff member C stated resident #1 went outside after dark with a small light attached to his wheelchair, which illuminated the ground next to the wheelchair tire, and not the resident. Staff member C stated resident #1 was not visible until, Headlights were on him, but it might be too late by then. Staff member C stated she feared resident #1 would be hit by a car and killed. During an interview on 6/5/19 at 4:00 p.m., staff member A stated the facility had tried to initiate a transfer to another local facility where smoking was allowed, but resident #1 and his family refused to be transferred. Staff member A stated she was not sure if resident #1 fit the five-criteria for a transfer to another facility. A review of resident #1's (MONTH) 2019 Order Summary Report, signed by the physician on 4/29/19, showed the resident was to have 3 liters of oxygen continuously. A review of resident #1's (MONTH) and (MONTH) 2019 Medication Administration Order showed orders for PRN Nicotine [MEDICATION NAME] 2 mg every 1 hours (sic) as needed for Health maintenance every 1-2 hours with a start date of 12/11/18 at 1:30 a.m. No [MEDICATION NAME] had been administered. A review of resident #1's Nurse's Notes, showed the following: - 5/4/19 at 6:31 a.m., .While exiting the facility, this nurse noted that this resident was out, in front of facility, on side of street, in his w/c, smoking with his O2 in place per NC. An oncoming car needed to swerve around him while passing him. I called facility to inform of this situation. - 5/4/19 at 8:19 p.m., .He had cigarettes in his pocket that were visible. Rsdt will not give cigarettes or lighter to staff. - 5/5/19 at 12:53 a.m., Rsdt is going in and out of the building. He has been reminded x2 that he has to sign out each time, but he doesn't. He stated it's just a way for us to control him. - 5/6/19 at 3:22 a.m., Rsdt continued to go outside w/o signing out all evening and into the night, until approx. 0100. He still has cigarettes and lighter on his person. Stated what he does is between him and God. - 5/8/19 at 4:42 a.m., Rsdt continues to refuse to sign out when going outside. He goes outside and off the property at all hours of the night. Rsdt has cigarettes and lighter on his person. Rsdt says he always turns off his O2 and sits on the tubing when he goes out to smoke. - 5/12/19 at 11:58 p.m., .As soon as his need is met he is back outside smoking. - 5/13/19 at 10:52 p.m., Rsdt has been out to smoke at least 8 times since (staff member arrived for shift) at 6 p.m. He will not sign out. Rsdt does not pay attention to traffic coming in and out of parking lot and is driving his chair fast out onto the street. I witnessed him not even seeing me when I pulled into parking lot and driving right out in front of me .Rsdt came in from smoking and requesting a nebulizer treatment ASAP. As soon as he finished treatment he was back outside smoking. - 5/14/19 at 10:53 p.m., Rsdt continues to go out onto the street to smoke w/o signing out . - 5/15/19 at 11:47 a.m., Received a call this morning from a neighboring business to inform us that there was a gentleman in an electric wheelchair wandering down the street. Informed her that we do have a resident that does that and that I would check on him. Resident continues to be unsafe when going outside to smoke and has been driving in the middle of the road. - 5/15/19 at 11:31 p.m., Earlier in the evening rsdt came in from smoking and up to me and asked for a breathing treatment. He spoke like he needed it right away. Rsdt did breathing treatment and went back out to smoke. A few hours later he was seen in his room using his inhaler and right after he went out to smoke. - 5/16/19 at 5:22 a.m., Rsdt has been up all night. Going outside on average of every 30 minutes. Continues to not sign out when leaving. Administration is aware. - 5/17/19 at 4:57 a.m., .Res also has cigarettes and lighter on his person and cont. to go outside with only a flash light no reflectors noted on W/C all night to smoke with oxygen on electric W/C. - 5/19/19 at 8:19 a.m., Another resident's family reported that (resident name) was in the middle of the street (name), with his oxygen on and smoking a cigerette. (sic) Resident did not sign out to go outside today and was noted by staff to go outside 12 times between 0600 and 1200. Resident verbalized understanding that he has to sign himself out to go outside but did not sign out at all today. - 5/20/19 at 12:28 a.m., .He has been outside smoking >10 times since 1800 (6:00 p.m.) . - 5/20/19 at 3:58 a.m., Rsdt has been awake all night drinking coffee and going out to smoke aprox (sic) every 30 min. Rsdt does not sign out. Rsdt has not been going off of the property every time. He was smoking outside near the front doors. - 5/21/19 at 1:26 a.m., N[NAME] CNA reported that rsdt was sitting outside in front building, right next to the no smoking sign smoking when she came in. Rsdt is weel (sic) aware that rsdts cannot smoke on property. Earlier in the shift rsdt was in room using [MEDICATION NAME] inhaler and asked this writer to set up (medication) nebulizer. Rsdt went outside to smoke and came back in and used nebulizer. - 5/22/19 at 3:45 a.m., Rsdt found outside next to building smoking. Rsdt was told again that he can't smoke on facility property. Rsdt stated he would go out to the street, but the cold wet weather was really getting to him. Rsdt contues (sic) to not sign out when leaving the building. - 5/23/19 at 6:25 p.m., .Resident went out with family, and went out to smoke every 15 minutes this shift with no signs of pain when he was outside. - 5/27/19 at 11:50 p.m., .Rsdt has been up in electric chair and outside smoking many times. - 5/28/19 at 9:00 a.m., Received phone call from a nurse across the street concerned about this resident being outside smoking with his oxygen on . - 5/28/19 at 9:16 a.m., Phone call received from a concerned nurse from the Dr.'s offices across the street stating, 'You have one of your patients outside smoking in the street with his oxygen on.' CNA then went outside to check on resident, resident came back inside upset and stating 'I wish everyone would relax about this and mind their own business.' Will continue to monitor. - 5/29/19 at 4:44 a.m., Rsdt continues to go outside and smoke at all hours of the day and night. He does not sign out. - 5/30/19 at 7:30 a.m., Left building to smoke on way out the door attempted to get him to come back and sign out, however he kept moving in his scooter and said he was 'fine'. Reinforced with him again that he needed to sign out if he was going off property for an reason. He stated, 'I have my rights.' - 6/5/19 at 5:32 a.m., Rsdt continues to go out to the street to smoke. He refuses to sign out before leaving the property. During an observation on 6/6/19 at 9:30 a.m., resident #1 exited the facility, drove to the street, with an oxygen tank attached to the back of his motorized wheelchair. The resident's oxygen tubing was coiled up and under the seat of the wheelchair. Resident #1 began smoking a cigarette. During an interview on 6/6/19 at 9:50 a.m., staff member [NAME] stated resident #1 had been admitted to the facility in the Fall of (YEAR) and was on a nicotine supplement. Staff member [NAME] stated the facility was a non-smoking facility and resident #1 was not allowed to smoke on the premises. The staff member stated resident #1's son had put small (0.5 inch by 1.5 inch) reflectors on the motorized wheelchair wheels used by the resident. Staff member [NAME] stated resident #1 did not use a wheelchair safety flag when he was on the street smoking. Staff member [NAME] stated resident #1 was not allowed to use the public easement area used by staff for smoking because the resident's wheelchair could not climb the curb. During observations on 6/6/19 at 10:00 a.m. and 10:28 a.m., resident #1 exited the facility, drove to the street, with an oxygen tank attached to the back of his motorized wheelchair. The resident's oxygen tubing was coiled up and under the seat of the wheelchair. Resident #1 began smoking a cigarette. During an observation on 6/6/19 at 10:40 a.m., resident #1 entered the facility, approached the nurse's station, and requested the oxygen tank on his wheelchair be replaced with a full tank. Staff member D replaced the tank, asked resident #1 if he wanted the tank regulator turned on, to which the resident replied, yes. Staff member D turned the tank on and the resident left the nurses station. During an observation on 6/6/18 at 11:18 a.m., resident #1 exited the facility, drove to the street, with an oxygen tank attached to his wheelchair. The resident drove up the street and took a left onto another street. Resident #1 drove approximately 3/4 of a mile, turned around, and went back to the facility. The resident was smoking a cigarette until he returned to the facility. During an interview on 6/6/19 at 1:00 p.m., NF2 stated, There was a resident outside, parked in the street, smoking a cigarette, and has an oxygen tank attached to his wheelchair. NF2 stated she had informed a facility staff member, but remained concerned, because nobody appeared to be assisting the resident. A review of resident #1's Smoking Assessment, dated 6/6/19 at 8:18 a.m., read, .10. Comments: resident signed the smoking policy on admission. he has since started smoking in the last couple months. he chose not to relinquish his smoking material and opted to keep them in a lock box that only he has a key to. he is independent and uses an electric wheelchair to go off property to smoke. he was provided and signed a risk vs benefit. he is non compliant with smoking policy. (sic) A review of a facsimile, dated 6/7/19 at 10:59 a.m., showed orders signed by resident #1's physician for, Nicotine gum and nicotine [MEDICATION NAME] as directed as tolerated. A review of the facility policy, Non-Smoking Compliance effective: 5/23/18, read, 1. Staff will be aware of facility non-smoking policy and will report any violations to the Administrator or Director of Nursing. 2. Daily Quality Conference will include any non-smoking issues. 3. Monthly QAPI Meetings will address any non-smoking compliance issues. 4. Non-Smoking signs will be posted at entrances. 5. All new admissions will be informed of facility non-smoking policy. 6. Residents are not allowed to have any smoking material on their person or in their possession. Smoking materials include but are not limited to: cigarettes, pipes, cigars, tobacco, cigarette paper, matches, lighters, butane, e-cigarettes .7. Facility will not hold in their possession any resident smoking material. 8. Non-compliance with non-smoking policy will result in a written warning for the first violation. A review of the Oxygen Regulator's manufactures instructions, page 3, read, .Smoking near oxygen equipment is strictly prohibited. Keep cigarettes, matches, burning tobacco and open flames, such as lighted candles, away from the area where the system is being stored or operated. Avoid creation of any spark, such as static electricity caused by any type of friction, near oxygen equipment . A review of the facility's policy, Non-Smoking Compliance effective 5/23/18, was signed by resident #1 and witnessed on 11/29/18.

