Every finding on record at New Hope Manor

Based on observation, interview, and record review, the facility failed to follow the menu for 7 of 30 residents reviewed (Resident #11, Resident #12, Resident #26, Resident #29, Resident #54, Resident #66) for diet orders. The facility failed to ensure dietary staff served ground meat on 3/16/2026 for residents on a mechanical soft diet. This failure could place residents on mechanical soft diets at risk of choking and not receiving adequate nutrition.Findings included: Record review of Resident #11's face sheet dated 3/18/2026 reflected a [AGE] year-old female readmitted on [DATE]. Record review of Resident #11's MDS assessment dated [DATE] reflected a BIMS score of 3, which indicated severely impaired cognition. Section I reflected that Resident #11 had diagnoses of non-traumatic brain dysfunction, hypertension (high blood pressure), cerebral vascular accident (stroke), and depression. Section K reflected that Resident #11 had no episodes of choking during meals in the 7-day lookback period. Section GG reflected that Resident #11 required setup or clean-up assistance with eating. Record review of Resident #11's physician order dated 11/10/2025 reflected a diet order for a MECH SOFT diet. Record review of Resident #11's care plan last revised on 1/08/2026 reflected that Resident #11 required mechanically altered foods and staff were to assess her for signs and symptoms of aspiration. Record review of Resident #12's face sheet dated 3/18/2026 reflected a [AGE] year-old female readmitted on [DATE]. Record review of Resident #12's MDS assessment dated [DATE] reflected a BIMS score of 9, which indicated moderately impaired cognition. Section I reflected that Resident #12 had diagnoses of heart failure, hypertension (high blood pressure), cerebral vascular accident (stroke), non-Alzheimer's dementia (neurocognitive disease), malnutrition, and depression. Section K reflected that Resident #12 had no episodes of choking during meals in the 7-day lookback period. Section GG reflected that Resident #12 required setup or clean-up assistance with eating. Record review of Resident #12's diet order dated 7/23/2025 reflected she needed a REG DIET MECH SOFT MEATS. Record review of Resident #12's care plan last revised on 1/06/2026 reflected that Resident #12 required mechanically altered foods and staff were to assess her for signs and symptoms of aspiration. Record review of Resident #26's face sheet dated 3/18/2026 reflected a [AGE] year-old female readmitted on [DATE]. Record review of Resident #26's MDS assessment dated [DATE] reflected a BIMS score of 1, which indicated severely impaired cognition. Section GG reflected that Resident #26 required setup or clean-up assistance with eating. Section I reflected that Resident #26 had diagnoses of non-Alzheimer's dementia (neurocognitive disease), anxiety disorder, depression, chronic kidney disease, muscle weakness, and lack of coordination. Section K reflected that Resident #26 had no episodes of choking during meals in the 7-day lookback period. Record review of Resident #26's diet order dated 2/26/2025 reflected she needed a MECH SOFT diet. Record review of Resident #26's care plan last revised on 3/16/2026 reflected that Resident #26 required mechanically altered foods and staff were to assess her for signs and symptoms of aspiration. Record review of Resident #29's face sheet dated 3/18/2026 reflected a [AGE] year-old female readmitted on [DATE]. Record review of Resident #29's MDS assessment dated [DATE] reflected a BIMS score of 3, which indicated severely impaired cognition. Section GG reflected that Resident #29 required supervision or touching assistance with eating. Section I reflected that Resident #29 had diagnoses of status post stroke, hypertension (high blood pressure), Alzheimer's disease (neurocognitive disease), malnutrition, depression, and anxiety disorder. Section K reflected that Resident #29 had no episodes of choking during meals in the 7-day lookback period. Record review of Resident #29's diet order dated 2/26/2025 reflected she needed a mechanical soft diet. Record review of Resident #29's care plan last revised on 3/05/2026 reflected Resident #29 required mechanically altered foods and staff were to assess her for signs and symptoms of aspiration. Record review of Resident #54's face sheet dated 3/18/2026 reflected a [AGE] year-old female admitted on [DATE]. Record review of Resident #54's MDS assessment dated [DATE] reflected a BIMS score of 8, which indicated moderately impaired cognition. Section GG reflected that Resident #54 required partial/moderate assistance with eating. Section I reflected that Resident #54 had diagnoses anemia, hypertension (high blood pressure), pneumonia, multidrug-resistant organism, hyperlipidemia (high cholesterol), arthritis, respiratory failure, and muscle weakness. Section K reflected that Resident #54 had one or more episodes of holding food in her mouth/cheeks or residual food in mouth after meals in the 7-day look-back period. Record review of Resident #54's diet order dated 2/19/2025 reflected she needed a MECH SOFT diet. Record review of Resident #54's care plan last revised on 3/02/2026 reflected t Resident #54 required mechanically altered foods and staff were to assess her for signs and symptoms of aspiration. Record review of Resident #66's face sheet dated 3/18/2026 reflected a [AGE] year-old female readmitted on [DATE]. Record review of Resident #66's MDS assessment dated [DATE] reflected a BIMS score of 5, which indicated severely impaired cognition. Section GG reflected that Resident #66 required setup or clean-up assistance with eating. Section I reflected that Resident #66 had diagnoses of status-post stroke, hypertension (high blood pressure), diabetes mellitus (uncontrolled blood sugar), hyperlipidemia (high cholesterol), seizure disorder, depression, malnutrition, and non-Alzheimer's dementia (neurocognitive disease), Section K reflected that Resident #66 no episodes of choking during meals in the 7-day look-back period. Record review of Resident #66's diet order dated 12/03/2023 reflected she needed a mechanical soft diet. Record review of Resident #66's care plan last revised on 2/20/2026 reflected that Resident #66 required mechanically altered foods and staff were to assess her for signs and symptoms of aspiration. During an observation of the kitchen on 3/16/2026 at 12:36 p.m. revealed that service line contained a turkey dish and there was no option with ground turkey-the pieces of meat were whole. During an observation and interview on 3/16/2026 at 2:39 p.m., Resident #12 was observed in bed, and she asked the surveyor what they thought about the length of her nails. During an observation on 3/16/2026 at 2:52 p.m., Resident #66 was sleeping in bed with her call light in reach. Resident #66 was unavailable for interview because she was sleeping. During an observation on 3/16/2026 at 3:24 p.m., Resident #29 was sleeping in bed with her call light in reach. Resident #29 was unavailable for interview because she was sleeping. During an observation and interview on 3/16/2026 at 3:47 p.m., Resident #11 was observed sitting in a geri chair in her room. Resident #11 said if her nails go much longer, she would need them trimmed. During an observation and interview on 3/17/2026 at 9:51 a.m., Resident #54 was observed in bed with her call light in reach. Resident #54 stated that she had concerns about her mattress being uncomfortable. During an observation and interview on 3/17/2026 at 10:08 a.m., Resident #26 was observed to be well groomed. Resident #26 said she just had her nails painted. During an interview on 3/17/2026 at 1:08 PM, Resident #54 stated that she did not have trouble eating her lunch the day prior on 3/16/2026. During an interview on 3/18/2026 at 10:36 a.m., the ST stated that she was familiar with Resident #11, Resident #12, Resident #26, Resident #29, Resident #54, and Resident #66. The ST stated that all of them had dysphagia except for Resident #29. The ST stated that Resident #54's dentures did not fit well, she liked to eat without them, and her dentition was the issue, not her swallowing. The ST stated that Resident #29 was on hospice, and a mechanical soft diet was recommended 2 years ago due to her cognition and for safety reasons. The ST stated that Resident #66 had dysphagia from a stroke, she did not wear her teeth, and she swallowed things whole. The ST stated that Resident #11 pocketed her food and was distractable during meals, so she had a swallow study. The ST stated that Resident #26 had a swallow study done because she had choked quite a bit in the past year. The ST stated that Resident #12 had dysphagia from a stroke. The ST stated that if meat were not ground, that cognitively, if they can't chew, they can choke or aspirate. The ST stated that residents might not know what to do with [the meat] and they could aspirate, choke, and get pneumonia. The ST stated if (the meat pieces) were big, I don't' think that would be safe. The ST stated that she would have put ground turkey in the pot pie. During an interview translated by HHSC translating services on 3/18/2026 at 11:50 a.m., the [NAME] stated she was trained via an online class and her manager trained her every week. The [NAME] stated that, depending on the meat, the meat gets pureed or it gets more cooked, so it gets more soft. The [NAME] stated no, I did not grind the meat. The [NAME] stated the meat was separated to cook longer for those on a mechanical soft diet. The [NAME] stated yes, there was a separate recipe for the mechanical soft turkey and that the recipe said the meat should have been ground. The [NAME] stated, if the meat is already soft, it doesn't have to be ground. The [NAME] stated, you always have to look at the quality of the meat. The [NAME] stated yes it was not necessary to grind the meat if it came soft already. The [NAME] stated, that day, the meat was digestible, so it wasn't ground. During an interview on 3/18/2026 at 12:47 p.m., the DM stated that meat needed to be ground for mechanical soft diets and that it should be like ground beef. The DM stated that staff were trained for 3-4 days when they started and then we check on them. The DM stated that cooks were trained on following recipes. The DM stated that on 3/16/2026, he did not check the service line, but the [NAME] told him that she had everything she needed for the three diets-regular, mechanical soft, and puree. The DM stated if residents on a mechanical soft diet received pieces of meat, they could choke. The DM stated he did not know why the [NAME] did not follow the recipe for ground turkey. The DM stated he was not sure if the [NAME] had a bad day or if she completely forgot. During an interview on 3/18/2026 at 4:34 p.m., the DON stated that she did not know who checked tray tickets on Monday 3/16/2026 but If residents on a mechanical soft diet received whole meats, it would increase the risk of choking. During an interview on 3/18/2026 at 4:50 p.m., the ADM stated that the DM trained the cooks and the [NAME] assumed that the turkey was small enough and she did not need to grind it. The ADM said the [NAME] had been in-serviced and it would be part of their training going forward. The ADM stated that charge nurses checked trays for accuracy and if residents on a mechanical soft diet received whole meats, they could choke. Record review of the facility's menu spreadsheet dated 3/16/2026 reflected that on Week 1 Monday, residents on a Mech Soft diet were to receive 6 ounces of ground turkey pot pie. Record review of the facility's recipe for 'Ground Turkey Pot Pie' dated 10/09/2025 reflected that staff were to place turkey in a food process and grind to an appropriate consistency. Record review of the facility's undated policy titled Texture Modified Policy reflected the following: The Mechanical Soft consistency is planned according to the Regular Consistency with the following exceptions:-Meat items are designated to be ground and served with a sauce, gravy or broth. All meat servings should be weighed to confirm proper portion as indicated on the menu/recipe.

Based on observation, interview, and record review the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable living environment to help prevent the development of transmission communicable diseases and infections for four (Resident #14, Resident #36, Resident #40, and Resident #68) of seven residents reviewed for infection control. 1.The facility failed to ensure the SW used the proper PPE prior to entering Resident #14's room on 3/16/2026. 2. The facility failed to ensure CNA B did not use the same disposable wipe to cleanse Resident #36's urostomy tubing from the stoma site and out the first time and wiped the suprapubic catheter tubing a second time and then used a clean wipe for the third wipe.3. The facility failed to ensure CNA B performed hand hygiene and change gloves after providing suprapubic catheter care to Resident #36.This failure could place residents at risk for transmission of disease and infection.Record review of Resident #14's face sheet dated 3/18/2026 reflected a [AGE] year-old female readmitted on [DATE]. Record review of Resident #14's MDS assessment dated [DATE] reflected a BIMS score of 15, which indicated no cognitive impairment. Record review of Resident #14's care plan last revised on 3/16/2026 reflected that she tested positive for ESBL in urine. Record review of Resident #14's Physician's Orders dated 3/16/2026 with an end date of 3/21/2026 reflected that she was on contact isolation for Diagnosis of VRE. Record review of Resident #36's undated face sheet revealed an [AGE] year-old male admitted to the facility on [DATE]. His diagnoses included benign prostatic hyperplasia with lower urinary tract symptoms (enlarged prostate with urinary symptoms involved), chronic kidney disease Stage 3b (moderate to severe kidney function loss. Symptoms include fatigue, swelling, and nausea), congestive heart failure (when the heart is not pumping as well as it should, and the body may not get the oxygen it needs), cerebral atherosclerosis (hardening of the arteries in the brain), and vascular dementia (changes in thinking and memory that occur when there isn't enough blood flow to part of the brain, as can happen with a stroke). Record review of Resident #36's Care Plan dated 03/18/2026 reflected: he had an indwelling suprapubic catheter. The goal reflected that the suprapubic catheter would remain in place without complications over the next 90 days. The approach reflected nursing to monitor for signs and symptoms of infection, bladder stones, septicemia (a serious bacterial infection that occurs when germs enter the bloodstream and spread throughout the body), hematuria (blood in the urine), skin breakdown, urine leakage around the catheter, and urinary tract infection, and to notify Medical Director of any abnormalities. Record review of Resident #36's Physician Orders reflected: Assure foley catheter in place with stat lock (StatLock was designed to minimize catheter movement). Enhanced barrier precautions for diagnosis of suprapubic catheter. Suprapubic catheter care every shift. Record review on 11/21/24 of Resident #36's Quarterly MDS assessment, dated 10/10/24 revealed a BIMS score of 14 indicating her cognition was intact. Further review of the MDS revealed Resident #36 was incontinent with bowel and bladder. Record review of Resident #40's Face Sheet, dated 03/18/2026, reflected an [AGE] year-old female, admitted [DATE] with diagnoses that included wedge compression fracture of vertebra (a type of spinal fracture where the front part of a vertebra collapses, creating a wedge-shaped deformity., subsequent encounter for fracture with routine healing), rash and other nonspecific skin eruption (an area of irritated or swollen skin, and skin changes that do not have a clear or defined cause), anxiety disorder (a mental health condition characterized by excessive, uncontrollable worry about everyday issues, affecting daily functioning and quality of life), hypothyroidism (thyroid gland doesn't produce enough thyroid hormone leading to a slowdown in metabolism), malaise (a general feeling of discomfort, illness, or unease), vascular dementia (a type of dementia caused by reduced or blocked blood flow to the brain, leading to brain cell damage and cognitive decline), and depression (a mood disorder that causes a persistent feeling of sadness and loss of interest). Record review of Resident #40's quarterly MDS dated [DATE], reflected a BIMS Score of 12, being moderately cognitively intact. Record review of Resident #40's Care Plan, dated 03/18/2026, reflected Resident #40 required assistance with bed mobility, bathing, hygiene, toileting, dressing, grooming, eating, and all assisted daily living care needs. The goals were for Resident #40 to maintain current level of function with assistance in his ADL care needs. Record review of Resident #68's Face Sheet, dated 03/18/2026, reflected an [AGE] year-old male, admitted [DATE] with diagnoses that included muscle wasting and atrophy lower left and right leg (loss of muscle mass and strength), muscle weakness (a condition where muscles cannot generate the expected amount of force, making movements more difficult than usual), difficulty in walking (hard to walk), lack of coordination (difficulty in controlling voluntary movements, resulting in clumsy, unsteady, or awkward motions), metabolic encephalopathy (a brain dysfunction that occurs due to systemic metabolic disturbances), atherosclerotic heart disease (the condition where plaque builds up in the coronary arteries, leading to reduced blood flow to the heart and increasing the risk of heart attacks and other cardiovascular issues), chronic kidney disease (a long-term condition in which the kidneys gradually lose their ability to filter waste and maintain essential bodily functions), and anxiety disorder (a mental health condition characterized by excessive, uncontrollable worry about everyday issues, affecting daily functioning and quality of life). Record review of Resident #68's quarterly MDS dated [DATE], reflected a BIMS Score of 7, which being cognitively impaired. Record review of Resident #68's Care Plan, dated 02/27/2026, reflected Resident #68 required assistance with bed mobility, bathing, hygiene, toileting, dressing, grooming, eating, and all assisted daily living care needs. The goals were for Resident #68 to maintain current level of function with assistance in his ADL care needs. During an observation and interview on 3/16/2026 at 11:20 a.m., Resident #14's room was observed to have PPE stocked in a drawer to the right of her room, but no signage was posted. CNA D stated that no PPE was required to enter Resident #14's room. Resident #14's door was open and Resident #14 said she had a bladder infection. During an observation on 3/16/2026 at 3:56 p.m., the SW was observed sitting on Resident #14's bed without any PPE. A sign was posted on the outer side of Resident #14's door to her room, which reflected that the resident was on contact precautions and a gown and gloves were required. During an observation on 03/17/2026 at 2:56 p.m. peri-care and suprapubic catheter care was conducted for Resident #36 with CNA B, who removed the soiled dressing around Resident #36's urostomy tube, and placed it in the trash receptacle. She did not conduct handwashing/hand hygiene and a glove change and then began cleansing the suprapubic catheter from the stoma site and out approximately 5 inches with a disposable wipe. CNA B folded the same wipe in half and cleansed the suprapubic catheter from the stoma site and out approximately 5 inches. She again did not conduct handwashing/hand hygiene and a glove change. CNA B then provided Resident #36 with peri-care. CNA B removed the soiled gloves and conducted hand hygiene and then put on clean gloves and cleansed Resident #36's bottom. During an interview on 03/17/26 at 3:18 p.m. CNA B stated she had folded the disposable wipe she had used to cleanse the urostomy tubing from the stoma site and out the first time and wiped the suprapubic catheter tubing a second time and then used a clean wipe for the third wipe. CNA B also stated she had realized she should have performed hand hygiene and a glove change should have been done after providing suprapubic catheter care. CNA B stated she had worked in the facility for 1.5 years and she had received training on infection control, hand hygiene, and catheter care. She stated that not following infection control protocols when providing resident care could lead to the residents getting an infection. During an observation on 03/18/2026 at 11:14 a.m., it was revealed facility staff went into Resident #68 room to speak with the Resident and did not hand sanitize per EBP sign posted in front of Resident #68 room then proceeded to enter into Resident #40 room to speak with Resident and exited the Resident #40 room without hand sanitizing. During an interview on 03/18/2026 at 12:00 p.m. with Resident #68, he stated the following: he does not know if facility staff are hand sanitizing when coming into the room. During an observation on 03/18/2036 at 12:01 p.m. of Resident #68, he appeared to be clean, and groomed with no visual concerns. During an interview on 3/18/2026 at 12:25 p.m., the NP stated that Resident #14 was placed on contact precautions for vancomycin resistant enterococcus bacteria in the urine. The NP stated that the precautions started on Sunday 3/15/2026. The NP stated that Resident #14 needed to stay in her room because of the vulnerable population in the facility. The NP stated that's not appropriate in response to being asked about the SW being in Resident #14's room without PPE. During an interview on 03/18/2026 at 1:23 p.m. with Resident #40, she stated the following: she knows facility staff usually have gloves on coming into her room and she thinks facility staff are hand sanitizing when coming to and from her room. Resident #40 stated has not seen hand sanitizing taking place in front of her, but she believes facility staff are since the staff come in with gloves. During an observation on 03/18/2036 at 1:24 p.m. of Resident #40, she appeared to be clean and groomed with no forms of visual concerns. During an interview on 03/18/26 at 4:27 p.m. with the DON stated it should not be on one person to ensure staff are doing hand hygiene and following Infection Control measures. She stated QA staff, the DON and the ADON were responsible for ensuring staff are doing hand hygiene/following infection control measures when providing resident care, and it should not fall on one person. The QA staff, which include the DON, conduct competencies, check offs and training with staff members. She further stated they were in the process of hiring a DON. The DON stated the DON, ADON, and nursing services should be monitoring how staff are conducting hand hygiene and following infection control measures. The DON stated the policy on hand hygiene during peri-care and foley/suprapubic catheter care included 4 hand hygiene competencies, including when going from dirty-to-clean and from clean-to-dirty. She stated she would have to look at the competency of Foley/suprapubic care. She stated she had been trained in infection control/hand hygiene. She stated a potential negative outcome for the residents was that it primarily puts the residents at risk for different disease processes and risk of infection transmission. During an interview on 3/18/2026 at 4:34 p.m., the DON stated a gown and gloves was required for contact precautions. The DON stated that staff were trained on PPE competencies upon hire and annually. The DON stated that initially, Resident #14 was diagnosed with ESBL, then it was VRE. The DON stated that nursing had to get the precautions signage from housekeeping because it was locked up but she said that housekeeping was not there on weekends. The DON stated that the procedure changed to keep the signage at the nurses station. The DON stated that the SW got confused with enhanced barrier precautions and she thought that as long as she wasn't touching Resident #14, she could go in without PPE. The DON stated that the SW had been educated. The DON stated that if staff did not put on the proper PPE, they could transfer the infection to a different resident. During an interview on 03/18/26 at 4:45 p.m., the ADM stated the DON and the QA/IP nurse were responsible for ensuring staff were doing hand hygiene when providing resident care, going in and out of resident rooms, and following infection control measures. She stated the responsibility would fall on nursing services. She stated the DON would monitor how staff are conducting hand hygiene and following infection control measures. She stated the policy on hand hygiene included removing jewelry, washing hands with soap and water for 20 seconds, the amount of time singing the Happy Birthday song, dry hands with paper towels and use paper towels to turn off the water. The ADM stated she had been trained on infection control/hand hygiene. The ADM stated a potential negative outcome of not following infection control measures would be the risk of spreading infection to the residents. During an interview on 3/18/2026 at 4:50 p.m., the ADM stated that a gown and gloves were required for contact precautions and that Resident #14 was placed on contact isolation after 3 PM on Sunday 3/15/2026. The ADM stated, there was some confusion with the NP . The ADM stated that environmental services had been responsible for placing signage on residents' rooms, but they changed their process so that it would be nursing's responsibility since housekeeping went home at 3 PM. The ADM stated if staff did not don the proper PPE, they could transfer infection. Record review of EBP sign reflected Everyone must clean their hands, including before entering and when leaving the room. Review of the facility Policy and Procedure on Infection Preventon and Control, dated 11/28/2027, reflected, The facility shall investigate, control and/or prevent infections through implementation of an Infection Prevention and Control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections utilizing current state, federal, and CDC guidelines as indicated. Isolation and/or enhanced barrier precautions (EBP) practices are included and used when required. A Physician's order shall take precedence over other infection control guidelines. Employees are required to use appropriate hand-washing and/or ABHR after each direct resident contact when indicated by current state and federal guidelines. Universal/Standard Precautions shall be used in the care of residents with EBP to be utilized following current state and federal guidelines in conjunction with CDC guidance. The intent of this regulation is to ensure that the facility: Require staff to follow hand hygiene practices consistent with accepted standards of practice. Develop and implement an ongoing infection prevention and control program (IPCP) to prevent, recognize, and control the onset and spread of infection to the extent possible and review and update the IPCP annually and as necessary. Establishes facility-wide systems for the prevention, identification, investigation, and control of infections of residents, staff, and visitors. It must include an ongoing system of surveillance designed to identify possible communicable diseases or infections before they can spread to other people in the facility and procedures for reporting possible incidents of communicable disease or infections. Record review of facility in-service education for EBP documentation dated 01/07/2026 reflected to have been provided and not completed by nursing staff including CNA A, CNA B, CNA C, and LVN E. Record review of Handwashing and Hand Hygiene policy dated 08/2019 reflected This facility considers hand hygiene the primary means to prevent the spread of infections. All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors. Use an alcohol-based hand rub containing at least 62% alcohol; or, alternatively, soap (antimicrobial or non-antimicrobial) and water for the following: Before and after direct contact with residents. Before and after entering isolation precaution settings. Review of the facility Policy and Procedure on Hand Hygiene, dated 08/2019, reflected, Statement – The facility considers hand hygiene the primary means to prevent the spread of infection.1. All personnel shall be trained and regularly in-serviced on the importance of hand hygiene in preventing the transmission of healthcare-associated infections.2. All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infection to other personnel, residents, and visitors. 3. Use an alcohol-based hand rub containing at least 62% alcohol; or, alternatively, soap (antimicrobial or anti-microbial) and water for the following situations:a. Before and after direct contact with residents;b. Before and after handling an invasive device (e.g., urinary catheters, IV access sites);c. Before handling clean or soiled dressings, gauze pads, etc.;d. Before moving from a contaminated body site to a clean body site during resident care;e. After contact with a resident's skin;f. After handling used dressings, contaminated equipment, etc.;g. After contact with objects (e.g., medical equipment) in the immediate vicinity of the resident;h. After removing glovesi. Before and after entering isolation precaution settings4. The use of gloves does not replace hand washing/hand hygiene. Integration of glove use along with routine hand hygiene is recognized as the best practice for preventing healthcare-associated infections. Record review of facility in-service education for Infection Control including hand hygiene documentation dated 12/22/2025 reflected to have been provided and completed by nursing staff including CNA A, and CNA B, but not completed by CNA C, or LVN E. Record review of the facility's policy titled Isolation – Categories of Transmission-Based Precautions revised in October of 2018 reflected the following: Policy Statement Transmission-Based Precautions are initiated when a resident develops signs and symptoms of a transmissible infection; arrives for admission with symptoms of an infection; or has a laboratory confirmed infection; and is at risk of transmitting the infection to other residents. Contact Precautions-1. Contact Precautions may be implemented for residents known or suspected to be infected withmicroorganisms that can be transmitted by direct contact with the resident or indirect contact withenvironmental surfaces or resident-care items in the resident's environment.2. The decision on whether contact precautions are necessary will be evaluated on a case by case basis.3. The individual on contact precautions will be placed in a private room if possible. If a private room is notavailable, the Infection Preventionist will assess various risks associated with other resident placementoptions (e.g., cohorting, placing with a low risk roommate).4. Staff and visitors will wear gloves (clean, non-sterile) when entering the room.a. While caring for a resident, staff will change gloves after having contact with infective material (forexample, fecal material and wound drainage).b. Gloves will be removed and hand hygiene performed before leaving the room.c. Staff will avoid touching potentially contaminated environmental surfaces or items in the resident'sroom after gloves are removed.5. Staff and visitors will wear a disposable gown upon entering the room and remove before leaving the roomand avoid touching potentially contaminated surfaces with clothing after gown is removed. Facility Lesson, [NAME] (37435) - Infection Control No Notes