Based on observation, interview, and record review, a facility staff member failed to help a resident with grooming and oral care, for 1 (#14); failed to apply compression wraps, per the physician order, to a resident's [MEDICAL CONDITION] legs, for 1 (#16); failed to bathe and provide adequate peri care and brief changes for a resident that emanated an odor, for 1 (#29); failed to provide a resident with clean sheets, warm food, towels, and respond to the resident's call light timely, for 1 (#348), failed to respond to a resident who was calling out for help, for 1 (#11); failed to assist a resident with incontinent care and toileting, for 1 (#19), failed to assist residents with oral hygiene, for 2 (#23 and 37), and, failed to provide bathing assistance, and baths/showers, for 5 (#s 2, 12, 15, 17, and 37), and resident #2 felt unwanted and considered leaving the facility, and was not assisted adequately with peri care after elimination; resident #12 was upset, started to cry, and felt smelly and dirty, due to the lack of assistance with hygiene care, and the resident had a skin concern which had the potential to worsen with poor hygiene care, and resident #15 was taken to the dining room with unkept and unclean hair, out of 31 sampled and supplemental residents. 1. During an observation and interview, on 2/20/19 at 7:03 a.m., staff member K assisted resident #14 with getting out of bed and getting ready to go to the breakfast meal in the dining room. Staff member K assisted resident #14 to the sink, in her bathroom, to wash her face and hands and brush her teeth. Resident #14 was sitting in the bathroom in front of the sink, and did not wash her face and hands, or brush her teeth. Hanging on the wall next to the sink was a decorative container that contained resident #14's hair brush and oral care items. Resident #14 stated she could not reach the container. Staff member K left resident #14's room after she finished making her bed. Resident #14 remained sitting in her bathroom until staff member K came back to assist her to the dining room. Staff member K took resident #14 to the dining room without asking or offering to assist her with oral care, or brushing her hair. Resident #14 went to the dining room with her hair sticking up on one side of her head. During an observation and interview on 02/21/19 at 7:38 a.m., staff member G assisted resident #14 to transfer out of bed and toilet. Staff member G stated resident #14 required assistance with her hygiene and grooming needs. After resident #14 was finished with toileting, staff member G assisted her with a transfer to her wheelchair. Staff member G placed toothpaste on resident #14's toothbrush and offered it to her. Resident #14 was able to brush her teeth at the bathroom sink. After resident #14 was done brushing her teeth, staff member G put away her toothbrush, in the container hanging on the wall. Staff member G obtained a brush, from the container hanging on the wall, and handed it to resident #14. Resident #14 was able to brush her hair independently. Resident #14 stated she was not able to see herself in her mirror in her bathroom. She stated it would be nice if she was able to see herself in her mirror. She stated everything is so high in here I can't reach things unless I stand up, and I can't stand up by myself. She stated if things were lower she could do things more for herself. Staff member G stated resident #14 did not do anything independently for herself. Staff member G stated resident #14 could wheel herself into the bathroom sometimes but was pretty limited. Review of resident #14's Annual MDS, with an ARD of 9/7/18, under Functional Status, showed the resident required extensive assistance with transfers and toileting, and limited assistance with personal hygiene. The Cognitive Status assessment showed resident #14's cognitive functioning was severely impaired. Review of resident #14's Care Plan, with a last review date of 1/4/19, showed she needed physical help with personal hygiene and oral care. 2. During an observation and interview, on 2/19/19 at 2:30 p.m., resident #16 stated he was concerned about the nurses not applying compression wraps to his legs everyday. Resident #16 explained he had [MEDICAL CONDITION] in both of his legs. He stated his doctor ordered his legs to be wrapped every day, before he got up, and then the nurses were supposed to remove the wraps when he went to bed. Resident #16 stated the nurses were not doing this everyday. He stated when his legs did not get wrapped, it caused increased swelling and pain, due to the increased swelling. Resident #16 pulled up his pant legs and showed both of his legs. Both legs were [MEDICAL CONDITION], the the left shin had a dry yellowish caking discharge on it. The resident's legs did not have compression wraps on them. Review of resident #16's physician orders [REDACTED].>two times a day, for [MEDICAL CONDITION], on in a.m., off at h.s., with an active date of 1/17/18. Review of resident #16's Care Plan, with the last review date of 12/19/18, showed a focus area for bilateral lower extremity [MEDICAL CONDITION]. Interventions listed included: staff to monitor for any signs and symptoms of infection, worsening ulcers, and wraps to bilateral lower extremities, daily, per the MD order. Review of resident #16's Treatment Administration Record showed on 2/19/19, under compression wraps daily, a check mark showing the wraps had been applied. Record review of the resident's nurse's notes, on 2/19/19, showed no documentation that the wraps had been removed that day, or include documentation on why the wraps were not on resident #16's legs when observed during the time period of his interview at 2:30 p.m. 3. During an interview, on 2/20/19 at 11:26 a.m., resident #13 stated if she wanted her teeth brushed she had to do it herself. She reported that her bath days were Wednesdays and Saturdays, and stated, Sometimes they skip my baths. During an observation and interview, on 2/20/19 at 3:10 p.m., staff member M stated when there are only two staff members working on the evening shift for the entire long term care unit, showers are over looked. During an observation and interview, on 2/20/19 at 3:34 p.m., staff member J stated that she had to shower resident #13 that evening because it was her bath day, but I probably won't get it done. She stated the resident is female care only for peri-care and showers. The only other available evening shift staff member was male. Staff member J stated it took approximately 30 minutes to complete resident #13's shower. With only two staff members for the unit, the nurse would have to stop her duties and cover the floor. Staff member J was tearful and upset during the interview due to the concerns brought forth. Review of Resident #13's bathing record, dated 12/23/18 - 2/21/19, showed the resident received one bath, which was on 1/23/19. Review of resident #13's Care Plan, dated 12/15/14, showed the resident's need for extensive assistance with dressing, grooming, and bathing. 4. During an observation on 2/19/19 at 12:12 p.m., a strong smell of vomit was present on resident #29, but visually, vomit was not observed. The resident was slumped over to her left side and was on the edge of her wheelchair seat. The resident stated she had been in her wheelchair since 8:00 a.m. The resident stated she did use attends for her incontinence. Her hands were visibly soiled with an unidentifiable yellow-brown crusty substance. The resident had a brownish colored material caked underneath her fingernails, and she was observed eating a banana during the lunch meal, with her soiled hands. During an observation on 2/20/19 at 7:44 a.m., resident #29 was being assisted up for the day. Resident #29 had a strong yeasty smell in her room. After resident #29 had used the bed pan, staff cleaned her with a cleansing wipe, but chose to not change the resident's brief, which she had on throughout the entire night. The staff stated the brief was not soiled. The brief, which the staff had chose to leave on the resident, was permeated with a yeast odor, which was emanated from the brief. Review of resident #29's bathing record, dated 12/23/18 - 2/21/19, showed one bath was provided on 1/5/19. The resident's documented bathing performance showed the resident was total dependence. Review of resident #29's Care Plan, revised 10/29/18, showed the resident's need for extensive assistance of 1-2 staff with dressing, grooming, and bathing. During an interview on 2/20/19 at 9:20 a.m., staff member G stated she felt the residents had been neglected when the facility was short-staffed, because We are busy answering call lights, and can't get to residents that don't, or can't, speak up. It feels like they are getting neglected. Staff member G stated last Tuesday and Wednesday there were only two staff members for the provision of resident care on the long term care unit on the day shift. Staff member H stated there had been 4 to 5 times in the last month where there were only two staff members on the day shift for the long term care unit. Staff member G stated when We are short-staffed like that, men don't get shaved, meals are served late and cold, residents do not get fed on time, residents don't get showered, and residents sit in soiled briefs for extended periods of time. 5. Lack of Staff Assistance and Care During an interview, on 2/19/19 at 11:50 a.m., resident #348 stated I have to wait a long time for someone to answer my call light, maybe 20 minutes or maybe an hour and a half. Resident #348 stated My sheets haven't been changed for a week, we have to ask, I don't get clean towels, I have to ask, they don't bring my tray in a timely manner. During an interview, on 2/19/19 at 2:48 p.m., resident #11 stated it depended on when a resident needed care, and On weekends and nights it's not good. Resident #11 stated, I saw a CNA on her phone (personal cell phone) when a resident was asking for help. During an interview on 2/20/19 at 5:34 a.m., staff member P stated the staffing is good and sometimes it's not. There was one CNA on this floor and sometime I have to go downstairs to help out. It's been that way for a long time. Staff member P stated, It's very rushed when I have to do upstairs and downstairs both. I like to get the cares I have to do done and not be rushed. We bring it up at staff meetings, and I have approached administration about it. During an interview on 2/20/19 at 6:00 a.m., staff member AA stated ,If the census is below 16, then there is only one CNA. I'm not able to get my care done when there is only one CNA. I have approached (staff Q) and told We can do it. During an interview, on 2/20/19 at 9:30 a.m., NF2 stated, The staffing is horrible. Staff don't toilet (resident #19) every two hours on the weekend. She doesn't get great care, she sits in a wet attend. They (staff) sit (use) on their phones. They don't check on her. I've seen staff sit at the desk with three lights going off and just sit there. Record review of resident #19's physician's orders [REDACTED]. Review of resident #19's Care Plan dated 3/18/18, showed the resident needed extensive assist of one staff with dressing, grooming and bathing, extensive assistance of one staff for toileting. Review of resident #19's toileting record ,for (MONTH) (YEAR), and January/February 2019, showed toileting assistance did not occur on the following shifts: - day shift: 2/4/19 - evening shift: 12/25/18, 12/27/18, 12/28/18, 12/29/18, 1/1/19, 1/3/19, 1/4/19, 1/10/19, 1/11/19, 1/15/19, 1/16/19, 1/17/19, 1/22/19, 1/29/19, 1/30/19, 1/31/19, 2/6/19, 2/7/19 - entire day: 1/15/19, 1/12/19, 1/20/19, 1/26/19, 2/1/19, 2/2/19, 2/8/19, 2/12/19, 2/15/19 6. During an interview, on 2/20/19 at 10:09 a.m., resident #17 stated I don't get to choose when I take my shower. When I ask the CNA's when I can get my shower they say they don't have time. Resident #17 stated I sometimes go two weeks without a shower. Review of resident #17's bathing documentation, for the period of 12/26/18 - 2/20/19, showed a one shower on 12/26/18, a refusal of a shower documented on 1/6/19, and no further documentation was noted for any other showers after that. Review of resident #17's Care Plan, dated 10/15/18, showed resident #17 needed supervision for bathing. 7. During an interview on 2/20/19 at 10:09 a.m., resident #37 stated We don't get enough showers. Review of resident #37's bathing record, for the past three months, showed documentation of one bath, which was on 1/17/19. Review of resident #37's Care Plan, with a revision date of 8/13/18, showed under the interventions for bathing, I need extensive assist of one staff with bathing, twice a week. During an interview on 2/21/19 at 8:22 a.m., staff member R stated most residents on the unit, which was the top level of the facility, can tell if they are not getting the help they need. Staff member R stated she assisted the residents, if needed. Staff member R stated, I see that care is not getting done. Staff member R stated the CNAs report bathing isn't done, especially downstairs. 8. During an interview on 2/21/19 at 12:54 p.m., resident #2 stated When I don't get my bath when it's scheduled it makes me feel like I'm not really wanted, and I'm thinking about finding another place to live. Resident #2 stated We're lucky if we have two aides. It's good while surveyors are here, but after you leave we go back to the way it was. Review of resident #2's bathing record, for the last three months, showed bathing occurred two times weekly on only three of the eight weeks. Toileting showed numerous days without documentation for the resident's assistance, which required cleansing following elimination 9. During an interview on 2/21/19 at 1:07 p.m., resident #12 stated When I don't get my bath when I need it, it makes me feel dirty and smelly. I sweat a lot. Resident #12 stated I get upset and it makes me want to cry. Review of resident #12's bathing record, for the period of 12/27/18 - 2/20/19 showed resident #12 received one bath between 12/27/18 and 1/17/19; and one bath between 2/11/19 and 2/19/19. Review of resident #12's Care Plan, revised 8/13/18, showed the need for resident supervision during bathing, and limited assistance of one with toileting. Further review showed a skin issue, Moisture Associated skin damage located in my groin, under my breasts, and in other skin folds, with an intervention of treatment as ordered. Review of the facility's ADL Assistance Provided per Care Plan Policy, Number NS0798, with an effective date of 11/2016, showed, To assure ADL assistance is provided to all residents based upon assessment and Care Plan and the Procedure showed Based upon resident/resident representative desires, assessment, and care plan, ADL assistance will be provided to any residents (sic) deemed necessary. Some examples were: - Shaving and hair grooming as needed. - Bathing/showering. - Incontinent residents shall be checked according to Care Plan and peri-care provided between changes. - Assistance as needed with oral hygiene to keep the mouth, teeth or denture clean. - Fingernails and toenails shall be clean and trimmed. - Bed linen shall be changed weekly or more often as needed. 10. During an observation on 2/19/19 at 2:40 p.m., resident #15 was observed laying in bed watching T.V. Resident #15 had a white, dried on substance coating the right side of her hairline, and her hair appeared dirty. Resident #15 was non-verbal due to a persistent vegetative state. During an interview, on 2/19/19 at 3:30 p.m., staff member L observed the white substance in resident #15's hair. Staff member L stated, I don't know what it is. I've been gone for four days, so I don't know when her last bath was. A review of resident #15's Care Plan, initiated 11/12/14, showed, I need a total assist of 2 staff with my bath. I take a tub bath twice weekly. A review of resident #15's bath record showed the last entry for Bathing: Support Provided was on 1/29/19 at 4 p.m. 11. During an observation on 2/20/19 at 7:30 a.m., Staff member I assisted resident #23 and #37 up for breakfast. Staff member I assisted resident #23 into the bathroom, then gave her a wet wash cloth for her face. Resident #23 did not brush her teeth. Staff member I assisted resident #37 by giving her a wash cloth for her face. Resident #37 did not brush her teeth. Staff member I did not assist either resident #23 or #37 with their oral hygiene needs. During an interview on 2/21/19 at 7:33 a.m., staff member I stated some of the residents may brush their teeth after breakfast, referring to resident #23 and #37, But if we dont get to it before breakfast, it usually doesn't get done. Staff member I stated. It sounds bad, but we are so busy and short staffed.