Based on observation, interview, and record review, the facility failed to ensure that all residents who were unable to carry out activities of daily living received the necessary services to maintain good grooming and personal hygiene for 2 of 8 (Resident #84 and Resident #102) residents reviewed for nail care. The facility failed to ensure Resident #84's and Resident #102's fingernails were trimmed. This failure placed residents at risk for poor grooming, poor personal hygiene, and skin tears.Findings included: Record review of Resident #84's face sheet dated 3/18/2026 reflected a [AGE] year-old male admitted on [DATE]. Record review of Resident #84's MDS assessment dated [DATE] reflected a BIMS score of 10, which indicated moderately impaired cognition. Section I reflected that Resident #84 had diagnoses of hypertension (high blood pressure), renal insufficiency (kidney disease), non-Alzheimer's dementia (neurocognitive disorder), Parkinson's disease (neurological disorder), and malnutrition. Section GG reflected that Resident #84 required supervision or touching assistance with personal hygiene. Record review of Resident #84's care plan last revised on 2/12/2026 reflected he had ADL deficit related to cognitive and physical limitations and staff were to anticipate and ensure his needs were met. During an observation and interview on 3/17/2026 at 9:48 a.m. revealed Resident #84 was sitting in his wheelchair and his fingernails were observed to have about 4 mm of whites showing. Resident #84 stated that he needed something to scratch his head but that he preferred his nails to be a little shorter. Resident #84 stated that he had been in the facility for three or four months and no one had asked him if he wanted his nails trimmed. Resident #84 stated that his last shower was on Saturday (3/14/2026) or Sunday (3/15/2026). During an observation and interview on 3/18/2026 at 9:11 a.m., CMA F stated that nail care was usually done in the shower because they were soft and easier to cut. CMA F stated that nurses did diabetic's nails and CNAs could trim nails if residents were not diabetic. CMA F stated that CNAs checked residents' nails after residents ate to make sure there was no food stuck. CMA F stated that Resident #84 was diabetic and she did not know when Resident #84's last shower was. During an observation CMA F walked into Resident #84's room, looked at Resident #84's fingernails, and walked out. CMA F stated that Resident #84's nails looked clean but needed to be cut. Record review of Resident #102's face sheet dated 3/18/2026 reflected a [AGE] year-old male admitted on [DATE]. Record review of Resident #102's MDS assessment dated [DATE] reflected a BIMS score of 3, which indicated severely impaired cognition. Section I reflected that Resident #102 had diagnoses of anxiety disorder and depression. Section GG reflected that Resident #84 required supervision or touching assistance with personal hygiene. Record review of Resident #102's care plan last revised on 3/14/2026 reflected that he had ADL deficit related to cognitive and physical limitations and staff were to anticipate and ensure his needs were met. During an observation and interview on 3/16/2026 at 10:58 a.m., Resident #102 was observed in his room. Resident #102's fingernails had about 3 mm of whites showing and he said he had been meaning to ask about getting his fingernails and toenails done. Resident #102 stated, I usually don't wear them this long and pointed at his hand. Resident #102 stated that his toenails were worse. During an interview on 3/18/2026 at 9:16 a.m., LNV G stated that nail care varied for every person. LVN G stated that for diabetics, staff did not do the toenails at all at the facility-she said diabetic residents were referred out to the podiatrist. LVN stated nail care for non-diabetics was done once a week on Sundays by aids or nurses. LVN G stated the AD or anyone who volunteers, organized a nail clinic as an activity once a week. During an observation and interview on 3/18/2026 at 9:19 a.m., LVN G was observed walking into Resident #102's room. LVN G then walked out and stated that Resident #102's fingernails were clean, not jagged, but probably needed to be trimmed. LVN G stated she was not Resident #102's nurse so she did not know if he refused care. During an interview on 3/18/2026 at 9:23 a.m., RN H stated that Resident #102 did not refuse care with her, and she did not know when his last shower was, but she could check. During an interview on 3/18/2026 at 4:28 p.m., the DON stated that CNAs trimmed and cleaned nails as needed. The DON said nurses timed nails as well. The DON stated they had podiatry services if they needed something more advanced. The DON said she had not seen Resident #84's or Resident #102's nails that week (3/16/2026-3/18/2026). The DON stated staff were trained on nail care during orientation and if residents did not receive nail care, it could increase risk for self-inflicted skin tears. During an interview on 3/18/2026 at 4:50 p.m., the ADM stated aides were supposed to do nail care as needed and staff had been trained. The ADM stated if residents did not receive nail care, they could get something underneath their nails, and it could cause infection if they scratched themselves. Record review of the facility's policy titled Activities of Daily Living (ADL), Supporting revised March 2018 reflected the following: Residents will be provided with care, treatment, and services as appropriate to maintain or improve their ability to carry out activities of daily living (ADLs). Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming, and personal and oral hygiene.2. Appropriate care and services will be provided for residents who are unable to carry out ADLs independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with: a. Hygiene (bathing, dressing, grooming, and oral care).

Based on observation, interview, and record review, the facility failed to make sure that drugs are stored properly and only authorized persons have access for 1 of 3 medication carts (MC #1) reviewed for drug storage and labeling. The facility failed to ensure MC #1, was locked, medications secured, and not accessible to other staff, residents, or visitors. This failure could place residents at risk of having unauthorized access to medications, decreased effectiveness of medication, or missing medications. Findings included: During an observation on 12/10/2025 at 8:24a.m., revealed MC #1, was in on 100-hall and unlocked. RN A was not on the hall while the medication cart was unlocked. MC #1 contained residents' prescription drugs, over the counter medications, and narcotics in a locked box in the medication cart. There was a resident walking past the medication cart while it was unlocked. During an interview with RN A on 12/10/2025 at 10:02a.m., she said she had been trained on medication storage. She said the policy was staff must lock the medication carts any time the medication cart was out of the staff members sight. She said if staff stepped away or turned their back the staff member was supposed to lock the medication cart. She said the person who was assigned to the medication cart at that time was responsible for ensuring it was locked. She said if it was left unlocked and unattended another nurse could get into the medication cart, or a resident and family member could get into the cart and take medications. She said everyone monitored to ensure that the medication cart were locked. She said staff monitored the medication carts through observation. She said she left the medication cart unlocked because a resident's lips were turning blue in the dining room and she ran to get her blood pressure cuff and forgot to lock the medication cart. During an interview with the DON on 12/10/2025 at 1:19p.m., she said she had been trained on medication storage. She said the policy was if the medication cart was out of sight of the staff it should be locked. She said the person who was on the medication cart was responsible for ensuring the medication cart was locked. She said all staff monitored to ensure staff were locking the medication cart. She said staff monitored by doing observations. She said if the medication cart was left unlocked and unattended anyone could get into the medication cart and access the medications. She also said the medication could get into the wrong hands and cause a drug diversion. She said all managers monitor to ensure the medication carts were locked. She said the managers monitored day to day by observations. She said that RN A had a situation in the dining room and forgot to lock the medication cart when she got her blood pressure cuff. During an interview with the ADM on 12/10/2025 at 1:30p.m., revealed that she had been trained on medication storage. She said the policy on the medication cart was that the medication cart should be locked any time staff walk away from the cart. She said the person on the cart was responsible for locking the cart. She said if the medication cart was left unlocked and unattended someone could get into the medication cart and steal medications, or a resident can get into the cart and have an adverse reaction. She said all the managers monitored to ensure staff were locking the carts. She said the managers monitored through observation. She said RN A did not lock the medication cart due to having an emergency and forgot because she was rushing back to the resident. Record review of Medication Labeling and Storage Policy dated 4/2019, revealed The facility stores all drugs and biologicals in a safe, secure, and orderly manner. Drugs and biologicals used in the facility are stored in locked compartments under proper temperature, light, and humidity controls. The nursing staff is responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner. Compartments (including, but not limited to, drawers, cabinets, rooms, refrigerators, carts, and boxes) containing drugs and biologicals are locked when not in use.

Based on interviews, and record review, the facility failed to incorporate recommendations from a PASRR evaluation report into a resident assessment, care planning, and transition of care for 1 (Resident #1) of 6 residents reviewed for PASRR services. The facility failed to submit a complete and accurate request for NFSS in the LTC online portal within 20 days after the IDT meeting. This failure could place residents who were PASRR positive at risk of not getting the PASARR services for a better quality of life and could lead to a decline in health. Findings included: Record review of Resident #1's face sheet, dated 08/13/2025, revealed a [AGE] year-old male, admitted to the facility on [DATE]. Resident #1's diagnoses included kidney failure, hypertension (high blood pressure), rash, cough, fever, lack of coordination, unsteadiness on feet, gastroesophageal reflux disease without esophagitis (heartburn), malaise (feeling of general discomfort), anxiety (feeling of uneasiness or worry), and unspecified intellectual disabilities (disorder characterized by less than average intelligence. Record review of Resident #1's Quarterly MDS, dated [DATE], revealed Resident #1 had a BIMS of 9 indicating moderate impairment. The MDS also indicated the resident had medically complex conditions, Hypertension (high blood pressure), End-stage renal disease, history of falling, weakness, and lack of coordination. Record review of Resident #1's care plan, dated revision date 08/05/2025, revealed Resident #1 was receiving rehabilitation therapy from the services of: Physical Therapy through PASRR services. Resident will complete therapy and achieve the highest level of functioning. The care plan also stated resident requires follow up on the PASRR level 2 screening. History of unspecified intellectual disabilities. Resident screening will be completed according to PASRR guidelines. The Care plan also stated the IDT meeting was on 02/19/2025. Record review of Resident #1's Preadmission Screening and Resident Review, dated 2/18/2025, revealed Resident #1 had intellectual disability. The PASRR indicated Resident #1 needed speech therapy. Record review of verification of Request for PASRR NFSS dated 04/14/2025 revealed the facility did not submit the request in the correct time limit of 20 business days from the IDT meeting. The Request was supposed to be submitted by 03/19/2025. During an interview with the ADM on 08/13/2025 at 1:51pm revealed she had not been trained on PASRR. She said that a resident had a PASRR completed before they were admitted to the facility. She said the MDS nurse was responsible for submitting the correct forms to the state agencies. She said she thought the facility had thirty days after the IDT meeting. She said if those forms were not submitted on time the resident would not get the PASRR services. She said she overlooked the email from the PASRR person with the state. She said she was not intending to disregard the email. She also said that Resident #1 was not denied therapy services. An interview with Resident #1 on 08/13/2024 at 2:03pm was unsuccessful. Resident was lying in bed. Resident appeared to be clean. No equipment was noted. During an interview with the MDS Nurse on 08/13/2025 at 2:26pm, revealed that she was not trained on PASRR. She said the MDSCPC was the one who did PASRR. She said the only thing she knew about PASRR was that a resident had to have the PASRR before they were admitted and then yearly. She said she did not know what the policy was. She said the MDSCPC was responsible for PASRR. She said she did not know who monitored for compliance because she did not do the PASRR's. She said she did not know when the PASSR Request for Specialized Services was supposed to be submitted. She said if not submitted, the resident would not get the services to which they were entitled. She did not know why Resident #1's request was not submitted timely to the NFSS. During an interview with the MDSCPC on 08/13/2025 at 2:38pm, revealed that she had been trained on PASRR. She said the resident had to have a PASRR before being admitted and when they got a new MD or ID diagnosis. She said she was responsible for submitting the forms to the correct state agencies. She said for a new resident the doctor would assess the resident and then she would do the PASRR. She said the process for identifying residents with MD or ID was through initial assessments, then the doctor would review the resident's history and tell her if the resident had a qualifying diagnosis. She said she would submit to the correct authority and if it were positive the facility would do an IDT meeting. She said she thought the facility had 30 days to submit the request form to NFSS. She said she did not know why she submitted the request to NFSS was submitted on 04/14/2025 instead of 03/19/2025. She also said that Resident #1 was already getting therapy services through Medicare part B. During an interview with CRNC on 08/13/2025 at 2:58pm, revealed she had not been trained on PASRR. She said the facility obtains a copy of the PASRR screening upon admission if coming from the hospital and if coming from home the facility did their own PASRR screening. She said the MDSCPC was responsible for making the appropriate referrals. She said that's something that would be noticed on the assessment if the resident had an MD or ID. She said she found out today that the facility had 20 days to submit the request to NFSS. She said that if the referral was not sent to the state agency the resident may not get the services through PASRR. She said she did not know why the facility delayed sending the referral to NFSS for Resident #1. She said that Resident #1 was getting services through his Medicare part B. Record review of Detail Item by Item Guide for Completing the Authorization Request for PASRR Nursing Facility Specialized Services Form Policy dated September 2023 revealed the NF has 20 business days from the date of the initial IDT or a specialized services review meeting to initiate all PASRR nursing facility specialized services (NFSS) for those with a positive PE for ID/DD recommended and agreed to at the meeting.

Based on observation, interview, and record review the facility failed to store food in accordance with professional standards for food service safety in the facility's only kitchen reviewed for kitchen sanitation. The facility kitchen staff failed to label and date 2 foods and discard of 1 food that was beyond use by date stored in the refrigerator. These failures could place residents at risk for food-borne illness and food contamination. The findings include: During an initial tour of the facility kitchen on 01/27/2025 beginning at 09:12 AM revealed the following: 1- 2-quart pitcher with a soup product that was unlabeled 1- serving tray with a sandwich that consisted of 2 pieces of white bread and 2 slices of cheese covered with saran wrap that was unlabeled 1- 2-quart pitcher labeled vejetale (sic) soup with use by date of 1-18-25. During an interview on 01/27/2025 at 09:15 AM with the CD she stated the items should be labeled and discarded by use by date. She stated the previous items would be discarded. She stated consumption by the resident could result in illness. During an interview on 01/29/2025 at 12:43 PM with the DS revealed his expectation for dietary staff were for all food to be labeled and dated and discarded when out of date. He stated consumption of unlabeled food or food beyond the use by date could lead to illness. During an interview on 01/29/2025 at 02:57 PM with the ADM revealed her expectation for dietary staff were for all food be marked and labeled. She stated the use by date varied on the food type. The ADM stated if the residents were to consume the food that was unlabeled or beyond the use by date could have caused illness. Record review of facility policy titled Food Storage dated 2021 revealed. Policy: Sufficient storage facilities will be provided to keep foods safe, wholesome, and appetizing. Food will be stored in an area that is clean, dry, and free from contaminants. Food will be stored, at appropriate temperatures and by methods designed to prevent contamination or cross contamination. Procedure: 12. Leftover food should be stored in covered containers or wrapped carefully and securely and clearly labeled and dated before being refrigerated. Leftover food must be used within 7 days or discarded as per the 2017 Federal Food Code. 13. Refrigerated food storage: f. All foods should be covered, labeled, and dated and routinely monitored to assure that foods (including leftovers) will be consumed by their safe use by dates, or frozen (where applicable), or discarded.

Based on observation, interview, and record review, the facility failed to properly store and label biologicals for 2 (200 and 400 halls and cart for 100 hall) of 6 medication carts reviewed for drug storage. The medication cart for the 200 and 400 halls had three unidentified loose pills. The medication cart for the 100-hall had one loose pill. These deficient practices could affect residents and result in a drug diversion due to medications not being properly disposed and secured. The findings were: Observation of medication cart for the 200 & 400 hall right side cart on 01/27/2025 at 11:07 AM revealed one round orange pill blank on both sides, one small round pill blank on one side and a non-legible letter on the other side. One small round white pill with L16 on one side and blank on the other side. LVN D was able to identify one pill as Levothyroxine, she identified the orange pill as Biscadoyl and thinks the other pill is melatonin. LVN D disposed of the pills into the sharp's container. During an interview on 01/27/2025 at 11:07 AM, LVN D stated she has not ever noticed any loose pills in the medication carts. LVN D stated everybody is responsible for checking the carts for loose pills and checking expiration dates. Staff are to check for loose pills at the beginning of their shifts. LVN D stated if a loose pill accidentally fell out of the cart there could be potential harm if someone accidentally took it. LVN D stated staff have been in-serviced on loose pills in the carts and the last in-service was probably weeks ago. During an interview on 01/27/2025 at 11:20 AM and on 01/28/2025 at 08:52 AM MA B stated she has noticed loose over the counter pills in the medication carts, and she disposes of them in the medication room when she finds them. MA B stated a potential harmful outcome for loose pills in the carts could lead to an issue with infection control. MA B stated the last in-service she received over loose pills in the carts was about a month ago . Observation of medication cart for the 100 hall 01/27/2025 at 11:48 AM revealed one oval pink pill with the number 5 on one side and 894 on the other side. LVN E was only able to identify the pill as Eliquis. LVN E disposed of the pills into the sharps container. During an interview on 01/27/2025 at 11:48 AM, LVN E stated she has not noticed any loose pills in the carts. LVN E stated if she or staff find any loose pills, they should try to figure out what kind of pill they are so they know where to properly dispose them. If narcotic, they are to dispose of them in the drug buster and report loose pills to DON right away. LVN E stated there could be a potential for harm for loose pills in the cart because if it fall out through a small hole in the cart and a resident could take it. LVN E stated every nurse should be checking their carts before they use them. LVN E stated it's been a while since she received an in-service on loose pills. During an interview on 01/28/2025 at 08:52 AM MA B stated sometimes staff get too careless when administering medications and go to fast and that can cause the pills to fall out of the bottles and we forget to find it and or dispose of it immediately. MA B stated if a pill falls staff are to try to find it and dispose of it in the drug buster in the medication room. Staff are to inform the DON of any loose pills in the cart. MA B voiced there could be some potential harm to the residents if there are loose pills in the carts because there are some residents that can't take certain medications and if they take them, it can be dangerous because every pill is different and some of them have to have them crushed and if they take it whole, they can choke. During an interview on 01/29/2025 at 09:09 AM MA C stated she has noticed some loose pills in the carts but not all the time. MA C stated if a pill falls when she is administering medications staff are supposed to dispose of it in the drug buster that is in the medication room. MA C stated loose pills in the medication carts could cause potential harm to the residents because staff might give the wrong medication to another resident by mistake so staff should dispose of any loose pills right away. During an interview on 01/29/2025 at 09:38 AM the ADON stated she has never noticed loose pills in the carts. If staff see loose pills in the carts, they should try to identify it and as long as it is not a narcotic medication, they can throw it away in sharps container. The ADON stated if it is a narcotic medication staff should have a witness with them when they discard of it in the drug buster. The ADON stated staff should let upper management know. The ADON stated if staff don't identify the pills and then give it to a resident that could be harmful to the resident. During an interview on 01/29/2025 at 10:03 AM the DON stated one staff member informed her that she dropped a pill so they searched for the pill in the whole cart and disposed of it in the drug buster. The DON stated staff have been informed to dispose of prescribed medications and or over the counter medications that fall inside the cart into a drug buster in the medication storage room. Staff have also been informed that if the medication is a narcotic, they are to discard the medication with another individual as a witness. The DON stated she does not see any potential harm to residents if there are loose pills in the carts. The DON verbalized nobody will be administering a loose pill that has been dropped in the cart. DON goes into carts to monitor routinely and staff are to check carts before their shifts start. Record review of the Policy/Procedure - Storage of Medications with a revision date of April 2019 revealed: Policy Statement: The facility stores all drugs and biologicals in a safe, secure, and orderly manner. Policy Interpretation and Implementation 2. Drugs and biologicals are store in the packaging, containers or other dispensing systems in which they are received. 3. The nursing staff is responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner. 10. Resident medications are stored separately from each other to prevent the possibility of mixing medications between residents.

Based on observation, interview, and record review, the facility failed to ensure that residents who needed respiratory care were provided such care, consistent with professional standards of practice, for 5of 7 residents (Residents #1, Residents #15, Residents #25, Residents #44 and Resident #84) reviewed for respiratory care The facility failed to ensure: 1. Resident #1, Resident #25, Resident #15, and Resident #44's nebulizing mask and tubing were bagged for sanitation when not in use as per the physician's order. 2. The nasal cannula of Resident #84 was uncovered and tucked under the handle of the oxygen concentrator, as observed on 01/27/25. This failure could affect residents who received respiratory services and place them at risk for respiratory infections. The findings included: Record review of Resident #1's face sheet on 01/28/25 revealed a [AGE] year-old female who was admitted to the facility on [DATE]. Her diagnoses were psychotic disturbance, mood disturbance, anxiety, Influenza due to unidentified influenza virus, Hypertension, Dementia and Acute respiratory disease. Record review on 01/28/25 of Resident #1's quarterly MDS assessment, dated 01/19/25 revealed a BIMS assessment could not be completed. Record review on 01/28/25 of Resident #1's care plan dated 12/04/24 did not indicate any respiratory issues or the need for medication using a nebulizer. Record review of Resident #1's physician's order reflected: 1.Ipratropium-Albuterol solution for nebulization; 0.5 mg-3 mg (2.5 mg base)/3 ml. Amount to Administer: One Vial (a small container); Inhalation. Frequency: Every 6 Hours. Start/end date: 01/23/2025 -Open Ended. 2. Replace nebulizer mask Q week and store in dated respiratory bag. Frequency Once a day on Sun, Start/end Date: 12/31/2024 -01/19/2025. Observation on 01/27/24 at 10:20am of Resident #1's room revealed, the mask of the nebulizer and tubing on the side table were exposed to the environment as it was not stored in its protective bag. Record review of Resident #44's face sheet on 01/28/25 revealed a [AGE] year-old male who was initially admitted to the facility on [DATE] and readmitted on [DATE]. His diagnoses were Dementia , intestinal obstruction, Schizoaffective disorder ( a type of mental illness), Dependence on wheelchair, Pain, Cough Hypertensive heart disease and Unsteadiness on feet. Record review on 01/28/25 of Resident #44's initial MDS assessment, dated 01/15/25 revealed a BIMS of 06 indicating severe cognitive impairment. The MDS identified Resident #44 had active diagnosis of COPD. Record review on 01/28/25 of Resident #44's care plan dated 11/20/24 did not indicate any respiratory issues and the need for medication using a nebulizer. Record review of Resident #44's physician's order reflected: 1.Ipratropium bromide solution; 0.02 %; Amount to Administer: 1 Vial; Inhalation. Frequency: Twice a day. Start/end date: 07/21/2023 -Open Ended. 2. Replace nebulizer mask Q week and store in dated respiratory bag. Frequency: Once a day on Sun, Start/end Date: 12/19/2024 -Open ended. Observation on 01/27/24 at 10:30am of Resident #44's room revealed, the mask of the nebulizer on the side table exposed to the environment as it was not stored in a dated respiratory bag as per the physician's order. Record review of Resident #15's face sheet on 01/28/25 revealed a [AGE] year-old male who was admitted to the facility on [DATE]. His diagnoses were Sepsis, Insomnia (lack of sleep), Hypertensive heart disease congestive heart failure ( Heart failure), Acute respiratory failure , Type 2 diabetes mellitus, Need for assistance with personal care and Muscle weakness. Record review on 01/28/25 of Resident #15's initial MDS assessment, dated 01/02/25 revealed a BIMS of 11 indicating moderate cognitive impairment. Record review on 01/28/25 of Resident #15's care plan dated 01/03/25 did not indicate any respiratory issues and the need for medication using a nebulizer for Resident #1. Record review of Resident #15's physician's order reflected: ipratropium-albuterol solution for nebulization; 0.5 mg-3 mg (2.5 mg base)/3 mL; Amount to Administer: ONE VIAL; inhalation Frequency: Twice a day. Start/end date : 01/22/2025 - 01/27/25. Replace nebulizer mask Q week and store in dated respiratory bag when in use. Frequency: once a day on Sunday. Start/end date : 01/20/2025-Open Ended. Observation on 01/27/24 at 10:40 am of Resident #15's room revealed, the mask of the nebulizer and tubing on the side table was exposed to the environment as it was not stored in a dated respiratory bag as per the physician's order. Record review of Resident #25's face sheet on 01/28/25 revealed a [AGE] year-old male who was admitted to the facility on [DATE]. His diagnoses were Dementia, anxiety, Cough, unspecified, psychotic disturbance, mood disturbance, anxiety, fatigue, Chronic kidney disease, stage 3 (A kidney failure with slow progression) ,Weakness and Shortness of breath. Record review on 01/28/25 of Resident #25's quarterly MDS assessment, dated 01/14/25 revealed a BIMS of 0 indicating severe cognitive impairment. MDS indicate Resident #25 had diagnosis of Acute respiratory failure with hypoxia ( respiratory failure with low oxygen intake) Record review on 01/28/25 of Resident #25's care plan dated 11/20/24 did not indicate any respiratory issues and the need for medication using a nebulizer. Record review of Resident #25's physician's order reflected: 1.Ipratropium-albuterol solution for nebulization; 0.5 mg-3 mg (2.5 mg base)/3 mL Amount to Administer: One Vial. Inhalation. Frequency: Twice a day. Start/end date: 01/15/2025 -01/24/2025. 1. Replace nebulizer mask Q week and store in dated respiratory bag when in use. Frequency: once a day on Sunday. Start/end date: 12/31/2024 -Open Ended. Observation on 01/27/24 at 11:55am of Resident #25's room revealed, the mask of the nebulizer and tubing on the side table was exposed to the environment as it was not stored in a dated respiratory bag as per the physician's order. Record review of Resident #84's face sheet dated 1/28/2025 revealed an [AGE] year-old female admitted on [DATE] with diagnoses including cerebral infarction (blood supply to the brain is disrupted causing a stroke), acute bronchiolitis (inflammation of the small airways of the lungs), dysphagia (difficulty swallowing), Gastrostomy status (presence of an artificial opening to the stomach in order to provide nutrition), and pneumonia (infection of air sacs in the lungs). Record review of Resident #84's admission MDS dated [DATE] revealed a BIMS score of 10 indicating mild cognitive impairment. Record review of Resident #84's care plan dated 01/03/2024 revealed Problem: Resident is at increased risk for MDRO (Multi drug resistant organism) related to g-tube/foley catheter, enhanced barrier protection to be used. Approaches included check for compliance with infection prevention practices (e.g. hand hygiene and PPE). No other care plans associated to oxygen or infection. Record review of Resident #84's order history dated 10/29/2024-01/29/2025 revealed oxygen during sleep titrates O2 to keep O2 saturations above 92%. During an observation on 01/27/25 at 10:47am in Resident#84's room revealed a nasal cannula (a tube used for administration of oxygen through the nose) tucked under the handle of the oxygen concentrator and not in a protective bag. During observation and interview on 01/27/2025 at 02:23 PM in Resident #84's room with the DON revealed the nasal cannula was uncovered and tucked under the handle of the oxygen concentrator. The DON stated that all soxygen items should have been in a respiratory bag. She stated that a negative impact to the resident could be infection. During an observations and interview with the DON on 01/27/25 starting at 2:05pm, Resident #1, Resident#44, Resident #15 and Resident #25's rooms revealed the masks and tubing of the nebulizers were not protected in a dated respiratory bag, as per the orders. The DON who witnessed the unprotected nebulizer masks stated masks were supposed to be sanitized before and after use and should have been stored in a protective bag whenever not in use. She stated this was necessary to avoid infections. During an observation by the surveyor and DON, and interview with the DON on 01/28/25 at beginning 9:10am, Resident #1, Resident #15, and Resident #25's rooms revealed the masks and tubing of the nebulizers were not protected in the bags. The DON stated she started in services on 01/27/25 regrading bagging respiratory tubes and masks when not in use. She stated there were staff members still there who had not participated in the refresher in service on bagging masks and tubing when not in use. She stated she would complete the in service for everyone so that all the staff would be educated and ensure that the medical equipment would be protected from contamination. During an interview on 01/29/25 at 1:30pm LVN G stated on 01/28/24 she received an in service on storing respiratory masks and tubing in a protective bag while not in use. She stated it was important to adhere to this practice to reduce the risk of transmitting contagious diseases. She stated she was careful to follow this practice in her nursing career. During an interview on 01/29/25 at 2: 15 pm the ADM stated she heard about the noncompliance in securing the respiratory masks and tubing in the protective bags . She stated the expectation was all staff to be compliant with infection control protocols. She stated the nebulizer masks and tubing were cleaned and safely stored in the protective bags provided. She stated there was a potential for respiratory infectious diseases with such a deficient practice. Record review of facility policies on 01/29/25 revealed there was no policy available for the safe storage of nebulizer and oxygen tubing and masks when not in use. When the Surveyor requested for the policy for safe storage of respiratory tubes and masks , the policy provided was on Oxygen Administration and there was no policy to address the issue in it.

Based on observations, interviews, and record review the facility failed to ensure the facility established and maintained an infection prevention program designed to provide a safe environment and to help prevent the transmission of communicable diseases for one of one staff (MA A) observed for infection control MA A failed to disinfect the blood pressure cuff in between Residents #19 and #40's during usage of obtaining their blood pressure readings for medication administration. This failure could place residents at increased risk of healthcare associated infections. Findings included: Review of Resident #19's Face Sheet reflected she was a [AGE] year-old female with an initial admitted [DATE] and readmitted [DATE]. Resident #19 has a diagnosis of pneumonia, anxiety, disturbances of salivary secretion, nausea, cellulitis of left lower limb (a common bacterial infection of the skin and underlying tissue), cerebrovascular disease ( a group of conditions that affect the blood vessels in the brain), weakness, pain in left finger(s), cerebral infarction (a condition where blood flow to the brain is interrupted, causing brain tissue to die), hordeolum externum left lower eyelid (refers to a medical term for a stye (bacterial infection) located on the outer edge of the lower left eyelid), essential primary hypertension, nasal congestion, shortness of breath, muscle wasting and atrophy. Review of Resident #19's MDS dated [DATE] reflected a BIMS score of 09 which indicated she is moderately impaired cognitively. Review of Resident #19's Care Plan 01/22/2025 reflected; Resident #19 with hypertension potential for complications. Prescribed medications in use. Effort will be made to have blood pressure within normal limits without further complications and not have any sign or symptoms of dehydration over the next 90 days. Review of Resident #40's Face Sheet reflected she was a [AGE] year-old female admitted on [DATE] with diagnoses of Alzheimer's disease, pain, needs for assistance with personal care, Hypertensive heart (a condition that develops when high blood pressure (hypertension) damages the heart over time) and chronic kidney disease (a long-term condition where the kidneys gradually lose their ability to filter waste products from the blood), lack of coordination (a neurological condition that affects the body's ability to plan and execute smooth, precise movements), weakness (the state or condition of lacking strength), fatigue (a feeling of tiredness, exhaustion, or lack of energy that can interfere with daily activities), allergic rhinitis (a common inflammatory condition of the nasal passages caused by an overreaction of the immune system to allergens), urinary tract infection and cough. Review of Resident #40's quarterly MDS dated [DATE] reflected a BIMS score of 07 which indicated she was severely impaired cognitively. Review of Resident #40's Care Plan dated 11/20/2024 reflected; Resident #40 with hypothyroidism (thyroid gland doesn't make enough thyroid hormone) potential for complications/uncomfortable symptoms. Prescriptions in use. Effort will be made to maintain thyroid hormone level within normal levels. Observation on 01/27/2025 beginning at 09:20 AM revealed MA A did not sanitize the blood pressure cuff in between each resident before and after checking blood pressures for Residents #19 and #40. In an interview on 01/28/2025 at 01:10 PM MA A stated this is her first Medication Aide job. MA A stated she did receive medication administration training during her new hire orientation, and she does not sanitize the blood pressure cuff in between residents. MA A stated she has never witnessed any other staff sanitizing the blood pressure cuffs in between residents. MA A voiced staff receive on going in-services pertaining to falls and cleaning carts, but she can't recall any trainings over blood pressure cuffs. MA A voiced she has been instructed to wash her hands with soap and water in between every three residents when administering medications. In an interview on 01/29/2025 at 08:52 AM, MA B stated she sanitizes the blood pressure cuff in between each resident to ensure infection control and to avoid transferring the flu or germs to other residents. MA B stated she received blood pressure and medication administration training during her new hire orientation and has been instructed to keep 2 blood pressure cuffs on her medication cart so she can alternate cuffs in between residents. MA B could not recall the last time she was in-serviced on blood pressure cuffs, but she verbalized staff are reminded frequently. In an interview on 01/29/2025 at 09:09 AM MA C stated the normal process for using blood pressure cuffs on residents is to wipe it down (sanitize) in between each resident to avoid passing germs. MA C stated staff had been instructed to have two cuffs on their carts so they can alternate them while they are drying off. MA C voiced she did receive blood pressure cuff training during her initial new hire orientation and could not recall the last time she was in-serviced over blood pressure cuffs. In an interview on 01/29/25 at 09:38 AM the ADON stated staff should be sanitizing the blood pressure cuffs with sanitizing wipes for infection control and if staff don't it could lead to germs being spread among residents. The ADON could not recall the last time staff were in-serviced over blood pressure cuffs but voiced they remind staff. In an interview on 01/29/2025 at 10:03 AM the DON stated staff are supposed to wipe blood pressure cuffs down with purple wipes in between each resident if staff don't it could affect infection control and contamination. The DON stated all new staff receive blood pressure cuff and medication administration training during new-hire orientation. The DON voiced staff get in-services anytime they see that type of practice being done in the facility. In an interview on 01/29/25 at 02:02 PM DON stated she is sure MA A received blood pressure cuff training in her new hire orientation. The DON voiced sometimes new hires tend to get overloaded with information and that might be why MA A doesn't recall getting the training during new hire orientation. The DON voiced the way to ensure staff are cleaning the cuffs in between residents it to make staff observations during medication passes and make sure staff are following behaviors. She will make sure to pull MA A to the side to provide a 1:1 education piece to close that gap. Surveyor requested blood pressure cuff and medication administration training records for MA A from DON. Did not receive records prior to exiting the facility. Review of Policy Review of Cleaning and disinfection of resident-care items and equipment with a revision date of October 2018 revealed: Policy Statement: Resident-care equipment, including reusable items and durable medical equipment will be cleaned and disinfected according to current CDC recommendations for disinfection and the OSHA Bloodborne Pathogens Standard. Policy Interpretation and Implementation 1. (d). Reusable items are cleaned and disinfected or sterilized between residents (e.g., stethoscopes, durable medical equipment). 2. (4). Reusable resident care equipment will be decontaminated and/or sterilized between residents according to manufacturer's instructions.