Based on observation, interview, and record review, the facility failed to ensure quality of care was provided for a resident who had multiple skin injuries, was at risk for further injuries and falls, and the resident required monitoring and staff assistance, for 1 (#7) of 18 sampled residents. This failure caused resident #7 to receive skin injuries and be at risk for future injuries, have tearful episodes, and the failure made the resident feel as though no one would listen to him. Findings include: Dignity and Privacy During an observation on 2/19/19 at 2:43 p.m., resident #7 was on the floor on a fall mat in his room, scooting around in a brief and a T-shirt, near the dresser. During an observation on 2/19/19 at 2:45 p.m., staff member X walked by resident #7's room and did not look in or assist the resident. During an observation on 2/19/19 at 2:47 p.m., staff member M walked by resident #7's room, looked in, mumbled something, then walked away without assisting the resident. During an observation on 2/19/19 at 2:59 p.m., resident #7 remained on the floor near the dresser, but he was on the opposite end of the room from the call light. He was on the carpet. During an observation on 2/19/19 at 3:13 p.m., resident #7 was back on his floor mat, on the floor. During an observation on 2/19/19 at 3:45 p.m., resident #7 was laying on the floor mat, with his brief off, and was exposed. The resident's door was open, and the length of the privacy curtain did not reach the floor, so the resident was visible to anyone who walked by the room. During an observation on 2/20/19 at 6:24 a.m., resident #7's fall mat was noted to be significantly soiled with several large brown stained areas. Resident #7 was observed to be crawling on the soiled fall mat. During an observation on 2/20/19 at 6:29 a.m., resident #7 had a pad call light for ease of use, but could not reach it from where he was in the room. During an interview on 2/20/19 at 6:36 a.m., resident #7 stated that he had not felt like staff had treated him with respect and dignity, and stated, no one listens to me. During an interview on 2/21/19 at 7:16 a.m., staff member Y stated she did not think it was a dignity issue for resident #7 to be on the floor, because the resident liked it. Staff member Y stated she had never personally asked the resident if he liked being on the floor, but stated I have known the resident a long time. Staff member Y stated she thought the CNAs asked the resident if he wanted to be on the floor. Staff member Y stated that would be a dignity issue missed by staff, regarding the situation when the resident was observed on the floor, and he had ripped his brief off, and was on the floor mat, in just a T-shirt. Skin Injuries During an interview on 2/20/19 at 6:32 a.m., resident #7 stated he does not like to crawl around on the floor. The resident stated when he was crawling around it was because he needed something or was looking for something. The resident stated crawling around on the floor hurts my knees and takes all the hide (skin) off. Review of resident #7's Care Plan, dated 9/3/18, showed, I like to sit/lay/crawl on the floor in my room when I choose to do so. During an observation on 2/20/19 at 6:32 a.m., resident #7 had multiple scabs and abrasions to his bilateral lower extremities, and his bilateral elbows, in various stages of healing. During an interview on 2/21/19 at 7:16 a.m., staff member Y did not know if resident #7 currently had any skin issues. Staff member Y stated skin issues were documented under assessments, orders, or progress notes on the computer. Staff member Y stated, The CNAs are good at reporting skin issues to the nurses, otherwise we do skin checks weekly. Staff member Y was providing care for resident #7 on this day. Review of resident #7's TAR, dated 2/1/19-2/28/19, lacked monitoring and treatment for [REDACTED]. Review of resident #7's TAR, dated 2/1/19-2/28/19, showed one completed skin check had been done on 2/19/19. During an interview on 2/21/19 at 12:35 p.m., staff member Z stated resident #7 had multiple abrasions from falls and crawling around on the floor that were all over his legs and arms. Staff members X and Z stated the intervention in place to prevent further skin issues was trying to keep resident #7 dressed. Review of resident #7's Care Plan dated, 7/29/18, showed Staff to allow resident to sit/lay or crawl on the floor if he chooses. Please just ensure call light is within reach and encourage of the same so he may have assistance up. During an interview on 2/20/19 at 6:44 a.m., resident #7 stated he had to holler to get help and more food, especially when he was on the floor, and sometimes I have to holler a long time, but sometimes they come quick. Resident #7 stated the resident across the hall would tell him to shut up when he was yelling out for help. Care Plan During an interview on 2/19/19 at 3:01 p.m., staff member X stated resident #7 had a [DIAGNOSES REDACTED]. Staff member X stated the resident was a high fall risk, and as an intervention for fall prevention, the resident was care planned to be allowed to crawl around on the floor. Staff member X stated staff placed a flat call light underneath the resident to notify staff when he was moving. During an interview on 2/21/19 at 7:16 a.m., staff member Y stated resident #7 received his new wheelchair approximately one month ago. Staff member Y stated there were many modifications made to the old wheelchair before the new wheelchair was purchased. Staff member Y stated the new wheelchair was to assist with fall prevention. Staff member Y stated resident #7's floor mats have been in place for about two months, because all the other interventions were not working to prevent falls for the resident, such as close supervision, activities, and a pancake call light. Review of resident #7's Care Plan, dated 8/31/18, showed encourage resident to spend time in the common area around nurses for more direct supervision. The care plan did not sufficiently address the resident's individual needs related to being on the floor to ensure the resident was protected from repeated skin injuries, and to ensure the provision of adequate monitoring, for necessary staff assistance.

Based on observation, interview, and record review, the facility staff failed to provide and assist residents with meals, snacks, and water, for those residents who needed the assistance, and there were weight concerns. The staff failed to document the amount of the meals consumed, and monitor the intake records for accuracy and completion, to allow the facility to identify if weight concerns were an outcome of poor intake, for 3 (#s 6, 7, and 13), and one, (#7) had a documented significant loss of weight, and resident #6 had a weight loss. These failures caused outcomes such as hunger and thirst due to the missed meals, snacks, and lack of fluids, and emotional distress due to the lack of food and fluid intake and staff assistance, out of 18 sampled and supplemental residents. Findings include: 1. During an observation and interview on 2/20/19 at 11:03 a.m., resident #13 requested fresh water with ice, and drank 300 cc of water at once. The resident asked staff member W several times not to take the water away from her mouth. The resident stated she was very thirsty. During an observation on 2/20/19 at 11:06 a.m., resident #13 was taken out of the dining room just before lunch was served. There was no lunch tray at the table in front of the resident. There was a small sandwich bag with a sandwich in it, tucked beside resident #13 in her wheel chair seat as she left the dining room. During an interview on 2/20/19 at 11:27 a.m., resident #13 stated the food was okay, and sometimes staff offer meal substitutions. The resident stated staff does not offer snacks to her often because They have to stay in my room and help me. She stated the staff tell her They don't have time to help her with snacks. The resident stated if she is sleeping, staff do not come in and wake her for meals. After 10:00 p.m., she stated she could not get anything to eat because the kitchen was locked, and staff could not get in to get food. During an interview on 2/20/19 at 3:04 p.m., resident #13 stated she did not get an early tray for lunch that day, before she went to her doctor's appointment, and she only received a half sandwich in place of the lunch she had missed. She stated she was hungry that afternoon, but did get a snack, which was not substantial enough. Resident #13 stated she needed help to eat her meals, and stated the staff was not helping her enough to consume her meals. The resident reported the staff tell her they don't have the time to sit there with her to help her eat. The resident stated her pain had affected her meal intake, as she was in too much pain to get out of bed and go the dining room. During an interview on 2/20/19 at 3:08 p.m., staff member W stated she was familiar with resident #13's care, and stated the resident did require assistance with eating. Staff member W stated resident #13 would occasionally refuse to get up for meals because she was In too much pain, or too tired. Staff member W stated resident #13 was a choking risk, and if the resident refused to get up, staff would offer to assist her to eat her meal in her room. Staff member W stated the CNAs would tell the resident that if she did not want to get up, then staff member W would give resident #13 a Boost supplement instead of her meal. Staff member W stated resident #13's refusal to get up for meals may be due to pain. During an interview on 2/20/19 at 3:10 p.m., staff member M stated he was familiar with resident #13's care. Staff member M stated the resident used to come down to the dining room, but over the last year resident #13 wanted to stay in her room more often. Staff member M stated there was not enough staff to stay in the room with resident #13 to assist her with meals, and staff member M did not feel like resident #13 was getting half as much food as she should, due to staffing and having to stay in her room to be assisted with her meals. Staff member M stated resident #13 was Full assistance, as of lately, for feeding. The staff member assisted resident #13 with meals by cuing, and stated the resident should receive finger foods, but if the resident did not want to eat, She took a boost (supplement). Staff member M stated he was not sure what they were doing with the meal intakes (documentation of intake) for the residents. He stated there was a clipboard in the dining room to chart a resident's meal intake. Staff member M stated he was unsure who was responsible for putting the meal intake amounts into the computer, but .maybe night shift? Staff member M stated it looked like resident #13 had lost weight. Staff member M stated that reporting changes for concerns or weight changes to a nurse was necessary, and the staff member would follow that. The employee believed resident #13 was weighed weekly, and on Saturday, Sunday, and Monday, there were only two staff members for evening shift, for both long term care hallways. Staff member M stated when they facility was short-staffed, resident showers were overlooked, and residents that were in their rooms for meals, were unable to be fed by the staff. Staff member M stated there had to be one staff member in the dining room during the meal and one staff member to pass hall trays and answer call lights. During an interview on 2/20/19 at 3:34 p.m., staff member J stated If there are only two staff members for both hallways during the evening shift, the only person who gets fed on the hall is (resident #10). There is not enough staff to assist with anyone else to eat in their rooms. Staff member J stated (Resident #13) is at risk for choking, and staff try to get her up at least once a day, for one meal. Staff member J stated on Saturday, Sunday, and Monday, (resident #13) did not get offered a dinner tray, due to no staffing. Staff member J stated, I did try to make sure she at least got a snack and a peanut butter and jelly sandwich. Staff member J stated, Nobody will help in the dining room, we just can't do it all. During an interview on 2/21/19 at 10:51 a.m., staff member T stated it was herself, the physician, and the interdisciplinary team, that were responsible for identifying residents at risk for weight loss. Staff member T stated a resident that was at risk for weight loss would be added to the Nutrition at Risk program. Staff member T stated that resident #13 was not at risk for impaired nutrition, and the resident will just cut back on what she eats, because she doesn't want to gain weight. Staff member T stated resident #13's nutritional status was reviewed 12/7/18, with her Annual MDS assessment. Staff member T stated resident #13 was receiving Boost, twice daily, as a supplement. Staff member T stated she had seen resident #13 eat on 12/7/18, when she evaluated her. Staff member T stated resident #13 usually eats all of the meals. Staff member T stated, All the supplement and meal intakes, and the resident's eating abilities, are documented in PCC (electronic health record program). Staff member T could not identify what resident not available meant on the meal intake record. Staff member T stated resident #13, did at times, refuse meals, but stated, that's when she takes her supplements. Staff member T, and the surveyor, reviewed the intake records for resident #13, and the staff member stated, This is interesting, I see that she has been refusing all meals. This is kind of new for her. Staff member T stated resident #13 was to be weighed monthly. When the surveyor and staff member T reviewed the current physician's orders [REDACTED].#13, staff member T stated she did not know that an order for [REDACTED].#13. When staff member T was asked when she had stopped monitoring weekly weights for resident #13, she stated, probably once she stabilized; I have to look back at my notes, hold on . then stated, It (the notes) doesn't say anything about discontinuing weekly weights. Review of resident #13's physician orders, dated 3/3/18, showed an active order for weekly weights one time a day, every seven days. Review of resident #13's Weights and Vitals Summary, dated 12/1/18 - 2/1/19, showed three weights listed, which were on 12/1/18, and the resident's weight was 201.4 pounds (wheelchair); 1/8/19, the resident's weight was 208.8 pounds; and, 2/2/19, the resident's weight was 208 pounds (wheelchair). Review of resident #13's MAR, for (MONTH) (YEAR), and January/February 2019, showed nursing staff documented the task of weighing the resident weekly, however, the CNAs were obtaining only monthly weights, as reflected on the Weights and Vital Summary. 2. During an interview on 2/20/19 at 6:49 a.m., resident #7 reported he was hungry all the time, and reported staff would not let him eat in his room. The resident reported he had lost weight, about 60 pounds. Review of resident #7's dietary progress note, dated 1/29/19, showed the resident needed assistance and cuing at meals in the dining room. Resident #7's weight was documented as 140 pounds, overall significant loss. The dietary progress note showed resident #7 consumed 75-100% of health shakes TID plus Boost pudding. Review of Resident #7's (MONTH) 2019 MAR, and the meal consumption report, did not show the amount of the Boost pudding supplement the resident had consumed. Review of resident #7's Care Plan, dated 1/29/19, showed encourage >50% of Health Shakes and pudding. During an observation on 2/20/19 at 10:50 a.m., resident #7 did not receive Boost pudding during his breakfast meal. Review of resident #7's (MONTH) 2019 MAR, showed nursing staff had administered Boost pudding at every meal. During an interview on 2/21/19 at 11:15 a.m., staff member T (who was not at the facility on a daily basis) stated resident #7 was to receive Boost pudding TID with meals. Staff member T stated, I know he gets it every day. During an interview on 2/21/19 at 11:54 a.m., staff member E stated she did not place physician ordered supplements on resident meal trays because it was the nursing staff's responsibility to make sure the resident received the supplement. Staff member E stated she needed to have a dietary communication slip from nursing, if the resident was placed on a supplement, that was to be given with meals. Staff member E stated she would put the supplement on the resident's dietary slip as a reminder, to help ensure staff got the supplement for the resident. Review of Resident #7's dietary slip showed no documentation for the Boost pudding supplement, as listed for breakfast, lunch, or dinner. Review of resident #7's physician's orders [REDACTED]. Review of resident #7's Care Plan, dated 9/3/18, showed staff to encourage po >50% at meals. Review of resident #7's Meal Intake report, dated 12/23/18 - 2/20/19, showed resident #7 ate <50% for 28 meals during this time period. During an observation on 2/20/19 at 6:51 a.m., there was no water pitcher at resident #7's bedside. During an interview on 2/20/19 at 8:50 a.m., staff member Z stated that she did not know how long resident #7's food had been sitting on the table. During an observation and interview on 2/20/19 at 10:50 a.m., resident #7 reported his food was cold. The resident was brought into the dining room when all meal trays had been passed and the staff were available to assist him. Resident #7's breakfast plate had been sitting on the table since the begin of meal service at 8:00 a.m. Staff did not offer to re-warm the resident's food, even after the resident verbalized the food was cold. Resident #7 was drinking his oatmeal through a straw from a bowl, no staff were available to assist him. During an interview on 2/21/19 at 12:33 p.m., staff member V stated everybody should have a water pitcher at the bedside. During an observation on 2/21/19 at 12:34 p.m., there was no water pitcher in resident #7's room. Review of resident #7's Care Plan, dated 1/11/19, showed maintain weight/hydration status. 3. During an interview on 2/19/19 at 12:55 p.m., staff member DD stated she did not take resident #6 to lunch as he was asleep and wiped out from his bed bath this morning. She stated that if the resident had swallowing precautions, We can't leave the (meal) tray (in the resident's room). Staff member DD stated We will bring him something when he wakes up. During an interview on 2/19/19 at 2:40 p.m., staff member B stated she wasn't sure if resident #6 had anything brought to him for lunch, and she wasn't sure where they charted it. A peanut butter and jelly sandwich was given to staff member DD by staff member B, but she was unsure if resident #6 ate the sandwich. Meal Intake Documentation Concerns: During an interview on 2/19/19 at 2:40 p.m., staff member U reported the meal charting for resident #6's lunch, on 2/19/19, showed not applicable. During an interview on 2/21/19 at 11:13 a.m., staff member AA stated the documentation una on the daily meal intake means the resident was in bed and didn't come to the meal. Staff member AA stated the missing documentation for supper percentages had been a problem for a long time. Review of resident #6's meal charting for the lunch meal, on 2/19/19, showed, amount eaten a percentage was not documented, and not applicable was marked. Review of resident #6's meal charting for amount eaten from 1/20/19 through 2/20/19 showed resident not available on three occasions, not applicable on one occasion, and twenty seven times where there was no documentation at all for meal percentage. Review of resident #6's Care Plan, with a revised date of 11/3/18, showed Needs cueing at meals in room or dining room; staff to provide set up and assist as needed. Mechanically altered diet related to chewing and swallowing difficulties. Review of resident #6's weight records showed a weight of 147 pounds on 10/30/19, and a weight of 137 pounds on 2/21/19, which reflected a 6.8 percent loss, in less than four months.