Based on interview and record review the facility failed to ensure residents were free of any significant medication errors for 1 of 3 residents (Resident#40) reviewed for significant med errors . The facility failed to ensure Resident #40's Metoprolol Succinate (prescribed to treat Atherosclerotic heart disease of native coronary artery without angina pectoris) was omitted during medication pass on the morning of 01/27/2025. This failure could place the resident at risk of not receiving the correct/prescribed medications as ordered. Findings include: Review of Resident #40's Face Sheet reflected she was a [AGE] year-old female admitted on [DATE] with diagnoses of Alzheimer's disease, pain, needs for assistance with personal care, Hypertensive heart (a condition that develops when high blood pressure (hypertension) damages the heart over time) and chronic kidney disease (damage or dysfunction of the kidneys), lack of coordination, weakness, fatigue, allergic rhinitis, urinary tract infection and cough. Review of Resident #40's quarterly MDS dated [DATE] reflected a BIMS score of 07 which indicated she was severely impaired cognitively. Review of Resident #40's Care Plan dated 11/29/2024 reflected; Resident #40 with hypertension potential complications. Prescription in use. Goal: Effort will be made for blood pressure remain within normal limits without further complications over next ninety days. Record review of Resident #40's Orders, start date 01/28/2025, reflected an order for Metoprolol Succinate tablet extended release 24 hour; 25 mg. Special instructions: Hold for systolic blood pressure less than 110 or heart rate less than 60. Give once a day. In an observation of medication pass on 01/27/2025 at 09:20 AM, MA A obtained a blood pressure cuff reading for Resident #40 with the following results of: BP 125/48 (Systolic blood pressure - top number is 125 and Diastolic blood pressure - bottom number is 48) with a heart rate of 66. Record review of Resident #40 medication orders revealed special instructions: Hold (omit) for systolic blood pressure less than 110 or heart rate less than 60. Give once a day. During an interview on 01/28/2025 at 01:10 PM MA A stated she probably got nervous while the surveyor was observing her administer medications and that is probably why she misread the order. MA A stated the whole purpose for the blood pressure medication is to help lower the blood pressure, if the medication is omitted the blood pressure will not go down. MA A stated the resident's blood pressure will not be regulated correctly and that's why they need the medication. MA A voiced she has not rec'd any in-service over med pass administration. During an interview on 01/29/2025 at 10:03 AM the DON stated if a resident doesn't get their blood pressure medication as prescribed it could lead to the resident having long term high blood pressure which could cause problems for the resident. The DON stated depending on how high the blood pressure was raised would be determine if it would be immediate harm. The DON stated new staff receive medication administration training during new-hire orientation and they get in-serviced all the time over medication administration. Record review on 01/29/2025 at10:36 AM revealed that on 11/19/2024 staff received in-service training over medication administration. MA A attended the training. Review of Policy Review of Administering Medications with a revision date of April 2019. Policy Statement: Medications are administered in a safe and timely manner, and as prescribed. Policy Interpretation and Implementation 4. Medications are administered in accordance with prescriber orders, including any required time frame.

Based on observation, interview, and record review the facility failed to ensure a resident who is fed by enteral means receives the appropriate treatment and services to prevent complications for 1 of 2 residents (Resident #84) reviewed for tube feeding. The facility failed to ensure Resident #84's formula bag and tubing set were changed out daily. This failure could place the resident as risk of illness, altered nutrition, and equipment malfunction. Findings included: Record review of Resident #84's face sheet dated 1/28/2025 revealed an [AGE] year-old female admitted on [DATE] with diagnoses including cerebral infarction (blood supply to the brain is disrupted causing a stroke), acute bronchiolitis (inflammation of the small airways of the lungs), dysphagia (difficulty swallowing), Gastrostomy status (presence of an artificial opening to the stomach in order to provide nutrition), and pneumonia (infection of air sacs in the lungs). Record review of Resident #84's admission MDS dated [DATE] revealed a BIMS score of 10 indicating mild cognitive impairment. Section K-Swallowing/Nutritional Status indicated resident received nourishment exclusively through a feeding tube. Record review of Resident #84's order history dated 10/29/2024-01/29/2025 revealed Enteral Feeding: Change bag QD and Enteral Feeding: Change irrigation set QD. Record review of Resident #84's care plan dated 11/11/2024 revealed Problem: Resident is NPO. Meds, nutrition, and fluids via j-tube. Goal: Effort will be made to prevent experience of an adverse effects from J-tube next 90 days. During observation on 01/27/2025 at 10:47 AM in Resident #84's room revealed Resident #84 receiving formula through an enteral feeding tube. The formula bag was dated and timed 1/27/25 0100 [01:00AM] in black marker. During interview and observation on 01/28/2025 at 01:56 PM in Resident #84's room with LVN G revealed resident receiving formula through an enteral feeding tube. The formula bag was dated and timed 1/27/25 0100 [01:00AM] in black marker. LVN G stated all enteral feeding bags had orders to be changed on the second shift (03:00PM-11:00PM). She stated she needed to review the documentation to verify the bag was changed. She then left the interview and returned with the DON. During an interview on 01/28/2025 at 02:13 PM with the DON revealed the nurse that was responsible for changing out the feeding bags was not at work. She stated that the nurse had worked extra hours and must have gotten the date wrong when she dated the bag. During an interview on 01/29/2025 at 11:06 AM, LVN G stated if a formula bag wasn't changed out as ordered then it could cause infection or spoilage. During an interview on 01/29/2025 at 01:11 PM with the DON revealed she expected her nursing staff to follow the orders. She stated not changing out the formula bag could lead to infections in the resident. During an interview on 01/29/2025 at 02:57 PM with the ADM revealed she expected staff to follow policy. She stated she was unsure of any impact to residents by not following policy.

Based on observation, interview, and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident that included measurable objectives and timetables to meet a resident's medical, nursing, and mental and psychosocial needs for 2 of 8 residents (Residents #23 and #61) reviewed for care plans. 1. The facility failed to update Resident #23's care plan to reflect current fall prevention interventions including a scoop mattress for fall prevention. 2. The facility failed to update Resident #61's care plan to reflect current advanced directives as Do Not Resuscitate. This failure placed residents at risk of not receiving the appropriate care to meet their current needs. Findings included: Record review of Resident #23's face sheet dated 01/29/2025 revealed an [AGE] year-old female admitted on [DATE] with diagnoses including Alzheimer's disease (a brain disorder that causes problems with memory, thinking, and behavior), unsteadiness on feet, need for assistance with personal care, repeated falls, and weakness. Record review of Resident #23's quarterly MDS dated [DATE] revealed the resident had a BIMS score of 1, which indicated her cognition was severely impaired. Record review of Resident #23's care plan dated 08/16/2022 and revised on 12/27/2024 revealed Problem: Resident is at risk for falls 10/3/21 self-transfer from bed, 1/4/23 fell during self-transfer, 5/21/23 slide from w/c, 8/31/24 self-transfer in br. Goal: Effort will be made to prevent falls/falls with injury. Approaches included: therapy, anticipate needs, call light within reach. Remind resident how to use as needed. Monitor for changes in residents' condition that may warrant increased supervision/assistance and notify the physician'. No mention of specialty mattress/scoop mattress revealed in Resident #23's care plan. During an observation on 01/27/2025 at 1:13 PM revealed Resident #23 was sitting up on edge of her low bed on a scoop mattress. During an observation on 01/28/2025 at 10:39 AM revealed Resident #23 was sitting in her wheelchair in her room. Scoop mattress was on Resident #23's bed frame. During an interview on 01/28/2025 at 01:26 PM with LVN E, she stated Resident #23 had falls in the past and they may be using the scoop mattress for that, but she was unsure. She stated that using a scoop mattress should be care planned. Record review of Resident #61's face sheet dated 01/29/2025 revealed an [AGE] year-old male admitted on [DATE] with diagnoses including dementia (a disorder affecting thought process and memory), heart failure (the heart is unable to adequately pump blood to meet the demands of the body), and Type 2 diabetes mellitus (a disorder where the body cannot regulate blood sugars). Record review of Resident #61's Quarterly MDS dated [DATE] revealed the resident had a BIMS score of 5, which indicated his cognition was moderately impaired. Record review of Resident #61's order history dated 9/25/2024-01/29/2025 revealed an order as follows: Code status: DNR with a start date of 01/08/2025 and Code Status: Full Code with a start date of 09/26/2024 and an end date of 01/08/2025. Record review of Resident #61's Care Plan dated 10/10/2024 revealed Problem: Resident with Full Code Status Directive to MD and Family; MPOA no D/C plans anticipated. During an interview on 01/28/2025 at 08:49 AM with the DON revealed that MDSC is responsible for updating care plans. During an interview on 01/28/2025 at 08:52 AM with MDSC revealed she had been employed at the facility for approximately [AGE] years. She stated she and a coworker work together to update care plans. She stated care plans should have been updated for a change in condition, new order for hospice, new order for therapy, change in diet or new order for antibiotics. She stated she monitored for care plan revision needs during the morning meetings. The MDSC stated care plans should have been updated with advanced directive changes and falls, including all interventions utilized. She stated the care plan helped the team communicate needs of residents so appropriate care can be provided. During an interview on 01/29/2025 at 11:06 AM with LVN G revealed she had been employed with the facility for 8 months. She stated the MDSC is responsible for updating the care plans. LVN G stated care plans should have been updated with any change in conditions. She stated that using a scoop mattress and changing the code status should have been care planned. She stated nurses used the care plans to provide custom care for the residents. During an interview on 01/29/2025 at 1:11 PM with the DON revealed, she expected staff to update the care plans for any change with the resident's care. She stated there was a meeting in the morning that reviewed all changes for all residents and the changes should occur after the meeting. She stated that scoop mattresses were used for the resident to be able to determine where the edge of the bed was in order to prevent falls. The DON stated scoop mattress should have been put in the care plan and the care plan should have been updated with a change in code status order. She stated not updating the care plan could lead to not honoring the resident's preferences, injury, or hospitalization . During an interview on 01/29/2025 at 01:25 PM with the CRN revealed Resident #23 did not have a care plan for a scoop mattress. The CRN stated the scoop mattress was utilized for this resident to indicate where the edge of the bed was. She stated it should have been updated after the last fall. She stated Resident #61 was care planned as full code status for advanced directives. During an interview on 01/29/2025 at 02:57 PM with the ADM, she stated she expected the MDSC to update care plans when changes occur, including fall and code status. She stated the nursing staff used the care plans and not updating them could affect the care provided to the resident. Record Review of facility policy titled Fall-Clinical Protocol dated 2001 and revised in December 2016 revealed: Policy Statement A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. Policy Interpretation and Implementation 13. Assessments of residents are ongoing and care plans are revised as information about the residents and the residents' conditions change. 14. The Interdisciplinary Team must review and update the care plan: a. When there has been a significant change in the resident's condition; b. When the desired outcome is not met; c. When the resident has been readmitted to the facility from a hospital stay; and d. At least quarterly, in conjunction with the required quarterly MDS assessment.

Based on observations, interviews, and record review, the facility failed to ensure each resident received adequate supervision and assistance devices to prevent accidents for one (Resident #1) of four residents reviewed for change in condition. LVN A did not ensure Resident #1, who had a history of a left hip fracture, had a footrest on her wheelchair before transferring her, resulting in a fractured left patella (kneecap). The noncompliance was identified as PNC IJ. The IJ began on 09/04/24 and ended on 09/21/24. The facility had corrected the noncompliance before the investigation began. This failure placed residents at risk of not receiving adequate assistance devices, accidents during transfers, harm, sustaining injuries, and hospitalization . Findings included: Review of Resident #1's face sheet, dated 09/30/24, reflected an [AGE] year-old female who was admitted to the facility on [DATE] and readmitted to the facility on [DATE]. Resident #1 had diagnoses including displaced transverse fracture (the pieces of an individual's bone moved so much that a gap formed around the fracture when the individual's bone broke) of the left patella with routine healing, unspecified pain, multiple fractures of the ribs on the left side with routine healing, unspecified fracture of the shaft (the main part of a cylindrical body) of the left femur (thigh bone) with routine healing, and an encounter for other orthopedic aftercare. Review of Resident #1's comprehensive MDS assessment, dated 07/25/24, reflected there was no BIMS score documented. Resident #1 also required partial/moderate assistance with most ADLs except transfers, in which she was dependent on staff assistance. Review of Resident #1's BIMS assessment, dated 09/02/24, reflected a 5 BIMS score, which indicated she had severe cognitive impairment. Resident #1 had a fall prior to admission and no falls since admission. Review of Resident #1's care plan, revised on 09/09/24, reflected staff noted Resident #1 had a left patella fracture without surgical intervention and had the potential for pain and limited joint movement complications. The staff were required to apply non weight bearing to her left leg, the immobilizer was not to be removed, transfer her with a sheet using more than four staff members, anticipate her needs, notify the MD with changes, follow-up with x-rays as ordered with results sent to the MD, implement fall risk precautions, maintain extremity alignment as directed, assess for complications, pain, limited range of motion, signs and symptoms of infection, abdominal bruising or numbness, post-op instruction as directed, arrange follow-up appointments as indicated, range of motion/activity as ordered, monitor tolerance/pain control, vitals assessment as directed, pain assessment ongoing, weekly skin assessment and as needed during care, wound care/treatments as directed, and monitor effectiveness. Review of Resident #1's orders, dated 09/30/24, reflected staff were given a general order on 09/05/24 to send Resident #1 to the ED per the NP on-call. Review of Resident #1's progress notes reflected the following: -LVN A documented on 09/04/24 1:34 p.m., Max assist x2 with transfer. Non-weight bearing on left leg. While pushing Resident #1 to the van for appointment, she yelled. Noted Resident #1 dragged her left leg to the floor. Assessed, no swelling or redness noted. Provided footrest. Administered Norco 5/325 mg as needed. After appointment, assessed again, no swelling, no redness. Notified physical therapy. Family aware. -LVN A documented as a late entry on 09/09/24 at 11:45 a.m. for 09/05/24 at 7:30 a.m., Addendum: Notified NP about her [Resident #1's] knee pain at 0730 am. She said if there is no swelling to monitor for any changes. Started the 72 hour follow up. -LVN B documented as a late entry on 09/06/24 at 3:49 p.m. for 09/05/24 at 4:00 p.m., Resident requesting to go to bed as she is sitting in wheelchair in common area. Aide pushed her into the shower room and nurse transferred to shower chair with no pain indicated. She was showered and nurse transferred back to wheelchair with no pain indicated. Nurse transferred resident to bed from wheelchair with no pain indicated with left leg elevated. Spent 30 mins time in room getting all the items situated for resident. She also wanted her movie put on, set up laptop with movie for resident. She is able to communicate pain verbally and via body language and she did not indicate any pain at this time when being placed back to bed. Noticed the left knee was swollen more than the right and hot/warm to touch. At 10pm, [Resident #1's family] translated from resident 'something is wrong and needs to see orthopedic doctor.' At this point we called NP and got verbal order to send her to ED for Xray. -LVN B documented on 09/05/24 at 10:21 p.m., Tylenol and muscle rub on left knee with an ice pack for pain. Knee is swollen and hot to touch. -LVN C documented on 09/05/24 at 10:37 p.m., Left knee swollen and warm to touch. Called NP. Send to ER for x-ray. If nothing is new to knee call for additional pain meds. Family, DON notified. 911 called. Review of LVN A's statement, dated 09/06/24, reflected while she was pushing Resident #1 through the lobby on 09/04/24, at about 7:30 a.m. to the van for an appointment, Resident #1 called out and she stopped. LVN A stated Resident #1's knee was slightly bent and got caught on the floor. LVN A stated she assessed Resident #1 and did not note any swelling or redness. LVN A stated Resident #1 received a narcotic pain medication before the incident. LVN A stated she provided the footrest and Resident #1 left for an appointment. LVN A stated Resident #1 returned from her appointment, complained of pain to the knee area, she administered Norco 5/325 MG, and noted no swelling or redness. LVN A stated Resident #1's family was aware of the incident, and she notified the physical therapy department to offer any changes to Resident #1's treatment. LVN A stated the physical therapy department assessed Resident #1, noted there was no swelling and suggested to apply ice. LVN A stated on 09/05/24, she received a report that Resident #1 complained of pain, she reached out to the NP, and the NP requested an x-ray of Resident #1's knee. Review of the van driver's statement, undated, reflected a nurse was wheeling Resident #1 out in the lobby and the blanket that was on Resident #1's lap got caught up in the wheels of Resident #1's wheelchair. Resident #1 started yelling. The van driver stated the nurse was checking Resident #1 and asking Resident #1 if she was okay. The van driver continued to state the nurse asked Resident #1 if she was in pain and offered pain medication. The van driver stated the nurse left, went to the back somewhere, and returned with pain medication. The van driver stated he thought there was a footrest on Resident #1's wheelchair. The van driver stated Resident #1 kept telling her family that she fell , but that did not happen. The van driver stated that the nurse did not appear to be in a hurry or rush. Review of LVN B's statement, undated, reflected on 09/05/24, revealed she was giving a shift change report to the 10-6 AM nurse, went to Resident #1's room to say goodnight, and a family member told her that Resident #1 was saying something was wrong with her leg on the inside and she needed to see an orthopedic doctor. Resident #1 had no complaint of pain, but she had an ice pack on her left knee that she gave to Resident #1. LVN B called the NP and explained the situation and the NP told her to send Resident #1 to the ED for an x-ray. LVN B notified Resident #1's family and called EMS at 10:30 PM. Review of LVN C's statement, undated, reflected on 09/05/24, Resident #1's family was in the room at 10:00 p.m. Resident #1 had an ice pack on her left knee. Resident #1 was not complaining of pain at the time, the left knee was swollen and warm to touch, the staff member gave Tylenol and muscle rub at that time. Resident #1's family member stated, something is wrong, and she needs and orthopedic Dr. LVN C and the 2-10 PM nurse called the NP and the NP ordered to send Resident #1 to the ER for x-rays. Review of Resident #1's pain assessment, dated 09/04/24, reflected Resident #1 had pain in left knee on 09/04/24. The cause of the pain was Resident #1's left leg was caught on the floor. Resident #1 received a scheduled Norco 5/325 MG that was administered as needed. Review of Resident #1's 72-hour follow-up, dated 09/05/24, reflected on 09/05/24 LVN A noted during the 6-2 PM shift that Resident #1 had pain to her left knee area. LVN A stated she witnessed left leg incident that was not a fall. LVN B noted during the 2-10 PM shift that Resident #1's knee was swollen and warm to touch and an ice pack was provided. LVN B stated Resident #1 had left leg pain. LVN C noted during the 10-6 AM shift that Resident #1's knee was swollen and warm to touch and Resident #1 was sent to the ER for an x-ray. LVN C stated Resident #1 had left leg/knee pain. LVN A documented on 09/04/24 at 7:30 a.m. that while pushing Resident #1 in her wheelchair, Resident #1 yelled. LVN A stated she assessed Resident #1 and Resident #1's left leg got caught on the floor. LVN A stated there was no swelling to Resident #1's knee or surgery area and no redness noted. LVN A stated Resident #1 complained of pain and received Norco 5/325 MG routine pain medication. LVN A stated after Resident #1 returned from her appointment, Resident #1 complained of pain and she administered Norco 5/325 MG as needed, assessed Resident #1 again, noted no swelling or redness, family was aware, incident happened on 09/04/24, and NP was notified and told LVN A that if no swelling to monitor for any changes. Review of Resident #1's hospitalist history and physical, dated 09/06/24, reflected she was sent to the hospital on 09/05/24 for a chief complaint of knee pain. Left knee x-ray results reflected Resident #1's bones were osteopenic (having reduced bone density) and she had a new acute fracture of the mid patella with approximately 10 mm distraction between major fracture fragments and adjacent soft tissue swelling. Review of Resident #1's hospital progress notes, dated 09/06/24, reflected Resident #1 was admitted on [DATE] for a chief complaint of knee pain. The history and physical section reflected, Apparently had a twisting of knee a couple of days ago when transferring to wheelchair for gastrointestinal appointment. She had knee pain and swelling since then. EMS was called. Knee x-ray showed patella fracture with displacement on the left side. Ortho consulted. Plan is for surgery 9/9 afternoon. Review of Resident #1's operative report, dated 09/06/24, reflected her pre- and post- operative diagnosis was left patella displaced transverse fracture. Resident #1 received surgery on her left patella fracture on 09/09/24. During an interview on 09/30/24 at 10:18 a.m., the ADM stated she still did not know how Resident #1 sustained a fracture. The ADM stated Resident #1 had no falls at the facility. The ADM stated Resident #1 had one incident in which her dress got caught in her wheelchair and LVN A helped pull out her dress. The ADM explained that Resident #1 started swelling in her left knee a few days after that incident. The ADM stated Resident #1 had been doing fine and receiving pain management and treatment anytime she experienced pain . During an interview on 09/30/24 at 11:07 a.m., the ADM stated LVN A was suspended and still suspended at the time of the interview because the facility was waiting for the SSA to investigate Resident #1's incident. During an interview on 09/30/24 at 11:28 a.m., LVN A stated on 09/04/24, she moved Resident #1 out from where Resident #1 was sitting to take Resident #1 to the van. LVN A explained that as she and Resident #1 got to the lobby, Resident #1 yelled out and she stopped the wheelchair. LVN A stated Resident #1 pointed at her dress, she observed Resident #1's long dress was caught in the wheelchair wheel. LVN A stated Resident #1's leg was not really down on the floor. LVN A stated she noticed Resident #1's leg was slightly bent, but there was not any kind of serious falling and Resident #1 did not fall. LVN A stated Resident #1 showed her that her leg was out. LVN A stated at the time of the incident on 09/04/24, Resident #1 did not have footrest attached to her wheelchair. LVN A stated Resident #1 probably was supposed to have a footrest attached to her wheelchair for safety reasons. LVN A stated she did not attach Resident #1's footrest to her wheelchair because she oversighted (overlooked) and did not realize Resident #1 did not have a footrest attached to her wheelchair. LVN A stated staff were supposed to attach residents' footrest to their wheelchairs before pushing a resident in the wheelchair. LVN A stated she left, came back, attached the footrest to Resident #1's wheelchair, and placed Resident #1's leg on the footrest after the incident happened. LVN A stated Resident #1's feet were not on the footrests when she pushed Resident #1 to the lobby before the incident happened. LVN A stated Resident #1's legs were picked up (raised up) when she pushed Resident #1 in her wheelchair. LVN A explained staff usually made sure there was footrest on residents' wheelchairs. LVN A stated staff were required to place residents' feet on the footrest in their wheelchair at times, especially for residents who cognitively do not know how to move their legs. LVN A stated Resident #1 knew how to move her legs. LVN A stated when moving a resident in a wheelchair, staff must ensure resident safety. LVN A stated all nursing staff were responsible for ensuring residents' footrests were attached to their wheelchairs. LVN A stated residents' health and safety could be at risk if their footrest was not attached to their wheelchair because residents could fall out of the wheelchair during a transfer. During an interview on 09/30/24 at 11:54 a.m., the ADM stated she was unsure if staff were in-serviced on proper wheelchair transportation. During an interview on 09/30/24 at 12:07 p.m., CNA E stated she worked during the 6:00 AM through 2:00 PM shift. CNA E stated she was trained on wheelchair transportation. CNA E stated if a resident had issues with their feet or had a footrest, then the resident would have a footrest. CNA E stated CNAs attached footrests to residents' wheelchairs and had nurses monitor to ensure footrests were attached to residents' wheelchairs before transporting residents. CNA E stated residents health or safety could be at risk if a resident did not have a footrest attached to their wheelchair. CNA E stated she worked with Resident #1 and was unsure if Resident #1 required a footrest attached to her wheelchair. CNA E stated she was in-serviced last month on wheelchair transport by the ADON, who taught her how to securely lock the wheelchair in place, how to adjust footrests, and always ensure Resident #1's footrest was attached to her wheelchair when being transported. During an interview on 09/30/24 at 12:18 p.m., CNA F stated she worked during the 6:00 AM through 10:00 PM shift. CNA F stated she was trained on wheelchair transportation. CNA F stated if a resident was unable to lift their legs, then the resident required a footrest attached to their wheelchair. CNA F stated CNAs ensured residents footrests were attached to their wheelchairs after placing residents in their wheelchairs. CNA F stated residents health or safety could be at risk if no footrests were attached to their wheelchairs because residents' feet could get caught if they cannot lift their legs. CNA F stated she worked with Resident #1 and was unsure if Resident #1 required a footrest attached to her wheelchair because Resident #1 never got up when she worked with her. CNA F stated she was in-serviced on wheelchair transport on Monday or Tuesday of last week (09/23/24 or 09/24/24) by the DON. CNA F stated the in-service discussed how to lock residents' wheelchairs before transferring residents in wheelchairs and making sure footrests were attached if residents required footrests. During an observation and interview on 09/30/24 at 12:26 p.m., Resident #1 had two wheelchairs with footrests sitting on the wheelchair seat. Resident #1 was lying in bed and had a knee sleeve on her left leg. Resident #1 also had family in her room at the time of the observation. Resident #1 stated LVN A was transporting her to the van, her foot got caught, and she fell forward. Resident #1 stated she did not have a backrest and footrest attached to her wheelchair the day the incident happened (09/04/24). Resident #1 stated LVN A went back into her room and grabbed her footrest after the incident happened. Resident #1 stated she started feeling pain one or two days after the incident. Resident #1 stated she told the nurses whenever she was experiencing pain in her left knee. Resident #1 stated the following day of the incident (09/05/24), she told her family that she felt something was wrong inside her left knee. Resident #1 did not indicate if she observed swelling in her left knee. Resident #1 stated she went and got surgery at the hospital for her left knee. She stated the staff have been attaching her footrest to her wheelchair whenever they transported her, the staff have been checking on her, the staff have been managing and treating her pain, and she felt safe. Resident #1's family stated they observed Resident #1's knee was swollen the night she was sent to the hospital (09/05/24). During an observation and interview on 09/30/24 at 12:47 p.m., Resident #2 was sitting in his wheelchair. Resident #2's feet were resting on a footrest attached to his wheelchair. Resident #2 stated staff always made sure a footrest was attached to his wheelchair, staff checked on him, treated and managed his pain, and he had no concerns and issues. During an interview on 09/30/24 at 12:51 p.m., LVN G stated she worked during the 6:00 AM through 2:00 PM shift. LVN G stated she was trained and in-serviced on wheelchair transportation last week by the DON and the ADON. LVN G stated she was taught how to put the residents' footrests on their wheelchairs to ensure residents were steady and how to transfer residents according to their diagnoses. LVN G explained that before transporting residents, she ensured their footrests were attached to their wheelchairs. LVN G stated residents could be at risk of getting their legs hurt if footrests were not attached to their wheelchairs because residents' legs could get caught by the wheelchair. LVN G stated CNAs and nurses ensured the residents' footrests were attached to their wheelchairs. LVN G stated residents' health or safety could also be at risk if footrests were not attached to their wheelchairs because their legs could get caught and that could cause an injury and fall. LVN G stated Resident #1 should have been required to have a footrest attached to her wheelchair. LVN G stated Resident #1 did not have a footrest attached to her wheelchair at all times because she did not always want the footrest on. An attempt to interview the van driver was made on 09/30/24 at 1:56 p.m. A voicemail and call back number was left. The van driver did not return the call prior to exit. During an interview on 09/30/24 at 2:39 p.m., the NP stated she was notified on 09/04/24 of Resident #1's incident, but she could not recall the details of the incident at the time of the interview . During an interview on 09/30/24 at 5:17 p.m., the DON stated residents self-propelled themselves in their wheelchairs when they were transporting inside the facility. The DON stated outside the facility, she expected residents' footrests to be present for residents who were unable to self-propel themselves in their wheelchairs. The DON stated she determined residents required footrests by if residents could self-propel in the facility or not. The DON stated newly hired staff completed competencies on ambulating residents in wheelchairs before they began to work with residents. The DON stated she did not know if the facility had a policy on ambulating residents. The DON stated ambulating residents was more of an education topic than an actual policy. The DON stated residents' health and safety could be at risk if they were ambulated without wheelchair footrests by the nurse or a staff member because residents' feet can drop to the ground. The DON stated Resident #1 did not require a footrest in the facility, but she required a footrest when going out of the facility. The DON stated she was notified during the 24-hour report clinical meeting by LVN A of Resident #1's incident. The DON stated the ADON asked for the incident report, which LVN A documented per instruction from the ADON. The DON stated LVN A did not explain why she did not attach a footrest to Resident #1's wheelchair when transporting Resident #1. During an interview on 09/30/24 at 5:48 p.m., the ADM stated she was unsure if the facility had a policy that specifically outlined how to ambulate a resident who was wheelchair dependent. During an interview on 09/30/24 at 6:19 p.m., the DON stated the facility did not have a policy that specifically outlined how staff were to ambulate residents who were wheelchair dependent. The DON stated ambulating resident's protocols were reviewed under the new employee training orientation, which was completed before staff started working with residents. Review of the facility's provider investigation report reflected Resident #1's incident occurred at an unknown date, time, and location. The incident was reported to SSA on 09/06/24 at 2:00 p.m. There were no witnesses and alleged perpetrators. Resident #1 sustained a new acute fracture of the mid patella. LVN B assessed Resident #1 on 09/05/24 at 10:50 p.m. and indicated that Resident #1's family reported to her that Resident #1 said there was something wrong inside her left knee. LVN B noted the left knee was swollen and warm to touch during Resident #1's head-to-toe assessment, provided Resident #1 with pain medication and applied ice to the affected area. Provider response reflected, Once notified by the hospital of the fracture, an internal investigation began. Upon receipt and review of hospital records, it was discovered there were family statements charted by hospital staff that suggested an injury may have been sustained in our facility during transport to gastroenterology appointment on 09/04/24. Based on statements from the family and events reported by staff, it was decidedly prudent for the safely of our residences, to suspend the LVN A on 09/06/24 until it was determined this was not abuse or neglect. When it was substantiated, this did not demonstrate abuse nor neglect the LVN A was reinstated on 09/07/24. The investigation summary reflected, On 9/6/2024, the facility received a call from the hospital and reported that Resident #1 had been diagnosed with a fracture of the left patella with displacement. Resident #1 was admitted to the facility on [DATE] for skilled therapy and medical management. Resident #1 had a history of osteoporosis. Prior to admission to the facility, Resident #1 sustained a fall in July 2024 with left distal peri prosthetic femur fracture requiring open reduction and internal fixation left knee trauma requiring arthroscopic surgery, fractures of the sixth and seventh ribs, followed by a complicated postop course. She is a poor historian with diagnosis of age-related cognitive decline with a BIMS of 5. Investigation revealed hospital records from 09/16/24 stated she had twisted the knee a day or 2 ago when transferring to wheelchair and hit on edge of wheelchair. Employee statements did not support any evidence of that occurrence. LVN charge nurse reports on 09/04/24 while transporting the resident from nurse's station to lobby, in a wheelchair, her left leg slipped to the floor bending her knee slightly. LVN Immediately assessed the knee, and no swelling or redness was noted. Resident #1 did complain of pain but had been given her three times a day scheduled dose of Norco 5/325mg prior to the incident. Resident #1 was being treated for post-surgical pain. Upon return from her appointment, LVN charge nurse reassessed the left knee and no swelling or redness was noted. Resident #1 complained of pain and LVN charge nurse administered as needed Norco 5/325mg at 10:10 a.m. NP was notified, and order was given to monitor for redness and swelling. No redness or swelling was noted in the nurse's notes from 09/04/24 to the evening of 09/05/24. Late evening 09/05/24, Resident #1 presented with left knee redness and swelling. LVN charge nurse called the NP and received an order to transport to the hospital for evaluation and treatment. Per our Investigations, van driver reports on 09/04/24, LVN charge nurse was transporting resident through the lobby to the transport van and saw the resident's long dress get caught in the wheel pulling the leg to the floor. Van driver reports the LVN charge nurse stopped the chair immediately and provided care to Resident #1. Van driver reports the nurse did not appear to be hurried or in a rush. Resident #1's family reports on 09/06/24, Resident #1 reported to her she was put in wheelchair and rushed causing her leg to catch under the wheelchair and falling forward. However, Resident #1 is a poor historian and was unable to reveal details. GI medical assistant with MD stated on 09/19/24, Resident #1 attended an appointment on 09/04/24. The medical assistant stated Resident #1 did not complain of pain unrelated to GI origin during the appointment. Investigative summary reflected, On 9/6/2024, the facility was informed Resident #1 had been diagnosed with a fracture to the left patella with displacement. The investigative process could not definitively identify the cause of the injury therefore we are unable to confirm a specific incident to be solely responsible for the fractured patella. The belief remains the Resident #1 pathological process of osteoporosis increased her risk for serious injury lo the left knee and the injury was not found to be due to abuse or neglect. Provider action taken post-investigation reflected LVN A was suspended, but it was lifted after investigation findings were inconclusive. In-services were also conducted on abuse and neglect, treatment of pain, and ambulating the wheelchair dependent. Review of the facility's incident/accident tracking log for September2024 reflected on 09/04/24 during the day shift, Resident #1 sustained an injury during handling and sustained a patella fracture by an unknown cause in which she was treated in the hospital, the incident was investigated and reported, and staff were trained. Review of the facility's accident/incident report, dated 09/05/24, reflected while pushing Resident #1 through the lobby to an appointment, Resident #1's foot got caught on the carpet. Resident #1 complained of pain, was assessed, and had no redness or swelling noted. The footrest was attached to the wheelchair. The incident happened on 09/04/24 at 7:30 a.m. in the resident's room, the unwitnessed fall occurred while Resident #1 was in her chair, Resident #1 slipped/tripped, had discolored skin, was alert, had no apparent injury, and a minimal bruise on left leg. There were no medication and mental status changes in the last seven days. Resident #1 received a scheduled pain medication Norco 5/325 MG prior to the incident. Resident #1's footrest was provided on the wheelchair. Physical Therapy was notified and suggested applying ice. Review of the facility's admission and discharge report, from 09/01/24 through 09/30/24, reflected Resident #1 was discharged to the hospital on 09/05/24 and returned to the facility on [DATE]. Review of the facility's in-services reflected staff were educated on abuse and neglect on 09/06/24 by the ADON. Staff were also educated on treatment of pain, ambulation, and abuse and neglect on 09/06/24 by the ADON. The staff were taught that when a resident complains of pain, the nurse must go and assess the resident for pain and administer pain medications as appropriate, the nurse must document administering the medication, outcome and effectiveness of the medication, documentation was paramount, nurses should be notified immediately when a resident complains of pain. Staff were also taught that while ambulating the wheelchair dependent resident to be aware of leg placement of the resident, ensure residents' legs were properly aligned, footrests were to be applied correctly and on the correct wheelchair, ensure their legs and feet were properly aligned, footrests were required every time a staff member assisted the resident with ambulation, only qualified staff may ambulate, self-propelled residents were not required to have footrests unless they were propelled by staff. and at that time footrests would be applied. Staff were also taught to ambulate a resident at a slow steady pace, be mindful of their feet at all times, only one resident was to be ambulated at a time, Trains were never acceptable for the ambulation of residents, all outside appointments required footrests, prepare residents for appointments the day prior and ensure the location of footrests, all incidents were not always falls, and to use the list on the incident report to determine incidents. Staff were educated on fall management clinical protocol on 09/21/24 by RN D, which taught them about all the steps in responding to a fall, assessing, and documenting, and reporting change in condition or level of consciousness. Staff were also educated on abuse prevention falls on 09/21/24 by RN D, which taught them about fall risk residents and fall interventions to implement. Staff were also taught and reviewed on abuse prevention on 09/21/24 by RN D. Review of the facility's change in a resident's condition or status policy and procedure, revised May 2017, reflected the following: Policy Statement: Our facility shall promptly notify the resident, his or her Attending Physician, and representative (sponsor) of changes in the resident's medical/mental condition and/or status (e.g., changes in level of care, billing/payments, resident rights, etc.). Policy Interpretation and Implementation: 1. The nurse will notify the resident's Attending Physician or physician on call when there has been a(an): b. discovery of injuries of an unknown source; d. significant change in the resident's physical/emotional/mental condition; e. need to alter the resident's medical treatment significantly; i. specific instruction to notify the Physician of changes in the resident's condition. 2. A significant change of condition is a major decline or improvement in the resident's status that: a. Will not normally resolve itself without intervention by staff or by implementing standard disease-related clinical interventions (is not self-limiting); b. Impacts more than one area of the resident's health status; c. Requires interdisciplinary review and/or revision to the care plan; and d. Ultimately is based on the judgment of the clinical staff and the guidelines outlined in the Resident Assessment Instrument. Review of the facility's assistive devices and equipment policy and procedure, revised January 2020, reflected, Policy Statement: Our facility maintains and supervises the use of assistive devices and equipment for residents. Policy Interpretation and Implementation: 1. Certain devices and equipment that assist with resident mobility, safety and independence are provided for residents. These may include (but are not limited to): c. Mobility devices (wheelchairs, walkers, and canes). 3. Recommendations for the use of devices and equipment are based on the comprehensive assessment and documented in the resident care plan. 4. Staff and volunteers are trained and demonstrate competency on the use of devices and equipment prior to assisting or supervising residents. 6. The following factors are addressed to the extent possible to decrease the risk of avoidable accidents associated with devices and equipment. a. Appropriateness for resident condition -the resident is assessed for l [TRUNCATED]