Based on observation, interview, and record review, the facility failed to identify, treat, and manage the pain for 1 (#13), which resulted in the inability of the resident to get up for meals, decreased meal intake and missed meals, and uncontrolled pain. The facility failed to treat and manage pain for 1 (#7) of 18 sampled residents, which caused increased anxiety, agitation, and tearful episodes. Findings include: 1. During an observation and interview on 2/20/19 at 9:52 a.m., staff member H was finishing resident #13's restorative exercises, and stated she was not able to complete the lower extremity exercises due to the pain the resident was having. Resident #13 stated she was in so much pain she was unable to get up, and had refused her breakfast tray. Staff member H stated she would report the resident's pain to the nurse when she completed resident #13's restorative exercises. During an interview on 2/20/19 at 11:06 a.m., resident #13 stated resident #13 stated her pain affected how she was eating, and her ability to get up for meals. During an interview on 2/20/19 at 3:08 p.m., staff member W stated resident #13 did require assistance with meals, and the resident did refuse to get up, because she was in pain or too tired. Staff member W thought resident #13's pain was affecting her ability to get out of bed for meals. Staff member W stated resident #13 did not have any scheduled pain medication, but stated it could be helpful in managing the resident's pain. She stated The resident had been on [MEDICATION NAME], which seemed to have worked well for the resident, but (the physician) won't prescribe it. Staff member W stated she had not talked with the physician currently responsible for the resident's care, to tell her what had worked to manage the resident's pain in the past. Staff member W stated she was unaware of the facility's policy for pain monitoring. Review of resident #13's Meal Intake report, for (MONTH) and (MONTH) 2019, showed concerns related to the resident's lack of intake and lack of attendance at meals. Refer to F692 for further detail. During an interview on 2/20/19 at 11:00 a.m., resident #13 stated her pain had not been managed well. She stated her pain was rated a 9 out of 10; 10 being the worst, in her feet that morning. She stated she had [MEDICAL CONDITION], and her pain had been worsened over the last couple of weeks. Review of resident #13's MAR, for (MONTH) (YEAR) and (MONTH) 2019, showed no pain monitoring documentation for each shift. Review of resident #13's MAR, for (MONTH) 2019, showed the resident received 20 doses of PRN [MEDICATION NAME] 500 mg. The resident had rated her pain at a six or greater for fifteen of those doses. The resident also received seventeen doses of Tylenol 650 mg. The resident rated her pain at a six or greater for fourteen of those doses. Review of resident #13's MAR, for (MONTH) 2019, showed Pain Monitoring: Monitor for pain every shift either verbal or non-verbal signs. Every shift Please use the PAINAD scale if the resident is unable to verbalize pain. **Must document intervention if resident is having pain.** Start date 2/20/19 at 6:00 p.m. Review of resident #13's MAR, for (MONTH) 2019, showed the resident received seventeen doses of [MEDICATION NAME] 500 mg. The resident rated her pain at a six or greater for thirteen of the doses of [MEDICATION NAME]. The resident also received eleven doses of Tylenol 650 mg. The resident rated her pain at a six or greater for seven of those doses. Review of resident #13's Weights and Vitals Summary dated, 1/1/19-2/20/19, showed the resident rated her pain at a six or greater (10 being the worst) sixty-one times. Review of resident #13's Care Plan, dated 9/27/18, showed I have pain/discomfort related to lower back pain and diabetic [MEDICAL CONDITION]. I experience mild pain frequently and have indicated that my pain makes it difficult for me to sleep at night and limits my day-to-day activities. I want to keep my pain level at the lowest possible level. During an interview on 2/20/19 at 3:34 p.m., staff member J stated resident #13 Had been frequently complaining about the pain in her feet, and stated the resident told her she is always in pain. Staff member J stated she did report the pain to the nurse every time the resident was in pain. 2. During an observation and interview on 2/21/19 at 7:34 a.m., resident #7 stated his pain was at a 7 out of 10; 10 being the worst, in his lower back. Resident #7 was very tearful and restless in his wheelchair when he was interviewed. During an interview on 2/20/19 at 6:57 a.m., resident #7 stated he had constant pain in his knees, shoulders and back. He stated on an average day his pain was at a 7 out of 10, and on bad days he stated his pain was at a 9 out of 10. The resident stated he did report pain, and the nurse would bring him pain medicine. He stated the pain medication was not very effective, It just makes me dopey. During an observation and interview on 2/20/19 at 6:32 a.m., resident #7 stated crawling around on the floor Hurts my knees and takes all the hide (skin) off. There were multiple scabs and abrasions observed on the resident's lower extremities and elbows, which were in various stages of the healing process. During an observation and interview on 2/21/19 at 7:37 a.m., staff member V stated the facility had used the PAINAD scale to assess residents, and The assessment tool was very subjective. Staff member V demonstrated the PAINAD tool for resident #7, which generated a pain level of 2 out of 10. Staff member V stated she would go talk with the resident and ask him if he had pain. Staff member V stated other staff should also be using the PAINAD assessment for pain. Staff member V stated she did try to anticipate the resident's pain by knowing the resident's routine, and medicate the resident before and after activities, as needed. Staff member V stated when a resident had received an as needed medication for pain, The MAR indicated [REDACTED]. During an observation and interview on 2/21/19 at 8:24 a.m., staff member V administered resident #7's morning medications. Staff member V stated she did not include any as needed pain medication with resident #7's morning medications. Staff member V stated she did not give pain medication with morning medications and stated He is fine. Staff member V stated when she asked if resident #7 was in pain that morning, he told her He was living in a nightmare that he can't wake up from, and began to cry. Staff member V did not investigate further why the resident was crying. Review of resident #7's Care Plan, dated 9/3/18, showed I want to keep my pain between a pain score of 1-4. A review of the facility policy, titled Pain Assessment and Management, with a revised date of (MONTH) (YEAR), showed under the heading of Policy The purpose of this procedure are (sic) to help the staff identify pain in the resident, and to develop interventions that are consistent with the resident's goals and needs and that address the underlying causes of pain. Under the heading, Recognizing Pain was listed Possible Behavioral Signs of Pain: a. Verbal expressions such as groaning, crying, screaming; . d. Behavior such as resisting care, irritability, depression, decreased participation in usual activities; e. Limitations in his or her level of activity due to the presence of pain; . g. Difficulty eating and loss of appetite; h. [MEDICAL CONDITION]; and, i. Evidence of depression, anxiety, fear or hopelessness .

Based on observations, record reviews, and interviews, the facility failed to ensure residents who smoke were safe when smoking for 4 (#s 1, 2, 3, and 5) of 20 sampled residents. On 5/23/18 at 11:59 a.m., the facility Administrator, Administrator in Training, and the Director of Clinical Services were notified that an Immediate Jeopardy situation was identified for the areas of deficient practice, which included F689 Accidents and Hazards, and F835 Administration. The Severity and Scope was identified at the level of J, and upon the removal of the immediacy for the deficient practices, the severity and scope would be lowered to a G. Findings Include: 1. Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #1 was admitted to Hospice services on 5/8/18 and passed away the morning of 5/24/18. Review of resident #1's Interdisciplinary progress notes in the medical record showed the following information: Progress Note 3/2/18 at 5:12 a.m.- . CNA had caught this patient smoking in her room the night before when the CNA smelled cigarette smoke . Progress Note dated 3/11/18 at 1:45 p.m. - Resident went down stair to bum a cig from female resident a lighter and went outside by resident letting her out the door and was smoking with 02 tank on nasal cannula draped on the handle of w/c. Talked with resident and was told smoking revoked due to incident yesterday and not safe to smoke reuses to follow smoking rules. very angry confiscated cigs from her. explained will need to talk with administrator in am on 3/12/18.(sic) Progress Note dated 3/11/18 at 9:23 a.m. - Resident smoking rights were revoked due to smoking in the dining room on 3/10/18 with oxygen on and placing other resident in harm. Nurse confiscated cigarettes and lighter on 3/10/18, explained no smoking until talked with administrator and DON on 3/12/18.(sic) Progress Note dated 5/1/18 - Staff report resident got burned. Upon arrival resident yelling repeated he told me it was off, why would he tell me it was off. Noted circumoral burns/blackened areas extending upward on the face. Burns/blackened areas noted to L hand -primarily around index, middle and ring fingers. Resident reportedly was smoking and did not remove her oxygen tubing from her face. Resident alert, follows commands, tracks individuals speaking. Noted pupillary response within norm. Nail beds of R hand pale but blanchable and radial pulse rapid and strong regular-resident with good circulation. Oxygen saturation 83% on RA. Oxygen applied and titrated up to 10L/min raising saturations to 93%- gas exchange adequate for vital function with supplemental 02 in place. Face mask blow-by held approx. 1 from residents face to prevent further trauma/pain if fully applied due to location of burns. Cool compress applied both face and hands to slow burning process. Unable to determine severity [MEDICAL CONDITION] to blackened color of skin. No sloughing of skin noted. Resident angry and lashing out at staff, calling them names, accusing them of letting her get burned, stating 'I will own this building.' Resident prompted several times that she needed to calm and focus on taking deep breaths to promote oxygenation and stop yelling. Resident complied. 911 called, ambulance arrived on scene and transported resident to ER for eval and treatment and to r/o [MEDICAL CONDITION] airway. Check of oxygen tank on residents wheelchair at this time-oxygen tank had been turned off prior to this writer arrival at resident. W/C and oxygen tank were still sitting on patio. Tubing was melted up to approx. 6' from oxygen tank. No further remains of tubing noted at that time. Overall resident upset and angry but stable.(sic) Review of resident #1's ER report dated 5/1/8 at 4:02 p.m., showed resident #1 received [MEDICAL CONDITION] on her usual liters of oxygen. Resident #1 reported to the ER physician she was not smoking but took a drag from another resident's cigarette when her oxygen ignited. She [MEDICAL CONDITION] her upper left lip and nares. The ER report said resident #1 singed hair over bilateral eyebrows and eyelashes. Soot on the left cheek, upper lips, and some singed mucosa in the left nares but not in the right, slight burn on the left upper lip but nothing intraoral. Soot and burn between second and third MCPJ on the left. The ER physician referred resident #1 to the plastic surgeon. Resident #1 was seen by the plastic surgeon on 5/3/18. A review of the surgeon's progress note showed .second [MEDICAL CONDITION] left nasal tip and asa (sic), left upper lip, and left cheek lateral to oral commissure. She documented there was soot present on upper lip and left nasal mucosa, moderate swelling of left cheek. There was a small superficial burn on dorsum of left index finger and soot on left upper lateral arm. Review of resident #1's smoking assessment dated [DATE] showed the resident had a vision deficit, and the facility needed to store the lighter and cigarettes, she needed assistance outside the door and was able to get in the building again. It showed the plan of care was used to assure resident was safe while smoking. Review of resident #1's smoking assessment, dated 5/2/18, showed the resident had vision and dexterity deficits, needed the facility to store her cigarettes and lighter, and the plan of care was not used to assure resident was safe while smoking. Review of resident #1's undated plan of care showed resident #1's cigarettes are to be stored in a locked container and distributed to her during assigned smoking times. Review of resident #1's plan of care initiated on 5/1/18 showed resident #1 has chosen not to smoke at this time. Review of resident #1's copy of the facility smoking policy was signed by the resident on 3/1/18 and 5/2/18. Both signed policies included information that residents are not allowed to possess cigarettes and lighters in the facility, and independent smokers will store lighter/matches in the lock box in the Goldrush nurses med room. During an interview on 5/22/18 at 10:20 a.m., resident #4 stated resident #1 was out on the patio by herself, on fire. He stated it took about ten minutes to get someone to her and to call EMS to get her to the hospital. He stated sometimes there wasn't any staff out there when the residents were smoking. He stated there was a code on the door so no one escapes. Observations: Resident #1 was observed on 5/22/18 at 8:45 a.m., lying in bed. Resident #1 had blackened areas to the left side of her face/cheek and mouth. Resident #1 had her oxygen on at 4.5 liters per nasal cannula. Resident #1 was calling for help, and stated she was in pain. The surveyor notified staff member E. Resident #1 continued to call out for help at 8:51 a.m., staff member F told the resident he would be right there. At 8:55 a.m. staff member F took resident #1 pain medication. Resident #1's oxygen tubing was not on, and staff member F placed the cannula on resident #1's face. Resident #1 was observed in her room sitting on the edge of her bed on 5/22/18 at 1:00 p.m. She was hunched over and moaning. Resident #1 stated she remembered burning her face. She stated There was a gal on the deck who gave them to me, when speaking of her cigarette. Resident #1 said it was another resident who gave the cigarette to her. Resident #1 stated she was not able to punch the code for the door, to get out of the smoking area. Resident #1 was observed on 5/23/18 at 6:00 a.m. She was moaning and groaning for help. Resident #1's blackened areas remained on her face. Two staff members went in the room at 6:10 a.m. to help her. During an observation of the smoking area on 5/22/18 at 9:40 a.m., there was a sign posted next to the door leading to the smoking area. The smoking area was located down stairs right outside of the dining room. The sign showed, one staff member from either floor to be out with residents. Staff will hand out one cigarette to each resident for each session. Staff make sure no lighter, matches, cigarettes are with residents. Return lock box to Gold Rush. There was a key pad next to the door that needed a code entered before you could open the door and go out to the smoking area. There was no fire extinguisher or fire blanket readily accessible in the smoking area. There was a no oxygen sign posted in the dining room just by the door of the smoking area. The sign on the wall read smoking times were 6:30 a.m., 9:30 a.m., 1:30 p.m., 4:30 p.m., and 8:30 p.m. During an observation on 5/24/18 at 10:35 a.m., two residents were observed sitting in the smoking area. Both stated they knew the code to get out of the building to the smoking area. During an observation on 5/24/18 at 1:30 p.m., eight residents were observed in the smoking area with one staff member. None of the residents wore a smoking apron. During an interview on 5/22/18 at 10:00 a.m., staff member G stated resident #1 had been caught smoking in her room before by staff, and staff member B told her that there was no safe discharge plan in place, and the resident would be allowed to continue to smoke, but staff would keep the cigarettes and lighter. She stated the resident was found after that smoking again, and the resident was once again given a warning. Resident #1 was then moved down stairs. Staff member G stated the resident was caught on three different occasions smoking and was still allowed to smoke. During an interview on 5/22/18 at 12:00 p.m., staff member M stated that she was not at the facility at the time of the incident with resident #1 but the nurses are supposed to keep the smoking materials and do not enforce it. She stated the management staff knew the nurses were not enforcing the locking up of the smoking materials. During an interview on 5/22/18 at 12:07 p.m., staff member I stated all the materials are locked up. He stated there are no smoking aprons for the residents to wear. He stated he had heard resident #1 got the cigarette from someone else but did not know who. During an interview on 5/22/18 at 1:30 p.m., staff member A stated prior to the incident with resident #1 the residents were allowed to smoke independently. She stated resident #1 was let outside by a therapist. She stated the residents were allowed to keep their materials in their room. She stated prior to the incident with resident #1, the residents were not required to sign the smoking policy. Staff member A stated she was aware of the incident on 5/1/18 with resident #1. During an interview on 5/22/18 at 2:42 p.m., staff member P stated the facility had the smoking aprons for some time now. She stated the management staff knew the smoking aprons were at the facility, and she was told by staff member D to put the aprons out on 5/22/18. During an interview on 5/23/18 at 6:15 a.m., resident #10 stated he .used to be able to keep his cigarettes and lighter and everything until resident #1 blew herself up . He stated the staff kept everything now and he does not like wearing the aprons when smoking. During an interview on 5/23/18 at 7:00 a.m., staff member L stated resident #1 has had numerous problems with breaking the smoking policy. She stated the resident was caught smoking in the dining room and in her room. She stated staff member D was notified of these instances. Staff member L said the staff would take the resident's cigarettes and lighters away, and the management would come in and say the resident could smoke and it was her right. During an interview on 5/23/18 at 7:00 a.m., staff member L stated resident #2 was smoking in her bathroom on the night of 5/21/18. She stated there was smoke in the bathroom, and the staff found the lighter on the shelf. She stated there were ashes on the toilet seat and a cigarette in the resident's hand. She stated they could see the smoke when they went in the bathroom. Staff member L said she reported the incident to staff member D. Staff member L said that as of about two weeks ago the staff were to go out with the residents when they smoked, prior to that, the staff did not go out with them. She stated there were no smoking aprons available currently. During an interview with staff member B on 5/23/18 at 7:29 a.m., he stated when resident #1 broke the policy he spoke with her about it and had resident #1 sign a smoking policy on 3/1/18. Staff member B stated he did not think he had documented the conversation with resident #1 on 3/1/18. During an interview on 5/23/18 at 10:55 a.m., staff member E stated he was alerted by a staff member that resident #1 needed help into the facility and was on fire. He stated he was by the nurses desk and when he got to the smoking door resident #1 was on fire at her shoulder area. He stated resident #1 probably could not have used the code and gotten outside by herself. He stated staff member F ran outside and doused the flame and made sure the oxygen tank was off. Staff member E stated part of the resident's w/c was smoking around the arm rest area. He stated resident #1 was hollering out. He stated he did not ask her if she had cigarettes and a lighter, and he did not check. 2. Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Interdisciplinary progress notes in resident #2's medical record showed the following information: Progress note dated 5/8/18 at 10:04 a.m. - While I was in my morning meeting, a CNA came in asked that someone come and speak to the resident because she was outside smoking . Progress note dated 5/21/18 at 6:30 p.m. - CNA caught resident smoking in her bathroom. CNA took lighter that was lying on the shelf. Rsdt denied having any more cigarettes. This writer spoke w/ rsdt and reminded her of the smoking rules. Rsdt voiced understanding and said it would not happen again. Room check done when rsdt downstairs. 0 cigarettes or lighter found.(sic) A review of resident #2's undated plan of care showed the resident's cigarettes and lighter are to be stored in a locked container and distributed to be during assigned smoking times. A review resident #2's plan of care dated, 5/4/18, showed the residents cigarettes and lighter are to be stored in a locked container and distributed during assigned smoking times. A review of resident #2's smoking assessment dated , 5/2/18, showed the resident had cognitive and vision deficits. The facility needed to store the lighter and cigarettes for the resident, and the plan of care was used to assure the resident was safe while smoking. A review of a signed smoking policy for resident #2, dated 5/2/18, included residents are not allowed to possess cigarettes and lighters in the facility, and independent smokers will store lighter/matches in the lock box in the Goldrush nurses med room. During an observation on 5/22/18 at 7:30 a.m., there were no smoke detectors in the resident rooms or bathrooms. During an observation on 5/23/18 at 1:20 p.m., resident #2 was ambulating in the hall, wearing a purple gown with small burn holes, which appeared to be cigarette burns, in the front. 3. Resident #3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #3 was oxygen dependent. Review of Interdisciplinary progress notes in resident #3's medical record showed the following information: Review of a smoking assessment dated [DATE] showed the resident had a vision deficit, needed the facility to store the cigarettes and lighter, and the plan of care was used to assure resident was safe while smoking. Review of a signed smoking policy, without a date, included residents were not allowed to possess cigarettes and lighters in the facility, and independent smokers will store lighter/matches in the lock box in the Goldrush nurses med room. Review resident #3's careplan, dated 5/2/18, showed her cigarettes and lighter were to be in a locked container, and would be distributed to her by staff during assigned smoking times. Review of the facility policy, titled Smoking Policy Residents updated Nov (YEAR), included, . Designated smoking areas include: . smoking aprons, or devices to assist residents in smoking . any smoking-related privileges, restrictions, and concerns (for example, need for close monitoring) shall be noted on the resident's individual care plan. The care plan will indicate how the smoking materials will be stored, i.e. secure/locked cabinets for residents deemed to be safe to smoke independently, allowing independent residents to maintain their smoking material on their own person, maintence of all smoking material at a secure designated area of another system as indicated to meet the residents need and within the ability of the facility . During an interview on 5/22/18 at 9:30 a.m., staff member A stated she met weekly with staff member B to go over things. She stated she had access to look things up in the computer system to see things like incident reports, census, admits, and discharges, therefore, staff member A was aware of resident events. During an interview on 5/22/18 at 1:40 p.m. resident #5 stated there was an accident with a lady with oxygen so now there was new procedures that everyone wears aprons, and the staff keep cigarettes and lighters locked up. During an interview on 5/22/18 at 2:42 p.m., staff member P stated the facility had the smoking aprons for some time now. She stated the management staff knew the smoking aprons were at the facility, and she was told by staff member D to put the aprons out on 5/22/18. A review of the packing slip for the aprons was dated 5/26/17. During an interview on 5/23/18 at 6:20 a.m., staff member N stated when staff members B and D were hired and started their administrative oversight for the facility, the smoking materials were not locked up. She stated she has smelled cigarette smoke in the building before but it could be from the outside. She stated there have been no smoking aprons available for the past year. During an interview on 5/24/18 at 2:30 p.m., staff member O stated resident #2 is the only person that is required to wear an apron now.