Based on observations, interviews, and record review, the facility failed to immediately inform the resident; consult with the resident's physician; and notify, consistent with his or her authority, the resident representative(s) when there is a significant change in the resident's physical, mental, or psychosocial status or a need to alter treatment significantly for one (Resident #1) of four residents reviewed for change in condition. The facility failed to notify the NP in a timely manner when Resident #1 voiced pain to her left knee, swelling, and heat to the touch was observed by LVN B. LVN B noted swelling and warm to touch on Resident #1's knee at approximately 4:00 PM. LVN B noted they contacted the NP when Resident #1's family was present at approximately 10:00 PM. Resident #1 was sent to the hospital and found to have a fractured left patella (kneecap). The noncompliance was identified as PNC IJ. The IJ began on 09/04/24 and ended on 09/21/24. The facility had corrected the noncompliance before the investigation began. This failure placed residents at risk of harm, injuries, and hospitalization . Findings included: Review of Resident #1's face sheet, dated 09/30/24, reflected an [AGE] year-old female who was admitted to the facility on [DATE] and readmitted to the facility on [DATE]. Resident #1 also had diagnoses including displaced transverse fracture (the pieces of an individual's bone moved so much that a gap formed around the fracture when the individual's bone broke) of the left patella, multiple fractures of the ribs on the left side, unspecified fracture of the shaft (the main part of a cylindrical body) of the left femur (thigh bone), and an encounter for other orthopedic aftercare. Review of Resident #1's comprehensive MDS assessment, dated 07/25/24, reflected there was no BIMS score documented. Resident #1 also required partial/moderate assistance with most ADLs except transfers, in which she was dependent on staff assistance. Review of Resident #1's BIMS assessment, dated 09/02/24, reflected a 5 BIMS score, which indicated she had severe cognitive impairment. Review of Resident #1's care plan, revised on 09/09/24, reflected staff noted on 07/19/24 that Resident #1 had an ADL deficit related to her cognitive and physical limitations. Staff were required to notify Resident #1's RP and MD of significant change in condition/function as needed as an intervention that started on 08/12/24. Staff also included revisions that reflected Resident #1 had a left patella fracture without surgical intervention, had the potential for pain and limited joint movement complications, and that staff were required to notify the RP and MD of any significant change in condition. Review of LVN A's statement, dated 09/06/24, reflected on 09/05/24, she received a report that Resident #1 complained of pain, she reached out to the NP, and the NP requested an x-ray of Resident #1's knee. Review of LVN B's statement, undated, reflected on 09/05/24, revealed she was giving a shift change report to the 10 PM-6 AM nurse, went to Resident #1's room to say goodnight, and a family member told her that Resident #1 was saying something was wrong with her leg on the inside and she needed to see an orthopedic doctor. Resident #1 had no complaint of pain, but she had an ice pack on her left knee that she gave to Resident #1. LVN B called the NP and explained the situation and the NP told her to send Resident #1 to the ED for an x-ray. LVN B notified Resident #1's family and called EMS at 10:30 PM. Review of LVN C's statement, undated, reflected on 09/05/24, Resident #1's family was in the room at 10:00 p.m. Resident #1 had an ice pack on her left knee. Resident #1 was not complaining of pain at the time, and the left knee was swollen and warm to touch. The staff member gave Tylenol and muscle rub at that time. Resident #1's family member stated, something is wrong, and she needs and orthopedic Dr. LVN C and the 2-10 PM nurse called the NP and the NP ordered to send Resident #1 to the ER for x-rays. Review of Resident #1's pain assessment, dated 09/04/24, reflected Resident #1 had pain in left knee on 09/04/24. The cause of the pain was Resident #1's left leg was caught on the floor. Resident #1 received a scheduled Norco 5/325 MG that was administered as needed. Review of Resident #1's progress notes reflected the following: -LVN A documented as a late entry on 09/09/24 at 11:45 a.m. for 09/05/24 at 7:30 a.m., Addendum: Notified NP about her [Resident #1's] knee pain at 0730 am. She said if there is no swelling to monitor for any changes. Started the 72 hour follow up. -LVN B documented as a late entry on 09/06/24 at 3:49 p.m. for 09/05/24 at 4:00 p.m., Resident requesting to go to bed as she is sitting in wheelchair in common area. Aide pushed her into the shower room and nurse transferred to shower chair with no pain indicated. She was showered and nurse transferred back to wheelchair with no pain indicated. Nurse transferred resident to bed from wheelchair with no pain indicated with left leg elevated. Spent 30 mins time in room getting all the items situated for resident. She also wanted her movie put on, set up laptop with movie for resident. She is able to communicate pain verbally and via body language and she did not indicate any pain at this time when being placed back to bed. Noticed the left knee was swollen more than the right and hot/warm to touch. At 10pm, [Resident #1's family] translated from resident 'something is wrong and needs to see orthopedic doctor.' At this point we called NP and got verbal order to send her to ED for Xray. -LVN B documented on 09/05/24 at 10:21 p.m., Tylenol and muscle rub on left knee with an ice pack for pain. Knee is swollen and hot to touch. -LVN C documented on 09/05/24 at 10:37 p.m., Left knee swollen and warm to touch. Called NP. Send to ER for x-ray. If nothing is new to knee call for additional pain meds. Family, DON notified. 911 called. Review of Resident #1's 72-hour follow-up, dated 09/05/24, reflected on 09/05/24 LVN A noted during the 6-2 PM shift that Resident #1 had pain to her left knee area. LVN B noted during the 2-10 PM shift that Resident #1's knee was swollen and warm to touch and an ice pack was provided. LVN C noted during the 10-6 AM shift that Resident #1's knee was swollen and warm to touch and Resident #1 was sent to the ER for an x-ray. Review of Resident #1's orders, as of 09/30/24, reflected staff were given a general order on 09/05/24 to send Resident #1 to the ED per NP on-call. Review of Resident #1's hospitalist history and physical, dated 09/06/24, reflected she was sent to the hospital on 09/05/24 for a chief complaint of knee pain. Left knee x-ray results reflected Resident #1's bones were osteopenic (having reduced bone density) and she had a new acute fracture of the mid patella with approximately 10 mm distraction between major fracture fragments and adjacent soft tissue swelling. Review of Resident #1's operative report, dated 09/06/24, reflected her pre- and post- operative diagnosis was left patella displaced transverse fracture. Resident #1 received surgery on her left patella fracture on 09/09/24. During an interview on 09/30/24 at 10:18 a.m., the ADM stated Resident #1 started swelling in her left knee on 09/05/24. During an observation and interview on 09/30/24 at 12:26 p.m., Resident #1 was lying in her bed with family at bedside. Resident #1 had a black brace on her left leg. Resident #1 stated she told the nurses whenever she was experiencing pain in her left knee on 09/05/24. Resident #1 stated on 09/05/24, she told her family that she felt something was wrong inside her left knee. Resident #1 did not indicate whether she observed swelling in her left knee. Resident #1 stated she went and got surgery at the hospital for her left knee. Resident #1's family stated they observed Resident #1's knee was swollen the night Resident #1 was sent to the hospital. During an interview on 09/30/24 at 1:58 p.m., LVN A stated Resident #1 went to the hospital because she complained of pain to her left knee. LVN A stated she did not observe any swelling to Resident #1's knee on 09/05/24. LVN A stated she did not know why the other nurse (LVN B) reported Resident #1 had swelling to her left knee because she did not see swelling to Resident #1's left knee during her shift, which was before LVN B's shift. LVN A stated she put a progress note later that she observed Resident #1 in the morning (09/05/24 at 7:30 a.m.) and Resident #1 complained of pain to her left knee. LVN A stated she notified the NP about Resident #1's knee pain and was instructed to notify her if there were any changes in Resident #1's knee condition . During an interview on 09/30/24 at 2:11 p.m., LVN B stated on 09/05/24 she observed Resident #1 holding and rubbing her left knee. LVN B stated she believed Resident #1 was holding and rubbing her left knee because Resident #1 was not often up in her wheelchair. LVN B stated she did not notify the NP about observing Resident #1's left knee was swollen more than the right and that it was hot/warm to touch because Resident #1's left knee was always bigger than the other knee. It was Resident #1's surgery leg, there was no swelling any more than normal. LVN B stated the LVN A (day nurse) told her that she notified the NP earlier on 09/05/24 (7:30 a.m.) and the NP told LVN A to let her (NP) know if there were any changes in Resident #1's left knee condition. LVN B stated on 09/05/24 at 10:00 p.m., Resident #1's family translated to her that Resident #1 said something was wrong inside her left leg, and she then notified the NP and got a verbal order to send Resident #1 out to the hospital for an x-ray . During an interview on 09/30/24 at 2:39 p.m., the NP stated Resident #1 complained of pain to her left knee in the morning on 09/05/24 (NP did not indicate what time in the morning Resident #1 complained of pain). She stated staff told her about the pain Resident #1 experienced on 09/05/24 around 1:00 p.m. or 2:00 p.m. and that there was no swelling or redness to her left knee. The NP stated she told staff to monitor and notify her of any changes or swelling to Resident #1's left knee. The NP stated staff did not notify her that Resident #1's left knee was swollen more than the right and hot/warm to touch and would have wanted to be notified of those changes. The NP stated later on in the evening (09/05/24 around 10:00 p.m.), her NP on-call was notified of the pain Resident #1 experienced. The NP stated her NP on-call ordered staff to send Resident #1 to the ER for an x-ray evaluation because the staff told the NP on-call that Resident #1 started to have swelling in her left knee. The NP stated if there was swelling earlier on 09/05/24 in Resident #1's left knee, she should have been notified by staff earlier . During an interview on 09/30/24 at 5:17 p.m., the DON stated LVN A notified the NP about Resident #1 experiencing pain in the left knee earlier in the day on 09/05/24. The NP instructed LVN A and staff to monitor Resident #1's left knee and notify the NP if there were any changes to Resident #1's left knee condition. The DON stated if there was a change in condition and the change in condition was not reported to the NP, then a resident's health and safety could be at risk. The DON stated she was not notified about staff noting that Resident #1's left knee was swollen more than the right and hot/warm to touch earlier in the day on 09/05/24 . The DON stated she expected staff to notify the NP/Physician of any changes in condition. Review of the facility's admission and discharge report, from 09/01/24 through 09/30/24, reflected Resident #1 was discharged to the hospital on 09/05/24 and returned to the facility on [DATE]. Review of the facility's in-services reflected staff were educated on change in condition on 09/21/24 by RN D, which covered nurses assessing and documenting/reporting change in condition or level of consciousness. Staff were also in-serviced on assessing, treating, and documenting pain and follow-ups and incident reporting on 09/06/24 . Review of the facility's change in a resident's condition or status policy and procedure, revised May 2017, reflected the following: Policy Statement: Our facility shall promptly notify the resident, his or her Attending Physician, and representative (sponsor) of changes in the resident's medical/mental condition and/or status (e.g., changes in level of care, billing/payments, resident rights, etc.). Policy Interpretation and Implementation: 1. The nurse will notify the resident's Attending Physician or physician on call when there has been a(an): b. discovery of injuries of an unknown source; d. significant change in the resident's physical/emotional/mental condition; e. need to alter the resident's medical treatment significantly; i. specific instruction to notify the Physician of changes in the resident's condition. 2. A significant change of condition is a major decline or improvement in the resident's status that: a. Will not normally resolve itself without intervention by staff or by implementing standard disease-related clinical interventions (is not self-limiting); b. Impacts more than one area of the resident's health status; c. Requires interdisciplinary review and/or revision to the care plan; and d. Ultimately is based on the judgment of the clinical staff and the guidelines outlined in the Resident Assessment Instrument. The noncompliance was identified as PNC IJ. The IJ began on 09/04/24 and ended on 09/21/24. The facility had corrected the noncompliance before the investigation began.