Based on interview, record review, and observation, facility administration failed to provide adequate oversight for the safety of residents, while smoking, which affected 3 (#s 1, 2, and 3) of 20 sampled residents. Resident #1 had actual harm from second [MEDICAL CONDITION] while smoking with oxygen. Resident #1 had three incidents of smoking in inappropriate places, times, and with oxygen in place. The facility failed to asses the smoking area for safety, perform smoking assessments, care plan, follow through with the smoking policy, provide smoking aprons and equipment as needed for residents, monitor and supervise residents while smoking, and provide for the safety of others. Findings include: On 5/23/18 at 11:59 a.m., the facility Administrator, Administrator in Training, and the Director of Clinical Services, were notified that an Immediate Jeopardy situation was identified for the areas of deficient practice, which included F689 Accidents and Hazards, and F835 Administration. The Severity and Scope was identified at the level of J, and upon the removal of the immediacy for the deficient practices, the severity and scope would be lowered to a G. 1. Resident #1 had been seen by staff smoking in the building on 3/2/18, 3/11/18 two times, and again on 5/1/18 when she was on fire and received second [MEDICAL CONDITION] her face.(Refer to F689) Staff members B and D were notified each time resident #1 was smoking where she should not have been either by phone or in person. A review of the facility smoking assessment for resident #1 showed the facility needed to store the lighter and cigarettes for resident #1 so she would not have access to cigarettes and lighters. Resident #1's smoking assessment revealed she was independent with smoking. During an interview on 5/22/18 at 1:30 p.m., staff member A stated prior to the incident with resident #1, the residents were allowed to smoke independently. She stated resident #1 was let outside by a therapist. She stated the residents were allowed to keep their materials in their room. She stated prior to the incident with resident #1, the residents were not required to sign the smoking policy. Staff member A stated she was aware of the incident on 5/1/18 with resident #1. During an interview on 5/23/18 at 7:00 a.m., staff member L stated resident #1 had numerous problems with breaking the smoking policy. She stated the resident was caught smoking in the dining room, and in her room. She stated staff member D was notified of these instances. Staff member L said the staff would take the resident's cigarettes and lighters away, and the management would come in and say the resident could smoke, it was her right. During an interview on 5/23/18 at 7:29 a.m., staff member B stated he spoke with resident #1 on 3/1/18 about the smoking incident in the dining room with her oxygen on and in place. He stated he educated her on the policy and resident #1 signed the smoking policy. He stated he did not think he documented the education. He stated a resident would only need to use a smoking apron if deemed so through the smoking assessment. During an interview on 5/23/18 at 6:15 a.m., resident #10 stated he .used to be able to keep his cigarettes and lighter and everything until resident #1 blew herself up . He stated the staff kept everything now, and he does not like wearing the aprons when smoking. During an interview on 5/22/18 at 10:00 a.m., staff member G stated resident #1 had been caught smoking in her room before by staff, and staff member B told her that there was no safe discharge plan in place, and the resident would be allowed to continue to smoke, but staff would keep the cigarettes and lighter. She stated the resident was found after that smoking again, and the resident was once again given a warning. Resident #1 was then moved down stairs. Staff member G stated the resident was caught on three different occasions smoking and was still allowed to smoke. 2. Resident #2 had been caught smoking in the building, and not during smoking times, on 5/8/18 and again on 5/21/18. During an observation on 5/23/18 at 1:20 p.m., resident #2 was wearing a purple gown with small burn holes, in the front of the gown, which appeared to be cigarette burns. During an interview on 5/23/18 at 7:00 a.m., staff member L stated resident #2 was smoking in her bathroom on the night of 5/21/18. Staff member L said she reported the incident to staff member D. Staff member L said that, as of about two weeks ago, the staff were to go out with the residents when they smoke. Prior to that the staff did not go out with them. She stated there were no smoking aprons available currently. 3. Resident #3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #3 wore oxygen at all times. During an observation on 5/24/18 at 1:30 p.m., eight residents were observed in the smoking area with one staff member. None of the residents wore a smoking apron. During an interview on 5/22/18 at 2:42 p.m., staff member P stated the facility had the smoking aprons for some time now. She stated the management staff knew the smoking aprons were at the facility. A review of the packing slip for the aprons was dated 5/26/17. Review of resident #3's smoking assessment dated [DATE] showed the facility needed to store the cigarettes and lighter. The smoking assessment showed resident #3 had a vision deficit. Review of the facility policy, titled Smoking Policy Residents updated Nov (YEAR) included, . Designated smoking areas include: . smoking aprons, or devices to assist residents in smoking . any smoking-related privileges, restrictions, and concerns (for example, need for close monitoring) shall be noted on the resident's individual care plan. The care plan will indicate how the smoking materials will be stored, i.e. secure/locked cabinets for residents deemed to be safe to smoke independently, allowing independent residents to maintain their smoking material on their own person, maintenance of all smoking material at a secure designated area of another system as indicated to meet the residents need and within the ability of the facility During an interview on 5/22/18 at 9:30 a.m., staff member A stated she met weekly with staff member B to go over things. She stated she had access to look things up in the computer system to see things like incident reports, census, admits, and discharges. During an interview on 5/23/18 at 6:20 a.m., staff member N stated when staff members B and D were hired and started their administrative oversight of the facility, the smoking materials were not locked up. She stated she has smelled cigarette smoke in the building before. She stated there have been no smoking aprons available for the past year. During an observation on 5/22/18 at 7:30 a.m., there were no smoke detectors in the resident rooms or bathrooms. During an observation of the smoking area on 5/22/18 at 9:40 a.m., there was no fire extinguisher or fire blanket readily accessible in the smoking area.

Based on interview, and record review, facility failed to protect 1 (#1) of 20 sampled residents from neglect of care causing harm while smoking. Findings include: Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #1 was admitted to Hospice services on 5/8/18 and passed away the morning of 5/24/18. Resident #1 had been seen by staff smoking in the building on 3/2/18, 3/11/18 two times, and again on 5/1/18 when she was on fire and received second [MEDICAL CONDITION] her face. (Refer to F689) Review of resident #1's Interdisciplinary progress notes showed the following information: Review of resident #1 Progress Note dated 5/1/18 - Staff report resident got burned. Upon arrival resident yelling repeatedly he told me it was off, why would he tell me it was off. Noted circumoral burns/blackened areas extending upward on the face. Burns/blackened areas noted to L hand -primarily around index, middle and ring fingers. Resident reportedly was smoking and did not remove her oxygen tubing from her face. Resident angry and lashing out at staff, calling them names, accusing them of letting her get burned, stating 'I will own this building.' 911 called, ambulance arrived on scene and transported resident to ER for eval and treatment and to r/o [MEDICAL CONDITION] airway. Check of oxygen tank on residents wheelchair at this time-oxygen tank had been turned off prior to this writer arrival at resident. W/C and oxygen tank were still sitting on patio. Tubing was melted up to approx. 6' from oxygen tank. No further remains of tubing noted at that time. Overall resident upset and angry but stable.(sic) Review of resident #1's ER report dated 5/1/8 at 4:02 p.m., showed resident #1 received [MEDICAL CONDITION] on her usual liters of oxygen. Resident #1 reported to the ER physician she was not smoking but took a drag from another resident's cigarette when her oxygen ignited. She [MEDICAL CONDITION] her upper left lip and nares. During an interview on 5/22/18 at 10:20 a.m., resident #4 stated resident #1 was out on the patio by herself, on fire. He stated it took about ten minutes to get someone to her and to call EMS to get her to the hospital. He stated sometimes there wasn't any staff out there when the residents were smoking. He stated there was a code on the door so no one escapes. During an interview on 5/22/18 at 1:30 p.m., staff member A stated prior to the incident with resident #1 on 5/1/18 the residents were allowed to smoke independently. She stated resident #1 was let outside by a therapist. Staff member A stated she was aware of the incident on 5/1/18 with resident #1. During an interview on 5/23/18 at 10:55 a.m., staff member E stated he was alerted by a staff member that resident #1 needed help into the facility and was on fire. He stated he was by the nurses desk and when he got to the smoking door resident #1 was on fire at her shoulder area. He stated resident #1 probably could not have used the code and gotten outside by herself. He stated staff member F ran outside and doused the flame and made sure the oxygen tank was off. Staff member E stated part of the resident's w/c was smoking around the arm rest area. He stated resident #1 was hollering out. During an interview on 5/22/18 at 2:42 p.m., staff member P stated the facility had the smoking aprons for some time now. She stated the management staff knew the smoking aprons were at the facility, and she was told by staff member D to put the aprons out on 5/22/18. During an interview on 5/22/18 at 9:30 a.m., staff member A stated she met weekly with staff memebr B to go over things. She stated she had access to look things up in the computer system to see things like incident reports, census, admits, and discharges, therefore, staff member A was aware of resident #1's incident on 5/1/18.

Based on record review, and interview, the facility failed to report and investigate the event with a resident smoking with oxygen, without supervision, who received second degree burns, for 1 (#1) of 20 sampled residents. This had the potential to affect other residents who smoked that were on oxygen. Findings include: Resident #1 had been seen by staff smoking on 5/1/18 when she was on fire and received second [MEDICAL CONDITION] her face. Review of resident #1's Interdisciplinary progress notes in the medical record showed the following information: Review of resident #1 Progress Note dated 5/1/18 - Staff report resident got burned. Upon arrival resident yelling repeated he told me it was off, why would he tell me it was off. Noted circumoral burns/blackened areas extending upward on the face. Burns/blackened areas noted to L hand -primarily around index, middle and ring fingers. Resident reportedly was smoking and did not remove her oxygen tubing from her face. (Refer to F689) Review of resident #1's ER report dated 5/1/8 at 4:02 p.m., showed resident #1 received [MEDICAL CONDITION] on her usual liters of oxygen. (Refer to F689) During an interview on 5/22/18 at 12:55 p.m., staff member A stated the facility did not report the incident on 5/1/18 regarding resident #1. No investigation was provided before the exit.

Based on observation, interview, and record review, the facility failed to adequately assess a Foley catheter for 1 (#11) resident, who had not received adequate pericare, and who was found to have a urinary tract infection, of 17 sampled residents. Findings include: Resident #11 was admitted to the facility with a Foley catheter in place. During an interview on 12/6/17 at 11:10 a.m., resident #11 said she knew she was getting a UTI again, before she went to the hospital this last time. Resident #11 said she asked a nurse to check out her vaginal area and the catheter placement. The nurse told her she had dried feces crusted around the catheter where it was going into her bladder. Resident #11 said she thought staff member B was the nurse who had examined her. Resident #11 said she was not surprised to have another UTI because the CNAs wipe her from back to front most of the time. Review of resident #11's physician's history and physical from a hospital, dated 9/6/17, showed resident #11 had a Foley catheter placed May of 2017 due to her non-weight bearing status. The history and physical also showed the resident had no history of [MEDICAL CONDITION] bladder, retention, or other issues. Review of resident #11's physician discharge summary from a hospital, dated 9/13/17, showed resident #11 had a right ankle fracture in May of 2017, and was treated with an ORIF by an orthopaedic surgeon. Resident #11 had the surgical hardware removed in August of 2017, by an orthopaedic surgeon. The note showed resident #11 was to be minimal weight-bearing on her right leg. The note showed resident #11 resided in a skilled nursing facility because of her minimal weight-bearing status, and that problem is what necessitated her indwelling Foley catheter. Review of resident #11's physician history and physical from a hospital, dated 11/27/17, showed resident #11 had a chronic indwelling Foley catheter. The history and physical also showed, The patient has a history of recurrent urinary tract infections and has recently been on [MEDICATION NAME]. Most recent organisms grown were from 11/16/17, Klebiella pneumoniae resistant to [MEDICATION NAME] and Escherichia coli resistant to [MEDICATION NAME], sulbactam, [MEDICATION NAME], intermediate to [MEDICATION NAME] and [MEDICATION NAME]; both were ESBL negative. The patient has grown same organisms in October 2017 and E. coli in September 2017. She has had urine cultures demonstrated to be negative. Review of a physician's history and physical from a hospital, dated 11/27/17, showed under Assessment and Plan; 4. Urinary tract infection, not altogether clear why the patient needs ongoing Foley catheter drainage. This may be something to look at over time. She will be treated with IV [MEDICATION NAME] as opposed to previously selected third generation cephalosporin and the reason this is being done as it is an agent that is less likely to induce broad spectrum cephalosporins when compared to [MEDICATION NAME]. The patient's [MEDICATION NAME] will be stopped. It is not likely that [MEDICATION NAME] is going to have any effect on preventing urinary tract infections, and in fact, the only way to prevent UTIs in somebody with an indwelling Foley catheter is to remove it. During an interview on 12/6/17 at 1:39 p.m., staff member B said the facility had not done an assessment for resident #11's Foley catheter. A record review showed Resident #11 had a Bladder and Bowel Assessment Combined 2016 in her EHR, and the assessment was dated 5/17/17, but was not completed. Review of resident #11's care plan showed in her focus area for her catheter I have a history of UTI's (sic) and am susceptible to same. A request for information was submitted to the facility on [DATE] at 7:34 a.m., which included, the resident's physician orders, diagnosis, and an assessment for resident #11's Foley catheter. The facility did provide a physician's orders [REDACTED]. The medical record had not contained this information prior to this. The facility provided a copy of another physician's orders [REDACTED].

Based on observation, interview, and record review, the facility nursing staff failed to assess and manage a resident's pain, and proceeded with the provision of care when the resident voiced pain, was guarding, wincing, and showing other indicators of pain, to include calling out and in pain, during the care, for 1 (#417) of 17 sampled residents. Findings include: During an observation and interview on 12/6/17 at 12:27 p.m., staff member I positioned resident #417 for a treatment. She lowered the head of resident #417's bed and he winced and said, Ow. Staff member I proceeded to lift resident #417's right leg with one hand under his upper leg and one under his lower leg. Resident #417 called out in pain, grimaced, and guarded the hip area. Staff member I stated, can you hear that cracking in his hip? She proceeded to reposition the resident by abducting the right hip, and placing a pillow under his right leg. Throughout the process, the resident intermittently called out, Ow, grimaced, winced, and guarded the right hip by drawing it in, as staff member I attempted to abduct it. Staff member I completed a treatment to the resident's penis, skin folds, and scrotum. He continued to call out and display nonverbal pain indicators. After the treatment, staff member I attempted to reposition resident #417 again in preparation for the sacral wound care and dressing change. Resident #417 called out, and grimaced, and verbalized he had pain to his right hip, tailbone, and wound area. Staff member I continued to attempt repositioning, and resident #417 withdrew his right leg, and called out, that hurts. Staff member I did not ask resident #417 what level of pain he was experiencing. She did not ask him if he needed pain medication. She stated resident #417 received scheduled [MEDICATION NAME] twice a day and she did not know when he received his last dose of pain medication. Resident #417 stated he might have had a pain pill at 12:00 (noon), but was still hurting a lot. At this point in the observation, 12:50 p.m., the surveyor asked the nurse if she would like to stop, assess resident #417's pain, provide appropriate treatment, and continue the wound care later. Staff member I stated she would. Staff member I told resident #417 she would check to see if he could have a pain pill. After a few minutes, staff member I returned with staff member J. Staff member J stated resident #417 had his scheduled pain medication at 10:18 a.m., and she would give him his prn [MEDICATION NAME] (pain medication). Staff member J gave the pain medication at 12:57 p.m. Staff member J stated the staff would give the prn pain medication more frequently, within the parameters of the order. Review of resident #417's MAR for 12/6/17 showed the [MEDICATION NAME] was given at 12:30 p.m. and the results of the effectiveness were unknown. During an observation on 12/6/17 at 4:47 p.m., staff member I stated, to resident #417, she was going to do the wound care and dressing change. Resident #417 stated he had a lot of pain to his wound area. Staff member I stated NF8 would be in to see the resident tomorrow and would address his pain. Resident #417 stated he had a lot of pain. Staff member I asked resident #417 if he wanted to wait until tomorrow to have his dressing changed, and he said yes. During an interview and record review on 12/6/17 at 4:53 p.m., staff member B stated comfort was the priority for resident #417. She stated she had spoken to NF8 regarding the resident's pain and the instruction was to continue the scheduled pain medications and to offer the prn pain medication as ordered. Staff member B provided a progress note showing the information regarding the conversation she had with NF8. Review of resident #417's December 2017 MAR indicated [REDACTED]. The MAR indicated [REDACTED] -12/6/17 at 4:28 p.m., for a pain level of 9. Results showed as effective. -12/7/17 at 7:53 a.m., for a pain level of 7. Results showed as unknown. -12/7/17 at 7:17 p.m., for a pain level of 7. Results showed as effective. -12/8/17 at 8:03 a.m., for a pain level of 9. Results showed as unknown. -12/9/17 at 10:48 p.m., for a pain level of 8. Results showed as effective. -12/10/17 at 3:08 a.m., for a pain level of 7. Results showed as effective. -12/10/17 at 1:02 p.m., for a pain level of 9. Results showed as ineffective. -12/11/17 at 12:44 a.m., for a pain level of 6. Results showed as effective. -12/11/17 at 6:40 a.m., for a pain level of 8. Results were not recorded at 8:20 a.m., the time of the record review. The MAR indicated [REDACTED]. Resident #417 received one dose on 12/10/17 at 10:08 a.m., for a pain level of 8. Results showed as ineffective. The MAR indicated [REDACTED]. One order showed the nurse was to complete a functional pain assessment and indicate functional pain score of 0-5. The second order showed the nurse was to monitor for pain and document yes if pain was monitored and no pain was observed or verbalized, or document no if pain was monitored and was observed or verbalized. The order showed directions to choose the code Other/See Nurse Notes and enter findings in appropriate progress note, including the pain level on a scale of 1-10. Review of resident #417's EHR showed no evidence resident #417's pain was monitored every four hours and prn pain medication was offered every four hours. Documentation of resident #417's pain was consistently rated 6-9 when it was documented, and there were gaps of 12 hours or more between doses of prn pain medication. During an observation on 12/11/17 at 8:27 a.m., staff member I and staff member R positioned resident #417 for a treatment, sacral wound care, and dressing change. Resident #417 winced and grimaced when his right leg was moved or head of his bed was lowered or raised. Staff member I stated resident #417 had a pain medication due at 10:00 a.m. and they would give it to him early, after the treatment, and sacral wound care and dressing change, were done. Staff member J was resident #417's nurse at the time, and she was in attendance in the room. As staff member I did the treatment, resident #417 winced, withdrew, and put his right hand in the air, and made a motion as if pushing staff member I away. Staff member I completed the treatment and stated the sacral wound care and dressing change would not be done at that time due to resident #417's pain. During an interview and record review on 12/11/17 at 9:30 a.m., staff member B stated the facility charted only by exception. She stated pain would be an exception that should be charted. Staff member B stated the pain monitor order, on the December 2017 MAR, did not have the correct monitors to show if resident #417 had pain. She stated she had been correcting erroneously written orders but had focused on medication orders, and had not gotten to all the monitors. Staff member B stated there should be documentation if prn pain meds were offered and refused. She stated the signatures on the order to monitor pain every shift (twice a day), and the administration of prn pain medication, was the only evidence that resident #417 had been monitored for pain. There was no evidence in resident #417's record the provider had been contacted for further instruction regarding management of the resident's pain. Review of a facility policy titled, Pain Assessment and Management, revised April 2016, showed, If pain has not been adequately controlled, the multidisciplinary team, including the physician, shall reconsider approaches and make adjustments as indicated.

Based on record review and interview, the facility failed to prevent, assess and treat pressure ulcers that worsened and became infected for 1 (#14) of 15 sampled residents. Findings include: Resident #14 was readmitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. Review of the nursing progress notes for resident #15 dated 8/18/15 showed Resident has a new blister on R buttock. Review of the Progress Note dated 9/8/15 showed (the resident) has a 2nd stage on right buttocks and 3rd to 4th stage on right hip. Review of the Medical Record showed no other documentation regarding the buttock and hip wounds until 9/16/15, which included Wound Care Skin Integrity Evaluation. Review of this record showed 3 stage III pressure ulcers, facility acquired. Review of the Progress Notes dated 10/16/15 showed a large amount of foul smelling drainage to the right medial buttock, stage III. Review of the Progress Notes dated 10/23/15 showed Eschar, foul drainage. Review of the Progress Notes dated 11/4/15 showed the wound had increased in size and continued to have a large amount of foul drainage. Review of the Treatment Administration Record dated 9/01/15 through 9/30/15 showed the treatment for [REDACTED]. It's original development was documented on 8/18/15. During an interview on 5/11/16 at 9:30 a.m., staff member C stated the facility could not find any other paper work related to the resident's treatment and worsening of the pressure sores. She also stated they did not have a skin program in place until sometime in October. Review of the Physician orders [REDACTED]. Also, the patient needs PEG tube. Review of the Hospital Course notes dated 12/10/15 showed, The most significant decubitus ulcer was involving the right buttock. Cultures of the decubitus [MEDICAL CONDITION]. He was found to have extensive protein calorie malnutrition. Review of the progress notes dated 12/10/15 showed resident #14 returned to the facility with IV medications [MEDICAL CONDITION] in the wounds, and he passed away on 1/9/16.

Based on observation, record review and interview, the facility failed to care for 1 (#1) of 15 sampled residents in a manner and environment that promoted maintenance or enhancement of her quality of life resulting in isolation and a loss of self-worth. Specifically, the facility failed to provide: activities, clean room, room free of clutter, home-like room, bathing for one month, the opportunity to get out of the room, stimulation, ordered equipment for contractures & comfort, and dignity. Findings include: During an observation on 5/09/16 at 7:45 a.m., resident #1 was laying in bed, in a dark room, hooked to an Enteral formula pump. Her eyes were open, and the television (TV) was playing a crime show. During an observation on 5/09/16 at 5:00 p.m., the resident was still laying in bed with the TV on, hooked to the pump. The program was a crime show. During an observation on 5/10/16 at 7:20 a.m., the resident's floor was dirty by her bed with old grime, a piece of garbage and an old glove. The tube feeding pump was dirty and had splatters on it. No foot cradle or hand split were observed. Review of the quarterly MDS, with the ARD of 4/19/16, showed the resident was in a Persistent Vegetative State. During an interview on 5/10/16 at 8:00 a.m., staff member V stated she had not worked with this resident for communication, cognition, or swallowing ability. I screen people when I have been told of a change. She did not know if resident #1 had been seen by a speech pathologist in the past. During an observation on 5/10/16 at 9:00 a.m., resident #1 had a breast exposed while in bed, and the window was open. I asked the resident if she was cold. She looked at me and opened her mouth. Her room contained a Hoyer lift and tracheal care supplies. The room was dark. The floor and pump were still dirty. Her closet was messy; her chair was piled high with blankets, pillows and stuffed animals. There were empty supply boxes on the floor. There was a vase of dead flowers on the dresser all four days of the survey. A crime show was playing on the TV. During an interview on 5/10/16 at 4:35 p.m., staff member B stated she thought the supplies were kept in the resident's room for staff convenience. During an interview on 5/10/16 at 12:45 p.m., staff member S stated she would get the resident up when a certain other staff member was at the facility to work with her. She stated she didn't have time on Monday or Tuesday. During an observation on at 5/11/16, at 10:05 a.m., the resident was placed in her chair. She was not removed from her room, but remained in front of the TV, watching crime shows, hooked to the tube feeding. During an interview on 5/12/16 at 1:40 p.m., staff members S and T stated they did not remove resident #1 from her room, because there was nothing for her to do. She does love to watch activities. During an observation of trachea care on 5/11/16 at 1:00 p.m., resident #1 was observed to be smiling and watching the staff member. Her lower body was exposed. Staff member G covered her up as he left the room. Review of the activity flow sheets for resident #1 showed: a. 2 room visits and 1 manicure for the month of February. b. 1 room visit, 1 school activity, and 1 Easter egg hunt for the month of March. c. 1 Sensory Fun and 1 Mothers day tea party for the month of May. d. 2 room visits, 1 school activity, and 1 birthday celebration for the month of April. The other 108 days for these months were listed as TV for her activity. Review of the Room Visit by activities on 5/06/16 showed the activity staff member went into her room. I found some love movies for her to watch. We talked about which one's she might like. She got really excited about 'Happy Ever After'. Review of the Room Visit dated 4/16/16 showed (resident) was all smiles when I walked in. When I mentioned she had a birthday coming up she got really excited and started kicking her leg. During an interview on 5/10/16 at 2:30 p.m., staff member L was asked how the facility knew resident #1 liked crime movies. She stated the resident liked love stories, and she liked to be around kids. She loved music. No music was played during the survey hours in resident #1's room. Review of the facility bath records showed no bath was provided for resident #1 for the month of April. During an interview on 5/11/16 at 5:00 p.m., staff member B said it could be a documentation error.