Based on observation, interview, and record review, the facility failed to ensure that pain management was provided to a resident who required such services, consistent with professional standards of practice for one (Resident #1) of four residents reviewed for pain, in that: The facility failed to provide effective pain management for Resident #1 while on hospice services and comfort measures in place. He was found by his Hospice Nurse on 12/24/23 writhing in pain, thrashing, grimacing, and mouthing help me. This failure resulted in an identification of an Immediate Jeopardy (IJ) on 01/24/24 at 5:01 PM. While the IJ was removed on 01/25/24 at 2:45 PM, the facility remained at a level of no actual harm at a scope of isolated that is not immediate jeopardy due to the facility's need to evaluate the effectiveness of the corrective systems. This failure placed residents at risk for prolonged and unnecessary pain and suffering and a decreased quality of life. Findings included: Review of Resident #1's undated face sheet reflected an [AGE] year-old male who was admitted to the facility on [DATE] with diagnoses including vascular dementia, prostate cancer, and COPD. Review of Resident #1's quarterly MDS assessment, dated 11/03/23, reflected a BIMS was not performed. Section J (Health Conditions) reflected he had received PRN pain medications within the last five days. Review of Resident #1's quarterly care plan, revised 12/21/23, reflected he was on hospice services with an intervention of assessing and monitoring his status and to notify MD, hospice, RP of change in condition or ineffective pain medication. Review of Resident #1's progress notes in his EMR, dated 12/21/23 at 1:53 PM and documented by RN C, reflected the following: .Family (of Resident #1) decided to refer to (hospice agency), and keep [Resident #1] comfortable, NP aware of decision. Review of Resident #1's Hospice Nursing Initial Comprehensive Admission Assessment, dated 12/21/23 at 5:00 PM and completed by HN D, reflected the following: What is most important to the [Resident #1] today? Family requests comfort . [Resident #1] appears pre-active and is using morphing PRN for pain and shortness of breath. He is also using a nebulizer. Staff nursing administer medications, and nebulizers. [Resident #1] is [AGE] year-old male veteran with a primary hospice diagnosis of prostate cancer with mets (metastasize) to pelvis and lymph nodes. [Resident #1] was diagnosed in 2016 s/p orchiectomy (a surgery to remove one or both testicles) and then did not follow up . was getting treatment for prostate cancer until late 11/2023 . Today [Resident #1] was diagnosed with hypernatremia (electrolyte problem characterized by increased sodium concentration in the blood), increased BUN and Creatinine and aspiration pneumonia via x-ray. He was on IV fluids and IM Rocephin and will stay on Rocephin till 12/27/23. Family wants to give him a chance have antibiotics help him and IVF but knows this likely will not work. . Pain: pain left hip managed with new pain regimen of morphine 5 mg po every 1-hour PRN Review of Resident #1's progress notes in his EMR, dated 12/22/23 at 11:58 AM and documented by the ADON, reflected the following: Palliative care form signed. Review of Resident #1's physician order, dated 12/21/23, reflected the following: Morphine concentrate - schedule II solution; 100 mg/5 mL (20 mg/ML); Amount to administer: 0.25ML; oral - every hour PRN for pain and dyspnea (shortness of breath) Review of Resident #1's TAR, December of 2023, reflected he was administered morphine by LVN B on 12/22/23 at 2:30 AM, on 12/23/23 at 7:24 AM for pain and agitation. It was documented as being effective (unknown time). He was also administered morphine on 12/23/23 after it was administered by the Hospice Nurse at 4:00 PM and 8:00 PM; on 12/24/23 at 12:00 AM, 4:00 AM, 8:00 AM, and 12:00 PM. Review of Resident #1's Hospice Visit Clinical Note, dated 12/23/23 at 10:22 AM and documented by HN E, reflected the following: [Resident #1] lying in his bed on his back upon RN arrival. [Resident #1] writhing in pain with mouth gaping open and gasping for breath. RN immediately spoke to his nurse [LVN B] who stated he did not receive any morphine overnight and she has given him 0.25 mils a few hours ago. RN called (hospice doctor) immediately and received an order to give one ML morphine Q 15 minutes as needed times three doses to get pain under control. This RN was nurse to administer morphine, [FM A] and [FM F]/MPA were at the beside and continued to stay they only want [Resident #1] to be comfortable. It did require three doses of morphine to get [Resident #1] comfortable as he continued to be in severe pain and shortness of breath until third dose took effect. [Resident #1] continually pulling off nasal cannula from oxygen with his current pain and agitation. For this reason, oxygen level was in the mid 80s when RN able to obtain via pulse oximeter when [Resident #1] finally calm and comfortable. Several medication orders were changed by (hospice doctor) and written to the facility. This includes scheduled morphine and lorazepam every four hours with continued availability of PRN. Morphine every hour for breakthrough pain. (Hospice doctor) sent changes to (pharmacy) as well per their request. RN counted number of medications with RN on staff and assured that [Resident #1] gas enough quantity of both morphine and lorazepam. [Resident #1] has had no intake of food or water in past 24 hours and is currently only oral care at this time. RN worked with staff CNA to get [Resident #1] into a comfortable position. [Resident #1] was resting calmly upon closure of RN visit. RN reminded staff to call hospice company at any time with any change in condition or for any needs, questions, or concerns. [FM A] and [FM F] to come back later to visit and grateful for hospice assistance. [Resident #1] is actively dying and expected to pass within the next 24 to 48 hours. Review of Resident #1's progress notes in his EMR, dated 12/23/23 at 1:15 PM and documented by LVN B, reflected the following: (Late Entry) Restless and agitated. Opens mouth but makes no verbal noise. Hospice nurse present and administered 3 does of 0.5ml Morphine 15 minutes apart per Hospice physician orders. New order for Ativan every 4 hours. Continues to remove oxygen. Morphine effective. Resting in bed in fetal position. During a telephone interview on 01/24/24 at 12:33 PM, HN D stated she admitted Resident #1 for hospice services on 12/21/23. She stated on that day he was not in any obvious pain but ensured facility staff knew he had an order for Morphine PRN for pain, shortness of breath, or agitation. She stated the family was adamant that they wanted palliative/comfort care only for Resident #1. She stated when HN E made her routine visit on 12/23/23 she found Resident #1 in extreme pain and distress. She stated she would have expected facility staff to contact them immediately if they were unable to control his pain. During a telephone interview on 01/24/24 at 12:47 PM, Resident #1's NP stated she last saw him on 12/22/23 and at that time, he appeared comfortable. She stated since Resident #1's order for Morphine was such a low dose and it had a short half-life., She stated she would expect nurses to assess the resident at least every hour after administering to assess the effectiveness. During a telephone interview on 01/24/24 at 12:58 PM, FM A and FM F stated when they walked into Resident #1's room on 12/23/23 around 10:30 AM, HN E was already there. FM A stated he was writhing in agony, thrashing in his bed, and pointing to his back. FM F stated HN E looked completely disheveled with the state Resident #1 was in. FM F stated HN E turned to them and said, He is mouthing 'help me, help me, help me'! FM F stated HN E stated, Honestly, I am not supposed to say this, but this is not okay. FM F stated LVN B walked in to the room and was surprised to see the condition Resident #1 was in and stated, Oh my God, I do not know how this happened and continued to apologize profusely. FM A and FM F continuously repeated how heart-breaking it was to walk in on their loved one in so much distress and pain. They both stated they repeatedly told the facility they wanted comfort measures only and felt like they neglected Resident #1. FM F stated after HN E administered three doses of morphine, Resident #1 finally looked peaceful and comfortable. FM A stated without the hospice agency, they did not know if Resident #1 would have passed away without pain or his dignity. FM A stated they just wanted to ensure this does not happen to anyone else's loved one. During a telephone interview on 01/24/24 at 2:27 PM, HN E stated Resident #1 had an order for morphine every hour or as needed for shortness of breath or pain since 12/21/23. She stated she was not contacted by the facility on 12/23/23 but was making a routine visit. She stated when she walked into Resident #1's room he was absolutely not comfortable as he was showing a lot of symptoms of pain such as thrashing his arms, mouth agape, and was extremely anxious. She stated even lightly touching him made him more agitated. She stated although it was hard to discern, but it did look like he was mouthing help me. She stated she asked LVN B when she last saw Resident #1 and she told her she administered morphine a few hours ago. She stated it appeared LVN B seemed to think his current condition at that time was normal. She stated she was extremely surprised because normally when a resident on hospice resided at a facility with nurses on staff, they typically do not see that type of situation because nurses are trained and licensed to know what to look for when it comes to pain and agitation. She stated she would expect for a resident who was on hospice services and receiving morphine to be assessed at least every hour if not more frequently. She reiterated she was very shocked at the state he was in and was glad she arrived when she did. During an interview on 01/24/24 at 2:44 PM, the ADON stated she saw Resident #1 on 12/21/23 and 12/22/23 and he seemed comfortable. She stated she was not in the building on 12/23/23 and had not heard of anything unusual happening. She stated it depended on resident's condition as to how often a resident should be assessed after being administered pain medication. She stated LVN B had administered Resident #1 morphine a few hours before HN E arrived and a change in condition could have happened five minutes before she arrived. She stated it could happen quickly especially with Resident #1 continuously taking his oxygen off. She stated LVN B marked the morphine as being effective. She stated there was no actual pain assessments in their electronic charting system for the nurses to complete. During a telephone interview on 01/24/24 at 4:17 PM, LVN B stated she started her shift on 12/23/23 at 6:00 AM. She stated she checked on Resident #1 sometime between 6:30-7:00 AM. She stated at that time he was restless, looked like he was in pain, grimacing, moving around a lot, and did not want to keep his oxygen on. She stated she administered morphine at 7:24 AM. She stated she went back assess to see if the morphine had been effective sometime that morning. She stated, nothing seemed to help and did not believe the morphine was helping. She was asked why she marked the morphine as being effective and she stated that must have been a time where he had quieted down. She stated she thought she had contacted hospice. She stated once HN E arrived, she (HN E) administered three doses of morphine every 15 minutes and that settled Resident #1 and he seemed calm and relaxed. She stated HN E then ordered scheduled morphine to be administered every four hours and PRN. She stated she was grateful for HN E as the morphine she administered really seemed to help Resident #1 a lot. Review of the facility's Pain Assessment and Management Policy, revised March of 2020, reflected the following: 1. The pain management program is based on a facility-wide commitment to appropriate assessment and treatment of pain, based on professional standards of practice, the comprehensive care plan, and the resident's choices related to pain management. 2. Pain management is defined as the process of alleviating the resident's pain based on his or her clinical condition and established treatment goals. 3. Pain management is a multidisciplinary care process that includes the following: a. Assessing for the potential for pain; b. Recognizing the presence of pain; c. Identifying the characteristics of pain; d. Addressing the underlying causes of the pain; e. Developing and implementing approaches to pain management; f. Identifying and using specific strategies for different levels and sources of pain; g. Monitoring for the effectiveness of interventions; and h. Modifying approaches as necessary. . 5. Acute pain (or significant worsening of chronic pain) should be assessed every 30 to 60 minutes after pain onset and reassessed as indicated until relief is obtained. Documentation 1. Document the resident's reported level of pain with adequate detail (i.e., enough information to gauge the status of pain and the effectiveness of intervention for pain) as necessary and in accordance with the pain management program. 2. Upon completion of the pain assessment, the person conducting the assessment shall record the information obtained from the assessment in the resident's medical record. Review of the facility's Hospice Program Policy, revised July of 2018, reflected the following: 10. c. Notifying the hospice about the following: (1) A significant change in the resident's physical, mental, social, or emotional status. (2) Clinical complications that suggest a need to alter the plan of care. d. Communicating with the hospice provider (and documenting such communication) to ensure the needs of the resident are addressed and met 24 hours per day. The ADM and ADON were notified on 01/24/24 at 5:01 PM that an Immediate Jeopardy had been identified due to the above failures and an IJ template was provided. The following POR was accepted on 01/25/24 at 12:35 PM: On 1/24/2024 an abbreviated survey was initiated at (facility). On 01/24/2024 the surveyor provided an Immediate Jeopardy (IJ) Template notification that the Regulatory Services has determined that the condition at the facility constituteds an immediate threat to resident health and safety. The notification of Immediate Jeopardy states as follows: Resident #1 was supposed to be on comfort care measures and was found to be in an uncomfortable amount of pain after not being administered pain medication. The facility needs to take immediate action to ensure residents are receiving proper treatment to alleviate pain. The following plan of action outlines immediate interventions employed by the facility to remove any further concerns surrounding the issues: Regional Director of Operations re-educated Administrator on ensuring resident pain control needs are met per current policy by facility staff. Initiated 1/24/2024. Completed 1/24/2024 Regional Nurse Consultant re-educated Interim Director of Nursing and Assistant Director of Nursing on ensuring resident pain control needs are met per current policy by facility. Initiated 1/24/2024. Completed 1/24/2024 Evaluation of all current residents for pain performed by DON/ADON and/or designee with orders verified and any changes required noted and enacted immediately upon finding of IJ allegation. Initiated 1/24/2024. Completed 1/24/2024 DON/designee completed audit of all resident charts for current pain documentation to be performed every shift and as needed according to individualized needs with routine pain assessments added to four consolidated orders found lacking routine pain assessment. There were no relevant findings of unaddressed pain found upon resident assessments and interviews as noted below. Initiated 1/24/2024. Completed 1/25/2024 Re-education of all licensed staff members occurred per DON/ADON and designees in areas of pain control, medication, pain scales, documentation, and communication to adjunct personnel such as hospice and monitoring noting concern, if any, following verbal understanding and post test noted by licensed staff. Initiated 1/24/2024 Completed 1/25/2024 All residents currently receiving pain control or possible pain indications immediately checked by ADON, unit managers, and a designated licensed nursing team member for appropriate interventions if any noted with no relevant findings of unaddressed pain found from resident assessment/interviews. Initiated 1/24/2024 Completed 1/24/2024 Interventions and Monitoring Plan to Ensure Compliance Quickly: The facility will follow current policy and procedure for compliance and maintenance of pain control with understanding of pain control management and communication by nursing staff to be obtained on hire by DON/ADON and/or appointed designee for all full time and PRN staff and at least annually with re-education to be performed by DON/ADON and/or appointed designee as noted per skills checklist. The facility does not employ the use of temporary or agency staff. Initiated: 1/24/2024 Completion: 1/25/2024 Audit of all existing and newly hired nursing staff to be performed weekly by DON and/or designee, to ensure completion of pain management understanding with emphasis on special circumstances, such as palliative care, to be ongoing following completion date per systems put in place. Initiated: 1/24/2023 Completion: 1/25/2024 and ongoing. Any nursing staff identified through ongoing education as noted above that require acute training on pain management will have education performed prior to presenting on shift until such time as knowledge and competencies in pain control and management are adequate. This will be ongoing following completion date per systems put in place. Initiated: 1/24/2024 Completion: 1/25/2024 and ongoing Return demonstration of understanding will be noted by post competency check for each person educated with a written post-test administered by Director of Nursing, Assistant Director of Nursing, and/or designee. For any nursing staff receiving re-education or training on pain control, including medication use, pain scales, documentation, communication, and management not found to be proficient through ongoing nursing proficiency checks following immediate education, on hire, annually, and as needed will receive one on one education with testing performed until such time as knowledge is of sound basis. Staff that are on leave from the facility, as well as newly hired staff in the future will be given the pain competency check off by the same individuals noted above before starting their next shift. This facility does not employ the use of agency personnel. This will be ongoing following the completion date per systems put in place. Initiated: 1/24/2024 Completion: 1/25/2024 and ongoing The facility DON/ADON will act as monitoring liaison to coordinate completion of audits for competencies to include Administrator for continuum of care to be documented through signed attendance sheet in ongoing morning stand up. Initiated: 1/24/2024 Completed: 1/25/2024 and ongoing Audit sheets to ensure nursing staff competency in pain management, documentation, medication, assessment, and communication to be reviewed by DON/ADON for completion by random chart audits and resident assessment at least weekly with indication of last performed check off to be ongoing to ensure addition of any new or returning staff. This will be ongoing following completion date per systems put in place. Initiated: 1/24/2024 Completed: 1/25/2024 and ongoing All new admission or readmission orders to be checked within 24 hours for implementation of pain assessments as ordered and pain scales available for immediate use with discrepancies or omissions to be immediately resolved to ensure adequate pain management. This will be ongoing following completion date per systems put in place. Initiated: 1/24/2024 Completed: 1/25/2024 and ongoing The policy and procedure for maintenance and control of resident pain to be reviewed by Regional [NAME] President of Operations and Regional Nurse Consultant with current policy remaining in place. Any changes to policies that may be required to be implemented will have education provided by DON/ADON and/or appointed designee to affected staff members, including newly hired, full-time and PRN staff upon implementation. Initiated: 1/24/2024 Completed: 1/25/2024 and ongoing All licensed staff not on duty during pain management and control education, as well as all newly hired staff in the future, which will be ongoing, will be checked as noted above prior to returning to the floor for their next scheduled shift. This will be ongoing following completion date per systems put in place. Initiated: 1/24/2024 Completed: 1/25/2024 and ongoing Independent education to be performed in conjunction with facility DON and Regional Nurse Consultant, by hospice company educator designated by facility for all licensed nursing staff as adjunct to facility education on 1/25/24 and every week until all licensed staff has received external pain control and management education by outside, independent source. Any further education to be assessed and implemented from independent education findings. This will be ongoing following completion date per systems put in place. Initiated: 1/24/2024 Completed: 1/25/2024 and ongoing Pain control to include monitoring, medication, communication, and assessment will be reviewed by the QAPI committee to meet 1/25/24 and then q3months with changes to the plan to be made as needed with need for ongoing continuation of competency related to pain control as related to this IJ to be determined by findings during QAPI meetings. This will be ongoing following completion date per systems put in place. Initiated: 1/24/2024 Completed: 1/25/2024 and ongoing The Medical Director was notified of Immediate Jeopardy and apprised of interventions and monitoring initiated with further updates to be given during QAPI meetings. Initiated: 1/24/2024 Completed: 1/24/2024 The Surveyor monitored the POR on 01/25/24 as followed: During an interview on 01/25/24 at 12:43 PM, the ADON stated all staff were in-serviced on all of the topics listed in the POR before the start of their shift. She stated she in-serviced staff the evening prior at 10:00 PM before their 10:00 PM - 6:00 AM shift. She stated a pain assessment was conducted on all residents in the facility with no concerns. During interviews conducted on 01/25/24 between 1:18 PM and 2:27 PM, two RNs, two LVNs, and two CNAs all stated they had been in-serviced prior to working their shift. They were able to describe signs and symptoms of pain such as moaning, yelling, facial grimacing, agitation, and restlessness. The CNAs stated if a resident voiced pain or if they noted any residents showing any signs and symptoms of pain, they would notify their nurse immediately. The nurses stated they needed to document all signs and symptoms of pain, ensure they re-assessed a resident after administering pain medication within 30 minutes to an hour, and completing a pain assessment. The nurses stated if the pain medication did not appear to be effective, they were to document it, and contact the hospice nurse or resident's NP immediately. During observations and interviews on 01/25/24 between 1:28 PM and 1:56 PM, three communicative residents stated they were not in pain and their pain was always addressed when they notified a staff member. Two residents who were sleeping in their rooms were observed and they were showing no signs or symptoms of pain. Observation on 01/25/24 at 2:05 PM revealed nurses, medication aides, and CNAs in the dining room being in-serviced by a hospice agency on signs and symptoms of pain and the importance of addressing and assessing pain. Review of all residents' pain assessments (utilized PAINAD for nonverbal residents), dated 01/24/24, reflected no pain concerns. Review of an in-serviced entitled Reporting Pain Symptoms, dated 01/24/24 and 01/25/25 and conducted by the ADM and the ADON, reflected all nursing staff from all shifts were reeducated on the following: Any staff that notes signs and possible pain or a resident tells staff they are in pain should report this to their charge nurse. The Charge nurse must assess for pain, treat pain, and record effectiveness. Communication is the key to proper care of our residents. Signs and symptoms of pain include: moaning, grimacing, restlessness, voiced pain, and change in behavior. Review of an in-serviced entitled PRN Pain Medication, dated 01/24/24 and 01/25/25 and conducted by the ADM the ADON, reflected nurses for all shifts were reeducated on PRN pain medication and monitoring for effectiveness. Review of an in-serviced entitled Pain Assessments, dated 01/24/24 and 01/25/25 and conducted by the ADM the ADON, reflected all nurses from all shifts were reeducated on the following: Pain assessments must be done at least every shift, and if change in condition causing increased pain. Notify NP/MD/hospice if pain management is not appropriate or not alleviating pain. Document in progress notes details - who notified, what response was given, any new orders, notification of RP and doctor. Review of the facility's Pain Assessment Post Test, dated 01/24/24 and 01/25/25, reflected all staff completed the test with the following questions: 1. Pain Assessments should be completed at least every shift for acute pain or significant changes in levels of chronic pain. (True/False) 2. If upon completion of pain assessment, it is determined that intervention is required, you may: 3. What are signs a resident can display of discomfort or pain? 4. What do you do if the pain medication is not effective? 5. If a hospice resident is experiencing a change in their pain intensity, the licensed nurse should notify the hospice agency immediately. (True/False) 6. What should be included in your progress note documentation regarding the pain event? While the IJ was removed on 01/25/24 at 2:45 PM, the facility remained at a level of actual harm at a scope of isolated that is not immediate jeopardy due to the facility's need to evaluate the effectiveness of the corrective systems.

Based on interview and record review, the facility did not provide pharmaceutical services to meet the needs of each resident for one (Resident #1) of four residents reviewed for pharmaceutical services, in that: The facility failed to follow a changed physician medication order resulting in Resident #1 receiving four times the intended dose of Erleada (a prescription drug used to treat prostate cancer) for approximately five days. This failure was determined to be PNC due to the facility correcting the deficient practice prior (11/17/23) to the investigation. This deficient practice could place residents at risk overdose, could result in worsening or exacerbation of chronic medical conditions, and hospitalization . Findings included: Review of Resident #1's undated face sheet reflected an [AGE] year-old male who was admitted to the facility on [DATE] with diagnoses including vascular dementia, prostate cancer, and COPD. Review of Resident #1's quarterly MDS assessment, dated 11/03/23, reflected a BIMS was not performed. Review of Resident #1's quarterly care plan, dated 12/21/23, reflected he had prostate cancer with an intervention of administering medication as ordered. Review of Resident #1's physician order, dated 06/02/23, reflected the following: Erleada tablet; 60 mg Directions: Four tabs (240MG); oral; Once a day Review of Resident #1's physician order, dated 11/17/23, reflected the following: Erleada tablet; 240 mg Directions: ONE; oral; Once a day Review of Resident #1's NP assessment, dated 11/17/23, reflected the following: Chief Complaint/Reason for this Visit: Drug overdose/Medication error . [FM A] notified me about the mediation error. [Resident #1] was getting Erleada 60mg tabs x 4 previously but during the last refill the medication was changed to 240mg tabs. [Resident #1] was given Erleada 240mg x 4 tabs instead of Erleada 240mg x 1 tab. Review of Resident #1's NP assessment, dated 11/21/23, reflected the following: Chief Complaint/Reason for this Visit: Follow-up on Erleada Overdose . CBC, CMP reviewed and is stable . DON has notified the Urologist about the drug overdose/medication error. Erleada is on hold since 11/17/23. During a telephone interview on 01/24/24 at 12:47 PM, Resident #1's NP stated he was administered the wrong dose of Erleada for 5-6 days before 11/17/23. She stated she was not notified until Resident #1's FM A informed her. She stated the staff did not review the new order when it came in. She stated it would be her expectation that physician orders be followed as it was part of the Five Rights of medication administration (Right patient, Right drug, Right dose, Right route, Right time). She stated labs were ordered and he was monitored for any signs and symptoms of toxicity and did not believe he was negatively affected by the medication error. During a telephone interview on 01/24/24 at 12:57 PM, FM A stated she was called by a staff member from the facility on 11/17/23 and was notified Resident #1 was almost out of his Erleada. She stated that was impossible because it had just gotten filled at the beginning of November (of 2023). She stated she was aware Resident #1 would at times refuse his medications, so it made sense that he had not run out sooner. She stated she was furious and called the Urologist to find out if it could negatively affect Resident #1. During a telephone interview on 01/24/24 at 1:51 PM, the UPT stated Resident #1 had been on 60 mg tablets of Erleada for a while and then the drug manufacturer came out with a 240 mg tablet in September of 2023 and FM A agreed to switch him to one tablet since he often refused his medications. She stated on 10/02/23 and 11/01/23, the pharmacy refilled his Erleada - 30 240 mg tablets. She stated both refills had a note on them alerting to the dosage change. She stated FM A called the pharmacy in mid-November (could not remember the exact date) and asked for another refill. She stated she told her it was too soon for a refill. She stated once FM A told them (pharmacy) what had happened, they were not sure what toxicity would look like so she reached out to the drug manufacture to find out what too much of the medication would cause but did not receive a conclusive answer. During an interview on 01/24/24 at 2:44 PM, the ADON stated Resident #1 had been receiving four tablets of Erleada since he was admitted in June (of 2023). She stated apparently in November, his Urologist changed the dosage but it got missed by his nurse, LVN B. She stated LVN B and whoever else administered his medication during that timeframe should a have verified the dosage. She stated when LVN B went to administer it after five or six days and noticed he was almost out of the medication, she called FM A who realized he had run out too early. She stated she contacted his Urologist to notify him and was instructed to run labs and monitor him for three days for toxicity concerns. She stated the labs came back normal and he had not had a change in condition from the medication error. During a telephone interview on 01/24/24 at 4:17 PM, LVN B stated apparently the doctor changed the dose and frequency of Resident #1's Erleada medication but did not send a new order, so she followed the original order in (electronic medical charting system). She stated she knew it was a mistake to not verify the order on the bottle and she felt horrible about it. She stated all nurses and medication aides were in-serviced on review each medication that was delivered and updating the MAR as necessary. During an interview on 01/25/24 at 1:28 PM, LVN G stated when a medication was delivered from the pharmacy, the nurses were to check the order to ensure the MAR was correct and updated it if the order had changed. She stated before dispensing medication, all orders should be reviewed. During an interview on 01/25/24 at 1:36 PM, RN H stated all medications should be reviewed against the resident's MAR before administering and when delivered to the facility. During an interview on 01/25/24 at 2:10 PM, MA I stated she always reviewed the medication orders before administering medications to residents. Review of an in-service entitled Proper Medication Verification, dated 11/17/23 and conducted by the DON, reflected nurses and medication aides were in-serviced on the following: When accepting a medication delivery, you must verify the order on the container with the order in our MAR and updated our MAR if necessary. When administering medications, you must compare the container to the order every time! *See attached 10 rights* 10 Rights for Safe Medication Administration: Right Drug, Right Patient, Right Dose, Right Time, Right to Refuse, Right Knowledge and Understanding, Right Questions or Challenges, Right Response or Outcomes, Right Advice Review of the facility's Documentation of Medication Administration Policy, revised April of 2007, reflected that it did not specifically address following physician orders. Review of the facility's Medication Orders Policy, dated January of 2020, reflected the following: Medication orders - When recording orders for medication, specify the type, route, dosage, frequency, strength, and the reason for administration. The policy did not specifically address following physician orders.