Based on record review, interview, and observation, the facility failed to provide adequate post fall treatment and assessments for 2 (#s 7 and 11), resulting in injury, and, failed to provide timely pressure ulcer assessments and treatments to prevent the worsening and infection of pressure ulcers, and provide a therapeutic dose of anti-[MEDICAL CONDITION] medication for 1 (#14) of 15 sampled residents. Findings include: 1. Resident #14 was readmitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. A. Review of the Physician order [REDACTED]. On 5/14/15 the level was 6.6 and flagged as low. The therapeutic range was identified as 10-20 ug/ml. Review of the lab work dated 6/2/15 showed a [MEDICATION NAME] level of 7.9, which was again below a therapeutic range. The [MEDICATION NAME] level at the hospital was 5.5. The [MEDICATION NAME] level was drawn on 12/31/15, after the [MEDICAL CONDITION], and was low at 5.3. During an interview on 5/12/16 at 10:35 a.m., a family member stated the hospital told her the [MEDICATION NAME] level was low. She was surprised, because the facility had always said it was fine. When resident #14 returned the facility on 12/10/15, she told nursing he needed an increase in his dosage. Review of the medical record showed the facility did not address the resident's low [MEDICATION NAME] level. During an interview on 5/12/16 at 3:15 p.m., staff member H stated it was just a skosh low, and the doctor may have chosen not to do any changes. The facility could not find evidence the physician had reviewed the [MEDICATION NAME] levels for 2015. Review of the Progress Notes dated 12/29/15 showed the resident had a [MEDICAL CONDITION] that lasted about 2 minutes. The resident was unresponsive for 15 to 20 minutes after. B. Review of resident #14's progress notes dated 12/10/15 showed he returned with orders for IV [MEDICATION NAME]. Review of the nurses progress notes for 12/13/15 showed a dose of [MEDICATION NAME] missed by night shift, did not realize it should have been started @0600. Given this a.m. Review of the December MAR indicated [REDACTED]. Review of the Progress Notes dated 12/30/15 showed called pharmacy when residents [MEDICATION NAME] did not come in with courier, they stated we have to talk to the main pharmacy when it opens. 2. Resident # 11 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. During an interview on 5/10/16 at 5:00 p.m., resident #11 stated she had fallen in the bathroom and fractured five ribs last fall. She further stated she had requested to go to the emergency room multiple times and was told she did not need to go. Finally, she demanded the facility call an ambulance to send her to the emergency room or she would call one herself. Resident #11 stated the pain was so severe she could not stand it any longer. Review of the MDS, with an ARD of 5/1/16, showed resident #11's cognition was 13 and was not impaired. Resident #11 needed stand by assist with ambulation and transfers. Review of the Care Plan, with an initial date of 7/12/15, showed a focus for Fall Prevention: My last fall assessment was done upon admission. Per that assessment, I am at risk for falls due to hx of falls. The care plan was not updated until 4/20/16, after resident #11 had 2 falls with major injuries. Review of the nurses notes showed: 9/29/15 at 2035 Resident had witnessed fall in bathroom at 1945. Attempting to sit on the toilet and fell between the sink and wall. Did not hit head, no injury noted. Does report some back pain. VSS .Will monitor. 9/30/15 had 5 doses of [MEDICATION NAME] 5/325mg with 3 of the pain levels at 9. 10/1/15 had 5 doses of [MEDICATION NAME] 5/325 mg with 1 pain level at 9 and 1 pain level at 10. 10/2/15 had 5 doses of [MEDICATION NAME] 5/325 mg with 1 pain level at 9. 10/3/15 had 5 doses of [MEDICATION NAME] 5/325 mg with 3 pain levels at 9 and 1 pain level at 10, and 2 doses of Tylenol 500 mg for pain levels of 8 and 9. 10/4/15 had 3 doses of [MEDICATION NAME] 5/325 mg with 1 at a pain level of 9. 10/5/15 had 4 does of [MEDICATION NAME] 5/325 mg with 2 pain levels at 9, and 2 doses of Tylenol 500 mg for pain levels at 8 and 9. 10/6/15 had 2 doses of [MEDICATION NAME] 5/325 mg prior to going to the ER with a pain level of 9 and 1 pain level at 10. 10/6/15 5:32 a.m., Resident asked for a [MEDICATION NAME] at 0450. I told aide to tell her I can bring her one at 5:30ish, and she could have another at that time. The aide came back and told me (resident name) wants to go to the hospital immediately because of pain .The problem with residents increased pain this last week is she had a fall in her bathroom last week. She has a x-large bruise from under her arm down to her hip. Review of the MAR for September 2015 showed an order for [REDACTED]. Review of the physician progress notes [REDACTED].large ecchymotic area to her L hip and rib area, there is mild tenderness to palpation .She states the pain is mostly to her L rib area. I am going to send her over for an X-ray to her L rib cage and L hip to ensure there are no fractures. Patient states the pain is constant and achy in nature. Review of the physician orders [REDACTED]. Review of the emergency room Note dated 10/06/15 under EKG and Imaging showed; Impression: Multiple lower rib fractures, moderated sized pleural effusion; Medical Decision Making: Pt was discharged back to (facility name) with instructions to increase her [MEDICATION NAME] dosing and keep using her oxygen. Pt is treated empirically for pneumonia. She understands she needs repeat chest x-ray and repeat examination in approximately three days .I presume that her pleural effusion is reasonably stable given that the trauma occurred 1 week ago. Review of chest X-ray dated 10/6/15 showed left lower rib fractures. Left pleural effusion with associated compressive atelectasis. Review of the Patient Instructions sheet from the Emergency Department showed resident #11 was to see own physician in 2-3 days and increase of [MEDICATION NAME] of 1-2 tablet every 4 hours as needed. Review of the physician progress notes [REDACTED]. Reports the pain is making it difficult to breathe .She was suppose to return in 3 days for repeat chest X-ray. She has not been evaluated since 10/6/15. Review of the X-ray report dated 10/13/16 showed; Impression: moderate sized left pleural fluid collection, likely pleural effusion or hemothorax in the setting of trauma. During an interview on 5/12/16 at 8:20 a.m., staff member C stated she was not sure why the follow-up x-rays were not completed as ordered by the ER physician. During an interview on 5/12/16 at 9:15 a.m., staff member E stated staff kept telling me they could hear lung sounds and there was nothing wrong with her. I could see bruising a day or 2 later. (Resident) would say she wanted to go to the ER and then she would say she didn't want to go. During an interview on 5/12/16 at 9:30 a.m., staff member N stated if a resident asked to go to the ER, the facility would send them, that was their choice. During an interview on 5/12/16 at 8:50 a.m., resident #11 stated she had asked to go to the ER everyday after the fall on 9/29/15 because of the pain. Resident #11 stated she was told the pain was musculoskeletal and the resident did not need to go to the hospital. Resident #11 stated she argued with staff member E about going to the ER. 3. During the initial tour interview on 5/9/16 at 8:00 a.m., staff member B said resident #7 had fallen in the facility and sustained a fractured pelvis. Review of the resident's record reflected she had fallen at her home in February 2016 and suffered a periprosthetic fracture around her interior prosthetic right hip. Review of a physician's orders [REDACTED]. In an interview on 5/12/16 at 11:15 a.m., staff member B said the resident had no additional falls between 3/11/16 at 3/15/16. Review of the resident's progress notes, showed the following falls. -3/30/16, room [ROOM NUMBER] near foot of bed. 0400 (4:00 a.m.) No witnesses. Pt. was toileted prior to laying down around 9:30 a.m. Pt. refused at 000 (12:00 midnight). Evening aid didn't turn on alarm on bed. -3/28/16, 2300 (11:00 p.m.), Resident was found at 2300 sitting on the floor leaning up against the bed. She said she was reaching for cell phone and slid out of bed. -3/16/16, 13:08 (1:08 p.m.) found on floor laying on L side between recliner and bathroom door. She had removed O2, call light, prior to attempting to self ambulate. Resident states she was attempting to use bathroom. -3/11/16, rsdt fell at 1600 (4:00 p.m.) found laying in doorway on L side. Review of the March 2016 MARs reflected prn pain medications [MEDICATION NAME] and [MEDICATION NAME] as the pain medications available before March 15th. The MARs showed the [MEDICATION NAME] (give 25 mg every 6 hours as needed for pain 1 tab for pain within a scale of 1 to 3 and 2 tabs for a pain scale of 4 to 10). The March MARs also reflected [MEDICATION NAME] tablet prn for pain 650 mg. Following the 3/11/16 fall, the MARs reflected the resident received [MEDICATION NAME] on 3/13/16 at 2113 (9:13 p.m.) for a pain rating of 5, 3/14/16 at 8:00 a.m. for a pain rating of 8 and 3/14/16 at 2105 (9:05 p.m.) for a pain rating of 10. Review of the progress notes from 3/11/16 to 3/15/16 reflected notes on the resident's prn pain medication which was received as noted on the MARs (3/13/16 and 3/14/16) but not with regards to the resident's status. In an interview on 5/12/16 at 2:40 p.m., staff member B said the COMs were another place nurses documented on the upper level residents. Review of the record showed documentation for 3/11/16 at 3:59 p.m., 3/12/16 at 12:49 p.m., 3/13/16 at 12:21 p.m., 3/15/16 at 3:16 a.m. and 3/15/16 at 10:19 a.m. There was no monitoring of resident #7's status on 3/14/16. The 3/11/16 record reflected ice being applied to the right hip for pain but did not mention the fall. The 3/12/16 entry reflected the resident had pain at a rating of 4 to the right hip area. The 3/13/16 entry did not suggest pain in the hip area. The 3/15/16 entry at 3:16 a.m., reflected the resident had severe leg pain. The entry of 3/15/16 at 10:19 a.m. showed the resident with pain in left leg and a fax was sent to the MD to report pain in the left leg. In an interview on 5/12/16 at 10:35 a.m., staff member P said they decided to send the resident to the ER because she was complaining of pain in the left groin area, and not weight bearing. Review of the doctor's orders, dated 3/16/16, reflected a [DIAGNOSES REDACTED].P.T. - Please inform that in addition to rehab for recent right [MEDICAL CONDITION]; pt now also has acute fx left superior & inferior pubic ramus . Review of the ER visit report dated 3/15/16 reflected that the visit was made at 14:15 (2:15 p.m.). This report reflected the resident was limited by short term memory impairment. The daughter reported the nursing staff at (the nursing home) told her that the pt was complaining of left hip pain. The daughter was also told that pt (sic) has fallen 2-3 times in the past week. Flexion to 45 degrees hurts in the proximal left hip and prevented any further flexion. Left hip x-ray impression left pubic fracture. This elderly woman presents after a fall while rehabilitating from open reduction and internal fixation of a right [MEDICAL CONDITION]. She now has left hip discomfort and evaluation shows an acute [MEDICAL CONDITION] superior and inferior pubic rami. In an interview on 5/11/16 at 4:07 p.m., the POA, said resident #7 was complaining of horrible pain two days before she was taken to the ER. She was hurting so bad it took 5 people to lift her onto the exam table at the ER. She had reached a point in her rehab that she was weight bearing before the fall and this fracture set her back. During an interview on 5/12/16 at 2:40 p.m., staff member B said she probably should have gone out to ER the night before.

Based on clinical record review, policy review and staff interview, the facility staff failed to provide care that facilitated bowel management for 2 (#s 4 and 7) of 15 sampled residents. Findings included: 1. Resident #7 was admitted to the facility on [DATE]; [DIAGNOSES REDACTED]. A Quarterly MDS was completed with an ARD of 5/11/11. The resident required the limited assistance of one person with toilet use (G0110 I 2/2). Based on CNA flow sheets from February-July 2011, the resident did not have a bowel movement on the following days: from 2/2/11 through 2/7/11 (6 days); from 2/10/11 through 2/13/11 (4 days); 4/21/11 through 4/25/11 (5 days); 4/30/11 through 5/3/11 (4 days); 5/31/11 through 6/5/11 (5 days); and 6/10/11 through 6/13/11 (4 days). On 3/20/11, the facility sent a fax to the resident's physician. The fax stated that the resident was having chronic diarrhea? since 3/14/11, and requested that the scheduled [MEDICATION NAME] and [MEDICATION NAME] medications be changed to PRN. The order was changed and noted on 3/21/11. A nursing note in the interdisciplinary notes from 6/14/11 at 16:55 (4:55 p.m.) was reviewed. The note included: "Removed fecal impaction (with) lubricated finger. Rsdt c/o (complained of) pain X1 (once), hard formed stool removed fairly easily". The interdisciplinary note from 7/2/11 at 19:00 (7:00 p.m.) was reviewed. The note included: "Rsdt having difficulty passing BM. This nurse palpated peri area and noted hard mass of feces in rectum. Broke up impaction (with) lubricated finger and removed". The MARs from March through June 2011 were reviewed. There was no indication that the PRN [MEDICATION NAME] or [MEDICATION NAME] was given during the four month period. A review of resident #7's current care plan did not contain updated information related to bowel management or hydration. ?MDS 3.0 definition of fecal impaction states, "a large mass of dry, hard stool that can develop in the rectum due to chronic constipation. This may be so hard that the resident is unable to move it from the rectum. Watery stool from higher in the bowel or irritation from the impaction may move around the mass and leak out, causing soiling, often a sign of fecal impaction." CMS's RAI Version 3.0 Manual page H-13. 2. Resident #4 was admitted to the facility on [DATE]; [DIAGNOSES REDACTED]. A quarterly MDS assessment was completed with an ARD of 4/13/11. The resident required extensive assistance with transfers, toileting and personal hygiene (G0110 1 B, I, J, 3). Based on the CNA Flow Sheet, the resident did not have a bowel movement from 6/10/11 through 6/18/11 (9 days). The physician had prescribed two bowel management medications, Milk of Magnesia and [MEDICATION NAME] suppository to be used every day as needed. Neither medication was administered from 6/10/11 through 6/18/11. The facility's bowel management protocol included the following guideline: "No resident will go longer than 3 days without a BM, without intervention." On 7/6/11 at 10:30 a.m., staff members B, D, and E were informed of the concern. No additional bowel documentation or interventions were provided.