Based on observation, interview, and record review, the facility failed to store, prepare, distribute food in accordance with professional standards for food service safety for one of one kitchen reviewed for kitchen sanitation. The facility failed to ensure Dietary Aide B, Dietary Aide C, and Dietary Cook D properly sanitized her hands between tasks. These failures could place residents who were served from the kitchen at risk for health complications, foodborne illnesses, and decreased quality of life. Findings included: 1. Observation on 12/12/2023 beginning at 7:40 AM revealed Dietary Aide B was not wearing gloves. She touched her shirt, picked up her personal cell phone, and touched disinfectant wet cloth to wipe the food prep table. Dietary Aide B touched all the fourchettes (a narrow strip that joins the front and back sections of the fingers of a glove) on both gloves when obtained the gloves from the container. Dietary Aide B did not wash her hands when she placed the pair of gloves on her hands. Dietary Aide B also touched her shirt and touched the disinfectant rag after placing gloves on her hands. She began to open raisin bread package and touched the bread to with all her fingers on her right hand. Dietary Aide B placed the raisin bread in the toaster oven for the resident's breakfast. In an interview on 12/12/2023 at 2:05 PM (interpreter was the Dietary Manager) Dietary Aide B stated she was in a hurry completing her tasks prior to breakfast. She stated she did touch her personal phone, touch her shirt, and may have touched the disinfectant rag to wipe off the food prep table. She stated she did not wash her hands prior to placing gloves on her hands and she did touch the outside of the gloves prior to placing the gloves on her hands. Dietary Aide B stated she touched the raisin bread bag when opening the bag to get the raisin bread and put the bread in the toaster oven. She also stated the germs from her cell phone, her clothes, the disinfectant rag, and the bread bag was considered contaminated. Dietary Aide B stated she was expected to wash her hands when she touched any item considered contaminated. She also stated when she placed gloves on her hands, she was not to touch the outside of the gloves where her fingers go inside the gloves. She stated she did contaminate the gloves. Dietary Aide B stated when she touched the bread and placed the bread in the toaster, she had a potential to contaminate the bread. She stated there was a possibility the bread may have germs on it from her gloves. She also stated if the bread was contaminated and a resident ate the bread, they resident may develop stomach issues such as diarrhea or vomiting from the bacteria. Dietary Aide B stated she had been in serviced within the past two months on hand hygiene and wearing gloves in the kitchen. 2. Observation on 12/12/2023 beginning at 11:50 AM Dietary Aide C was not wearing gloves. She touched her clothes, cleaned the food prep area, the sink with a disinfectant rag, and touched a portion of her hair (underneath the hair covering on the right side of her head). Dietary Aide C moved a tray of small bowls with sliced apple pies in the small bowls from one food prep table to another food prep table. When Dietary Aide C placed the tray of apple pies on the second food prep table some of the cellophane covering the bowls came off and she touched three of the sliced apple pies in bowls with her middle finger, forefinger, and ring finger on both hands. She had a paper towel and discarded the paper towel into the garbage can and touched the lid of the garbage can. Dietary Aide C moved another tray of slice apple pies in the small bowls from one food prep table to another food prep table and she touched two of the apple sliced pies when she re-covered the pies with cellophane. Dietary Aide C walked from the food prep area of the kitchen toward the dishwashing area of the kitchen. She obtained two gloves and placed the gloves in her shirt pocket. Dietary Aide C washed her hands and continued to enter the dishwashing area of kitchen. After she washed her hands, she touched her shirt, her face, and another person shirt with the forefinger, middle finger, and ring finger of her right hand. Dietary Aide C removed the gloves from her shirt pocket with all her fingers on her right hand and touched all the fourchettes (a narrow strip that joins the front and back sections of the fingers of a glove). Dietary Aide C exited the dishwasher room and returned to the kitchen area. She picked up 4 clean plates to be used for the lunch meal with her right gloved hand and all her fingers touched the plates. In an interview on 12/12/2023 at 2:20 PM (interpreter was the Dietary Manager) Dietary Aide C stated she was not wearing gloves and had not washed her hands when she was cleaning the food prep table with disinfectant rag. She stated the entire time she was completing different tasks with moving the bowls of sliced apple pies on a tray she did not wash hands or wear gloves. She stated she moved the apple pies after she had touched the disinfectant rag and after she touched the garbage can lid. Dietary Aide C stated she was trying to get the pies ready for the lunch meal. Dietary Aide C also stated she did touch the applies with her fingers and her fingers were not clean. She stated there was a possibility germs from her hands may contaminate the apple pies. Dietary Aide C stated the only time she washed her hands was when she was going into the dishwasher room. She stated she did place gloves in her shirt pocket. Dietary Aide C stated the pocket of her shirt was considered dirty with germs. She stated her hands and the gloves were contaminated. She stated she did pick up clean dishes in the kitchen area after she exited the dishwasher room. Dietary Aide C stated there was a possibility the dishes had germs on them from her dirty gloves. She stated if a resident ate the apple pie or ate from the plates she touched, the resident had a potential of having gastro problems with their stomach such as: vomiting and diarrhea. She also stated there was a possibility a resident may need to be hospitalized due to becoming very sick with stomach issues. 3. Observation on 12/12/2023 beginning at 12:10 PM the Dietary Cook was not wearing gloves. He placed his right hand in his pocket. He did not wash hands prior to placing gloves on his hands. There was one glove from the container that fell on to the floor. Dietary Cook picked up the glove from the floor. His forefinger, middle finger, and part of the palm area of his right hand touched the floor. The Dietary Cook placed his right hand inside the sandwich bags to open them. He picked up three sandwiches with his right hand and placed them in separate sandwich bags. The dietary manager explained to him the sandwiches needed to be discarded in the garbage. In an interview on 12/13/2023 at 2:35 PM Dietary cook stated he had been in-serviced on wearing gloves and washing hands in the kitchen. He stated he was expected to wash hands and change gloves in between tasks. Dietary Cook stated there was a possibility he may have contaminated the sandwiches and the sandwich bags by touching them with his right gloved hand. He stated he did not recall if his right hand or fingers on his right hand touched the floor, however, there was a possibility his hand did touch the floor when picking up the glove. He stated if a resident ate one of the sandwiched, he touched with his glove there was a possibility a resident may ingest bacteria and may become physically ill with a foodborne illness. Dietary Cook stated there was a possibility a resident may need to be transferred to hospital for further care from a physician. In an interview on 12/14/2023 at 8:35 AM the Dietary Manager stated all staff were expected to wash their hands when entering the kitchen, prior to placing gloves on their hands and anytime they remove gloves from their hands. He stated if staff was wearing gloves and the staff touched anything considered contaminated such as: disinfectant rag, clothes, inside pockets, floor, bread package, and/or cell phone, the staff was expected to remove gloves and discard the gloves, wash their hands before placing new gloves on their hands. He stated with the bread bag anyone could touched the bread bag prior to the bread being delivered to the kitchen. Dietary Manager stated no one knows who touched the bread bag outside of the facility. He also stated if anyone is touching a disinfectant rag and does not wash their hands, it was a possibility the disinfectant may transfer from the staff hands onto food and contaminate the food. He stated if a resident ate food with a possibility of having bacteria or disinfectant on the food the resident may become seriously ill and would need to be admitted to the hospital. He stated he did not know the extent of illness a resident may receive from bacteria or disinfectant; however, it may affect their immune (protected against a particular disease) system. In an interview on 12/14/2023 at 10:00 AM the Administrator stated all staff was expected to wash their hands prior to placing gloves on their hands. She also stated the staff was expected to remove gloves from their hands if the gloves were contaminated and between tasks. The Administrator stated any parts of clothing, the floor, garbage can lid, touching disinfectant rag would be considered contaminating staff hands and /or gloves. She stated staff was expected to wash their hands and change their gloves immediately. She also stated when the cook touched the sandwiches with contaminated gloves the sandwiches was expected to be thrown away immediately. The Administrator stated if a resident ingested bacteria from their food, plates, and/or silverware there was a potential a resident may become ill with a food borne illness such as vomiting and diarrhea. She also stated a resident may become dehydrated. She stated if the facility were not capable of caring for the resident's physical condition the resident would be transferred to the hospital for further evaluation. Review of the facility's policy on Hand Washing not dated reflected employees will wash hands as frequently as needed throughout the day using proper hand washing procedures. Hands and exposed portions of arms should be washed immediately before engaging in food preparation. When to wash hands: - after touching bare human body parts other than clean hands and wrists - during food preparation, as often as necessary to remove soil or contamination and to prevent cross contamination when changing tasks. - before placing disposable gloves on for working with food and after gloves are removed. - after engaging in other activities that contaminate the hands. Review of the FDA Food Code 2022 Section 2-301.14 When to wash reflected Food employees shall clean their hands and exposed portions of their arms immediately before engaging in food preparation including working with exposed food, clean equipment and utensils and unwrapped single service and single use articles and: A) After touching bare human body parts other than clean hands and clean, exposed portions of arms; E) After handling soiled equipment or utensils F) During food preparation, as often as necessary to remove soil and contamination and to prevent cross contamination when changing tasks.

Based on record review and interview, the facility failed to assess each resident quarterly using the Minimum Data Set form specified by the state and approved by CMS not less frequently than once every 3 months for 2 of seven residents (Resident #2 and #63) reviewed for quarterly assessments. The facility failed to ensure a quarterly MDS assessment was completed within 92 days of the previous quarterly assessment for Resident #2 and Resident #63. This failure could place residents at risk for not having their needs meet. Findings Included: Review of Resident #2's Face Sheet dated, 11/13/2023 reflected a [AGE] year-old female admitted to the facility on [DATE] with the following diagnoses Alzheimer's Disease (A type of brain disorder that causes problems with memory, thinking and behavior. This is a gradually progressive condition.), Multiple Sclerosis (A disease that affects central nervous system. The immune system attacks the myelin, the protective layer around nerve fibers and causes Inflammation and lesions. This makes it difficult for the brain to send signals to rest of the body.), and Age-related debility (a state of general weakness or feebleness that may be a result or an outcome of one or more medical conditions that produce symptoms such as pain, fatigue, cachexia and physical disability, or deficits in attention, concentration, memory, development and/or learning.) Review of Resident #2'Quarterly MDS dated [DATE] was the last quarterly MDS completed and transmitted by the facility. Review of Resident #2's Quarterly MDS dated [DATE] reflected in the electronic medical record the MDS was in progress. In section Z of the MDS, Z0500, Signature of RN Assessment Coordinator Verifying Assessment Completion, was not signed or dated. The Quarterly MDS was required to be completed, signed, and transmitted by the due date of 12/01/2023. Review of Resident #2's last Comprehensive Care Plan was completed on 12/05/2023 and there was not an MDS completed to reflect what was documented on the care plan dated on 12/05/2023. Review of Resident #63's Face Sheet dated, 11/13/2023 reflected a [AGE] year-old female admitted to the facility on [DATE] with diagnoses of Hypertension (High pressure in the arteries (vessels that carry blood from the heart to the rest of the body), history of falling ( to drop to a lower place through loss or lack of support), chronic atrial fibrillation ( causes the chamber of your heart to beat irregularly), major depressive disorder ( causes a persistent feeling of sadness and loss of interest and can interfere with daily routine), bradycardia ( a slow heart rate), and age related physical debility (a state of general weakness or feebleness that may be a result or an outcome of one or more medical conditions that produce symptoms such as pain, fatigue, cachexia and physical disability, or deficits in attention, concentration, memory, development and/or learning). Review of Resident #63'Quarterly MDS dated [DATE] was the last full MDS completed and transmitted by the facility. Review of Resident #63's Quarterly MDS dated [DATE] reflected in the electronic medical record the MDS was in progress. In section Z of the MDS, Z0500, Signature of RN Assessment Coordinator Verifying Assessment Completion, was not signed or dated. The Quarterly MDS was required to be completed, signed and transmitted by the due date of 11/23/2023. Review of Resident #63's last Comprehensive Care Plan was completed on 10/11/2023 and there was not an MDS completed to reflect what was documented on the care plan dated on 10/11/2023. In an interview on 12/14/2023 at 8:40 AM the MDS Coordinator stated the due date for Resident #63's Quarterly MDS was 11/23/2023. She stated she had not transmitted the MDS with the ARD date of 11/9/2023 she stated the assessment was complete, but she had 90 days to do it. She stated the same for Resident #2 with her due date being 12/1/2023 she stated she did not speak well and was maybe not telling the surveyor the right thing so she would speak to her DON and get the DON to explain and bring the facility policy and procedure. In an interview on 12/14/23 at 9:39 AM the DON she stated her expectation was that assessments be completed and transmitted on time. She stated she tracks the completion of the MDS's, and the report did not show any late assessments. She stated after looking in the EMR that Resident #2 and Resident #63 MDSs were still in process and had not been transmitted. She stated it appeared to be an education issue with the MDS Coordinator and she would provide her more training. She further stated she would get with IT to see why her report was not showing the MDS's had not been transmitted to CMS. Review of the facility policy Transmission of the MDS dated ,d+[DATE] reflected All MDS assessments (e.g., admission, annual, significant change, quarterly review, etc.) and discharge and reentry records will be completed and electronically encoded into our facility's MDS information system and transmitted to CMS' QIES Assessment Submission and Processing (ASAP) system in accordance with current OBRA regulations governing the transmission of MDS data . 6.The MDS Coordinator is responsible for ensuring that appropriate edits are made prior to transmitting MDS data and that feedback and validation reports from each transmission are maintained for historical purposes and for tracking.

Based on observation, record review, and interview the facility failed to ensure a PASRR screening was completed for residents with mental disorder or an intellectual disability for one of three residents (Resident # 11) reviewed for PASRR Level I screenings. The facility failed to ensure an accurate PASRR Level I screening (a preliminary assessment completed for all individuals prior to admission to a Medicaid - certified nursing facility to determine whether they might have a mental illness or intellectual disability) was completed for Resident #11. Resident #11 was readmitted after hospitalization on [DATE] with the diagnosis of Bipolar disorder. This failure could place residents at risk for a diminished quality of life and not receiving necessary care and services accordance with individually assessed needs. Findings include: Review of the Face Sheet for Resident #11 reflected she was a [AGE] year old female admitted on [DATE] with diagnosis of: Chronic Atrial fib , Weakness, Bipolar Disorder(02/08/22), Osteoporosis , unspecified Dementia (2/08/22). Resident #11 was readmitted on [DATE] after hospitalization for change in mental status. Review of the quarterly MDS assessment for Resident #11 dated 8/23/23 reflected a BIMS score of 11 indicating moderately impaired cognitive abilities. Her functional assessment reflected she needed extensive assistance for all ADLs except eating. She was assessed as incontinent of bowel and bladder. Review of the Care Plan dated 11/08/23 for Resident #11 reflected interventions were in place for: Behavioral symptoms- making accusations about roommate, refuses to allow brief changes, Insomnia, Osteoporosis, History of Falls, Resists care-bathing, bipolar disorder with extreme mood swings, Dementia, DNR order in place. Resident #11's care plan listed behavioral symptoms including impaired judgement, dangerous/extreme mood swings and refusal to complete tasks. Review of Records for Resident #11 reflected her PASRR evaluation dated 11/13/2020 was negative and no diagnosis of mental illness was checked. Resident #11 facility records reflected she had a diagnosis of bipolar disorder dated 2/08/22. Review of History and Physical Records for Resident #11 dated 12/16/22 reflected the resident had a diagnosis of Dementia, Bipolar Disorder, a history of falls and high blood pressure. Observation of Resident #11 on 12/12/23 at 10:02 am revealed her room contained a strong urine odor smell. In an interview Resident #11 stated her roommate was responsible for the odor and refused care from staff. Observation of Resident #11 on 12/12/23 at 3:05 pm revealed the urine smell was gone from the room. Resident #11 stated she had received a shower that day, but her roommate had refused to shower. In an interview on 12/13/23 at 9:25 am LVN P stated Resident #11 had a behavior of refusing incontinence care. She stated she tried to stay on top of Resident #11's care and offered to bath her frequently. The LVN stated a Resident #11 had a history of mental illness. In an interview on 12/14/23 at 10:20am the DON stated Resident #11 most recent PASRR uploaded reflected she was negative for mental illness. She consulted with other staff and stated her diagnosis of bipolar disorder was not new and the resident had her needs met and her condition was stable. She stated therefore the PASRR evaluation would be negative for further services. The DON stated the regional coordinator was in the building and a new PASRR evaluation would be completed today. The document the DON showed the surveyor had mental illness diagnosis was checked and bipolar disorder was written in . In a further interview at 10:38 am the DON stated the facility was wrong and the PASRR should have been redone when Resident #11's Bipolar diagnosis was verified. She confirmed the bipolar disorder diagnosis was added on 2/08/22 after Resident #11 returned from an acute care hospital for treatment of Pneumonia. She stated the facility was in the process of redoing the PASRR assessment immediately. In an interview on 12/14/23 at 11:25 am the Administrator stated staff should have been following guidance and reassessing Resident #11's needs when the Bipolar diagnosis was added. Review of the Facility Policy on PASRR assessments supplied to surveyor on 12/14/23 reflected a new PL1 (PASRR level 1) assessment should be completed when a resident returns from hospital. The policy reflects any person diagnosed with a major mental disorder as listed in the Diagnostic and Statistical Manual of Mental Disorders (DSM-III-R) should be noted as positive in a PL1 assessment.

Based on observation, interviews and record review the staff failed to provide daily hygiene and dressing assistance to one of two residents (Resident #30) reviewed for ADL care. Staff failed to provide Resident #30 with a change of clothes for threee days. The facility failed to assist Resident #30, who required staff assistance, to change her clothes for 3 days on 12/12/23, 12/13/23 and 12/14/23. This failure could place residents at risk of not receiving care and services to meet their needs and a decreased quality of life. Findings include: Review of the Face sheet for Resident #30 reflected she was admitted on [DATE] with diagnosis of: Dementia, Pneumonia, Bronchitis, Heart Failure, Senile Degeneration of brain, Alzheimer's disease, Obstructive Uropathy , Generalized Anxiety disorder. Her chart reflected she had a Do Not Resuscitate (DNR )order and was receiving Palliative care . Review of the MDS for Resident #30 dated 10/04/23 reflected a BIMS score of 5 indicating severe cognitive impairment. Her assessment had no behaviors marked. Her functional assessment reflected she required one person assistance for most ADLs and two person assist for mobilizing. Resident #30 was asessed as requiring moderate or more than half the work for dressing herself. She was assessed as always continent of bowel and bladder. Review of the Care Plan for Resident #30 reflected interventions were in place for: Hard of Hearing with hearing aides, Cognitive loss/Dementia, Osteoporosis , Occasionally incontinent of bowel and bladder, needs extra time for ADLs, Fall risk. The plan listed interventions for one to one activities to be offered in her room. The Care Plan did not mention refusal behaviors except to allow the Resident extra time and to honor her choices for clothing, food and her physical limitations. No other interventions for dressing assistance were listed, only provide time for care and ensure and allow appropriate clothing choices. Review of Progress Notes dated from 9/01/23 to 12/14/23 reflected infrequent notations of Resident #30 refusing to bath. On 12/14/23 a progress note mentioned three aides had reported Resident #30 had refused to change her pink nightgown. The name of the aides was not listed. Review of the Skin Assessment for Resident #30 dated 12/01/23 reflected no impairment of the skin was found. Observation on 12/12/23 at 10:02 am revealed a strong urine smell was present in the room housing Resident #30 and #11 . Resident #30 was seated in her wheelchair, wearing a pink nightgown with her name written on the back. She stated she was fine and had no complaints about her care. Observation on 12/13/23 at 8:55 am of Resident #30 revealed she was wearing the same pink nightgown as the previous day. The strong urine smell in the room was gone. In an interview on 12/13/23 at 9:00 am CNA H she stated she was not aware Resident #30 wore the same clothing as the previous day, she stated she did not regularly work on Hall 4. She stated Resident #30 was due for a shower today . In an interview on 12/13/23 at 9:25 am LVN P stated Resident #30 was due for a shower today and had a behavior of wanting to not change her clothing each day. In an interview on 12/14/23 at 8:15 am LVN P stated Resident #30 should have received a shower yesterday and she had no idea why she would be wearing the same pink nightgown for three days. Observation on12/14/23 at 8:02 am of Resident #30 seated in wheelchair in room [ROOM NUMBER] revealed she was clothed in the same pink nightgown as on previous days. In an interview on 12/14/23 at 8:33 am the DON stated she was not aware Resident #30 was wearing the same pink nightgown for three (3) days. She reviewed computer records and stated Resident #30 was due for a shower on 12/13/23 and she would check if she received one. She noted Resident #30 had a history of behaviors of refusing care, showers and clothing changes. In a further interview on 12/14/23 at 10:00 am the DON stated Residents on 400 hall were bathed twice a week and if a resident refused a shower or bath, they could go up to seven days without a bath. The charge nurse was responsible for supervising Resident care. In an interview on 12/14/23 at 10:30 am CNA G stated she had worked with Resident #30 many times and she just flatly refused to shower or change her clothes at times. She stated her family member visited daily and she would ask her to convince her mom to shower and change. When asked what the facility did when Resident #30 refused care, CNA G responded they called her family member. Observation on 12/14/23 at 10:35 am revealed Resident #30 was seated in her wheelchair and wearing the same pink nightgown with her name on the back. In an interview on 12/14/23 at 11:25 am the Administrator stated her expectation was ADL care would be completed daily by aides. She stated the charge nurse and DON were responsible for overseeing care. The facility stated no policy was available for assisting residents with ADL care.